Case Study Organized Health Care Delivery System • August 2009 Marshfield Clinic: Health Information Technology Paves the Way for Population Health Management D ouglas M c C arthy, K imberly M ueller, and S arah K lein I ssues R esearch , I nc . ABSTRACT: Marshfield Clinic is a not-for-profit, physician-governed multispecialty group practice serving residents of rural Wisconsin through a regional ambulatory care system, The mission of The Commonwealth an affiliated health plan, and related foundations supporting health research and education. Fund is to promote a high performance health care system. The Fund carries Marshfield has engaged its physicians and staff in a program of clinical performance out this mandate by supporting improvement aimed at enhancing patient access, coordination of care, and efficiency of independent research on health care clinical operations. An internally developed electronic health record acts as a care planning issues and making grants to improve tool for delivering preventive care and managing chronic diseases. A telemedicine network health care practice and policy. Support expands access to care for patients living in rural and remote areas. Marshfield Clinic’s for this research was provided by experience shows how an organized group of physicians can improve patient outcomes and The Commonwealth Fund. The views presented here are those of the authors reduce costs by undertaking a population-based approach to ambulatory care management and not necessarily those of The supported by robust information technology. It also suggests that group-level performance Commonwealth Fund or its directors, incentives that are aligned with an organization’s strategic goals have the potential to officers, or staff. enhance population health management.      For more information about this study, please contact: OVERVIEW Douglas McCarthy, M.B.A. In August 2008, the Commonwealth Fund Commission on a High Performance Issues Research, Inc. Health System released a report, Organizing the U.S. Health Care Delivery dmccarthy@issuesresearch.com System for High Performance, that examined problems engendered by fragmen- tation in the health care system and offered policy recommendations to stimulate greater organization for high performance.1 In formulating its recommendations, the Commission identified six attributes of an ideal health care delivery system (Exhibit 1). To download this publication and Marshfield Clinic is one of 15 case study sites that the Commission learn about others as they become examined to illustrate these six attributes in diverse organizational settings. available, visit us online at www.commonwealthfund.org and Exhibit 2 summarizes findings for Marshfield. Information was gathered from register to receive Fund e-Alerts. Marshfield Clinic health system leaders and from a review of supporting docu- Commonwealth Fund pub. 1293 ments.2 The case study sites exhibited the six attributes in different ways and to Vol. 26 2T he  C ommonwealth F und Exhibit 1. Six Attributes of an Ideal Health Care Delivery System • Information Continuity Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record (EHR) systems. • Care Coordination and Transitions Patient care is coordinated among multiple providers, and transitions across care settings are actively managed. • System Accountability There is clear accountability for the total care of patients. (We have grouped this attribute with care coordination since one supports the other.) • Peer Review and Teamwork for High-Value Care Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other’s work, and collaborate to reliably deliver high-quality, high-value care. • Continuous Innovation The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery. • Easy Access to Appropriate Care Patients have easy access to appropriate care and information at all hours, there are multiple points of entry to the system, and providers are culturally competent and responsive to patients’ needs. varying degrees. All offered ideas and lessons that people. About one-half of its physicians practice in may be helpful to other organizations seeking to Marshfield and the other half in outlying communities. improve their capabilities for achieving higher levels The Clinic expanded from its original Marshfield loca- of performance.3 tion in response to invitations from underserved com- munities, through mergers with and purchases of other ORGANIZATIONAL BACKGROUND local physician practices, and from the ongoing devel- Marshfield Clinic, headquartered in Marshfield, opment of new clinic sites (several under way) that Wisconsin (population 19,500), is a not-for-profit have been chosen to help maintain a balanced patient multispecialty group practice founded in 1916 with a demographic base encompassing all segments of the mission to serve patients by providing accessible, population. high-quality health care, research, and education. The Clinic’s main campus in Marshfield is adja- Marshfield employs almost 800 physicians and 6,400 cent to St. Joseph’s Hospital, a 500-bed Catholic staff and serves 377,000 individual patients at 41 teaching institution and regional referral center owned ambulatory care sites located in 33 communities in by Milwaukee-based Ministry Health Care. Marshfield predominantly rural areas of northern, central, and Clinic and Ministry Health Care jointly own and oper- western Wisconsin (Exhibit 3). Patients made 3.6 mil- ate a 25-bed critical-access hospital in Park Falls and a lion visits during 2008. Roughly 28 percent of the diagnostic and treatment center on a shared medical clinic’s physicians, including those in family practice, campus in Weston. Marshfield also recently assumed general internal medicine, and pediatrics, provide pri- control of a 75-bed acute-care hospital in Rice Lake, mary care—33 percent when including those who spe- known as Lakeview Medical Center. cialize in obstetrics and gynecology. Marshfield Clinic sponsors Security Health Plan Marshfield operates as a regional ambulatory (SHP) of Wisconsin, the successor to the Greater care system. Its market share is 34 percent of the pri- Marshfield Community Health Plan—one of the first mary care delivered in its service area, which covers health maintenance organizations to serve a rural area 60 percent of the state and includes about 1 million of the United States.4 SHP arranges employer group, M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 3 Exhibit 2. Case-Study Highlights Overview: The not-for-profit Marshfield Clinic serves residents of northern, central, and western Wisconsin through a multispecialty group practice of almost 800 physicians who provide care to 377,000 patients visiting 41 ambulatory clinics in 33 rural communities, a health plan covering 150,000 people living in 32 counties, and related foundations supporting the institution’s research and education mission. Attribute Examples from Marshfield Clinic Information Continuity An electronic health record (EHR) with decision support and electronic prescribing is available across all Clinic sites and on portable tablet PCs. The system enables physicians to access patient medical records and laboratory and radiology results from hospital and ambulatory settings or from home. When indicated, the EHR requires physicians to acknowledge the risk of a severe drug interaction before proceeding with a prescription. A patient Web portal provides patients with online access to health information, immunization records, and prescription refill requests. A Web-based immunization registry links health care providers, health departments, schools, day-care centers, and a retirement community in a 23-county area. Care Coordination and The EHR shows when preventive and chronic care services are due and generates an intervention list of Transitions; System patients with high-risk chronic conditions who are not meeting treatment goals to support physicians and Accountability* their assistants in care planning and follow-up. A messaging tool enables providers to request assistance or lab tests from the exam room, streamlining communication with support staff while also creating an electronic record of those interactions. Nurses manage telephonic care following physician-approved protocols for anticoagulation, heart failure, and cholesterol control. Peer Review and Teamwork Physicians engage in improvement through guideline-based performance feedback, coaching, and for High-Value Care education. Regional medical directors attend local departmental meetings to share performance results and improvement strategies and solicit feedback. Continuous Innovation Clinic leaders have made the achievement of high performance an integral part of the organization’s core strategy and vision. Participation in the Medicare Physician Group Practice (PGP) Demonstration enables the medical group to assess the effects of performance incentives on outcomes. Local sites are engaged in redesign efforts to optimize workflows, e.g., assigning medical assistants specific clinical tasks such as conducting diabetic foot exams. The Biomedical Informatics Research Center invents and tests new approaches to information synthesis that enhance and facilitate the clinical use of information technology by physicians and staff. A personalized medicine research project aims to develop an individually tailored approach to prevention, diagnosis, and treatment based upon a person’s unique genetic profile. The Center for Community Outreach supports evidence-based population and environmental health im- provement strategies in priority areas identified by the State of Wisconsin. Easy Access to Marshfield serves all patients who seek care, regardless of ability to pay. Its contractual partnership with Appropriate Care a federally qualified community health center provides medical and dental care to low-income uninsured and underinsured individuals and families. A mobile health screening van provides testing and referral for women regardless of insurance. Advanced-access scheduling increases timeliness of appointments and continuity with the same physi- cian. Nurses staffing a 24-hour call line use the EHR to tailor advice to care plans, perform triage using online guidelines, and schedule clinic appointments (at select clinics) as needed. Telehealth services expand access to care in rural and remote areas to overcome transportation barriers and health provider shortages. “Telepharmacy” services enable drug dispensing in remote locations that lack a pharmacy. * System accountability is grouped with care coordination and transitions, since these attributes are closely related. 