Change from the bottom: community nursing in the Netherlands

Usually when we think of innovation, we assume that a small organization, even a single individual, will create something new, demonstrate it works, and then a large established organization will take it to scale. Very rarely will the innovators themselves grow to scale. In either case, the scaled-out innovation is supported by an organization with the usual management hierarchy and overhead.

Here's an example of an innovative care model and an innovative management model. Both aspects focus on what really makes a difference, understanding what is essential for the organization to nurture its people and its customers, and what is something best left undone or done by others.

This model for home health services builds on local teams of nurses who place high value on the relationships with the people they serve, favoring continuity of provider over specialized providers. It came out of nurse frustration with the fragmented care they had previously given.

Buurtzorg is a community nursing organization in the Netherlands. It started small, focused on the needs of the professional care team and the people in their community. It puts the local team in charge of the care and how they run the team to provide that care.

Buurtzorg provides high nurse satisfaction by "letting nurses be nurses", to build relationships with their patients, to be part of a small supportive team that shares the workload, to cover for each other, to build on each other's skills and knowledge, to access specialty resources as needed. A learning health system at the level of a team of ten or twelve.

A trio of remarkable outcomes were achieved.

1. Extremely satisfied patients with excellent outcomes and reduced home care costs (40% below the expected cost). 
2. Extremely satisfied workers. Buurtzorg was the Netherlands Employer of the Year for three years in a row.
3. Explosive growth, from the first team of 4 nurses in 2007 to 9,000 in 2015. Buurtzorg now provides 80% of the community nursing services in the Netherlands. This has occurred with almost no corporate overhead (a central staff of 50 or so including 15 team coaches).

There are essential, but intentionally limited, services from a central support organization. A key central service is the team's coach, who facilitates communication within the team and helps them network with other teams, but who has no decision making authority.

Buurtzorg Organizational Structure

Shared IT focuses on

• An electronic health record
• A social network
• A team dashboard

There are some outsourced services, such as payroll and legal. Buurtzorg has taken to heart the guideline of keeping the services that differentiate the organization and having others do everything else.

How to build on this?

While Buurtzorg has changed the home healthcare experience and cost, the total cost of care, including all other medical services, such as physician and hospital care, on a risk-adjusted basis, were no different from the average in the Netherlands. Are similar innovations possible in other areas of health and healthcare?

There have been studies of Buurztorg by many others from around the globe. What is special about community nursing in the Netherlands? How might this model be recast in other places?

Here are some references on Buurtzorg.

Buurtzorg Nederland (in Dutch. Google translates it remarkably well into English.)

Buurztorg USA

TEDxGeneva (2015) Jos de Blok - Healthcare: humanity above bureaucracy

The Commonwealth Fund (2015): Home Care by Self-Governing Nursing Teams: The Netherlands' Buurtzorg Model

Public World Consulting (2015): Repository of all things Buurtzorg

Frederic Laloux (2014): Reinventing Organizations (I first learned about Buurtzorg in this book on organizational paradigms. The information on Buurtzorg is spread throughout the book.).

AARP The Journal (2013): Buurtzorg Nederland: Nurses Leading the Way!

KPMG Insights (2013): Empowering caregivers

Interlinks (2010): Care in the neighbourhood: Better home care at reduced cost

ONC RFI Assessing Interoperability for MACRA - part 2 - ONC RFI

Here's a summary of the Request For Information from ONC. Much of what follows is loosely quoted from the RFI, a Request for Information regarding assessing interoperability for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Comments are due by 11:59pm ET on June 3, 2016.

MACRA and the ONC RFI both focus on measures of interoperability to be able to assess whether "widespread interoperability" has been achieved.

As background and on-going framework, the RFI makes frequent reference to the Shared Nationwide Interoperability Roadmap version 1.0.  

MACRA requires that the interoperability measures be established by July 1, 2016. This timeline effectively requires using metrics that are based on data which is currently being collected. Recognizing the limitations this time constraint creates, ONC also asks for comments about other metrics that might require more time to implement and would better measure the ambitious goal of widespread interoperability.

MACRA defines interoperability as the ability of two or more health information systems or components to:

1. Exchange clinical and other information and
2. Use the information that has been exchanged using common standards to provide access to longitudinal information for healthcare providers in order to facilitate coordinated care and improve patient outcomes.

The ONC RFI asks for comments in three areas:

1. Measure population and key components of interoperability that should be measured
2. Current data sources and potential metrics that address section 106(b)(1) of MACRA
3. Other data sources and metrics ONC should consider with respect to section 106(b)(1) of MACRA or interoperability measurement more broadly

[The text of MACRA Section 106(b)(1) is included in my earlier blog post.]

1. Measure population and key components of interoperability 

MACRA requires assessment of interoperability among meaningful EHR users and clinicians and health care providers with whom they exchange clinical and other information - their exchange partners. The exchange partners do not have to be meaningful EHR users themselves.

ONC is looking to measure interoperability across populations and settings beyond that required by MACRA, as they have previously laid out in the Interoperability Roadmap. In the RFI, they ask for comments on this broader measure population.

