Franklin Mutual Shares A (TESIX) a Zacks Rank #1 (Strong Buy) was incepted in July 1949 and is managed by Franklin Advisers, Inc.
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Israel-based developer of robotic technology and products, Mazor Robotics Ltd. (MZOR), recently announced the receipt of 21 surgical guidance system orders in fourth-quarter 2016.
On Dec 29, 2016, we issued an updated report on United Therapeutics Corporation (UTHR).
Israel-based developer of robotic technology and products, Mazor Robotics Ltd. (MZOR), recently announced a three-system order for the Mazor X, from a leading mid-Atlantic health care organization.
Fidelity Select Health Care Fund (FSPHX) seeks capital appreciation
As payers and providers in the U.S. health care system shift from fee for service to value-based approaches that pay providers for quality, they are turning to two models: One is procedure- and DRG-based bundled payments that pay one price for all the care related to treating a condition. The other is population-based “global” or “capitated” payments” such as accountable care organizations in which a provider is paid a fixed amount to cover all of a patient’s health needs for a specified period of time. The Center for Orthopedic Research and Education (or CORE Institute) — a group of musculoskeletal, neurologic, and rehabilitative physicians in Arizona and Michigan that includes orthopedic, spine, and pain-management physicians and a number of other types of clinicians — is pioneering an approach that represents a middle ground. It addresses a central criticism of bundled payments: that the approach doesn’t prevent unnecessary care. Here’s how it works: The provider is accountable for the full cost of treating a patient with a particular diagnosis but then can decide which particular type of treatment to provide or, most significantly, not to provide. For example, while the current bundled-payment model covers the full cost of the care related to a knee replacement from surgery through physical therapy, CORE’s model allows a provider to be paid if the provider chooses alternative therapy to a knee replacement (e.g., injections of medication into the joint and/or physical therapy). Insight Center Innovating for Value in Health Care Sponsored by Medtronic Exploring cutting edge ways to lower costs and improve quality. For medical conditions or sets of related medical conditions that can easily be treated on their own, the advantage of this model relative to the global payments model is that the provider is only financially accountable for the types of diagnoses that it can reasonably influence. Initially, beginning in 2009, CORE began taking on financial accountability for all musculoskeletal physician-related medical expenses (paid claims) with one insurer, which pays CORE a per-member per-month (PMPM) fee that represents about 20% of the total physician medical expense for musculoskeletal care. In this early model, the institute has upside financial potential if the total musculoskeletal physician-related medical expense for a patient is below the negotiated benchmark and effectively loses money if that total expense exceeds the benchmark, regardless of whether CORE or another provider delivered the care. (If CORE refers the patient or the patient chooses to go to an outside physician, CORE is responsible for the charge — an obvious risk to CORE.) The CORE Institute has now expanded the scope of its model from physician payments so it is now accountable for the entire diagnosis-based spend annually. For example, if an unnecessary MRI is ordered by a physician, it is ultimately paid for by CORE. If a physician performs a knee replacement on that patient, the hospitalization and all the care provided in the hospital, and all facilities for that matter, are ultimately paid for by CORE, as are all of the medications related to the patient’s musculoskeletal conditions during the year. If a patient falls and is seen in an urgent care center with a diagnosis of shoulder pain, all the care, medications, and testing are covered. Why is CORE willing to take on such global risk? Relative to procedure- or DRG-based bundled payments, the medical-condition-based bundled payment/population health model provides three levers to influence the costs and outcomes for patients beyond those available to providers in procedure-based bundles. The first shift is that the provider wins by keeping patients healthy and preventing conditions from occurring. For instance, the institute has launched a bone health program to reduce the likelihood of patients developing fragility fractures and to manage osteopenic patients preoperatively before elective surgery to improve outcomes and decrease complications. The institute houses its own clinic for postoperative blood clots to keep patients out of the emergency room, which are both higher cost and often over-treat patients, leading to postoperative bleeding and the need for additional surgery. By using evidence-based, proven care pathways, and algorithms, which are fully standardized and vetted by a national quality team of physician specialists and experts, the appropriate care is provided to each patient. A second lever afforded by medical-condition-based bundles is that providers win by selecting high value treatments and care pathways. For instance, the CORE Institute’s Excellence through Evidence pathways and protocols define when non-operative treatments are and are not likely to be more successful than surgery. To use another example, a provider accountable for all care for a particular type of bone cancer would have an incentive to be mindful of whether surgery, chemotherapy, radiation, and so on would be the highest-value care pathway for a given patient in a given situation. A third lever is the ability to select the appropriate site of service for each type of care. Most bundled payment models today such as the Comprehensive Care for Joint Replacement program start with the admission to a participating hospital. A medical-condition-based bundle allows for delivering care at the best location, whether that is a different hospital or type of facility. For instance, the most appropriate way to perform a hip replacement for one patient may be as an inpatient at a large tertiary hospital with an ICU, while it might be best to perform the same surgery on another patient at a surgery center where he or she could go home the same day. To be able to optimally pull these levers in a consistent fashion across