4T he  C ommonwealth F und Exhibit 3. Marshfield Clinic Locations Source: The Marshfield Clinic. individual, Medicaid, Medicare, and Children’s Health research,” said Humberto Vidaillet, M.D., medical Insurance Program coverage, as well as third-party director of the research foundation. The foundation has administration, for 150,000 residents of 32 Wisconsin five centers, which focus on clinical research, rural counties through a network of 42 affiliated hospitals health, human genetics, epidemiology, and biomedical and 3,800 providers (including Marshfield Clinic phy- informatics (see Continuous Innovation section for sicians). The health plan offers open access to its spe- more on the latter). The Marshfield Clinic Education cialists, without the need for a referral from a primary Foundation sponsors graduate medical residency and care physician. While 22 percent of Marshfield’s fellowship programs, continuing professional medical patients are enrolled in the health plan, SHP is both education, patient education, and other learning oppor- administratively and financially separate from the tunities. Marshfield Clinic is also a designated aca- Clinic and does not subsidize its operations.5 demic campus of the University of Wisconsin School Other business ventures include Marshfield of Medicine, where many Marshfield physicians hold Laboratories, which provides clinical testing services clinical teaching appointments. for clients nationwide, occupational health services, The organization is governed by a board of and an applied sciences division that seeks commercial directors on which Clinic physicians are eligible to applications for biotechnology innovations. serve after two years of employment. The board elects Two related foundations help fulfill the a nine-member executive committee and meets Clinic’s research and educational mission. The monthly to review the committee’s actions, make Marshfield Clinic Research Foundation employs scien- major decisions, and set policy. Roughly 75 percent of tists and supports the Clinic’s physician investigators Marshfield’s net revenue ($906 million in 2008) comes in the conduct of approximately 450 clinical research from commercial sources, including Security Health trials and other health research projects that are Plan, which pays the Clinic on a capitated basis that designed to advance and communicate scientific promotes proactive care management. The remainder knowledge that improves health. The goal is “integrat- comes from Medicare, Medicaid, and federally quali- ing research into practice and clinical practice into fied health center (FQHC) programs. M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 5 Information Continuity testing that often results from missing information. Marshfield Clinic has developed an electronic health The presentation of this information and other patient record (EHR) of increasing sophistication since 1985, data can be customized to highlight results that are with electronically coded clinical information on all important to particular specialties. For instance, a car- patients dating back to 1960. Clinic physicians were diologist may highlight electrocardiogram results and provided wireless, tablet-style personal computers in discharge summaries for easy viewing, while a neph- 2003 for quick access to the EHR and for electronic rologist may highlight laboratory results for dialysis prescribing and dictation. The EHR, named patients. The integration of electronic dental and medi- CattailsMD, allows providers to access patient infor- cal records is another new focus. mation including diagnoses, procedures, medications, test results, radiology images, and physicians’ notes at E-Prescribing with Decision Support. Electronic pre- all Clinic locations. Digital ink-over forms enable phy- scribing allows physicians to take account of patients’ sicians and staff to complete forms quickly and add drug allergies (tracked by the EHR) and reduces prob- drawings or other free-form notes to the medical lems related to illegible handwriting, thus minimizing record as necessary. A data warehouse supports the the incidence of medication errors, pharmacy call- EHR’s analytic and reporting functions. backs, and patient time spent waiting for prescriptions Marshfield’s ongoing information technology to be filled. When indicated, the software prompts investments, including the cost of the EHR, represent physicians to acknowledge the risk of a severe (i.e., about 3.5 percent of its annual revenue. The Clinic contraindicated) drug interaction before proceeding eliminated paper charts in 2007, saving an estimated with a prescription. After making such acknowledg- $7 million per year (about 25 percent of its health ment mandatory, the rate at which such prescriptions information management and medical transcription were cancelled increased from 8 percent to 31 percent. budget) by reducing space and centralizing job functions. Marshfield encourages physicians to consider Overall patient satisfaction increased during implemen- the use of “preferred alternatives” in prescription drug tation of the EHR, and anecdotal feedback suggests that classes that have interchangeable drug products, a patients are responding positively to the Clinic’s use of large difference in monthly cost, and a large volume of information technology. The EHR has enabled a num- prescriptions with variation in prescribing practices. ber of improvements, as described below. After the Clinic required physicians to document in the EHR the reason they chose not to use the preferred Web Portal for Patients. Patients can use a Web portal alternative, prescribing patterns changed, saving pay- to communicate electronically with the Clinic and per- ers and patients $2.5 million in one year. The majority form such tasks as requesting prescription refills, of those savings came from increased use of two pre- checking on needed preventive care, viewing their ferred drugs: Prilosec OTC (an over-the-counter ver- health history and laboratory results, and learning sion of a popular “proton pump inhibitor”), whose use about various medical topics. The Clinic is considering rose from 49 percent of its drug class to 63 percent, expanding the services the portal provides to include and a preferred statin (cholesterol-lowering drug) that e-visits and electronic scheduling. Approximately 16 jumped in use from 35 percent of its drug class to 65 percent of patients now make use of it. percent. The benefits accrue to many stakeholders. “If you have electronic prescribing with appropriate deci- Electronic Access to Lab Results. Laboratory test sion support, you should be able to decrease the cost results and imaging studies are available electronically of drug therapy to society, to payers, and to patients, for physician or consulting specialist review, eliminating ultimately,” said Gary S. Plank, Pharm.D., corporate delays in document or film transfer and the duplicate director of pharmacy services. 6T he  C ommonwealth F und Electronic Registries and Databases for Tracking MESA as a study population. When the researchers Immunizations and Community Health. During the discovered in early 2009 that the flu strain circulating 1990s, Marshfield Clinic collaborated with local in the community was one the CDC had identified as immunization providers to develop an electronic regis- being resistant to the commonly prescribed antiviral try for tracking childhood immunizations. Today, the drug oseltamivir, the Clinic was able to alert its physi- Web-based Registry for Effectively Communicating cians of these findings immediately via e-mail. “That Immunization Needs (RECIN) links physicians, hospi- has huge implications for correct treatment and better tals, nursing homes, public health departments, patient care,” said Theodore Praxel, M.D., M.M.M., schools, day-care centers, and a retirement community Marshfield Clinic’s medical director for quality in a 23-county area and interfaces with the Wisconsin improvement and care management. “Avoiding an Immunization Registry to document up-to-date immu- ineffective treatment means not wasting the patient’s nization history across a patient’s life span. RECIN resources on a medication that wouldn’t help,” he said. incorporates a decision-support system to avoid over- Ministry Health Care, which operates hospitals or under-immunization, warns about vaccine contrain- and medical groups in Marshfield Clinic’s service dications and allergies, improves the efficiency of vac- area, recently agreed to purchase Marshfield Clinic’s cine administration and billing, and facilitates outreach EHR system for implementation in its facilities over to patients who are due or overdue for immunizations. the next three to five years (the EHR is already being Within 14 months of the registry’s deployment, the used at one Ministry Medical Group location and in immunization rate for two-year-olds in Wood County two Ministry hospitals). The two organizations plan to (where Marshfield Clinic is located) rose from 67 per- link their systems as part of a regional health informa- cent to the national goal of 91 percent.6 tion organization allowing shared access to 2.5 million In 1991, the Marshfield Clinic Research patient records.7 The EHR met 2006 standards for Foundation created the Marshfield Epidemiologic functionality, interoperability, and security issued by Study Area (MESA) to facilitate population-based the nonprofit Certification Commission for Healthcare health research. MESA is a region of 24 zip codes in Information Technology. northern and central Wisconsin where the majority of the 85,000 residents receive their medical care from CARE COORDINATION AND TRANSITIONS: Marshfield. Researchers combine data on the popula- TOWARD GREATER ACCOUNTABILITY FOR tion in this region with primary and specialty care TOTAL CARE OF THE PATIENT records from the Clinic and tertiary care records from Primary Care Teams. Marshfield Clinic views care the local hospital. The relative stability of the local management as a critical component of its population population enables continuity in data collection for health management philosophy, which emphasizes the tracking and studying changes in the health of the role that primary care teams can play in coordinating community over longer periods. care for patients within the larger environment of a The database also can be tapped to monitor multispecialty practice.8 