{"subscriber":false,"subscribedOffers":{}} Diffusion Of Innovation To Improve Health Care Value: Physician-Led Care Redesign | Health Affairs

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Doi: 10.1377/forefront.20190308.817613

Medical care in the United States is generally outstanding, as evidenced by individuals who travel from other countries to benefit from the health care practices offered by our physicians and surgeons. Every day, dedicated, knowledgeable, and experienced clinicians deliver highly effective care to improve the health of the patients they serve. At the same time, many reports have highlighted the role that low-value care—use of tests and treatments that don’t improve outcomes—play in health care costs

While the cost of health care must be addressed by those within and outside of the health care sector, physicians across the country have responded to the opportunity to improve health care value by reducing unnecessary tests and treatments. Physician-led care redesign is gaining strong momentum and is essential to ensure that health care quality and safety are not compromised by cost-driven changes. Holding fast to the mission of medicine, performance improvement teams in hospitals and health systems across the country are responding to inappropriate use by implementing educational campaigns, integrating evidence-based clinical decision support guidance into the electronic medical record, and distributing individual provider performance feedback reports in an effort to reduce unnecessary use of tests and treatments. 

Specific interventions vary in effectiveness, but early observations have found, for example, that avoidance of a single unnecessary lab test (CK-MB [creatine kinase-muscle/brain] in patients with acute chest pain) in one hospital safely eliminated more than $1 million in unnecessary charges. Another example is reducing unnecessary blood transfusions, which saved one health system more than $2 million per year. Recent data have confirmed that judicious transfusion practice does not compromise long-term outcomes. Scaling these interventions has the potential to reduce unnecessary expenditure while maintaining or improving outcomes. 

Start Small, And Scale Fast 

Frontline efforts to optimize appropriate use of medical resources don’t garner big headlines, perhaps due to their small scale relative to the potential pool of avoidable expenditures. Regardless, a home-grown approach to addressing clinical variation and inappropriate use driven by evidence-based best practices can increase health care quality, safety, and affordability. To deliver measurable improvements, effective interventions need to be identified locally and rapidly adopted on a national scale. Yet, diffusing these reforms through our conventional model of dissemination (presentations at medical meetings and publications in journals) will not suffice given the urgency of the burden on our patients. Traditional means of medical information transmission typically take years to change physician behavior, with one review concluding that the lag time between research publication and change in practice is 17 years

Recognizing the need to move faster, two of us (Johnson and Ziegelstein) set out in 2016 to open the channels of communication among high-value performance improvement teams in different institutions. With the support of the dean of Johns Hopkins University School of Medicine, we invited all US academic medical centers to join a national information exchange network focused on care redesign. This organization, the High Value Practice Academic Alliance (HVPAA), quickly grew to include more than 90 institutions. Participants include practicing physicians from large and small teaching hospitals in the US, Canada, Japan, and Norway, representing 30 different medical specialties. Membership in the organization is free but requires approval from a member’s health system leadership or departmental chair and a pledge to implement at least one value improvement initiative each year. 

Building An Army Of Value-Minded Physicians 

According to Everett M. Rogers, diffusion of innovation has four key components: innovation, communication, time, and a social system. The HVPAA has addressed these areas by identifying successful care redesign initiatives and disseminating them through a weekly email, monthly conference calls, a national conference, and a website. This diffusion of innovation model has fostered a community of physicians and care teams across 90 medical centers and beyond, with outreach expanded through leadership programs available to trainees and junior faculty in any medical center and through peer-reviewed publications. At the core of the alliance is the national conference, designed to broadly disseminate quality-driven, value-improvement work and bring the teams together to reinforce the social system. The first two national conferences in 2017 and 2018 facilitated the sharing of 350 value-improvement projects across 70 medical centers, and the conference abstracts and educational presentations are available free online for any institution interested in improving value. 

Effective And Efficient Diffusion Requires Engagement, Education, And Empowerment 

The HVPAA advances adoption of value-improvement initiatives by diffusing information through our network of physician high-value champions and: educating them about the stakeholders (physicians from other specialties, house staff, nurses, pharmacists, and so forth) and resources needed to affect the change; creating new educational resources and assembling multicenter teams to facilitate key interventions; and empowering them to advocate for change by communicating to their leadership that other academic institutions have adopted an HVPAA approved initiative. The HVPAA is leveraging the power of cross-institutional competition to overcome hurdles to low-value care avoidance, such as deeply entrenched practice patterns and potential loss of health system revenue. 

Rogers’ diffusion model indicates that innovation “takes off” at the 10–20 percent adoption rate. A baseline survey of HVPAA members identified multiple value-improvement initiatives that had been adopted by at least 20 percent of institutions before joining the alliance, which became the focus of the HVPAA’s early work within the organization through monthly presentations by experienced medical centers delivered by webinar to all members of the organization. Teams of physician and resident champions co-authored a series of implementation guide publications in JAMA Internal Medicine on these topics, designed to assist members internally and drive broad adoption outside of the organization. The alliance directors are currently evaluating effectiveness at the two-year mark through a survey of our members and plan to share these findings, but objective measures of success include, to date: the 2017 award for Innovations in Clinical Care from Johns Hopkins Hospital, the 2018 Award for Excellence in Teamwork in Quality Improvement from the Society of Hospital Medicine, the 2018 Costs of Care/American Board of Internal Medicine Foundation Teaching Value Innovator Awards for the Future Leader Program and the Order Wisely conference, approval as a Centers for Medicare and Medicaid Services Qualified Provider Led Entity for their Appropriate Use Criteria Program, and a three-year conference grant from the Agency for Healthcare Research and Quality to support the national meeting. 

Improvements In Five Areas Can Produce Higher-Value Care Experiences 

The baseline survey and national conference served to enlighten us about the improvements in care delivery necessary to create a truly high-value system, which resulted from the bidirectional nature of the diffusion. The breadth of work detailed in more than 100 abstracts presented at the 2017 national conference defined a roadmap for value improvement, or the “architecture of high value health care,” which goes far beyond reducing overuse and includes performance improvement across five pillars of care delivery: 

Broadening Collaboration 

In 2018, the American Hospital Association (AHA) and its Physician Alliance became a key partner with the HVPAA. The mission of the HVPAA is aligned with the AHA’s strategy of advancing health in the United States as well as enhancing administrative and clinical partnership. AHA leaders help design the national conference, provide insights, and engage hospitals and health systems in their 5,000-member network to share leading practices that address affordability, reduce variation, and improve outcomes. Through this partnership the HVPAA hopes to disseminate the organization’s work outside of academia and foster a culture of value across each organization to support frontline clinicians as they work to deliver high-value care to their patients. 

No silver bullet will improve access, quality, safety, and affordability of care for all patients, but an evidence-based, quality-driven approach to care redesign ensures that changes maintain, or ideally, improve patient outcomes. The HVPAA is designing, delivering, and disseminating a scaffolding of evidence-based practice that can safely improve affordability. And we invite the other sectors in health care to partner with us in these efforts. We know what to do. We must now transfer this knowledge into practice. 

Authors’ Note

Pamela T. Johnson, MD, is on the advisory council for Oliver Wyman Practicing Wisely® and receives salary support from the Agency for Healthcare Research and Quality Grant No. R13 HS26350-01. Martin Makary, MD, MPH, is on the advisory council for Oliver Wyman Practicing Wisely®.