providers and patients, CORE has developed, invested heavily in, and implemented a set of tools and management systems. These informatics systems include patient-engagement tools, complications-tracking applications, automated clinician-evaluation software that audit provider compliance with evidence-based practice, and functional and patient-reported-outcomes scoring tools. Most uniquely, due to the standardized data set available to the group now, they have successfully launched predictive analytic tools. For example, one validated tool will predict before a surgery whether a patient will need to be sent to a skilled care center instead of home after surgery, and will identify what variables need to be modified to allow such a patient to go home if possible. Access to these types of technologies is critical for providers who want to succeed with medical condition-based bundles. The CORE Institute has been shown to provide better outcomes at costs as much as 30% below others in the region. Between 2012 and 2016 the organization saw almost a 50% reduction in PMPM costs with certain at risk populations they managed. These savings were driven by reductions in readmissions of up to 50% compared to competitors, decreased wasteful utilization for interventions with little or no benefit, decreased utilization of post-discharge facilities such as nursing homes, decreased complication rates, and transparent partnerships with progressive, high quality hospital systems such as Banner Health. These global risk programs also involve the engagement of primary care physicians and specialists in new and unique ways. Two-way communication and two-way education between everyone touching the continuum of care around a diagnosis is of paramount importance for these broader programs to be successful. For medical conditions or sets of related medical conditions that can easily be treated on their own, the advantage of the condition-based payment model relative to the global payments model is that the provider is only financially accountable for the types of diagnoses that it can reasonably influence. As a physician group of largely orthopedic surgeons, the CORE Institute would not be in a position to take on accountability for the total medical expense of patients across all conditions, such as emphysema. However, specialists can manage the costs of musculoskeletal care better than any non-specialist group. The coalescence of such high value networks of different specialties by insurers, hospital systems, or large provider groups might just be the high-value solution that our patients have been waiting for. Lila Kelso of Harvard Business School provided valuable research support for this article.
Imagine an oncologist with more than a decade of practice experience is evaluating a lung cancer patient today. During her training years ago, there would have been a handful of therapy options to consider. Today there are dozens of additional options, in addition to hundreds of open clinical trials, each representing a potentially more effective treatment for the patient. Not only does she have to know about these new drugs and the active clinical trials, she also should be up-to-date on all of the published articles in this area so she can understand the science behind each therapy option in order to make the best decisions for her patient. But it is simply unrealistic for a doctor — or any human being — to stay abreast of that much information, much less be able to recall accurately the relevant information on demand. As the Institute of Medicine highlighted in a 2012 report, this gap in knowledge contributes to variation in care and suboptimal outcome. While basic technologies such as Google and Pubmed exist that can help automate the search for specific information, they are not sufficient and will prove even less tenable in the future as the advancement in medical science continues to accelerate. We simply have to find a better way. Create “paralegals” for medicine. One option is to borrow from the legal profession, where lawyers largely rely on human paralegals and automated systems to conduct research for cases. This frees up the lawyers to work directly with clients to understand their specific needs and design and execute the overall legal strategy. We need a similar “para-medical” function in medicine. This could include specialized staff, such as nurses and junior doctors trained to research and identify clinical trials and therapy options, as well as technology that can automate the search process much as has been done with legal discovery. Insight Center Innovating for Value in Health Care Sponsored by Medtronic Exploring cutting edge ways to lower costs and improve quality. We have already begun to go down this road. One service, called UpToDate, employs 6,300 physician authors, editors, and peer reviewers to manually review the most recent medical information to produce synopses for practicing doctors. A Harvard study found that such service could improve patient outcomes. Another strategy is to translate consensus clinical guidelines to standardized practice protocols with clinical decision support algorithms (e.g. sequences of yes/no decisions with specific test and treatment options). For example, Intermountain employed a team of paid clinical experts to develop such clinical-decision-support algorithms based on scientific literature and Intermountain’s own experience in order to standardize how common medical conditions (such as pneumonia) are diagnosed and treated by its physicians. However, such reliance on manual curation creates not only a scale problem but also quality and consistency challenges. With the arrival of more advanced analytics such as IBM Watson, we can imagine more intelligent system such as MD Anderson’s Oncology Expert Advisor that one of us (Lynda) previously developed. It combines human expertise with machine learning to synthesize a large knowledge base in cancer and suggests treatment options tailored to a specific patient in real time. This will help doctors make better decisions based on up-to-date knowledge in a time efficient manner. Build a learning medical information ecosystem. For these intelligent systems to be effective, there is a need to connect the broader community as a medical information ecosystem in which not only patient data but also knowledge of doctors, researchers, nurses, and other stakeholders such as pharmacists and caregivers are integrated and shared. Importantly, that means we need a change in the culture of medicine from a highly siloed field of specialities to one in which all stakeholders actively collaborate to provide the best care to the patient. Project Diabetes Obesity Control, an initiative in South Texas sponsored by the University of Texas System under leadership of one of us (Lynda), shows that mobile technology and advanced analytics could catalyze such changes in the culture of medicine. Project DOC was able to establish digital connectivity across traditional primary care clinics, remote (e.g., at home or at retail sites) services for monitoring biometrics such as blood pressure or blood glucose so real-world patient data can be shared and integrated to make possible more frequent and more proactive management of diabetes. The path forward is clear. Through better connectivity, information technology is improving the practice of medicine as never before. MD Anderson’s Oncology Expert Advisor is an example of a technology that can put the world’s medical knowledge at doctors’ fingertips, synthesized and organized by artificial intelligent (AI) systems. However, to realize the full effect of these newfound technological capabilities, we need to break down the silos and facilitate collaboration among medical professionals and all other stakeholders so they can work seamlessly to deliver coordinated care on behalf of the patients.
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However the Trump administration and the Republican U.S. Congress replace or revamp the Affordable Care Act, it is unlikely to halt America’s ongoing move from the rightfully maligned fee-for-service payment system to one that pays for “value” — the quality of outcomes relative to the price. Despite the progress that’s been made, there is still a long way to go. What new investments will be required? What legacy costs will be incurred as providers strive to optimize their business processes to deliver comprehensive value-based health care? How will leadership teams and boards of directors orchestrate the strategic transformations of their currently successful businesses? To gain insight into these questions, we are interviewing executives at academic health systems. Thus far, we have interviewed executives of systems affiliated with these universities: Vanderbilt, Johns Hopkins, Harvard, Virginia Commonwealth, and the University of Utah. The consensus is the challenges facing them will be daunting and organizations will be strained to finance and manage it. The transformation will necessitate substantial investments in finance, technology, human capital, operations, and infrastructure, and a substantial disinvestment of legacy resources in these areas. This pivot will entail a transformation of the workforce, physical infrastructure, and technologies that support and drive the care of patients. And organizations will have to orchestrate and execute concurrent investments and operational changes across multiple organizational structures within an already complex health care delivery organization. Our interviews indicate that care organizations are not yet ready to make such substantive operational changes and resource investments. Insight Center Innovating for Value in Health Care Sponsored by Medtronic Exploring cutting edge ways to lower costs and improve quality. One noteworthy finding was the need for additional investment in information technology to support the new business model. The Federal government has provided almost $30 billion to support the digitization of health care over the last several years. Yet the technology needs of the emerging population-health strategy differ significantly from those of the current fee-for-service model. In a value-based, care-delivery model, care organizations will have to focus on managing the utilization patterns of populations of patients. To do this, they will have to be able to access and analyze claims and clinical data, which will require flexible data-warehouse platforms and business intelligence tools. As one health system executive told us, “Organizations will need to have a single ‘shadow IT system’ that resembles [that of] a full-blown health insurance carrier to integrate members from multiple payers for member services, claims, actuarial analysis, case management, and utilization, among other sources.” Finally, organizations will need to engage patients proactively with digital tools so patients can, for example, connect with providers virtually via mobile devices. While respondents were keenly aware that the transformation would require significant cash outlays, they were less clear about where the money would come from. All of them said their organizations would likely have to secure financing from outside sources. But this may be easier said then done given the nonprofit status of most academic health systems. Persuading their boards of directors to make these immense investments may also be challenging. It is also unclear whether their boards have the expertise required to understand the changing dynamics of the health care market and oversee the potentially massive and disruptive investments that will be required. There is a growing realization that the transformation of the health care system will require existing organizations to develop new business models and new organizational structures. Leaders will have to decide whether they should undertake a single, massive transformation of their existing organization or make multiple, smaller investments in novel business models optimized for the new payment models. The former approach will require extensive long-range planning with little room for error. The latter model affords organizations a bit more operational and financial flexibility by allowing them to adapt at a slower pace without completely abandoning their current core business. Most of the interviewed executives favor this latter approach. As one health system executive explained, “We will be operating and managing in two very different worlds for a period of time…fee for service and risk/population health. These two businesses are very different and require different management skills. Many hospital-based systems will try to manage them under the same leadership but will learn that it doesn’t work over time. So there will be major new investment in management talent to run the portion of the business focused on risk.” Clearly, the upheaval that has shaken health care systems in recent years is nothing compared to the seismic changes that lie ahead.
The starting point for achieving value in any health care system is to measure outcomes. Although this can present leadership challenges related to shifting strategy, culture and operations, it certainly isn’t rocket science. There are hundreds of provider organizations the world over that have already implemented outcomes measurement, and this number increases every week. Regardless, many providers still believe that measuring outcomes is too difficult to do. Through regular interaction with our global network of value innovators, we at the International Consortium for Health Outcomes Measurement (ICHOM) have developed a 10-step implementation “blueprint” that any provider can follow. Of course, there is no one-size-fits-all solution for measuring outcomes, and all providers must make specific tweaks in order to make it work for them. However, all must take similar steps, traverse similar challenges, and build similar infrastructures to facilitate outcomes measurement. Here we describe how one of the world leaders in outcomes measurement, Erasmus Medical Center in the Netherlands, used this blueprint in one of its pediatric surgery departments – for cleft lip and palate. To build a successful measurement program like this one, follow these steps: 1. Get Institutional Commitment You need to have senior management that really understands what value-based health care (VBHC) is all about. Back in 2012, Erasmus’s CEO, Professor Hans Buller, was a huge proponent of VBHC and led the development of the organization’s 5-year VBHC strategy with one of us (Dr. Hazelzet). The board approved, and Erasmus’s next CEO – Ernst Kuipers – drove this forward from 2013. Insight Center Innovating for Value in Health Care Sponsored by Medtronic Exploring cutting edge ways to lower costs and improve quality. Engaging institutional leadership in the outcomes or quality domain – representing the numerator of the value equation – is vital to begin measuring outcomes. Engaging leadership in the finance domain – representing the denominator of the value equation – is helpful as it will ensure dedicated resources. Once the senior administrators are on board, the next step is to issue a call to arms to the workforce. This includes clinicians, administrators, information technologists, researchers and others. Everyone in the organization needs to be engaged so that ownership will follow. It is important to speak the right language and frame this correctly. Emphasizing improved “quality” and “outcomes” is far more motivating to staff than cost-cutting or emphasizing the need to avoid “penalties”. This is a learning and improvement opportunity for all which will align interests across disciplines. And don’t just describe outcomes measurement as a vision – the senior management must have a clear operational plan and show this to their staff, making it real. 2. Pick a High-Yield Pilot Site Erasmus’s lead cleft surgeons had conducted research on outcomes measurement in the past and had already made efforts to implement what they had learned within the cleft department – before they were asked to. Erasmus’s leadership, therefore, logically decided to run the first pilot on this fertile ground. By no means was the whole organization behind the VBHC strategy at this point; however, it is important to start with the believers and prove the concept locally so that others will follow. 3. Set Up a Steering Committee and Project Team Outcomes measurement needs a multidisciplinary approach because it will ultimately affect the way all functional areas operate. Erasmus brought together a centralized steering committee and project team of clinicians, information technologists, project managers, and an epidemiologist to provide oversight and act as leadership nodes for their respective functional areas. This team must be assembled at the start of the process in order to provide multidisciplinary ownership and, therefore, commitment. This facilitates persistence later if the program encounters skepticism or administrative or technological obstacles – as does sometimes happen. 4. Develop a Project Management Plan for the Pilot Erasmus set up 90-minute evening project meetings that ran after clinic. During the most difficult phase – the ramp-up to data collection – this occurred fortnightly. Once collection had started, meetings were held monthly; once data-gathering was going smoothly, meetings became ad-hoc. It is vital to have key milestones, action items and clear accountability from all disciplines, and this needs to be enforced by a single VBHC node – typically a project manager – supported by the senior management. From a project management perspective, it is important to maintain momentum, even in the face of early skepticism. Plan for small, incremental changes rather than mass overhaul. 