The Role of Research in Integrated Healthcare Systems: The HMO Research Network

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The American Journal of Managed Care, September 2004, Volume 10, Issue 9

Science is the basis of medicine. Good science leads to better decisions and more effective systems to support those decisions. Most individuals associate science primarily with academic institutions. However, top-quality research relevant to managing the health of populations and the care of specific clinical conditions is increasingly being carried out by investigators working in integrated healthcare systems. This introduction outlines the activities of the HMO Research Network, whose researchers have made and continue to make important contributions to the field of health research. Its objective is to inform readers of the activities and value of systems-based health research. We describe the importance and extent of the research conducted by HMO Research Network members, as well as the advantages of conducting research in such settings.

(Am J Manag Care. 2004;10:643-648)

Integrated care health maintenance organizations (HMOs) provide an ideal mix of population base, electronic medical and financial databases, and longitudinal observation for much health research. They are especially well situated for research addressing issues such as the costs and effectiveness of prevention and treatment practices, organization of care, secular trends in diseases, and relative priorities on how to apportion scarce resources. The HMO Research Network (HMORN) is carrying out research that is crucial to improving the quality, availability, and effectiveness of healthcare. The 13 HMORN research centers perform 90% of all research conducted by HMOs with formal research centers.1

The first integrated care system research center was founded in 1961, and the advantages of conducting research in such environments led to the formation of additional centers. In 1994, these centers established a professional organization, the HMORN, to encourage high-quality, public domain research within HMOs. The 13 geographically dispersed HMORN centers represent integrated care systems with approximately 13 million members. Collectively, they study a broad range of health issues. Research conducted by member organizations is in the public domain, and results of their studies are published in approximately 1200 peer-reviewed publications annually.

Members of the HMORN include several exclusively prepaid group practices, several mixed-model HMOs, and 1 independent practice association HMO. These centers vary in structure and organization, as do their parent health plans. However, they have common access to a defined population of members and data regarding these members, much of it electronically available, which permits longitudinal evaluation of health practices. Their placement within large health systems makes rigorous evaluation of alternative approaches to care feasible. The members of the HMORN have electronic medical records systems or are in the process of installing them. As they come online, these systems will provide unprecedented opportunities to evaluate alternative approaches to treatment, longterm outcomes of care, cost-effectiveness and cost-benefits, rare disease epidemiology and treatment, and many other critical healthcare issues.

Table 1 lists the members of the HMORN and selected characteristics of their research centers. Each center is funded primarily through competitive grants and contracts from federal, foundation, and proprietary funding organizations. The annual HMORN scientific meeting combines presentations of scientific papers with seminars on how to develop collaborative research studies that permit the member organizations to address research questions that cannot be carried out within single healthcare organizations.

Research from the HMORN centers has affected the organization, quality of care, federal and state health policies and regulations, plan benefits, and many other aspects of healthcare delivery. The studies summarized in Table 2 are some examples of HMORN projects that have influenced healthcare, health law, and health policy. At any given point in time, the members of the HMORN are conducting more than 2000 research studies.

The HMORN research centers have also been key participants in some of the nation's most important multisite National Institutes of Health studies, including the Multiple Risk Factor Intervention Trial,24 Systolic Hypertension in the Elderly Program,25 Study of Osteoporotic Fractures,26 Trials of Hypertension Prevention,27 Beta-Blocker Heart Attack Trial,28 Women's Health Initiative,29 Dietary Approaches to Stop Hypertension,10 and others. The HMORN participates in 5 federally funded, national, multisite research networks (Table 3): Cancer Research Network, Center for Education and Research in Therapeutics, Cancer Care Outcomes Research and Surveillance, Integrated Delivery System Research Network, and Vaccine Safety Datalink. The HMORN also has formal partnerships with the American Association of Health Plans and the Alliance of Community Health Plans for the conduct of public health research.

