The Dartmouth-Hitchcock Medical Center's Spine Center in Lebanon, N.H., opened in 1997 with a mission to provide patient-centered, comprehensive, coordinated, interdisciplinary and cost-effective care.
William Abdu, MD, MS, is the medical director of The Spine Center at Dartmouth-Hitchcock and a member of the DHMC Board of Governors. He is the principal investigator at DHMC for the Spine Patient Outcomes Research Trial and was a member of the web operations committee responsible for implementing the quality reports web page for the medical center.
Here, Dr. Abdu discusses the Spine Center's care model and how better data analysis will impact spine care in the future.
Clinical practice model: Multidisciplinary
"Everyone who walks through our door has an option for dealing with their problem," says Dr. Abdu. "We have a functional restoration project for patients with pain to work on their goals for improving function. We have a comprehensive 2 ½ week program where patients learn to do more than what they have been, and that has been very successful."
While some multidisciplinary programs include nurse navigators or other gatekeepers to direct patients to different specialists, the DHMC Spine Center program relies on the primary care physician's recommendation and funnels patients according to referrals. AS a result, patients who expect to see a surgeon are satisfied and the center acknowledges the referring physician's expertise.
"We've learned that it's hard to predict ahead of time to a significant degree what the patient will need," says Dr. Abdu. "So, if the primary care physician believes the patient needs surgical evaluation, that's where they start and once they get to the spine center we can make subsequent referrals. We are all in the same workspace so we have the opportunity to review patient imaging studies and get advice from others who are involved in their care."
Patients are given clinical decision making aids to review about their diagnosis, potential outcomes and risk. Dr. Abdu and his colleagues also distribute the primary outcomes papers from the SPORT trial and give patients access to patient data from Dartmouth-Hitchcock to review.
New payment model: ACO
DHMC has investigated bundled payments, but currently are not using them in spine. They are, however, participating in risk-based projects including a pioneer accountable care organization.
"We have low rates of spine surgery compared to the national averages and low rates of imaging studies because we practice evidence-based medicine," says Dr. Abdu. "We follow the guidelines from the SPORT trial. From a societal point of view, our costs are very low and we believe our rates are the right rates."
To track clinical data, the center constructed a home-built EMR several years ago and is currently switching to a national vendor. The EMR allows all medical professionals to record and access patient data. The patient also records feedback with validated outcomes survey.
"The beauty of the system so far is that it allows us to bridge the gap between clinical research and practice because now every data point becomes part of the EMR and in the future we'll be able to use them much more to our advantage in analyzing individuals or populations of patients for benchmarks," says Dr. Abdu. "The patients can give feedback from home on the internet or here at the clinic. The surveys allow us to gather information about how the patient is doing physically and psychologically to provide insight you don't traditionally have access to."
Future initiatives: Defining value
DHMC is currently participating in a high value care initiative that includes spine patients as a top priority. Dr. Abdu and his colleagues are working with a group to examine best practices and define better value.
"We are excited about where that will go in the future," says Dr. Abdu. "The data will drive where we go. Right now we don't have the data we want to know where to go with our procedures. That's why we are working with the EMR and high value collaborative to benchmark the outcomes."
He also hopes to see national spine organizations develop functional registries devoted to spine to pool resources that would indicate when patients would have better outcomes with non-operative treatment than spine surgery and vice versa.
"We may be spending billions of dollars on procedures that don't have value," he says. "We don't know that for sure but we need to find that out. We're really excited about that. This way every patient encounter becomes a datapoint and every datapoint can be analyzed and used to teach us what works and what doesn't work."
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