5. Determine Which Outcomes You’re Going to Measure During Erasmus’s early transition to value based health care, ICHOM had been working with the medical center’s cleft surgeons on the Cleft Lip and Palate Standard Set – a globally-standardized, core set of patient-centered outcomes. Naturally, the center’s cleft department wanted to measure the outcomes indicated in this standard set. Most departments will already be measuring some outcomes, and it is logical to begin by performing a gap analysis to determine which outcomes you are already measuring and which you would like to but aren’t. Some of these will be easier to begin measuring than others, so start with these first – the “low hanging fruit”. Generally speaking, this will mean starting with clinical and administrative outcomes, then moving onto patient-reported outcomes. In the cleft program, for instance, these easy-to-measure outcomes included body weight, surgical complications, and hospital readmissions. 6. Map Patient Pathways and Clinic Operations Process mapping the patient pathway through the clinic and between clinic appointments helped Erasmus identify suitable points for data collection during the entire cycle of patient care. It was determined that data should first be collected via a web portal before any appointment when patients are at home and later in clinic waiting rooms during “dead time” before patients were seen by the cleft team. Mapping this out will inform which data-collection tool providers use and will reveal numerous other opportunities for streamlining your clinic operations and patient pathways. 7. Set Up Your Data Collection Tool Once providers know when and where they will collect outcomes data, they can select or build a tool that best facilitates this. There are lots of solutions out there – from paper forms and Microsoft Excel to bespoke web portals and plug-ins for electronic medical records (EMRs). Erasmus decided to build its own electronic data capture tool, which allows the center to construct data collection forms and distribute these to patients via a web portal. It is imperative for the clinical and IT teams to work together on this: clinicians need to tell IT what they want, and the IT team needs to get on the shop floor to determine exactly what “user-friendly” means for patients and clinicians. 8. Start Collecting on a Small Number of Patients At this stage, you will have a raw-data collection model and basic tools. You’ll know which outcomes you’re going to collect, and where and how you will collect these. Erasmus tested its model by collecting data on a small number of selected patients with different profiles. As part of this, the team communicated with patients about what it was doing and why in advance to ensure that they were happy to participate. Unsurprisingly, all patients were supportive, as they understand that positive outcomes and robust data collection are linked. 9. Front-Load Troubleshooting and Refine Your Model There will inevitably be hiccups, particularly in the beginning. Therefore, the VBHC team must front-load troubleshooting. At Erasmus, the team was present in the clinic every day from the beginning to deal with problems – from errors with electronic forms to clinic flow disruptions. Dealing with these issues early gave both clinicians and patients more confidence. As data collection became smoother, Erasmus continued to refine its model, and the VBHC team and participating staff met regularly to discuss improvement opportunities. For any provider, it is vital to show all staff involved with outcomes measurement how their efforts are paying off. Celebrate positive results, and learn from poor ones. 10. Scale Up to More Patients, More Clinics, and to Other Hospitals You will know that your data collection model is working when you routinely get high response rates. Erasmus’s cleft department is achieving over 95% compliance for patient-reported outcomes such as appearance, speech, and outcomes related to social interaction, and 100% compliance for clinician-reported and administrative outcomes (such as length of hospital stay). Once the model is up and running, slowly scale up to more patients in the same clinic – and then to other clinics – simply by replicating what you have done in the first clinic. Erasmus’s cleft department has now reached beyond its own hospital, coordinating with the Dutch Association for Cleft and Craniofacial Anomalies national initiative, to support all other cleft centers in the country to measure the same set of outcomes. Scaling requires sharing resources to lower barriers for others. Erasmus has made its electronic data capture tool, Zorgmonitor Schisis, available for other cleft departments around the world to use. As value-based health care continues to gain traction, providers not yet measuring outcomes should take heed: the first movers have made it easier for you. It’s time to start measuring.