BENEFITS OF RESEARCH IN INTEGRATED CARE SYSTEMS

Integrated care research has unique access to entire populations, comprehensive data systems, and realworld delivery issues.

Study Populations

Defined Population Base. Defined populations of plan members permit long-term observation, with numerators (the sick) and denominators (the population). This permits the estimation of rates that are essential to understanding changes over time, cause-and-effect relationships, and factors associated with disease incidence and treatment outcome.

Stable Population Base. In integrated care systems, many cohorts exist naturally, and data on those cohorts are present in electronic form. This permits long-term cohort studies to be conducted retrospectively and at reasonable cost. The experiences of health plan members can identify secular trends, outcomes of system interventions, and risk factors and their interactions.

High Volunteer Rates. Health plan members are more likely to respond to an appeal for research volunteers when that appeal is from their own health plan. Recruitment and retention rates from integrated care system research cohorts are substantially higher than those from community recruitment and, therefore, afford high external validity. Representativeness. Large, often nonprofit, integrated care systems are usually demographically representative of their geographic populations, enabling findings that are generalizable to other defined populations.

Diverse Ethnicity. The members of the HMORN are diverse ethnically, culturally, and geographically, facilitating studies that address racial and other disparities and are generalizable to other populations.

Data Systems and Sources

Comprehensive Medical Records. Integrated care systems maintain medical records that may include information across inpatient and outpatient settings and different clinical providers, thus enabling comprehensive pictures of a population's health and healthcare use.

Electronic Data Facilitating Preliminary and Rare Disease Studies. Successful research requires preliminary data, often collected at considerable expense, time, and energy. Comprehensive data information systems in integrated care can serve much of this need. Many research ideas can be developed without pilot funds beyond those required for retrieving and analyzing data from existing databases.

Electronic data permit identification of less common diseases and treatments. Accessing 5 of 11 Cancer Research Network sites identified 132 580 cancer cases for one study,30 including 2680 pancreatic cancers, 2788 ovarian cancers, 2986 bladder cancers, and 5147 non-Hodgkin lymphomas.

Automated Medical Records. Perhaps the greatest innovation in medical care in the 21st century will grow out of the shift to electronic medical records. Electronic medical records systems have the capacity to facilitate use of consensus guidelines, minimize drug interactions and reactions, design prevention and care plans that are individually tailored, and provide extraordinary epidemiologic opportunities to observe disease trends, disease outcomes, and disease or risk factor associations. They will provide health economists the opportunity to study the relative costs and effectiveness of different approaches to care and will assist in designing and evaluating alternative structures for delivering care.

Translation Into Practice

Ability To Test Efficacy of Care Alternatives. Large integrated delivery systems often experiment with innovations in delivery. These innovations can be rigorously evaluated when trained researchers are involved.

Location Inside Healthcare Systems. The presence of the HMORN centers within healthcare systems encourages interactions and critical partnerships among researchers, clinicians, and managers early in the research process. This promotes implementation and testing in real-world settings. The perspectives of managers, clinicians, and staff often lead researchers to modify initial assumptions about what will or will not work within their systems, nurturing the development of functional innovations that can be successfully translated into practice. Facilitating research serves the clinicians, the patients, and, ultimately, the entire system. These partnerships create an environment that translates research findings into practice.

COMMENT

The US healthcare system faces serious challenges in the years ahead.31,32 Meeting clinical and economic goals is difficult because of complex reimbursement processes, perverse incentives that encourage excessive services, a preoccupation with expensive technologies, the inability to stop doing what does not work, a legal system that encourages faultfinding instead of remedial action, and the lack of a systematic means for learning from mistakes. Research within integrated care systems can develop new concepts and methods that define basic goals, produce practical tools that document the nature and magnitude of problems and outcomes, evaluate strategies and interventions for improving care, and assess new models, programs, and systems.33 These systems are also ideal venues for studies that examine the relative benefits and priorities for using healthcare resources.