Because many patients have emerging public health concerns, such as the effective- multiple chronic diseases, the Clinic seeks an inte- ness of the flu vaccine and available treatments each grated approach to disease management as an exten- flu season, with immediate benefits to Marshfield sion of primary care. Physician assistants and nurse Clinic patients. For example, prior to the 2008–2009 practitioners, who provide care to defined panels of influenza season, Marshfield Clinic’s research team patients or handle urgent care visits, also extend the was working in collaboration with the Centers for role of primary care within the Clinic. Disease Control and Prevention to conduct real-time Primary care teams use the EHR-generated effectiveness studies of influenza vaccines, using “iList” (short for intervention list) to identify patients M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 7 with chronic conditions (e.g., diabetes, heart failure, The system streamlines communication and helps ensure high blood pressure) who are not meeting treatment that tasks are completed. Physicians also use the sys- goals. The primary care physician’s medical assistant tem to print graphs and other reports to aid in educat- reviews the list and follows evidence-based protocols ing patients and tracking their progress over time. to perform delegated tasks and outreach. For example, Customization features within the EHR allow the medical assistant might call a diabetic patient to physicians to accelerate patient monitoring schedules, schedule an overdue blood lipid test so that lab results when, for example, patients need closer follow-up are available at the patient’s next planned care visit. after abnormal test results or when they have a family This proactive approach enhances the physician’s abil- history of cancer. Physicians can refer patients who ity to engage in care planning and reduces the need for face challenges controlling diabetes to an intensive follow-up later. “Our physicians have found that using self-management education program taught by a multi- [the iList] has been an eye-opener as far as putting a disciplinary team including diabetes educators, dieticians, face on those patients who could be slipping through pharmacists, behavioral specialists, and therapists. the cracks,” Douglas J. Reding, M.D., M.P.H., These and other quality improvement interven- the Clinic’s vice president, said in recent tions—such as the use of evidence-based guidelines Congressional testimony.9 and standing orders, the provision of continuing medi- To facilitate comprehensive care during patient cal education and performance feedback, and standard- visits, the “PreServ” (preventive services) application ization of care processes—are associated with substan- organizes clinical information within the EHR into an tial improvements in “bundles” of quality measures electronic “dashboard” that highlights needed preven- that the Clinic tracks for its population of approxi- tive and chronic care services (e.g., immunizations, mately 17,500 patients with diabetes.10 cancer screenings, laboratory tests for diabetes). Physicians can communicate with support staff to • The proportion of diabetics who received all order these services or request other assistance without of seven chronic care services—blood pressure leaving the exam room by using a messaging tool in measurement, two hemoglobin A1c tests, a the EHR that links the message to the medical record. fasting lipid profile, a microalbumin test Exhibit 4. Marshfield Clinic: Effects of Diabetes Quality Improvement Initiative on Process of Care Percentage of patients achieving all seven measures* 100 Diabetic foot exam process standardized 80 Deployment of iList 60 wireless tablets application completed deployed 40 Goal 27.8% 20 0 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007 Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Note: Electronic reminder system deployed in first quarter 2005. * Measures include: blood pressure, hemoglobin A1c, two hemoglobin A1cs, fasting lipid profile (LDL), microalbumin/evidence of nephropathy, pneumococcal vaccination, and foot exams. Source: Marshfield Clinic. 8T he  C ommonwealth F und (or evidence of nephropathy), pneumococcal patient’s situation (5 percent to 10 percent of cases). vaccination, and a foot exam—rose from zero Patient encounters are documented in a tracking data- in 2004 to 47 percent in 2008 (Exhibit 4). base and in the EHR for physician review and sign-off. In a controlled study comparing outcomes for • Diabetics achieving three treatment goals—con- patients on Coumadin who were enrolled in the antico- trol of blood glucose, blood pressure, and low- agulation service to outcomes for those receiving density lipoprotein (LDL) cholesterol—rose usual care (Exhibits 7 and 8), the anticoagulation from 8 percent to 21 percent from 2004 to 2008 service patients: (Exhibit 5). • achieved anticoagulation control more • The rate of all-cause hospitalizations among often (77.4% vs. 59.1% of the time in the diabetic patients fell from 360 per 1,000 in target range) 2005 to 317 per 1,000 in 2007. The Clinic esti- • experienced 55 percent fewer anticoagulant- mates that this reduction saved $5 million to related adverse events (2.98 vs. 6.67 per 100 $14 million from avoided hospital admissions person-years) (Exhibit 6). • had 41 percent fewer hospital admissions Telephonic Care Management Programs. Marshfield (41.5% vs. 70.2% per 100 person-years)11 has developed telephonic care management programs for patients who require ongoing support or monitoring Cost-savings for Medicare beneficiaries were between physician visits. These programs, which are estimated at $9,443 per avoided hospitalization staffed and administered by the Clinic, use guideline- (including $1,222 in patient charges) or $271,014 per driven protocols that are individualized for each 100 person-years in year-2000 dollars.12 Most of these patient. An anticoagulation service is the most mature savings accrue to Medicare under fee-for-service reim- example of this approach; similar programs have been bursement, making it difficult for the Clinic to recover developed for patients with heart failure and those who the costs of running the program. The Medicare need help controlling cholesterol levels. The Clinic Physician Group Practice Demonstration (described chose to focus on these three conditions first because below) provided an opportunity for the Clinic to expand of the costs associated with them, the number of the anticoagulation service to all of its approximately patients involved, and the potential impact of improving 6,500 patients using anticoagulation medication. care for these conditions on performance under the Patients in the heart failure care management Medicare Physician Group Practice Demonstration program statistically had more office visits and labora- (described in the Continuous Innovation section below). tory tests done than did patients who were not enrolled Patients on anticoagulant medication in a care management program. They were also statis- (Coumadin), who require regular monitoring to ensure tically more likely to have decreased mortality, blood optimal dosing to prevent the formation of blood clots pressure control at goal levels, and LDL cholesterol at while minimizing the risk of bleeding, are introduced goal levels, and to receive influenza vaccines, pneu- to the anticoagulation service by their physician or mococcal vaccinations, and recorded weight measure- referred upon discharge from the hospital. Registered ment at an office visit. nurses educate and coach patients to promote treat- Patients with diabetes or coronary artery disease ment adherence, monitor patients’ lifestyles and who had high levels of LDL cholesterol at the time of monthly blood testing, and adjust medication dosages enrollment in the care management program receive as needed according to physician-developed protocols. education regarding medication and therapeutic lifestyle Nurses consult with a medical director or the patient’s changes to help them reach an LDL goal set by their physician when the protocol does not address the primary care providers. Registered nurses monitor M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 9 Exhibit 5. Marshfield Clinic: Effects of Diabetes Quality Improvement Initiative on Outcomes Percentage of patients achieving all three measures* 50 Diabetic foot exam process standardized 40 Deployment of iList wireless tablets application 30 completed deployed Goal 20 10 0 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007 Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Note: Electronic reminder system deployed in first quarter 2005. *Measures include: blood pressure<130/80mmHg, hemoglobin A1c<7.0%, and fasting lipid profile (LDL)<100mg/dL. Source: Marshfield Clinic. laboratory results and adjust medication according to confidential feedback to physicians. Confidential per- physician protocol. Among 875 patients enrolled in the formance feedback is provided by a peer review com- program, the median time it takes to achieve a goal of mittee, along with development of individualized LDL less than 70mg/dL is 101 days (67 days if the improvement plans as appropriate. Physicians are fur- goal is 100mg/dL). ther engaged in improvement through the use of online clinical practice guidelines, continuing medical educa- PEER REVIEW AND TEAMWORK FOR tion, and peer coaching. HIGH-VALUE CARE Marshfield also provides mentorship to new Marshfield Clinic uses its investment in informatics to physicians by assigning them to experienced physicians produce individualized reports, or “storyboards,” that who have prepared themselves for this role by volun- use charts and graphs to display quality metrics for teering to undergo an eight-hour training program Exhibit 6. Marshfield Clinic: All-Cause Hospitalizations Among Diabetes Patients Rate per 1,000 500 400 300 Goal 200 100 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 Source: Adapted from T. A. Praxel, D. Erickson, T. Gabert et al., “Moving the Big N: Improving Diabetes Care for a Large Population,” presentation at the Institute for Healthcare Improvement National Forum, Orlando, Fla., Dec. 9–12, 2007. 