4. Systems View Scenarios

This page contains additional references for Chapter 4 of Responding to Healthcare Reform: A Strategy Guide for Heatlhcare Leaders.  The most current additions are at the top of the page.  It also includes the annotated references from the book and their associated hyperlinks.

Current References

Zuckerman, A. M. 2011. “What would You do? does the Strategic Plan Require Updating because of Healthcare Reform?” Healthcare Financial Management 65(2): 102.

Introduction:  Metro Health System (MHS) is a successfiil integrated delivery system (IDS) and the second largest healthcare organization operating in its metropolitan area. With the passage of healthcare reform into law, however, MHS s leaders see a need to review and possibly revise the organization’s strategic plan. Although MHS’s relatively recent full plan update still should be valid, over the past nine months, board members and executives have raised important questions about the strategy. The question is, does MHS need to finetune its plan or is a more significant change in strategic direction required?

Frisse,Mark E. “Health Information Technology: One Step At A Time.” Health Affairs., 2009, 28, 2, w379-384

Abstract: The development, implementation, and management of health care information technologies are prominent components of the American Recovery and Reinvestment Act of 2009. How these technologies will affect our health care system will depend on the collective choices made in the months ahead. Focusing on a limited set of near-term objectives will build trust, confer near-term benefit, and create the building blocks required to harness the altruistic and entrepreneurial motivations most likely to create future health care delivery systems. Decisionmakers must concentrate on putting in place the immediately important information technology foundations that will be essential for reaping long-term benefits.

Zhou,Yi Yvonne; Kanter,Michael H.; Wang,Jian J.; Garrido,Terhilda. “Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients.” Health Affairs., 2010, 29, 7, 1370-1375

Abstract: The American Recovery and Reinvestment Act identified secure patient-physician e-mail messaging as an objective of the meaningful use of electronic health records. In our study of 35,423 people with diabetes, hypertension, or both, the use of secure patient-physician e-mail within a two-month period was associated with a statistically significant improvement in effectiveness of care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, the use of e-mail was associated with an improvement of 2.0–6.5 percentage points in performance on other HEDIS measures such as glycemic (HbA1c), cholesterol, and blood pressure screening and control.

Maxson,Emily R.; Jain,Sachin H.; McKethan,Aaron N.; Brammer,Craig; Buntin,Melinda Beeuwkes; Cronin,Kelly; Mostashari,Farzad; Blumenthal,David.  “Beacon Communities Aim To Use Health Information Technology To Transform The Delivery Of Care.” Health Affairs., 2010, 29, 9, 1671-1677

Abstract: The Beacon Community Program, authorized under the 2009 American Recovery and Reinvestment Act (ARRA), aims to demonstrate the potential for health information technology to enable local improvements in health care quality, cost efficiency, and population health. If successful, these communitywide efforts will yield important lessons that will assist other communities seeking to harness technology to achieve and sustain health care improvements. This paper highlights key programmatic details that reflect the meaningful use of technology in the fifteen Beacon communities. It describes the innovations they propose and provides insight into current and future challenges.

DesRoches,Catherine M. ; Campbell,Eric G.; Vogeli,Christine; Zheng,Jie; Rao,Sowmya R.; Shields,Alexandra E. ; Donelan,Karen ; Rosenbaum,Sara ; Bristol,Steffanie J.; Jha,Ashish K. “Electronic Health Records’ Limited Successes Suggest More Targeted Uses.” Health Affairs., 2010, 29, 4, 639-646

Abstract: Understanding whether electronic health records, as currently adopted, improve quality and efficiency has important implications for how best to employ the estimated $20 billion in health information technology incentives authorized by the American Recovery and Reinvestment Act of 2009. We examined electronic health record adoption in U.S. hospitals and the relationship to quality and efficiency. Across a large number of metrics examined, the relationships were modest at best and generally lacked statistical or clinical significance. However, the presence of clinical decision support was associated with small quality gains. Our findings suggest that to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient. Instead, policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.

Fernandopulle,Rushika; Patel,Neil. “How The Electronic Health Record Did Not Measure Up To The Demands Of Our Medical Home Practice.” Health Affairs., 2010, 29, 4, 622-628

Abstract: The American Recovery and Reinvestment Act (ARRA) of 2009 will soon provide billions of dollars to small physician practices nationwide to encourage adoption of electronic health records. Although shifting from paper to computers should lead to better and cheaper care, the transition is complex. In this paper we describe our struggles to adapt a commercial electronic health record to an innovative practice serving high-cost patients with chronic diseases. Limitations in the technology gave rise to medication errors, interruptions in work flow, and other problems common to paper systems. Our experience should encourage providers and policy makers to consider alternative software and informatics models before investing in currently available systems.


