CENTER FOR HEALTHCARE DELIVERY SCIENCES Department  of  Medicine,  Brigham  and  Women’s  Hospital  and  Harvard  Medical  School             PROGRESS  REPORT     July  2014       Niteesh  K.  Choudhry,  MD,  PhD   Executive  Director   nchoudhry@partners.org   www.c4hds.org  
                                                                   CENTER FOR HEALTHCARE DELIVERY SCIENCES Department     ...
CENTER FOR HEALTHCARE DELIVERY SCIENCES   Motivation  and  Mission   Optimizing  how  we  engage  patients  and  providers  and  deliver  care  are  central  priorities   in  our  learning  healthcare  system.    Many  organizations  are  experimenting  with   innovative  and  promising  models  to  address  these  issues.    Unfortunately,  few  of  these   have  undergone  rigorous  and/or  independent  evaluation  to  determine  their  value  with   regard  to  outcomes  of  direct  relevance  to  payers,  providers,  patients  or  funders.    This  is   especially  true  for  early-­‐stage  interventions  for  which  refinement  and  credible   evaluation  may  help  determine  whether  or  not  to  expend  additional  time  and  money  on   their  development.     The  CHDS  was  created  with  support  from  the  Brigham  and  Women’s  Hospital  (BWH)   Department  of  Medicine  and  its  Division  of  Pharmacoepidemiology  and   Pharmacoeconomics  to  addresses  these  deficiencies  by  bring  together  clinical   innovators,  evaluation  experts,  behavioral  scientists,  technology  developers  and   implementation  partners  with  the  shared  mission  of:   1. Designing,  implementing,  and/or  rigorously  evaluating  novel  ways  of  maximizing   healthcare  value     2. Developing  and  refining  methodologies  for  conducting  delivery  system   evaluation   3. Training  the  next  generation  of  delivery  science  academics  and  implementers     Areas  of  focus   Effectively  engaging  patients  and  providers  in  health  quality  improvement  has  been   increasingly  recognized  as  central  to  successful  care  transformation.    Because,  there   remain  many  opportunities  to  refine  how  to  achieve  greater  engagement,  we  have   chosen  to  focus  CHDS’s  activities  on  the  development,  refinement  and  testing  of   solutions  for  increasing  engagement  and  restructuring  care  that  are  scalable  across   settings  and  which  could  help  address  multiple  related  engagement  problems  such  as   medication  adherence,  smoking  cessation  and  weight  loss.     From  a  methodological  perspective,  we  are  principally  interested  in  the  use  of  low-­‐cost   clinical  trials  embedded  in  real-­‐world  delivery  systems.  Our  work  is  heavily  influenced  by   the  experiences  of  our  faculty  leading  these  types  of  studies.    These  include  MI  FREEE,   which  was  conducted  in  partnership  with  Aetna  and  evaluated  the  use  of  financial   incentives  for  reducing  vascular  events  after  myocardial  infarction,  REMIND,  which  is   assessing  the  benefit  of  low-­‐cost  reminder  devices  for  chronic  disease  medications   www.c4hds.org   2  
CENTER FOR HEALTHCARE DELIVERY SCIENCES         Motivation     and     Mission      Optimizing     how     we     engage  ...
CENTER FOR HEALTHCARE DELIVERY SCIENCES   among  approximately  45,000  beneficiaries  of  CVS  Caremark  and  STIC  2  IT,  which  is  a   NIH-­‐supported  trial  in  development  with  Atrius  Health  that  will  evaluate  the  impact  of  a   technologically-­‐enabled  pharmacist  intervention  to  improve  outcomes  for  patients  with   common  chronic  conditions.           SOLUTIONS   patient   interactions  with   their  own  care   PROBLEMS   non-­‐ adherence   obesity   FINANCIAL   INCENTIVES   smoking   REMINDERS   readmissions   FEEDBACK  TOOLS   patient   interaction  with   health   information   interactions   between   patients  and   providers   interactions   between   patients  and   others   SHARED   DECISION   MAKING   ALTERNATIVE   PRIMARY  CARE   LITERACY   INTERVENTIONS   SOCIAL  MEDIA   AND  ONLINE   COMMUNITIES   BIOMETRIC   MONITORING   OPTIONS   PEER   MENTORING   narcotic  abuse     While  we  develop  novel  and  creative  patient  and  provider  engagement  strategies  of  our   own,  we  also  seek  to  foster  collaborations  with  external  healthcare  innovators  to  refine   their  solutions  and  to  evaluate  with  them  in  partnership  with  payers,  provider   organizations  and/or  other  implementation  organizations.         Current  projects   In  the  months  since  its  inception,  CDHS  has  launched  several  projects.  These  include:   § A  large-­‐scale  trial  of  Medicare  beneficiaries  being  conducted  in  partnership  with   the  Center  for  Medicare  and  Medicaid  Services,  the  Center  for  Disease  Control   and  the  U.S.  Behavioral  Insights  Team,  that  will  evaluate  the  use  of  commitment   techniques  to  increase  uptake  of  the  flu  vaccination;   § A  randomized  evaluation  of  the  accelerated  adoption  of  primary  care  practice   characteristics  associated  with  higher  quality  and  lower  spending  being   conducted  in  partnership  with  the  Stanford  Center  for  Clinical  Excellent  Research.   § A  small  randomized  controlled  trial  evaluating  the  impact  of  SMS  text-­‐based   reminders  to  increase  exercise  among  patients  after  myocardial  infarction.       www.c4hds.org   3  
CENTER FOR HEALTHCARE DELIVERY SCIENCES         among     approximately     45,000     beneficiaries     of     CVS     Ca...