10T he  C ommonwealth F und Exhibit 7. Marshfield Clinic: Effects of the Coumadin Clinic Initiative on Anticoagulation Control Percentage of time that measures of anticoagulation control are in range 100 Coumadin Clinic Control Clinic 80 74 77 60 59 60 40 20 0 Tests in range Time in range Source: J. Schmelzer, “Can Disease State Management Deliver on Its Potential in Rural Areas: Evidence From a Coumadin Clinic Initiative,” presentation at the International Society for Quality in Health Care 20th International Conference, Nov. 2–5, 2003. covering leadership and operational issues specific to medicine. The regional medical directors attend the Clinic. The program helps in retaining physicians departmental meetings to share group-level perfor- and acculturating them to the Clinic’s unique approach mance results and improvement strategies and solicit to group practice, said Karl Ulrich, M.D., M.M.M., feedback on the Clinic’s quality initiatives. In this way, Marshfield Clinic’s president and CEO. The Clinic medical directors help tailor the Clinic’s performance also runs a program for physicians who are restarting improvement strategy to meet the needs of physicians their medical practices after a long break. while also inculcating Marshfield’s population health The Clinic’s seven regional divisions are each management philosophy throughout the organization. overseen by a medical director and an administrator Rather than just hiring smart people for leader- who work in a partnership designed to combine effec- ship posts and hoping they will do good things, the tively the clinical practice and the business aspects of Clinic also defines metrics that give the administration Exhibit 8. Marshfield Clinic: Effects of the Coumadin Clinic Initiative on Service Use Utilization rates per 100 person-years 120 116 Coumadin Clinic Control Clinic 100 79 80 70 60 43 42 40 37 20 0 Urgent care/ED Inpatient All events Note: ED = Emergency Department. Source: J. Schmelzer, “Can Disease State Management Deliver on Its Potential in Rural Areas: Evidence From a Coumadin Clinic Initiative,” presentation at the International Society for Quality in Health Care 20th International Conference, Nov. 2–5, 2003. M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 11 of practice an objective basis, Ulrich said. The goal is exceeded nine of 10 quality targets for diabetes set by “to augment experience with performance data in real Medicare. In year two, it exceeded all 27 quality tar- time,” he said. Augmented by the specific improve- gets set by Medicare for diabetes, coronary artery dis- ment strategies described above, this approach has ease, and congestive heart failure. been associated with improvements in care, such as a To prepare for its participation in the demon- 9 percent increase in the control of high blood pressure stration, the Clinic created the Workflow Efficiency among hypertensive patients after the Clinic began Group, comprising providers, medical assistants, and sharing performance feedback with providers.13 process improvement staff, to pursue five goals: Physician compensation is based on productiv- 1) improve the patient experience; 2) implement a ity (relative-value units of work) and comparative mar- model of care that focuses on chronic illness manage- ket considerations by medical specialty. To align salary ment; 3) improve patient access and the delivery and with Marshfield’s strategy and culture, physicians are coordination of care through practice redesign; 4) min- also compensated for administration, research, and imize waste and rework; and 5) commit to using infor- teaching activities. The Clinic is pilot-testing a “pay- mation technology tools to improve service delivery.15 for-performance” program that would reward individ- Specific activities that the Clinic undertook to carry ual physician performance on clinical quality metrics. out these goals16 included: CONTINUOUS INNOVATION • accelerating information system enhancements Marshfield Clinic leaders have made the achievement such as the creation of the iList (described of a high performance health system—based on the above) to support chronic disease management, Institute of Medicine’s six aims for safe, timely, • expanding the anticoagulation care management effective, efficient, equitable, patient-centered program and developing a care management care—an integral part of the organization’s strategy program for heart failure and vision. The following Clinic initiatives illustrate this commitment. • providing performance feedback and education to providers Assessing the Impact Effect of Performance • defining best-practice models to standardize Incentives. Marshfield Clinic is one of 10 sites partici- care processes for chronic care management pating in Medicare’s Physician Group Practice (PGP) Demonstration, which is assessing whether giving A best-practice model packages clinical practice physicians the opportunity to share in financial savings guidelines with strategies and tools (such as patient generated through quality and efficiency improve- education materials) for putting the guidelines into ments will lead to better outcomes for Medicare bene- practice. Regional medical directors and clinical nurse ficiaries. An independent evaluation credited the Clinic specialists work as a team with providers and their with reducing Medicare spending for 42,000 Medicare staff to implement specific improvement techniques. patients by $25 million in the first two years of the One example of practice redesign is the dele- ongoing five-year demonstration. As a result, gation of defined clinical tasks to medical assistants on Marshfield earned performance payments of $4.6 primary care teams. For instance, medical assistants million for meeting financial and quality targets in have been trained to conduct diabetic foot exams fol- the first year and $5.8 million in the second year. lowing a standardized process, with physicians becom- Marshfield Clinic was one of only two sites to earn ing involved when there is an abnormal result requir- this distinction in the first year and one of four sites to ing intervention. Following this change, the rate of do so in the second year.14 In the first year, the Clinic comprehensive foot exams documented appropriately improved on all measures from the baseline year and in the EMR (using digital ink-over forms) increased 12T he  C ommonwealth F und from 13.5 percent to 72 percent of diabetic patients. "The clinician will no longer function in an Praxel stressed that workflow redesign is essential to assembly-line fashion, but will become more like increasing the efficiency of primary care teams, since a dispatcher or air-traffic controller, electronically it is not otherwise possible to deliver all recommended monitoring many processes simultaneously." preventive care within the time available in a typical patient visit.17 Marshfield Clinic's Biomedical Informatics Research Center Deploying Innovations in Information Technology. While developing its EHR system, Marshfield Clinic physicians, who need to identify the subset of patients recognized the need to develop expertise in informa- who will most benefit from greater attention and tion technology innovation and deployment, which its improvement in care. leaders believe is critical to promoting high-perfor- To help make sense of such data, BIRC mance medicine. The goal is to help physicians make invented a visualization tool (known internally as a “cogent decisions in real time,” said Ulrich. The work “starfield”) that enables physicians to filter results by is conducted by the Marshfield Clinic Research various criteria, zoom in on those that are out of rec- Foundation’s Biomedical Informatics Research Center ognized clinical bounds, and track whether their efforts (BIRC), which acts as an “innovation engine” for the are leading to improvement. The use of such tools may Clinic. When the Clinic finds that it cannot purchase help bring about a transformation in the physician’s or develop computer software that meets its needs, it role and, consequently, productivity. “The clinician calls upon BIRC’s scientists and technicians to invent will no longer function in an assembly-line fashion,” and test new approaches that enhance and facilitate the BIRC’s Web site predicts, “but will become more like use of information technology and solve problems in a dispatcher or air-traffic controller, electronically information synthesis. monitoring many processes simultaneously.” As an example, BIRC developed interpretive software so that nontechnical staff can use natural lan- Developing the Capacity to Deliver Personalized guage to query the Clinic’s data warehouse, thus Medicine. Initiated in 2002, the Marshfield Clinic avoiding the need to know specific diagnosis codes. Personalized Medicine Research Project aims to trans- BIRC also developed natural-language processing late genomic research into clinical care by integrating algorithms to parse text in medical records and extract population-based genetic data with information that terms related to medication usage. This methodology has been collected on Marshfield patients for almost allowed researchers to correlate patients’ use of three decades. The latter includes patient histories of cholesterol-lowering medications to cholesterol levels environmental and occupational exposure and clinical derived from laboratory blood tests.18 Physicians can data from the Marshfield Clinic EHR. The goal of the use a graphical display of this relationship to educate personalized medicine program is to improve patient patients on the benefits of adhering to their treatment outcomes by tailoring prevention, diagnosis, and treat- regimen. ment of health conditions to a person’s unique genetic BIRC’s scientists are also seeking to tackle the profile. The Marshfield Clinic Research Foundation, challenges of information overload. For example, the which has received federal and state grants to carry out growing use of home monitoring devices enables the translational research, collaborates with the University collection of large volumes of physiologic data to of Wisconsin Institute for Clinical and Translational track and interpret. Likewise, the multitude of perfor- Research and other academic research institutions mance indicators now being used to measure quality of engaged in the Wisconsin Genomics Initiative, recently care presents a challenge for the Clinic’s leaders and convened by Wisconsin’s Governor Doyle.19,20 M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 13 Marshfield Clinic is an ideal testing ground for The Healthy Lifestyles initiative fosters com- this project, as it has been serving a relatively stable munity-based collaboration between employers to patient population for many years. The project has facilitate the implementation of work-site wellness enrolled almost 20,000 research subjects, who have policies and programs that support healthier lifestyle volunteered DNA, plasma, and serum samples, and choices by employees. An employer tool kit provides has permitted researchers access to medical records strategies, guidelines, communications materials, and that have captured on average 29 years of clinical his- an audit/checklist to help employers identify ideas and tory. The Personalized Medicine Research Database areas for intervention. The tool kit is supplemented by uses a cryptographic key system to combine genotypic community meetings that allow employers to share and clinical data for research studies while protecting successes, learn from best practices and one another’s the privacy of research subjects. experiences, and connect with health-promoting “We’re looking at not just the genetic markers resources in their communities.22 that predict the development and progression of dis- ease, but how they interact with personal factors or EASY ACCESS TO APPROPRIATE CARE environmental exposures to increase the risk of devel- Serving All Segments of the Population. Marshfield opment and progression of disease,” said Catherine Clinic serves all who seek care, regardless of their McCarty, Ph.D., M.P.H., director of the Marshfield ability to pay. When patients treated at Marshfield Clinic Research Foundation’s Center for Human Clinic have no health insurance, staff of the Clinic’s Genetics. The project also seeks to improve knowledge Patient Assistance Center help them find programs that of pharmacogenetics or “how genetics predict might cover them. If none are found and the patients [patients’] response—both good and bad—in terms of meet financial qualifications, the Clinic pays for care efficacy and adverse reactions to medications,” she through its Community Care program. Approximately said. For example, one study is examining how certain 3,000 patients receive care this way annually. The gene variants affect the body’s metabolism of the anti- organization provided charity care worth $13 million coagulant medication warfarin.21 Results should help in fiscal year 2007. physicians determine more optimal medication dos- Marshfield also participates in Medicare, ages for particular patients. Medicaid, and BadgerCare, the State of Wisconsin’s coverage program for low-income adults and children. Engaging with the Community. Marshfield Clinic in The estimated costs of patient care provided by the 1998 created the Center for Community Outreach Clinic in excess of reimbursements received from (CCO) to address more fully the health-related needs Medicare and Medicaid were $150 million in 2007. of its patients by establishing stronger linkages The Clinic’s service area includes several geographi- between the Clinic and the communities in which it cally remote communities in federally designated operates. The CCO supports evidence-based popula- Health Provider Shortage Areas. Providing dental care tion and environmental health improvement strategies to underserved communities is a new focus. in priority areas identified by the State of Wisconsin, The Clinic has a contractual partnership with such as preventing alcohol, tobacco, and other sub- the Family Health Center of Marshfield, a federally stance abuse and addiction, combating obesity, and qualified community health center, through which the improving access to primary and preventive health ser- Clinic (and other local medical professionals) provides vices. As an example, the Clinic helps fund the Youth medical and dental care to nearly 4,000 low-income Net program, which engages eight- to 18-year-olds in uninsured and underinsured individuals and families at after-school activities to promote educational, social, several locations. Enrollees pay a sliding-scale pre- fitness, and citizenship development. mium (supplemented by state and federal funds) in this 14T he  C ommonwealth F und insurance-like program, which emphasizes primary pays for itself by decreasing the call burden on pri- and preventive care, with access to specialty care as mary care providers, thereby improving physicians’ needed. Marshfield’s research division helped support productivity and work life and aiding in their retention the Health Center’s creation through contributions of and recruitment. The call center also ensures consis- expertise and resources to apply for federal grants. tency of information given to the patient and triage to Through the Community Health Access the care setting appropriate to the patient’s needs. Program, patients of the Family Health Center and Patient satisfaction surveys related to the call center Marshfield Clinic’s Community Care program receive are consistently high: More than 80 percent of patients assistance from care managers to find a primary care give the service a five-star rating, the highest possible. provider. These patients complete a health assessment, Security Health Plan also recently began offer- and those judged to be at high risk for chronic illness ing its members a nurse navigator program to supple- or to have unmet preventive care needs receive health ment the routine assistance available from customer education, advocacy, and support from registered service staff. Registered nurses, supported by medical nurses. Nurses conduct “motivational interviewing” to directors, are available by telephone to answer questions help patients take a more active role in their care and about treatment options and coverage, help connect assist in making appointments when necessary. members with appropriate services, facilitate commu- nication with providers, and provide other services. Providing Comprehensive Care in the Community. Drawing on federal and state grants, Marshfield Given the large size and rural character of the Clinic’s Clinic created a mobile health screening unit offering service area, it seeks to disperse specialty care services mammography and osteoporosis (bone density) testing throughout its regional network so that patients aren’t to women 18 years of age and older, regardless of required to travel long distances to the main campus in whether they have health insurance. The unit coordi- Marshfield. “Health care is a local phenomenon, and nates with health departments, church groups, busi- care should be provided in the community when possi- nesses, and other providers to take the 40-foot, self- ble,” said Ulrich. High-cost quaternary care (such as contained van to any location in Wisconsin. Screening gamma-knife surgery) is an exception to this general unit staff contact patients with results and help arrange rule, since centralization ensures efficient and effective follow-up care as needed. use of such highly specialized resources. Improving the Timeliness of Appointment Serving Patients Outside Clinic Visits. The Clinic Scheduling. Marshfield is redesigning patient schedul- operates a 24-hour nurse-advice call center available to ing for all of its locations using an “advanced access all of its primary care patients. Nurses use the Clinic’s model” with the goal that patients will be able to see a EHR to tailor advice to the patient’s care plan, to per- primary care physician within one day and a specialty form triage using online guidelines, and, when appro- physician within five days of an appointment request. priate, to schedule a physician appointment (at selected This approach aims to balance the demand for and clinics). The call is documented in the EHR and the supply of care by reducing the backlog of patients patient’s physician receives an e-mail notification for seeking appointments, simplifying the way that review and follow-up as needed. The nurse-advice call appointments are made, and addressing operational center also answers calls from Security Health Plan protocols that affect patient access, such as staff enrollees, under a contract with the Clinic. absences. Reserving some appointments for unfore- Clinic leaders believe that the call center, which seen needs makes it more likely that patients will see handles a volume of more than 94,000 calls annually, their usual physician when they need care. This M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 15 approach helps to avoid duplicate visits for those who days with a range from zero to 44 days), according to would otherwise see another physician or visit the ER the Wisconsin Collaborative for Healthcare Quality.25 and then require follow-up with their regular doctor. Like other organizations serving rural areas, Improving the accessibility and continuity of care also Marshfield Clinic feels the effects of the current short- may help prevent costly disease complications for age of primary care physicians, making the availability patients with chronic illness. of primary care providers at specific sites a limiting Some of Marshfield’s primary care clinics factor in improving access, Praxel said. have successfully reduced appointment waiting times. At the Clinic’s Family Practice Clinic in Rice Lake, Improving Access to Care Through Telehealth. for example, physicians and staff participated in a Marshfield Clinic TeleHealth (MCT) leverages infor- 14-month Web-based learning collaboration with the mation and communications technology to provide Institute for Healthcare Improvement to implement clinical and educational services in remote and rural advanced-access principles. The timeliness of appoint- areas where transportation barriers and health provider ment scheduling improved, as measured by a decrease shortages make in-person encounters difficult.26 in the number of days until the third-next available Marshfield Clinic developed telehealth over the past appointment (a commonly used accessibility metric) 11 years as a tool for access for both patients and pro- from 20.3 to 1.8 (Exhibit 9).23 The Clinic has learned viders with $4.5 million in grant assistance from the that successful change requires top management sup- federal Office of Rural Health Policy and subsequently port, leadership from physicians at the departmental the federal Office for the Advancement of Telehealth. and clinic levels, educating clinic teams on process MCT services are now fully supported by operational improvement principles, and ongoing review of data at funding as a means of conducting the business of the clinic level to reinforce progress.24 health care at Marshfield Clinic; grant money is used Systemwide, 11 of Marshfield’s 56 primary care to pursue new initiatives and expand sites and services. office locations offered a third-next available appoint- MCT currently links 47 sites with 43 clinical services, ment for a routine office visit within one day during resulting in approximately 4,500 interactive patient the third quarter of 2008 (the median wait was 4.4 Exhibit 9. Marshfield Clinic Rice Lake Center: Effects of Advanced Access to Primary Care Number of days until third-next available appointment 30 25 20 15 10 5 0 June August October December February April June 2004 2004 2004 2004 2005 2005 2005 Note: Average of 13 providers. Marshfield Clinic Indianhead Center is now known as Rice Lake Center. Source: Adapted from Marshfield Clinic Indianhead Center, “Improving Access in Primary Care—Virtually,” Improvement Report (Boston, Mass.: Institute for Healthcare Improvement, 2006). 