In keeping with the MACRA requirement, ONC further states that they are looking to measure not just exchange but use of information that has been exchanged.

ONC proposes a framework for use:

• Sending
• Receiving
• Finding (Request or Query)
• Integrating or Incorporating
• Subsequent use of information from other providers

ONC is asking for comments to cover the following: 

• Should the focus be limited to the MACRA requirements, Meaningful EHR users and their trading partners, or more broadly as laid out in the Interoperability Roadmap?
• How should participants in the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) be addressed?
• Do the ONC components of sending, receiving, finding, integrating and using information meet the exchange and use requirements of MACRA?
• Should the measurement be limited to certified EHR technology (C-EHR-T)? Measurement outside of C-EHR-T?

2. Available Data Sources and Potential Measures

ONC is looking at a combination of two perspectives

1. By provider, based on the proportion of Meaningful EHR users exchanging information with other clinicians and subsequently using that information
2. By transactions, based on the proportion of care transitions and encounters where information is electronically exchanged and used.

The data sources being considered include

• National surveys from stakeholder associations and federal entities
• American Hospital Association, Health IT Supplement Survey (hospitals)
• National Center for Health Statistics, National Electronic Health Record Survey (office-based physicians)
• CMS Medicare and Medicaid EHR Incentive Program

[As an aside, ONC maintains a Health IT Dashboard across a variety of data sources.]

2.1 Measures based on national survey data

• Strengths: The surveys measure exchange with outside providers. Multiple years of survey data are available.
• Weaknesses: self-reported data subject to bias and interpretation. Do not cover all providers. Do not provide transaction-level data.

Survey measures under consideration include

• Proportion of health care providers who are electronically sending, receiving, finding and integrating key health information
• Proportion of health care providers who use the information they receive from outside providers for clinical decisions
• Proportion of health care providers who electronically perform reconciliation of clinical information

The survey results may provide insight into enablers and barriers to interoperable exchange.

Questions about these survey measures:

• Do the survey questions adequately address both exchange and use?
• Could office-based physicians serve as adequate proxies for all Eligible Professions included in the EHR Incentive Program?
• Do the surveys provide necessary information to determine why information may not be widely exchanged?

2.2 Measures based on the CMS Medicare and Medicaid EHR Incentive Program

The EHR Incentive Program is administered differently for Medicare and Medicaid. Provider-level data is collected by Medicare, but the states report Medicaid data as an aggregate. Changes in the data reported by the states would be required to get more granular, provider-level data.

The interoperability objective of the EHR Incentive Program has limited scope, simple ensuring that a summary of care is sent, but not what was done by the receiving provider.

ONC recognizes limitations in these data sets and is looking for comment on the strengths and weaknesses of these data sets as well as other data sets that could be sources for measuring interoperability.

EHR Incentive Program measures under consideration include

• Proportion of transitions of care or referrals where a summary of care record was created and exchanged
• Proportion of transitions or referrals and patient encounters in which the health care provider receives, requests or queries for an electronic summary of care document (beginning in 2017)
• Proportion of transitions of care where medication reconciliation is performed
• Proportion of transitions or referrals where the health care provider performs clinical information reconciliation for medications, medication allergies and problem lists (beginning in 2017).

ONC states that electronic reconciliation may include a combination of electronic and non-electronic information, but that it serves as a proxy for assessing electronic exchange.

Questions about the use of EHR Incentive Program include

• Do the potential measures adequately measure exchange?
• Do the reconciliation-based measures adequately measure use?
• What alternative measures (for example, clinical quality measures) should ONC consider to assess use?
• Can state Medicaid agencies share health care provider-level data with CMS similar to how Medicare collects the data? If not, what are the barriers? What are some alternatives?
• These measures assess interoperability across encounters or transitions of care. Would it also be valuable to develop measures of interoperability across health care providers, even if limited to the Medicare EHR Incentive Program?

3. Other Data Sources and Measures

ONC is looking for additional potential data sources and measures. For example

• Medicare Fee for Service claims data
• Performance data from other programs
• Performance data from the Merit-Based Incentive Payment System (MIPS)
• Performance data from Alternative Payment Models (APMs)
• Electronically generated data from C-EHR-T or other systems

Overarching Questions

• Should ONC select measures from a single data source for consistency? Or leverage a variety of data sources? Would a combination of EHR Incentive Program and national survey data be appropriate? 
• What, if any, other data sources and measures should ONC consider?
• What measures might be provided by EHR vendors, Health Information Service Providers (HISPs), Health Information Exchange Organizations (HIEs, HIOs) or other organizations that enable exchange?
• What information might be added by using measures based on Medicare Fee for Service claims?
• Which are the highest priority measures to consider?
• Address comments within the December 31, 2018 deadline for evaluating interoperability.
• What might be useful for measuring interoperability more broadly?
• How should ONC define "widespread"? What can be in quantifiable terms?

ONC presented a summary of the RFI in a presentation to the Health IT Policy and Standards Committees on April 19, 2016.

ONC Interoperability Measure Framework with MACRA Focus