Jha,Ashish K.; DesRoches,Catherine M.; Kralovec,Peter D.; Joshi,Maulik S. “A Progress Report On Electronic Health Records In U.S. Hospitals.” Health Affairs., 2010, 29, 10, 1951-1957

Abstract: Given the substantial federal financial incentives soon to be available to providers who make “meaningful use” of electronic health records, tracking the progress of this health care technology conversion is a policy priority. Using a recent survey of U.S. hospitals, we found that the share of hospitals that had adopted either basic or comprehensive electronic records has risen modestly, from 8.7 percent in 2008 to 11.9 percent in 2009. Small, public, and rural hospitals were less likely to embrace electronic records than their larger, private, and urban counterparts. Only 2 percent of U.S. hospitals reported having electronic health records that would allow them to meet the federal government’s “meaningful use” criteria. These findings underscore the fact that the transition to a digital health care system is likely to be a long one.

Blumenthal,David; Tavenner,Marilyn. “The “Meaningful Use” Regulation for Electronic Health Records”.  N.Engl.J.Med., 2010, 363, 6, 501-504

Introduction: The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice. But inevitability does not mean easy transition. We have years of professional agreement and bipartisan consensus regarding the potential value of EHRs. Yet we have not moved significantly to extend the availability of EHRs from a few large institutions to the smaller clinics and practices where most Americans receive their health care.

Goldstein,M.M.; Thorpe Jane,H. “The First Anniversary of the Health Information Technology for Economic and Clinical Health (HITECH) Act: the regulatory outlook for implementation.”  Perspectives Health.Inf.Manag., 2010, 7, 1c, United States

Introduction: Since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act provisions included in the American Recovery and Reinvestment Act (ARRA) in February 2009, the government has released three sets of statutorily required regulations: one addressing breach notification requirements for protected health information (PHI) and two addressing Medicare and Medicaid incentives for meaningful use of electronic health records (EHRs).1 These regulations build on the framework and financial support authorized under ARRA for increased use of EHRs and enhanced privacy and security provisions for PHI.

The first rule, released by the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) on August 24, 2009, addresses notification requirements in the event of a breach of unsecured PHI.2 The second rule, released by the HHS Centers for Medicare and Medicaid Services (CMS) on December 30, 2009, addresses incentive payments available under the Medicare and Medicaid programs for hospitals, physicians, and other healthcare providers that qualify as “meaningful users” of EHRs.3 The third rule, released by the HHS Office of the National Coordinator for Health Information Technology (ONC), details, among other things, the certification criteria for EHR technology.4 These rules strongly encourage greater use of EHRs and other types of health information technology (HIT) while protecting information privacy and security. However, as discussed below, there remain critical issues that will need to be addressed as providers and other stakeholders take the next steps toward secure electronic health information exchange.


Margolius,David; Bodenheimer,Thomas.  “Transforming Primary Care: From Past Practice To The Practice Of The Future.”  Health Affairs., 2010, 29, 5, 779-784

Abstract: The gap between the supply of primary care physicians and the demand for primary care continues to grow. Primary care practices must find a way to increase their patient capacity without sacrificing quality of care or adding more work to already overburdened physicians. A transformed primary care practice addressing these issues must redefine the physician role such that the physician no longer sees all patients assigned to the practice but acts as a leader for a well-trained, highly functioning primary care team. The team’s overall goal would be to advance the health of an entire patient panel. New payment models are among changes that will be central to this transformation.

Borkan,Jeffrey ; Eaton,Charles B.; Novillo-Ortiz,David; Rivero Corte,Pablo; Jadad,Alejandro R.  “Renewing Primary Care: Lessons Learned From The Spanish Health Care System.”  Health Affairs., 2010, 29, 8, 1432-1441

Abstract: From 1978 on, Spain rapidly expanded and strengthened its primary health care system, offering a lesson in how to improve health outcomes in a cost-effective manner. The nation moved to a tax-based system of universal access for the entire population and, at the local level, instituted primary care teams coordinating prevention, health promotion, treatment, and community care. Gains included increases in life expectancy and reductions in infant mortality, with outcomes superior to those in the United States. In 2007 Spain spent $2,671 per person, or 8.5 percent of its gross domestic product on health care, versus 16 percent in the United States. Despite concerns familiar to Americans—about future shortages of primary care physicians and relatively low status and pay for these physicians—the principles underlying the Spanish reforms offer lessons for the United States.

Bodenheimer,Thomas ; Pham,Hoangmai H. “Primary Care: Current Problems And Proposed Solutions.” Health Affairs., 2010, 29, 5, 799-805

Abstract: In 2005, approximately 400,000 people provided primary medical care in the United States. About 300,000 were physicians, and another 100,000 were nurse practitioners and physician assistants. Yet primary care faces a growing crisis, in part because increasing numbers of U.S. medical graduates are avoiding careers in adult primary care. Sixty-five million Americans live in what are officially deemed primary care shortage areas, and adults throughout the United States face difficulty obtaining prompt access to primary care. A variety of strategies are being tried to improve primary care access, even without a large increase in the primary care workforce.

Hooker,Roderick S.; Cawley,James F.; Leinweber,William. “Career Flexibility Of Physician Assistants And The Potential For More Primary Care.”  Health Affairs., 2010, 29, 5, 880-886

Abstract: In part because of their core generalist education, physician assistants can change clinical specialties over the course of their work life. This is known as career flexibility. Using medical care providers who can adapt quickly to new opportunities could help alleviate medical workforce shortages in primary care. We studied annual surveys undertaken by the American Academy of Physician Assistants to determine how many physician assistants changed specialties and how frequently. Over four decades, 49 percent of all clinically active physician assistants changed specialties sometime in their careers. This suggests that incentives, such as educational grants, could draw more physician assistants to work in primary care. These findings suggest that an array of new incentives under health reform could draw and retain more physician assistants into primary care medicine.