In integrated care systems, key factors intersect. Economics pushes those systems to avoid unnecessary services; quality assurance processes such as the Healthplan Employer Data Information Set direct them toward quality improvement; and the clinical setting requires them to take into account the real-world realities of delivering care. These settings are ideal for testing and evaluating preventive and treatment services.

The HMORN recognizes that access to these extraordinary resources is a public trust. The HMORN vision is to "transform US health care through research on the diverse populations served by integrated health systems." It strives to achieve this goal through public domain research that serves the public interest. The work of the research centers of the HMORN supports good decision making by clinicians, managers, policy makers, and members of their respective health plans. Because integrated care systems are such an ideal setting in which to conduct many types of applied medical research, the larger integrated care delivery systems have a social obligation to support and participate in such research. High-quality medical care requires high-quality research and evaluation. Clinicians, managers, and the public must come to view research as an integral part of what health systems do. The design of data systems in large healthcare organizations needs to include considerations relating to research and evaluation. University researchers should develop closer partnerships with their health system research colleagues to improve the quality and quantity of research in these settings,34 and we welcome such collaborations.

Acknowledgments

We thank the many persons who contributed information for inclusion in this article, including:

Jerry Gurwitz, MD, Diana Petitti, MD, Robert S. Zeiger, MD, Barbara Stoddart, MBA, Arne Beck, PhD, Paul Barrett, MD, Maggie Gunter, PhD, Eric Larson, MD, Andy Nelson, MPH, Kate Rardin, MPH, Barbara Olson Bullis, MA, Deborah Shatin, PhD, Mary Durham, PhD, Don Freel, MBA, Ryne Lee, MBA, Richard Platt, MD, MSc, and Ann Plasso, BA.

From the Center for Health Research, Kaiser Permanente, Hawaii, Honolulu (TMV); Henry Ford Health System, Detroit, Mich (JE-L); Kaiser Permanente, Atlanta, Georgia, (DT); and Group Health Cooperative, Seattle, Wash (SMG).

Address correspondence to: Thomas M. Vogt, MD, MPH, FAHA, Center for Health Research, Kaiser Permanente, Hawaii, 501 Alakawa Street, Suite 201, Honolulu, HI 96817. E-mail: tom.m.vogt@kp.org.

1.Nelson AF, Quiter ES, Solberg LI. The state of research within managed care plans: 1997 survey. Health Aff (Millwood). 1998;17(1):128-138.

2. Colombo TJ, Saward EW, Greenlick MR. The integration of an OEO health program into a prepaid comprehensive group practice plan. Am J Public Health. 1969;59:641-650.

3. Greenlick M. Medical service to poverty groups. In: Somers A, ed. The Kaiser Permanente Medical Care Program: A Symposium. New York, NY: Commonwealth Fund; 1971:138-151.

4. Greenlick MR, Lamb SJ, Carpenter TM Jr, et al. Kaiser-Permanente's Medicare Plus Project: a successful Medicare prospective payment demonstration. Health Care Financ Rev. 1983;4:85-97.

5. Black SB, Shinefield HR, Fireman B, Hiatt R, Polen M, Vittinghoff E, Northern California Kaiser Permanente Vaccine Study Center Pediatrics Group. Efficacy in infancy of oligosaccharide conjugate Haemophilus influenzae type b (HbOC) vaccine in a United States population of 61 080 children. Pediatr Infect Dis J. 1991;10:97-104.

6. Mullooly JP, Bennett MD, Hornbrook MC, et al. Influenza vaccination program for elderly persons: cost-effectiveness in a health maintenance organization. Ann Intern Med. 1994;121:947-952.

7. Selby JV, Friedman GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med. 1992;326:653-657.

8. Hollis JF, Lichtenstein E, Vogt TM, Stevens VJ, Biglan A. Nurse-assisted counseling for smokers in primary care. Ann Intern Med. 1993;118:521-525.

9. Hollis JF, Vogt TM, Stevens VJ, