Implementation of Preventive Services in an HMO Practice STEPHEN C. SCHOENBAUM, MD, MPH Practice d o e s n o t c o n f o r m to guidelines u n l e s s the guidelines are specifically implemented and performance is m o n i t o r e d . Several examples o f implementation in o n e health maintenance organization (HMO) are given. These include immunization f o r influenza and follow up o f posiave s c r e e n i n g tests f o r c o l o r e c t a l and cervical cancer. Each implementation effort has required the development o f systems, which in this HMO are automated. Several i s s u e s influencing implementation are discussed, including resource constraints and priorities f o r the allocation o f new resources. Developers cannot expect that their guidelines will be incorporated into clinicalpractice. They must foster specific implementation plans. Key words: health maintenance organization,, implementation; guidelines; reminder systems; immunizations; preventive screening. J GEN INTERN MED 1990; 5 ( s u p p l ) : S 1 2 3 - S 1 2 7 .
those in the report of the U.S. Preventive Services Task Force, is only a first step in delivering a p p r o p r i a t e preventive medical care to a population. The next steps include organization of an i m p l e m e n t a t i o n p r o g r a m for each guideline, followed by assessment and m a n a g e m e n t of the p e r f o r m a n c e of the clinical delivery system in w h i c h the guideline has b e e n introduced. The objective is to follow the guideline w h i l e using available resources optimally. This report describes the i m p l e m e n t a t i o n and m a n a g e m e n t of preventive services at Harvard C o m m u n i t y Health Plan (HCHP), a 4 0 0 , O 0 0 - m e m b e r health maintenance organization (HMO) in the Greater Boston area. It describes a few specific programs and t e c h n i q u e s that have b e e n d e v e l o p e d or used to manage preventive care and p r o b l e m s that have b e e n encountered, and the results to date. On the basis of this specific e x p e r i e n c e , w e discuss several general issues that arise in the m a n a g e m e n t of preventive services. By w a y of background, HCHP consists of two types of HMOs. The Health Centers Division (HCD) of HCHP was the original organization. It o p e n e d in 1969 and is a staff-model HMO that serves 2 9 0 , 0 0 0 m e m b e r s , e a c h of w h o m receives a m b u l a t o r y care in one of ten health centers. All primary care physicians in this part of the organization are salaried employees. Eight of the ten health centers, w i t h a b o u t 2 3 0 , 0 0 0 m e m b e r s , are served b y an a u t o m a t e d medical record system. HCHP was the original beta-site for the COSTAR a u t o m a t e d medical record software d e v e l o p e d b y G. Octo Barnett. 1 THE DEVELOPMENT OF GUIDELINES, s u c h a s
Received from the Harvard Community Health Plan, 10 Brookline Place West, Brookline, Massachusetts 02146. Presented at the conference, Frontiers in Disease Prevention, The Johns Hopkins University, June 5 - 6, 1989. Address correspondence to Dr. Schoenbaum. Reprints are not available.
In its Medical Groups Division (MGD), HCHP contracts with ten i n d e p e n d e n t medical groups to care for about 110,000 members. This g r o u p n e t w o r k division was formed w h e n HCHP m e r g e d w i t h another health care plan in 1986. The ten medical groups operate a b o u t 20 patient-care sites and are i n d e p e n d e n t l y incorporated, each w i t h its o w n manual record system. Since almost all of HCHP's activities to date for managing preventive services have o c c u r r e d in the HCD, most of the e x a m p l e s in this p a p e r c o m e from that division.
EXAMPLE OF THE MANAGEMENT OF IMMUNIZATION Many of HCHP's activities in managing preventive services in the HCD have involved the use of the autom a t e d record system. An e x a m p l e is the influenza immunization program. 2 Any HMO c o u l d mail influenza i m m u n i z a t i o n r e m i n d e r postcards each fall to m e m b e r s over 65 years of age by accessing its e n r o l l m e n t files; and for many years HCHP did so. Since only a small p e r c e n t a g e of HCHP m e m b e r s w e r e over 65, it s e e m e d likely that m a n y m e m b e r s at high risk for complications of influenza, such as those u n d e r 65 with chronic cardiac or respiratory conditions, w e r e not receiving the r e m i n d e r cards. Accordingly, in 1983 w e began to use our a u t o m a t e d record system to generate lists of m e m bers u n d e r 65 w h o carried diagnoses c o m p a t i b l e w i t h one or m o r e high-risk conditions and to send t h e m mailed reminders to get vaccinated. In 1984 w e realized that identifying high-risk persons c o u l d help acc o m p l i s h two goals. Each patient c o u l d b e mailed a reminder. In addition, a r e m i n d e r c o u l d be printed for clinicians each time a high-risk m e m b e r had a primary care visit. Automated systems are rigid, and i t w a s soon apparent that the lists of high-risk patients n e e d e d to be improved. Our clinicians told us that reminders w e r e being printed for some p e o p l e w h o w e r e not really at high risk. For e x a m p l e , a p e r s o n w h o carried a diagnosis of bronchitis in the a u t o m a t e d medical record system might have had just one episode of bronchitis and not have chronic bronchitis, the true high-risk condition. In 1985, in an a t t e m p t to i m p r o v e u p o n the lists, w e started to send each primary care doctor the names of the persons in his or her practice w h o w o u l d be receiving reminders. The physicians can add or subtract names from the list. Because the clinician has ultimate control over the names of the patients on the r e m i n d e r list, in effect w e are r e m i n d i n g our clinicians to immunize the patients they think should b e i m m u n i z e d . This SIZ3