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Few recent trends in health care delivery have more power to improve population health, patient and provider experience, and hospital business models than virtual care. But for an industry reliant on, and in many ways limited by, brick-and-mortar facilities, this movement will mean significant disruption for providers. As more commercial and state payers offer telehealth coverage and patients come to expect virtual care as standard practice, meeting the demand is quickly becoming clinically and financially imperative. Like many hospitals, Brigham and Women’s Hospital (BWH) is actively preparing for the era of virtual care in order to best meet our patients’ needs. We are at the cusp of this transition. As Medical Director for Telehealth at BWH as well as the Partners Healthcare Center for Population Health, I rarely go a week without hearing about a new practice interested in offering one of our virtual care services, a patient inquiry about our telehealth programs, or a significant change in the reimbursement landscape that may affect virtual care delivery. In spite of this growing buzz, however, virtual care at our institution and most other academic medical centers remains more of a future vision than a daily reality. For smaller or community-based providers, this gap is even wider. For virtual care to move from an innovation pilot to a standard service, five questions need to be answered by any provider: Which clinical services should be offered virtually, and why? Which technology tools will meet the demographic, clinical, and business needs for these services? Should telehealth programs be offered directly to patients or only among providers? How does virtual care create value for my practice or organization? How can this value be assessed from the patient’s perspective as well as the organization’s? Our strategy has been guided by nuanced answers to these questions. Here is what we did at BWH, organized by the three clinical and strategic problems we aimed to solve through virtual care. Virtual Visits: Improving Access and Population Health in Chronic Disease Management Our virtual care strategy began with video-based visits for outpatients with chronic diseases. In 2015 we started to engage those clinical departments whose providers saw patients with conditions requiring frequent follow-up visits and infrequent physical exams, and who lived in Massachusetts but had difficulty coming into the office. While a broad set of patients met these conditions, our providers targeted those with inflammatory bowel disease, diabetes during pregnancy, mood disorders, hypertension, ischemic heart disease, prostate disease, and airway disorders. We outfitted exam rooms and provider offices with cameras and trained the providers how to use a secure video platform to connect with patients remotely, while designing practice workflows to effectively move patients through the program. Providers were compensated at a rate roughly commensurate with routine office-based billing, regardless of payer mix. In addition to working with participating providers to target clinical populations for whom virtual care would be appropriate, we asked providers to offer virtual visits to align with BWH population health and access goals. We specifically focused on patients who would not need to come into the office for in-person care in addition to receiving virtual care, so as to avoid increasing overall utilization. And we chose providers willing to open up their schedules to see patients virtually, either more efficiently during their clinical hours or during their non-clinical time. Insight Center Innovating for Value in Health Care Sponsored by Medtronic Exploring cutting edge ways to lower costs and improve quality. Approximately 600 visits have been conducted virtually through this program to date, freeing up about 200 hours for participating providers to see patients. Among patients surveyed after their initial encounter, 97% were satisfied with the experience and would recommend the program, and 74% felt that the interaction actually improved their relationship with their provider, allaying some of our concerns that what patients would gain in convenience they would lose in a remote interaction. From a population health perspective, where our goal was to remove some of the lower-value in-person visits to make room in our providers’ schedules for more-complicated cases, we were encouraged to find that 87% of patients said they would have needed to come into the office to see a provider face to face if it weren’t for their virtual visit. The greatest adoption of this program to date has been in our medical and surgical specialties, as well as in psychiatry. As we grow this program, we plan to evaluate its value in a number of innovative ways. One hypothesis is that we can improve no-show rates by offering virtual care, given the dramatic improvement in patient convenience. Related, we will be tracking different measures of the time saved by virtual care for both providers and patients. Indeed, increasing the time spent at home and work, instead of traveling to see our providers, will be a major victory for our patients. Moreover, we believe that by reducing no-shows and increasing the number of patients who engage with their doctor, we can improve quality and help prevent costly downstream events, such as hospital admissions or readmissions. Finally, as we focus our energy on provider burnout, we hope that virtual care will allow for more-flexible provider schedules over time, permitting clinicians to provide some care from outside their practices if they wish. E-Visits: Providing On-Demand, Virtual Urgent Care for Simple Symptoms At the other end of the clinical complexity spectrum, we wanted to offer a virtual care program for patients with common, acute symptoms