The Los Angeles County Department of Health Services (DHS) is the second-largest public healthcare system in the nation, treating more than 800,000 patients each year and employing more than 23,000 staff members spread throughout its network of 19 community-based clinics and four hospitals. Each of the sites include a model patient-centered medical home, which allows the Department to provide quality, cost-effective healthcare to its residents. The Enterprisers Project recently interviewed Dr. Jeffrey Guterman, chief research and innovation officer of the Department, to learn more about how they’re using technology to improve the care delivered to patients.
The Enterprisers Project (TEP): Can you tell us more about patient-centered healthcare and how it’s working for the L.A. County Department of Health Services?
Guterman: One of the concepts behind the patient-centered medical home is that instead of a patient just being cared for by a licensed independent healthcare provider that has M.D. after their name, there is an entire team empowered to work at the top of their license to get the patient what they need. Traditionally, there’s lots of stuff that doctors do that don’t take a doctor’s skill set.
That’s part of the frustration for patients as well as for doctors. Neither patients or doctors like 15-minute visits; yet economic reality in primary care dictates that’s what most doctors’ schedules are like today. Patients hate feeling rushed — if you do an analysis of what the doctor is actually doing in those visits, in traditional practices, more than half of what they’re doing doesn’t take a doctor’s skill set.
One of the things we’re doing in the L.A. County DHS is using a decision support engine for every patient on the schedule. Using that engine, we do a listing of all their missing preventive health measures, and we have certified medical assistants or nurses under protocols, ordering all of those tests and arranging those procedures before the patient’s visit, so that when the doctor has the face-to-face, all of that stuff that’s really simple, protocol-driven and rules-based doesn’t take up any of the doctor’s time.
TEP: It sounds like that was a massive change in the way you delivered care.
Guterman: It has been a real, fundamental sea change accompanied by an enormous cultural shift. Three years ago we didn’t have certified medical assistants at all in the department. Now for each provider we have two, whose job it is to really increase patient flow, let the provider take care of a large panel of patients, but have the patients not feel rushed and have the providers not feel rushed. We’re shifting some of the work to someone without a medical degree with a knowledge-based resource.
TEP: Are you able to do analytics on that information you collect — how much quality time you’re giving back to the doctors, how patient satisfaction rates are changing, or is it still early days?
Guterman: It’s still early in the transformation. As a large governmental bureaucratic organization. I think people are happy to say, “The providers look happier, the patients look happier, no one is complaining, this is a great change.” And that’s one of the things I believe over the next five years is really going to change, that we’re going to start building in measurement as part of the processes instead of as an afterthought.
TEP: From an innovation perspective, what even led you into going down the path of a decision support engine? Once you identified the problem, was there anything unique in the way that you solved it?
Guterman: Sure. So first things first, in healthcare it’s really easy to get labeled an innovator. All you have to do is look at what people in other industries are doing and apply it to healthcare, and all of a sudden you’re a brilliant innovator. In some ways it’s sad and in some ways it’s made my life really easy. This project started with a discussion that I had many years ago with the director of public health, where we broke healthcare into three broad categories.
There’s primary preventive care, which are things like immunizations, doing things to avoid a clinical condition that you don’t have or you’re not particularly at risk for. There’s secondary prevention, so you take people who are obese and you do things to make sure they don’t get diabetes. And there’s tertiary prevention, taking people with a disease and doing interventions to avoid the complications of those diseases.
So in my meetings with the director of public health, we had a spirited debate. We said the primary prevention stuff is fully in the public health daily activities. However, tertiary prevention, because it’s highly targeted to a patient population and has rapid return on investment, is really what we can focus on. And we created these disease management programs focused specifically on reducing what I call reactive rescue care, things that cause patients to show up in the emergency department and get admitted to the hospital. If you can reduce one heart failure hospitalization, you save around $20,000. So the payoff is really tremendous. And that's what all my research has been focused on, and that’s what most of my interventions have been focused on.
TEP: How does the decision support system that you’ve developed work?
Guterman: It’s very simple. It looks at of the patient’s clinical encounters, all their tests, and all their clinical conditions. And we have hundreds of rules that are all simple Boolean logic rules, like if the patient has diabetes and their last hemoglobin A1c was above 8 and it’s been more than three months since the test was done, look and see if there’s been any change in their medications that control glucose. If there are none, ping the doctor just to say, “Hey, Jeff Guterman has had a hemoglobin A1c above 8 for more than three months. You haven’t made any changes. Either tell me a reason you’re not making the changes or do something about it.”
TEP: That sounds pretty sophisticated for healthcare.
Guterman: Well, it’s pretty sophisticated for healthcare, but it’s pedestrian for any other industry.
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Jeffrey J. Guterman is the Chief Research and Innovation Officer in the Ambulatory Care Network of the Los Angeles County Department of Health Services. He is a Clinical Health Sciences Professor of Medicine and Emergency Medicine at the David Geffen School of Medicine at UCLA. In Dr. Guterman’s former role as Chief of Ambulatory and Community Medicine at Olive View - UCLA Medical Center, he was responsible for developing and operating the primary and managed care delivery network in the San Fernando and Santa Clarita Valleys. His research focus on the application of information technology to enhance the efficiency and effectiveness of medical care resulted in practical and implementable solutions that are changing the way care is delivered.