SlZ4
Schoenbaum, PREVENTIVESERVICESIN HMO PRACTICE TABLE 1
Comparison of Influenza Immunization Rates Between Patients of Automated and Manual Record Centers, from Medical Record Review of Harvard Community Health Plan Age under 65 Years
Age over 65 Years
Automated Record Centers (%)
Manual Record Center (%)
Automated Record Centers (%)
Manual Record Center (%)
1984-85
39
30
42
26
1985-86
42
*
31
42
33
1986-87
56
*
28
60
Year
*
24
*Significant difference between proportions (p
those in the report of the U.S. Preventive Services Task Force, is only a first step in delivering a p p r o p r i a t e preventive medical care to a population. The next steps include organization of an i m p l e m e n t a t i o n p r o g r a m for each guideline, followed by assessment and m a n a g e m e n t of the p e r f o r m a n c e of the clinical delivery system in w h i c h the guideline has b e e n introduced. The objective is to follow the guideline w h i l e using available resources optimally. This report describes the i m p l e m e n t a t i o n and m a n a g e m e n t of preventive services at Harvard C o m m u n i t y Health Plan (HCHP), a 4 0 0 , O 0 0 - m e m b e r health maintenance organization (HMO) in the Greater Boston area. It describes a few specific programs and t e c h n i q u e s that have b e e n d e v e l o p e d or used to manage preventive care and p r o b l e m s that have b e e n encountered, and the results to date. On the basis of this specific e x p e r i e n c e , w e discuss several general issues that arise in the m a n a g e m e n t of preventive services. By w a y of background, HCHP consists of two types of HMOs. The Health Centers Division (HCD) of HCHP was the original organization. It o p e n e d in 1969 and is a staff-model HMO that serves 2 9 0 , 0 0 0 m e m b e r s , e a c h of w h o m receives a m b u l a t o r y care in one of ten health centers. All primary care physicians in this part of the organization are salaried employees. Eight of the ten health centers, w i t h a b o u t 2 3 0 , 0 0 0 m e m b e r s , are served b y an a u t o m a t e d medical record system. HCHP was the original beta-site for the COSTAR a u t o m a t e d medical record software d e v e l o p e d b y G. Octo Barnett. 1 THE DEVELOPMENT OF GUIDELINES, s u c h a s
Received from the Harvard Community Health Plan, 10 Brookline Place West, Brookline, Massachusetts 02146. Presented at the conference, Frontiers in Disease Prevention, The Johns Hopkins University, June 5 - 6, 1989. Address correspondence to Dr. Schoenbaum. Reprints are not available.
In its Medical Groups Division (MGD), HCHP contracts with ten i n d e p e n d e n t medical groups to care for about 110,000 members. This g r o u p n e t w o r k division was formed w h e n HCHP m e r g e d w i t h another health care plan in 1986. The ten medical groups operate a b o u t 20 patient-care sites and are i n d e p e n d e n t l y incorporated, each w i t h its o w n manual record system. Since almost all of HCHP's activities to date for managing preventive services have o c c u r r e d in the HCD, most of the e x a m p l e s in this p a p e r c o m e from that division.
EXAMPLE OF THE MANAGEMENT OF IMMUNIZATION Many of HCHP's activities in managing preventive services in the HCD have involved the use of the autom a t e d record system. An e x a m p l e is the influenza immunization program. 2 Any HMO c o u l d mail influenza i m m u n i z a t i o n r e m i n d e r postcards each fall to m e m b e r s over 65 years of age by accessing its e n r o l l m e n t files; and for many years HCHP did so. Since only a small p e r c e n t a g e of HCHP m e m b e r s w e r e over 65, it s e e m e d likely that m a n y m e m b e r s at high risk for complications of influenza, such as those u n d e r 65 with chronic cardiac or respiratory conditions, w e r e not receiving the r e m i n d e r cards. Accordingly, in 1983 w e began to use our a u t o m a t e d record system to generate lists of m e m bers u n d e r 65 w h o carried diagnoses c o m p a t i b l e w i t h one or m o r e high-risk conditions and to send t h e m mailed reminders to get vaccinated. In 1984 w e realized that identifying high-risk persons c o u l d help acc o m p l i s h two goals. Each patient c o u l d b e mailed a reminder. In addition, a r e m i n d e r c o u l d be printed for clinicians each time a high-risk m e m b e r had a primary care visit. Automated systems are rigid, and i t w a s soon apparent that the lists of high-risk patients n e e d e d to be improved. Our clinicians told us that reminders w e r e being printed for some p e o p l e w h o w e r e not really at high risk. For e x a m p l e , a p e r s o n w h o carried a diagnosis of bronchitis in the a u t o m a t e d medical record system might have had just one episode of bronchitis and not have chronic bronchitis, the true high-risk condition. In 1985, in an a t t e m p t to i m p r o v e u p o n the lists, w e started to send each primary care doctor the names of the persons in his or her practice w h o w o u l d be receiving reminders. The physicians can add or subtract names from the list. Because the clinician has ultimate control over the names of the patients on the r e m i n d e r list, in effect w e are r e m i n d i n g our clinicians to immunize the patients they think should b e i m m u n i z e d . This SIZ3
SlZ4
Schoenbaum, PREVENTIVESERVICESIN HMO PRACTICE TABLE 1
Comparison of Influenza Immunization Rates Between Patients of Automated and Manual Record Centers, from Medical Record Review of Harvard Community Health Plan Age under 65 Years
Age over 65 Years
Automated Record Centers (%)
Manual Record Center (%)
Automated Record Centers (%)
Manual Record Center (%)
1984-85
39
30
42
26
1985-86
42
*
31
42
33
1986-87
56
*
28
60
Year
*
24
*Significant difference between proportions (p
