At the vast 20-hospital University of Pittsburgh Medical Center (UPMC) health system in western Pennsylvania, with over 400 physician offices and outpatient locations, more than 3,200 employed physicians, and even its own provider-sponsored health plan, clinician and executive leaders are moving forward on many fronts to improve patient safety, care quality, efficiency, and many other outcomes. And not surprisingly, given the fact that UPMC is one of the largest integrated health systems in the U.S., its leaders are making advances in the area of developing the concept of the patient-centered medical home (PCMH), and have been working assiduously to leverage information technology strategically to facilitate PCMH development. For a look at some of UPMC’s broader IT facilitation of the PCMH concept, please turn to Healthcare Informatics’ May cover story .

Meanwhile, one clinician executive at UPMC who has been a major leader on the PCMH front has been Francis X. Solano, M.D., vice president of the health system’s Physician Services Division and president of its Community Medicine Division. Dr. Solano also continues to practice part-time in internal medicine (he has been in medical practice since 1984). Dr. Solano spoke recently with HCI Editor-in-Chief Mark Hagland about his involvement in PCMH development at the clinic level at UPMC. Below are excerpts from that interview.

You’ve been very involved in the patient-centered medical home development at UPMC?

Correct. About six years ago at UPMC, Diane Holder, the president of the insurance division, and I, had a meeting to discuss how we could really transform our practices. And I was struck with the fact that they were hiring commercial disease management vendors and spending a lot of money, to do telephonic outreach to UPMC Health Plan members. And I said, Diane, there are a lot of nice things that go on from an education perspective, but you can’t really do the full care management. So I said, instead of spending all of that money, why don’t you pay for us to hire a nurse and to do some care management? So what the health plan did was that they decided to take these care managers and give them a virtual back-office functionality—and by that, I mean, access to all of UPMC’s care management boutique of services.

So right now, we have programs in weight loss, smoking cessation, depression management, social services, durable medical equipment. And rather than having to create this individual resource in my practice, they’ve connected this person to what I call a virtual back office. We have about 35 care managers within the physician services division as well as in private practices in the community; and they provide  education on weight loss, diabetes, smoking cessation, lifestyle changes; and they can connect them with other resources, some of them telephonic. The beauty of this is that the face-to-face encounter actually connects the physician, the health plan, and the patient together. So it’s seamless; it doesn’t look like the health plan is reaching out to you, it looks like Fran Solano is reaching out to you. In my office, it’s Nadine, who’s a nurse care manager and also a diabetes educator; and all of my patients know her.

So one of the functions of that person in my office is initiating that face-to-face education and care management; the other function is managing transitions of care for patients. My nurse care manager receives every day a list, generated from our central computer service at the health plan, of the high-risk members who’ve been in the emergency room or admitted to the hospital. The nurse care managers in every one of our physician offices receive this. And our nurse case manager talks to each patient on that list and works out with them whatever they might need.

In addition, we have a program called Central Discharge, for anyone who’s been discharged with medical diseases. Our central call center every day gets a list of all the patients who have been discharged with acute MI [acute myocardial infarction]congestive heart failure, community-acquired pneumonia, asthma, and about 10 other conditions. Those patients get a call the day they’re discharged, to set up a primary care follow-up visit. And all of this is integrated; we all work together collaboratively. And this is all synergistic for the medical home. And we have a 68-percent success rate in getting discharged patients scheduled for a follow-up PCP [primary care physician] within five business days.

What we’ve found through our own health plan’s analysis is that if you haven’t been seen by your primary care physician within 30 days of your discharge from the hospital, your risk of readmission is 30 percent; if you have a planned visit within 30 days, your risk of readmission is 11.5 percent, and if you have a follow-up visit within five days, it’s 8.4 percent.

So it turns out that you can predict some of these things.

Well, there’s a lot of controversy about these things: the New England Journal of Medicine had two counter-opposed studies published this week. [See one guest editorial here: http://www.nejm.org/doi/full/10.1056/NEJMp1201268 ]
 I personally think the most important thing is getting back in touch with your primary care physician within a pretty quick period of time. We did a demonstration project on this with congestive heart failure, a little pilot we did within our community practice, that ran for six months. I expect that we’ll achieve even better results over the course of a year.

And if patients know they’re being cared for, they’ll be more participatory, right?

Yes, you’ve got to get patients engaged.

What are the IT strategic implications in all this, from your perspective?

There are a lot of IT components were built to help coordinate this. Anne Docimo, M.D. [chief medical officer at UPMC Health Plan] helped put together all the back-office IT components of this, so that when Nadine needs something, it’s very easy; she puts it into a work cue. Basically, if someone needs depression care, she knows where to look.

Is it in the EHR?

Well, the health plan has developed their own back-office functionality, so there is documentation that takes place in that electronic record; and our care managers can use our EHR as well, as a communication tool. The key is that you don’t have someone sitting in a telephonic situation, in a call center, who has no connection with the doctors. This way, Nadine can say, ‘Let me talk to Dr. Solano about that.’ It’s a so much better thing to have someone right here in the office with the resources. The person sitting in a call center in Colorado is a nice thing, but this is far more effective. But it takes resource development. The Geisinger Health System just published something in the American Journal of Managed Care in which they haven’t been able to document direct ROI. But I’ve got to believe that the care quality is better. And we have level three NCQA recognition. And it’s so much better having everyone feel really connected.

Do you have any explicit advice for CIOs and CMIOs in facilitating these kinds of advances?

It’s a long journey, and there are a lot of dead ends. We’ve done a lot of things that don’t always pan out. But I think that, first of all, your efforts have to be integrated. And I’d love to see the health plan integrate with me, but legally, that’s a challenge right now. Our lawmakers should know that we would be better off if we could receive information directly from payers, because right now, there’s a lot of information we can’t get. So we’re going to have to become a lot more transparent in that way.

It will take some time and development, I think.

Let me tell you a great story: we have ranking reports by practice and by doctor, by key metrics, across a number of dimensions for patient care. And we took our top and bottom 25 doctors, and looked at cost and efficiency metrics and the differences between the top and bottom tier guys; and disappointingly, the top-tier guys cost more money and used more resources. That was disappointing, but to do good preventive care costs more money, and to do good chronic care costs more money. In my mind, I’m optimistic over the long run that providing better care will ultimately lead to better outcomes and results. I look at our practice of nine providers, and our average daily inpatient census is two to four patients, which is pretty good, because we have nine doctors, and so that’s a pretty low census. But if you keep people alive longer, they’ll ultimately need more care.

And this is a collaborative effort between and among the physicians, the medical management team, the IT team, and the business team. We all work together—this is truly a team effort. So I would add, you can’t silo yourself—and that’s such a cliché to say, but this is the ultimate anti-silo experience.