16T he  C ommonwealth F und encounters in 2008. Service volume is growing about regulatory standards and guidelines for delivering tele- 15 percent annually.27 health services. It was the first organization in MCT offers primary and specialty dental and Wisconsin to be approved for Medicaid reimbursement health services (e.g., dermatology, psychiatry, oncol- of telemedicine services. Today, nearly all of the ogy, endocrinology) through interactive clinical video- Clinic’s primary payers, including Medicare, Medicaid, conferencing and patient peripheral technologies, such and Marshfield Clinic’s Security Health Plan, reim- as digital stethoscopes, handheld exam cameras, and burse MCT for services delivered via telehealth. mobile retinal imaging, that facilitate remote patient A survey conducted as part of a quality exams. MCT also offers patient case management ser- improvement activity indicates that patients are more vices, telepharmacy, telepathology, and education for satisfied with telehealth encounters than with in-person health professionals and patients. About one-third of health care visits, and providers also reportedly the regional sites are non–Marshfield Clinic locations, express satisfaction with telehealth visits. “The enabling providers to extend their services to children patients appreciate the ability to receive specialty in Head Start classrooms and to individuals in tribal- health care services in rural communities. It improves run clinics, nursing homes, and a county jail. their quality of life. They don’t have to take time from Integration with the Marshfield Clinic EHR promotes work, they don’t have to pay babysitters, and they the same quality of care in remote encounters that don’t have to incur the expense and the risk of travel- patients receive in person in the larger secondary and ing on Wisconsin roads” (during the winter months, tertiary centers. when driving conditions can be difficult), said the pro- Marshfield Clinic has been a leader in promot- gram’s director, Nina M. Antoniotti, Ph.D., M.B.A., ing the adoption of telehealth and in developing R.N. Overall, the high degree of satisfaction, high related business strategies and financial models to adoption rates, and widespread use of telehealth by make the service viable. The Clinic works at the patients and providers alike reflect a successful focus national level to develop reimbursement, legal, and on the human relationship in a technologically enhanced patient encounter, Antoniotti noted. Exhibit 10. Selected Externally Reported Results and Recognition: Marshfield Clinic* Ambulatory Care Quality Clinical quality (34 measures): Security Health Plan ranked in the top quartile of (NCQA Quality commercial health plans nationally or regionally on 22 measures, and in the top Compass 2008) decile on 15 of those measures. Patient experience (10 measures): Security Health Plan ranked in the top quartile of commercial health plans nationally or regionally on five measures, and in the top decile on two of those measures. National Recognition Verispan Top 100 Integrated Health Networks (2006). and Ratings National Committee for Quality Assurance: Security Health Plan received Health Plan Excellent Accreditation, with Quality Plus Distinction in Member Connections as well as in Care Management and Health Improvement. US News & World Report Best Health Plans: Security Health Plan ranked among the top 50 commercial plans in 2005–2008 and among the top 25 Medicare plans in 2005, 2007, and 2008. * See the Series Overview, Findings, and Methods for analytic methodology and explanation of performance recognition. NCQA = National Committee for Quality Assurance (Quality Compass 2008 represents the 2007 measurement year). M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 17 RECOGNITION OF PERFORMANCE as a guiding framework to improve the care of In addition to the results of the specific interventions individual patients. described above, Marshfield Clinic has achieved nota- The Clinic’s EHR contains many features that ble results on selected externally reported performance can be customized by specialty and physician to indicators and has received recognition for its perfor- increase the efficiency of physician work flow. “That mance on several national benchmarking or award pro- customization is absolutely key” to the successful grams (Exhibit 10). Medicare data compiled by the uptake of the EHR among physicians, said Edna Dartmouth Atlas project indicates that the cost of phy- DeVries, M.D., Marshfield Clinic’s Central Division sician services in the Marshfield hospital referral medical director. Physician involvement has been criti- region was 64 percent of the national average during cal to the development of the EHR system. “If you 2001–2005, reflecting both a lower rate of visits (70 look at our software, it wasn’t developed by some IT percent of the national average) and a lower payment folks in a vacuum. Doctors are on the development per visit (91 percent of the national average) for team,” she noted. Marshfield’s investment in technol- Medicare beneficiaries in their last two years of life.28 ogy is a long-standing one. “Clinic leaders back in the Marshfield Clinic ranked in the top quartile on ’60s and ’70s saw a vision of what computers might 13 of 16 performance measures among medical groups do with medicine … and, since that time, clinic leader- in Wisconsin participating in the Wisconsin ship—which has kept rotating over time—has stayed Collaborative for Healthcare Quality. On seven of the true to trying to invest for the future,” said Ulrich. measures, the Clinic was in the top decile (10%) of the Marshfield’s leaders raised several lessons 19 to 21 organizations ranked on the voluntary report learned from the use of informatics to achieve perfor- card as of June 2009. The identification of areas of mance improvement. First, technology and electronic excellence does not mean that the Clinic has achieved records alone are not enough to drive improvement. perfection, however. Like the other organizations in “Doing the same old thing with more technology will this case study series, Marshfield has room for con- not reduce costs or improve care,” said Peggy Peissig, tinuing improvement on performance measures (for M.B.A., associate director of the Marshfield Clinic’s example, on screening for tobacco use and care of Biomedical Informatics Research Center. To bring patients with uncomplicated hypertension). The about transformational change, processes must be Clinic’s track record of improvement suggests that the reengineered before being automated. Second, raw organization will continue to innovate so as to achieve data in the EHR must be made clinically actionable by higher performance over time. converting it into alerts and reminders that embed clin- ical guidelines into daily practice. Third, and perhaps INSIGHTS AND LESSONS LEARNED most difficult, the roles of the care team must be rede- Marshfield Clinic’s experience indicates that a well- fined to use tools for more efficient workflow. developed electronic information infrastructure pro- The Clinic’s leaders viewed participation in vides a critical foundation for building higher levels of the Medicare PGP demonstration as a way to prepare performance through improved patient care manage- for a future in which providers will be rewarded rather ment. “While we don’t ever want to lose the individual than penalized for doing the right thing for patients.29 aspect of patient care, we’re trying to close the loop The sentiment of the organization’s leaders is that the from the individual back to the population to raise Clinic was providing good-quality care prior to the awareness of how the physician is doing with a given Medicare PGP demonstration. Under the prevailing disease or constellation of diseases for their entire fee-for-service reimbursement system, however, qual- panel of patients,” Praxel said. Physicians can then ity improvements can be difficult to sustain because apply that broader population health perspective much of the savings can flow to third-party payers.30 18T he  C ommonwealth F und The opportunity to earn a performance payment meant "While we don’t ever want to lose the individual that the Clinic could make investments in systems and aspect of patient care, we’re trying to close the loop programs to further enhance performance with a rea- from the individual back to the population to raise sonable expectation of recouping its costs if its efforts awareness of how the physician is doing with a were successful. The Clinic’s executive director, Reed given disease or constellation of diseases for their Hall, J.D., credited the Clinic’s success in the demon- entire panel of patients." stration to “an accumulation of incremental gains” made Theodore Praxel, M.D., M.M.M., medical possible by the EHR and care management initiatives.31 director for quality improvement and care Because the Clinic applied these interventions management at Marshfield to all of its patients, not just to Medicare patients, the benefits of its participation in the Medicare demonstra- Marshfield Clinic’s leaders also recognize tion have likely extended to other payers as well. opportunities to benefit from outside expertise and col- “From an ethical perspective … there was no other laboration. While the Clinic has traditionally devel- choice. This decision [to apply interventions to all oped its own clinical guidelines, the process has patients regardless of coverage] is consistent with our become increasingly burdensome as the subjects that mission and is the way we care for patients. Our pro- need to be addressed have multiplied. In response, the viders do not usually know patients’ insurance at the Clinic recently joined the Minnesota-based Institute time of the office visit,” Praxel said. “We feel that the for Clinical Systems Improvement (ICSI), a regional demo has had a positive impact on the Clinic’s collaboration of medical groups and health plans that Medicare population, as evidenced by the fact that [the develops clinical guidelines and shares best practices health plan’s] NCQA rankings in care for patients with for improving care. On the other hand, the Clinic also coronary artery disease and [in] disease management has learned that performance improvement must be [two areas stressed by the PGP demonstration] on the tailored to the local environment. The optimal US News & World Report national rankings are quite approach in a large clinical center may be different good,” he said. Security Health Plan was ranked the from what works best at a smaller site. “In a small nation’s fifth-best Medicare plan in the magazine’s center, a single person may play multiple roles in the 2008 rankings. care process for patients,” Praxel said. When develop- The leadership of Marshfield Clinic believes ing work-flow strategies, those variations must be kept that its nonprofit character and physician governance in mind. structure help promote confidence among patients that Marshfield has faced barriers in proactively clinical decisions will be made in their best interests. coordinating inpatient care because it does not own Congruent with this organizational heritage, the Clinic and control the hospitals where most of its patients are favors in-house development of information systems admitted. (The Clinic does employ hospitalist physi- and care management programs—an approach that cians working in some of those hospitals, and its phy- provides flexibility to customize solutions to meet the sicians make up the majority of admitting physicians evolving needs of its physicians and patients. The in some facilities.) “Working with 14 different hospi- Clinic’s leaders believe that this strategy has been an tals in multiple systems and not having a direct ability important factor in the willingness of Clinic physicians to effect change within those institutions has made to adopt such solutions. It also promotes integration coordination of transition from inpatient to outpatient a and coordination; for example, following a patient’s very large challenge,” Praxel said. “We can make sug- call to the 24-hour advice line, a nurse can access that gestions, which they may or may not find to be appro- patient’s EHR and send a follow-up e-mail to his or priate.” The recent addition of Lakeview Medical her physician. M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 19 Center’s hospital to its network is allowing Marshfield physicians—supported by group-level financial incen- to test the integration of inpatient and outpatient care. tives that reward the group for investing in programs Although the Clinic may be at some disadvan- that improve patients’ health—have also been a key to tage compared with fully integrated groups in this sustaining and furthering these gains. regard, it has nevertheless met cost-savings targets in Future challenges include current reimburse- the Medicare Physician Group Practice Demonstration. ment methodologies, which do not support extensive This experience suggests that, with proper incentives, care management strategies. The Clinic is also con- a robust approach to ambulatory care management cerned about the increasing number of patients with can be effective in improving patient outcomes and chronic diseases, who need such services, as well as reducing costs. the poor state of the economy, which is forcing uninsured The Clinic’s relationship with Security Health and underinsured patients to forgo care until their con- Plan (SHP) presents an ongoing, though less serious, ditions are more advanced and more costly to treat. challenge. Because the two are affiliated organizations Marshfield’s leaders offer the following advice but maintain separate operations and financial state- to organizations seeking to achieve similar results: ments, they must strive not to duplicate each other’s pursue quality outcomes with an altruistic mission services or confuse patients who may receive care from the start; prepare the organization for the pace at from the Clinic, but may also receive disease manage- which resulting changes need to occur; use an EHR ment assistance from the Health Plan. To help coordinate that provides actionable data and decision-support efforts, Praxel serves on the quality improvement com- tools; and develop physicians and senior leaders who mittee for SHP. Both the Clinic and SHP have joined can serve as champions. They also note the importance ICSI, which provides common guidelines for care. of developing care management programs that serve as In summary, Marshfield Clinic’s experience an extension of the providers’ practice rather than a suggests that the sophisticated use of an EHR to sup- barrier to its effective interaction with patients. Their port care management, together with the active leader- advice for small practices that wish to follow these ship of physicians and the engagement of staff in clini- methods: invest in an EHR with clinical decision sup- cal workflow redesign, are crucial elements for port tools and link the EHR to care management ser- improving clinical and organizational performance. vices that apply its potential. Ongoing performance monitoring and feedback to For a complete list of case studies in this series, along with an introduction and description of methods, see Organizing for Higher Performance: Case Studies of Organized Health Care Delivery Systems— Series Overview, Findings, and Methods, available at www.commonwealthfund.org. 20T he  C ommonwealth F und N otes 4 During the 1990s, Marshfield Clinic and Security Health Plan were defendants in an antitrust law- 1 T. Shih, K. Davis, S. Schoenbaum, A. Gauthier, suit brought by Blue Cross Blue Shield United of R. Nuzum, and D. McCarthy, Organizing the U.S. Wisconsin, one of the Clinic’s partners in Greater Health Care Delivery System for High Performance Marshfield Community Health Plan. Although the (New York: The Commonwealth Fund Commission Clinic lost at jury trial, the judgment was mainly on a High Performance Health System, Aug. 2008). overturned in the Clinic’s favor on appeal to the U.S. Court of Appeals for the Seventh Circuit (see 2 Information on Marshfield Clinic was derived Blue Cross & Blue Shield United Wisconsin and from presentations made during a site visit (see the Compcare Health Services Insurance Corporation Acknowledgments section for participants), and in v. Marshfield Clinic and Security Health Plan of part from a prior Commonwealth Fund case study: Wisconsin, Inc., 65 F.3d 1406 (7th Cir. 1995). For a D. McCarthy, “Improving Quality and Efficiency in detailed account of this litigation, see J. G. Coombs, Response to Pay-for-Performance Incentives Under “The Perils of Antitrust in the Health Care Market- the Medicare Physician Group Practice Demonstra- place,” Chapter 10 in The Rise and Fall of HMOs: tion,” Quality Matters (New York: The Common- An American Health Care Revolution (Madison: wealth Fund, Sept. 2006). Additional information University of Wisconsin Press, 2005). was obtained via e-mail correspondence with Dr. Praxel and from the organization’s Web site and 5 As they are affiliated organizations, the assets and other public documents including: G. C. Pope, J. revenues of Security Health Plan and Marshfield Leung, R. Constantine et al., Marshfield Clinic Clinic are combined for limited reporting purposes. Physician Group Practice Demonstration: Site They maintain separate balance sheets and do not Visit Final Report (Research Triangle Park, N.C.: share earnings. RTI International, for the Centers for Medicare and 6 Information on RECIN was obtained from its Web Medicaid Services, 2006); D. J. Reding, Testimony site (http://www.recin.org) and Coombs, The Rise Before the Subcommittee on Health of the House and Fall of HMOs: An American Health Care Revo- Committee on Ways and Means, Hearing on Pro- lution. The American Academy of Pediatrics and the moting the Adoption and Use of Health Informa- Centers for Disease Control and Prevention honored tion Technology (Washington, D.C.: U.S. House RECIN with their inaugural Protect Award in 2002 of Representatives, July 24, 2008); M. Hillman, in recognition of its role in preventing childhood Testimony Before the Subcommittee on Health of diseases. RECIN was also identified as a Model of the House Committee on Ways and Means, Hear- Practice by the Rural Healthy People 2010 project ing on Promoting Disease Management in Medicare at the Southwest Rural Health Research Center (Washington, D.C.: U.S. House of Representatives, (http://www.srph.tamhsc.edu/centers/rhp2010/mod- April 16, 2002). els.htm). 3 A summary of findings from all case studies in the 7 P. L. Dolan, “Marshfield Clinic Puts Its EHR on series can be found in D. McCarthy and K. Mueller, the Market,” AMNews, July 21, 2008; Ministry Organizing for Higher Performance: Case Studies Health Care, “Ministry Health Care Partners with of Organized Delivery Systems. Series Overview, Marshfield Clinic to Create State’s Largest Patient Findings, and Methods (New York: The Common- Database,” http://ministryhealth.org/MinistryHealth/ wealth Fund, 2009). News/MinistryHealthCarePartners.nws. M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 21 8 Population health management can be defined as 14 Participants in the Physician Group Practice (PGP) “the technical field of endeavor which utilizes a demonstration were selected through a competitive variety of individual, organizational and cultural process by the federal Centers for Medicare and interventions to help improve the morbidity patterns Medicaid Services. Elderly and disabled fee-for-ser- (i.e., the illness and injury burden) and the health vice Medicare beneficiaries are assigned to the dem- care use behavior of defined populations,” (L. S. onstration site (retrospectively) if they receive the Chapman, Health Management: Optimal Approach- majority of their outpatient care from the participat- es for Managing the Health of Defined Populations ing PGP. A PGP may earn a bonus of up to 80 per- (Seattle: Summex Corp, 1997) as quoted by M. cent of any Medicare cost-savings that it achieves Hillman, Testimony Before the Subcommittee on that exceed 2 percent of its expenditure target (the Health, 2002). PGP is not