Brook,Robert H. ; Young,Roy T. “The Primary Care Physician and Health Care Reform.” JAMA, 2010, 303, 15, 1535-1536

Intorduction:  Whatever forrm it takes, health care reform will increase the number of Americans covered by health insurance. But there is concern that the legislation will not bend the cost curve—that is, will not reduce the growth of health care costs so that it more closely resembles the growth of the US gross domestic product (GDP). Currently, health care consumes about 16% of the GDP; advocates of bending the cost curve hope that in 2020 it will still consume roughly the same proportion.

Chen,Catherine; Garrido,Terhilda; Chock,Don; Okawa,Grant; Liang,Louise. “The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care.” Health Affairs., 2009, 28, 2, 323-333

ABSTRACT: We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.

Peikes,Deborah; Chen,Arnold; Schore,Jennifer; Brown,Randall.  “Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials.” JAMA, 2009, 301, 6, 603-618

Objective: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries.

Results: Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], –0.283 to –0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (–$84; 90% CI, –$171 to $4; P=.12; –$358; 90% CI, –$934 to $218; P=.31; and –$112; 90% CI, –$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined.

Conclusions: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care.

Loeppke,R.; Edington,D.W.; Beg,S . “Impact of the prevention plan on employee health risk reduction.”: Population.Health.Management., 2010, 13, 5, 275-284, United States

Abstract: This study evaluated the impact of The Prevention Plan_ on employee health risks after 1 year of integrated primary prevention (wellness and health promotion) and secondary prevention (biometric and lab screening as well as early detection) interventions. The Prevention Plan is an innovative prevention benefit that provides members with the high-tech/high-touch support and encouragement they need to adopt healthy behaviors. Support services include 24/7 nurse hotlines, one-on-one health coaching, contests, group events, and employer incentives. Specifically, we analyzed changes in 15 health risk measures among a cohort of 2606 employees from multiple employer groups who completed a baseline health risk appraisal, blood tests, and biometric screening in 2008 and who were reassessed in 2009. We then compared the data to the Edington Natural Flow of risks. The cohort showed significant reduction in 10 of the health risks measured (9 at P_0.01 and 1 at P_0.05). The most noticeable changes in health risks were a reduction in the proportion of employees with high-risk blood pressure (42.78%), high-risk fasting blood sugar (31.13%), and high-risk stress (24.94%). There was an overall health risk transition among the cohort with net movement from higher risk levels to lower risk levels (P<0.01). There was a net increase of 9.40% of people in the low-risk category, a decrease of 3.61% in the moderate-risk category, and a 5.79% decrease in the high-risk category. Compared to Edington’s Natural Flow model, 48.70% of individuals in the high-risk category moved from high risk to moderate risk (Natural Flow 31%), 46.35% moved from moderate risk to low risk (Natural Flow 35%), 15.65% moved from high risk to low risk (Natural Flow 6%), and 87.33% remained in the low-risk category (Natural Flow 70%) (P<0.001).

Annotated References from Responding to Reform

Crosson, F. J., and L. A. Tollen. 2010. Partners in Health: How Physicians and Hospitals Can Be Accountable Together, 31. San Francisco: Jossey Bass.

DesRoches, C. M., E. G. Campbell, C. Vogeli, J. Zheng, S. R. Rao, A. E. Shields, K. Donelan, S. Rosenbaum, S. J. Bristol, and A. K. Jha. 2010. “Electronic Health Records’ Limited Successes Suggest More Targeted Uses.” Health Affairs 29 (4): 639. Frisse, M. E. 2009. “Health Information Technology: One Step at a Time.” Health Affairs 28 (2): w379.

Patientslikeme.com. 2011. [Online information; retrieved 1/7/11.] www.patientslikeme.com/
Patients Like Me is focused on individuals with life-changing conditions.  Its intent is for patients to learn from the real-world experiences of other similar patients. 

Smerd, J. 2010. “Work-Site Clinics Gaining Favor as Retail Locations Lag.” Workforce Management 89 (4): 8.

StudentDoc. 2011. “Physician Salaries—Salary Survey Results.” [Online information; retrieved 1/7/11.] www.studentdoc.com/salaries.html
The StudentDoc website maintains an active survey of current salaries paid for each specialty. 

US Department of Health and Human Services (US DHHS). 2011. “Maternal and Child Health Bureau.” [Online information; retrieved 1/7/11.] http://mchb.hrsa.gov/.
The federal Health Resources and Services Administration funds and oversees this program. 

Wilson, A. R., X. T. Zhou, W. Shi, H. Rodin, E. P. Bargman, N. A. Garrett, and T. J. Sandberg. 2010. “Retail Clinic Versus Office Setting: Do Patients Choose Appropriate Providers?” American Journal of Managed Care 16 (10): 753.

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