requiring rapid triage and management but who had trouble fitting into their providers’ schedules. In some ways, we’ve learned from retail urgent care competitors such as CVS Minute Clinic: For certain common and irritating symptoms, seeing one’s provider in the office is often less important than obtaining a speedy and reliable answer. For this reason, we collaborated with a large group of stakeholders across Partners Healthcare to develop a set of short algorithmic questionnaires designed to cover the most common primary care complaints, including cough, red eye, urinary symptoms, and back pain. We made these questionnaires available on our patient portal and directed patients to them to allow for effective asynchronous care. Why depend on a practice voicemail box when you could directly send a brief summary to your provider online and receive a reply that day? The questionnaires appeared in primary care providers’ electronic inboxes as dedicated encounter types called “e-visits,” from which medications and tests could be ordered, and which could be routed to other team members for collaborative management. We compensated providers per question (at about half the rate we paid for video visits) and expected same-day service in return. After an initial pilot of 700 e-visits among a subset of our primary care practices, we began expanding across our system. Unlike video-based visits, which take less total time for the patient (because there is no transit or practice wait time) but about the same time for the provider, we expect provider and practice efficiency gains for e-visits to be significant. The efficiency metrics we will assess from our medical record platform (EMR) are still in development, but from early experiences we know that a 15-minute office visit for urinary symptoms or cough can be done in under five minutes through this program. We also plan to experiment with midlevel provider models, where dedicated physician assistants, for instance, would spend part of their time each day answering e-visits, becoming increasingly proficient and responsive to the growing number of patients using the service. As we and other systems consider payment models that incentivize population-based, panel-driven provider work and compensation, we will likely test approaches where provider time is strategically protected for asynchronous care for large groups of patients. We believe this program will become increasingly vital as the market offers more virtual urgent care options. E-Consults: Broadening the Reach of Specialty Care In addition to telehealth services offered directly to patients, we use virtual tools to improve care and communication among our providers. Our E-Consult program attempts to solve a daily problem in ambulatory care: A clinical question arises that may or may not require a referral but that the primary clinician cannot answer alone. These questions are often related to referrals (“Does this patient need to be seen by you, by a colleague, or can I manage with your support?”) or other moments of clinical management (“I’m choosing between two medications, can you help me select which is more appropriate?”) that face primary and specialty care providers on a daily basis. E-consults ordered in our EMR provide a dedicated, responsive, and findable communication channel that can be ordered like any medication or test. Providers formulate a question and synthesize relevant information, and then route these requests to established specialist teams we centrally organize, support, and compensate at a rate similar to e-visits. In the past year of the program, roughly 300 of our providers have sent nearly 2,000 questions to our specialist e-consultants. Primary care physicians represent 80% of the sending volume, with specialist senders making up the remaining 20%. Among our 20 specialist teams, the highest-volume groups consistently are cardiology, endocrinology, gastroenterology, hematology, infectious disease, orthopedics, and urology. The program has two strategic aims, targeted at improving access and population health: to better support primary care providers so that more primary care can be managed without referrals, and to assure that when referrals do take place, they are better packaged and triaged by the referring provider so that the specialty consultation is more effective for the patient. In a chart review last year of a large sample of these questions, we found that when a sending physician intended to refer a patient to a specialist but first virtually consulted a specialist in that field, about 50% of the time the referral was avoided. From a cost perspective, this means fewer unnecessary specialist visits — a significant driver of medical spend. From a specialty access perspective, these results suggest that reduced referrals generated greater capacity for complex and appropriate specialty care. We have also received consistent feedback that e-consults are deeply helpful and supportive to primary care providers and fill the management gap created by challenging clinical scenarios. As this program grows throughout our network, our goal is to maintain the high degree of service our local clinicians have come to expect as our specialists begin fielding questions from new sources. As virtual care streams toward us from the horizon, there will soon be a day when providers will be deciding not whether to offer telehealth, but how much. Virtual care holds the promise of revolutionizing health care delivery, but it needs to be carefully guided through complex clinical, financial, and technologic decisions in our mixed-payment universe. We’ve focused on three core use cases — complex specialty care, urgent primary care, and specialty consultations. The challenge has not been in finding opportunities for virtual care; it’s been in focusing our work on those with the highest value today.