penalized if it does not meet its target). The expenditure target is based on the PGP’s own 9 D. J. Reding, Testimony Before the Subcommittee base-year costs inflated by the risk-adjusted annual on Health, 2008. expenditure growth rate for a comparison group 10 T. A. Praxel, D. Erickson, T. Gabert et al., “Moving of Medicare beneficiaries. If the PGP qualifies for the Big N: Improving Diabetes Care for a Large a bonus, a portion (30 percent the first year, rising Population,” presented at the Institute for Healthcare to 50 percent by the third year) is tied to the PGP’s Improvement National Forum, Orlando, Fla., Dec. performance on quality targets. Medicare retains 9–12, 2007; personal communication with Theodore the remaining 20 percent of savings achieved by Praxel, M.D., Dec. 2008. the PGP plus any bonus set aside for quality perfor- 11 The study was funded by the federal Agency for mance that is not earned by the PGP. See: J. Kautter, Healthcare Research and Quality under the Inte- G. C. Pope, M. Trisolini et al., “Medicare Physi- grated Delivery System Research Network program cian Group Practice Demonstration Design: Quality (AHRQ Contract 290-00-0016 TO #2). Interven- and Efficiency Pay-for-Performance,” Health Care tion-group patients (N=185) were consecutively Financing Review, Fall 2007 29(1):15–29; Govern- enrolled and observed during Jan. 1998 to Mar. ment Accountability Office, Medicare Physician 2001; control-group patients (N=223) were random- Payment: Care Coordination Programs Used in ly selected and observed during May 2000 to Oct. Demonstration Show Promise, but Wider Use of 2001 (there was a minimum 12-week observation Payment Approach May Be Limited (Washington, period). All patients were under the care of a Marsh- D.C.: GAO, Feb. 2008); Centers for Medicare & field Clinic cardiologist. Source: J. Schmelzer, “Can Medicaid Services, Physician Groups Continue to Disease State Management Deliver on Its Potential Improve Quality and Generate Savings Under Medi- in Rural Areas: Evidence From a Coumadin Clinic care Physician Pay for Performance Demonstration Initiative,” presented at the International Society for (Washington, D.C.: U.S. Dept. of Health and Hu- Quality in Health Care 20th International Confer- man Services, Aug. 2008). ence, Dallas, Tex., Nov. 2–5, 2003, http://www. 15 M. Trisolini, G. Pope, J. Kautter et al., Medicare isqua.org/isquaPages/Conferences/dallas/DallasAb- Physicians Group Practices: Innovations in Qual- stractsSlides/Tuesday_in_Dallas.html. ity and Efficiency (New York: The Commonwealth 12 M. Hillman, Testimony Before the Subcommittee on Fund, Dec. 2006). Health, 2002. 16 T. A. Praxel, “Participating in the CMS Physician 13 Pope, Leung, Constantine et al., Marshfield Clinic Group Practice Demonstration: Lessons Learned,” Physician Group Practice Demonstration: Site Visit presented at the American Medical Group Associa- Final Report. tion Institute for Quality Leadership, Dallas, Tex., Sept. 24–27, 2008, http://www.amga.org/Education/ IQL/p2p_iql.asp. 22T he  C ommonwealth F und 17 K. S. H. Yarnall, K. I. Pollak, T. Østbye et al., “Pri- 25 Wisconsin Collaboration for Healthcare Quality, mary Care: Is There Enough Time for Prevention?” “Time to a Third Next Available Appointment,” American Journal of Public Health, April 2003 http://www.wchq.org/reporting/third_avail_appt. 93(4):635–41. php, accessed Jan. 9, 2009. 18 P. Peissig, E. Sirohi, R. L. Berg et al., “Construc- 26 Telehealth is a strategy for bridging geographic tion of Atorvastatin Dose—Response Relationships gaps between providers or between patients and Using Data from a Large Population-Based DNA providers using electronic information and commu- Biobank,” Basic & Clinical Pharmacology & Toxi- nications technologies such as videoconferencing, cology, April 2007 100(4):286–88. transmission of diagnostic test results, and remote monitoring of patient vital signs and clinical condi- 19 S. Wesbrook, P. F. Giampietro, I. Glurich et al., tions. Applications of telehealth include the provi- “Community Based Approaches to Personalized sion of clinical care (telemedicine) and of support- Health Care: Marshfield Clinic,” Community Re- ive services such as continuing medical education port, presented at the National Summit on Personal- for providers or health promotion for patients. ized Health Care, Deer Valley, Utah, Oct. 5–7, 2008, http://www.personalizedhealthcaresummit.org/ 27 Sources of information on Marshfield Clinic Tele- community-reports; C. A. McCarty, D. Chapman- health included personal communication with Nina Stone, T. Derfus et al., “Community Consultation M. Antoniotti, Jan. 2009; V. Glaser, “Telethinking and Communication for a Population-Based DNA with Nina M. Antoniotti,” Telemedicine Journal and Biobank,” American Journal of Medical Genetics E-Health, 2005 11(5):517–21; N. M. Antoniotti, Part A, Dec. 2008 146A(23):3026–33; C. A. McCa- “TeleHealth and EMRs: Talking the TeleHealth rty, P. Peissig, M. D. Caldwell et al., “The Marsh- Language” (presentation given at American Tele- field Clinic Personalized Medicine Research Proj- medicine Annual Meeting, Nashville, Tenn., May ect: 2008 Scientific Update and Lessons Learned 2007); Health Resources and Services Administra- in the First 6 Years,” Personalized Medicine, Sept. tion, Telehealth Grantee Directory, http://www.hrsa. 2008 5(5):529–41. gov/telehealth/granteedirectory/overview_wi.htm; American Telemedicine Association, “Wisconsin 20 The Wisconsin Genomics Initiative includes Marsh- Medicaid and Telehealth,” Policy White Papers, field Clinic, the University of Wisconsin School of http://www.americantelemed.org/files/public/policy/ Medicine and Public Health, the Medical College MEDICAL_ASSISTANCE_AND_TELEHEALTH. of Wisconsin, and the University of Wisconsin– pdf. Milwaukee. 28 “Medical Care Cost Equation,” Dartmouth Atlas of 21 M. D. Caldwell, T. Awad, J. A. Johnson et al., Health Care, http://www.dartmouthatlas.org. “CYP4F2 Genetic Variant Alters Required Warfarin Dose,” Blood, April 15, 2008 111(8):4106–12. 29 Marshfield Clinic’s history includes several ex- amples in which the market did not reward doing 22 Wisconsin Manufacturers & Commerce Associa- what its physicians considered the “right thing” for tion, “Innovative Healthcare Solutions: Marshfield patients and the community, e.g., offering commu- Clinic Center for Community Outreach,” Wiscon- nity-rated premiums. For more, see: Coombs, The sin Business Best Practices, http://www.wmc.org/ Rise and Fall of HMOs: An American Health Care healthcare/index.php. Revolution. 23 Marshfield Clinic Indianhead Center, “Improving 30 S. Leatherman, D. Berwick, D. Iles et al, “The Busi- Access in Primary Care—Virtually,” Improvement ness Case for Quality: Case Studies and an Analy- Report (Boston, Mass.: Institute for Healthcare sis,” Health Affairs, April 3, 2003 22(2):17–30. Improvement, 2006). 31 R. E. Hall, “The Marshfield Clinic Experience,” 24 L. Pelton, “Improvements in Access to Care,” presentation at MemorialCare’s Forum on Health presented at the Wisconsin Collaborative for Health- Care Reform Issues, Irvine, Calif., Sept. 2008, care Quality, Fall Forum 2005, www.wchq.org/ http://www.memorialcare.org/About/gov_relations/ pdf/2005Forum/Breakout3.pdf. pdf/3_reed_hall.pdf. M arshfield C linic : H ealth I nformation Technology P aves the Way for P opulation H ealth M anagement 23 A bout the A uthors Douglas McCarthy, M.B.A., president of Issues Research, Inc., in Durango, Colorado, is senior research adviser to The Commonwealth Fund. He supports The Commonwealth Fund Commission on a High Performance Health System’s scorecard project, conducts case studies on high-performing health care organizations, and is a contributing editor to the bimonthly newsletter Quality Matters. He has more than 20 years of experience working and consulting for government, corporate, academic, and philanthropic organizations in research, policy, and operational roles, and has authored or coauthored reports and peer-reviewed articles on a range of health care–related topics. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. During 1996–1997, he was a public policy fellow at the Hubert H. Humphrey Institute of Public Affairs at the University of Minnesota. He can be e-mailed at dm@cmwf.org. Kimberly Mueller, M.S., is a research assistant for Issues Research, Inc., in Durango, Colorado. She earned an M.S. in social administration from the Mandel School of Applied Social Sciences at Case Western Reserve University and an M.S. in public health from the University of Utah. A licensed clinical social worker, she has over 10 years’ experience in end-of-life and tertiary health care settings. She was most recently a project coordina- tor for the Association for Utah Community Health, where she supported the implementation of chronic care and quality improvement models in community-based primary care clinics. Sarah Klein has been writing about health care for more than 10 years as a reporter for Crain’s Chicago Business and American Medical News. She serves as a contributing writer to Quality Matters, a newsletter published by The Commonwealth Fund. She received a B.A. in Asian studies from Washington University in St. Louis. A cknowledgments The authors gratefully acknowledge the following individuals who kindly provided information on Marshfield Clinic and its initiatives during a site visit: Karl Ulrich, M.D., M.M.M., president and CEO; Reed Hall, J.D., M.S., executive director; Theodore Praxel, M.D., M.M.M., medical director for quality improvement and care management; Marilyn Follen, R.N., M.S.N., administrator of quality improvement and care management; Edna DeVries, M.D., medical director of the Clinic’s Central Division; Gary S. Plank, Pharm.D., corporate director of pharmacy services; Nina M. Antoniotti, Ph.D., M.B.A., R.N., director of Marshfield Clinic’s TeleHealth Network; Humberto Vidaillet, M.D., director of the Marshfield Clinic Research Foundation; Catherine McCarty, Ph.D., M.P.H., director of the Center for Human Genetics; and Peggy Peissig, M.B.A., associate director of the Biomedical Informatics Research Center. We are also grateful to other Marshfield Clinic staff and the authors of previous case studies and reports, which we have cited, for their contributions to documenting the Clinic’s prac- tices. The authors thank the staff at The Commonwealth Fund for advice on and assistance with case study preparation. Editorial support was provided by Joris Stuyck. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.