CENTER FOR HEALTHCARE DELIVERY SCIENCES   Faculty  and  personnel   Identifying  and  recruiting  exceptional  faculty,  trainees  and  staff  are  central  priorities  for   CHDS.    We  are  particularly  interested  in  the  recruitment  and  mentoring  of  early-­‐stage   investigators  who  show  great  promise  as  there  is  no  clear  academic  career  path  for   trainees  who  want  to  pursue  careers  in  delivery  and  implementation  science.  In  parallel   with  our  search  for  such  core  faculty,  we  have  already  received  enthusiastic   commitment  from  16  more  senior  faculty  to  provide  guidance  on  CHDS’s  activities  and   collaboration  on  specific  projects.    These  faculty  affiliates  come  from:   § within  BWH  (including  the  Department  of  Medicine’s  Divisions  of   Pharmacoepidemiology  and  Pharmacoeconomics  and  General  Internal  Medicine   as  well  as  the  Department  of  Emergency  Department  as  well  as  the  Hospitalist   Program)   § the  broader  Harvard  community  (including  MGH  and  the  Department  of  Health   Care  Policy  at  HMS)   § other  academic  institutions  (including  Dartmouth,  the  University  of   Pennsylvania,  and  Stanford)   § private  intuitions  (including  Google  Ventures,  Merck  and  CVS  Caremark).     We  have  also  attracted  several  exceptionally  talented  fellows  from  BWH,  HMS  and   Harvard  Business  School  to  work  with  CHDS  on  a  part-­‐time  basis.    They  have  been   instrumental  in  both  the  strategic  and  initial  academic  endeavors.    Finally,  a  recent   graduate  of  BWH’s  Deland  Fellows  program  has  been  serving  as  interim  Chief  of  Staff;  a   search  for  a  permanent  individual  to  fill  this  role  is  underway.     Implementation  partners   In  an  effort  to  establish  partnerships  within  the  BWH  and  Partners  community  we  have   met  with  the  leadership  of  the  Brigham  and  Women’s  Physician  Organization,  the   Center  for  Clinical  Excellence,  and  Population  Health  Management  at  both  BWH  and   Partners  Healthcare.    In  additional  to  gauging  general  reactions  and  suggested   refinements  to  CHDS’s  mission,  the  specific  purpose  of  these  meetings  was  to  identify   opportunities  for  potential  collaborative  pilots.         A  promising  area  of  investigation  that  appears  to  meet  the  needs  of  these  organizations   and  the  interests  of  CHDS  is  the  testing  of  engagement  strategies  on  BWH  and/or   Partners’  own  employees.    BWH/Partners  has  a  clear  interest  and  a  financial  incentive  to   improve  health  outcomes  and  productivity  as  well  as  to  reduce  unnecessary  spending   www.c4hds.org   4  
CENTER FOR HEALTHCARE DELIVERY SCIENCES         Faculty     and     personnel      Identifying     and     recruiting     ...
CENTER FOR HEALTHCARE DELIVERY SCIENCES   for  its  own  employees.  Many  Partners  employees  also  receive  care  from  Partners   physicians,  thereby  making  clinic  or  care-­‐site  based  interventions  feasible.    In  this  same   spirit,  work  place  interventions  are  uniquely  possible  in  this  context.    We  are  the  process   of  developing  specific  proposals  for  consideration  by  the  individuals  we  have  already   met  as  well  as  key  decision-­‐makers  in  the  BWH  leadership,  including  in  Human   Resources.     Externally,  we  have  had  the  unique  opportunity  to  interact  with  many  organizations  that   have  a  strong  interest  in  improving  patient  and  provider  engagement,  including  the   Center  for  Disease  Control  and  Prevention,  the  White  House  Office  of  Science   Technology  and  Policy,  the  Center  for  Evidence-­‐Based  Policy,  the  U.S.  Behavioral  Insights   Team,  and  Stanford’s  Clinical  Excellence  Research  Center.    As  described  above,  we  have   launched  several  projects  with  these  organizations  and  have  others  under  development.     Fellowship  program   In  order  to  train  and  foster  the  next  generation  of  delivery  science  researchers,  we  plan   to  offer  a  novel  fellowship  program  consisting  of:   § training  in  health  services  research,  epidemiology,  biostatistics  and  “biodesign”   § pre-­‐selected  thesis  projects  that  use  a  multidisciplinary  team-­‐based  approach     § mentorship  from  academics,  industry  leaders,  clinicians  and  thought  leaders  in   medicine,  health  policy  and  technology.     The  fellowship  program  will  provide  formal  training  through  courses  offered  by  Harvard   Catalyst,  the  Harvard  School  of  Public  Health  and  other  Harvard  graduate  schools.     Enrollment  in  a  Harvard  graduate  degree  program  will  be  highly  encouraged.    In   addition  to  project-­‐based  and  peer  learning,  trainees  will  be  supervised  by  world-­‐class   faculty  mentors  and  affiliates.  To  formalize  the  process  of  solutions  development,  we   have  also  begun  discussions  with  Stanford’s  Clinical  Excellence  Research  Center  who   have  uniquely  adapted  training  in  “biodesign”  (a  systematic  approach  to  needs  finding   and  the  invention  and  implementation  of  new  biomedical  technologies)  to  care  delivery   problems.       We  hope  to  launch  our  first  fellowship  class  for  the  summer  of  2015  and  have  met  with   the  BWH  Internal  Medicine  program  directors  and  the  Harvard  Vanguard  Medical   Associate  residency  class  to  discuss  these  opportunities.   www.c4hds.org   5  
CENTER FOR HEALTHCARE DELIVERY SCIENCES         for     its     own     employees.     Many     Partners     employees    ...
CENTER FOR HEALTHCARE DELIVERY SCIENCES     Funding   Developing  a  model  for  sustainable  funding  is  a  top  priority  for  CHDS.    Our  ultimate  goal   is  to  be  adequately  resourced  from  a  diversity  of  sources  that  we  will  be  able  to   collaborate  with  implementation  partners  to  develop,  refine,  deploy  and  evaluate  new   methods  of  engaging  patients  and  providers  without  needing  to  ask  them  for  direct   financial  support.       We  are  currently  pursuing  funding  from  three  sources:   1. Grants  from  public  agencies  and  foundations  for  specific  projects.   2. Endowment  support  from  philanthropists  who  an  inspired  by  our  mission.   3. Contracts  from  insurers,  venture  capitalist  and  technology  developers  who  are   interested  in  the  academic  evaluation  of  care  innovations.     To  this  end,  we  are  in  the  final  stages  of  securing  our  first  project-­‐specific  grant.  We   have  meet  several  philanthropists  who  are  informally  advising  us  about  how  best  to   position  CHDS’s  offerings  to  attract  the  level  of  funding  that  we  will  require  to  properly   establish  our  Center.    After  these  meetings,  we  will  formally  solicit  the  help  of  the  BWH   Development  Office.     We  have  also  met  with  payers  and  venture  capitalists,  with  other  meetings  forthcoming,   to  pursue  contract  funding.    Our  faculty  has  an  extensive  track  record  of  working  with   private  funders  to  support  the  design  and  evaluation  of  studies  to  evaluate  care  delivery   innovations.    We  have  received  great  encouragement  that  venture  capitalist  and  other   similar  entities  also  seek  such  independent,  academically  rigorous  evaluation  and  to   have  the  results  of  these  analyses  published  in  the  peer-­‐reviewed  literature.    This  is   especially  true  for  care  innovations  early  in  the  development  process  in  order  to   determine  whether  or  not  to  expend  additional  resources  on  their  refinement.    We  are   currently  further  exploring  this  avenue  of  funding.     Public  outreach   Having  launched  our  website  (www.c4hds.org),  we  are  now  in  the  process  of  writing   and  designing  our  communication  material,  establishing  a  social  media  presence  and   increasing  awareness  through  our  network  of  collaborators.         www.c4hds.org   6  
CENTER FOR HEALTHCARE DELIVERY SCIENCES               Funding      Developing     a     model     for     sustainable     ...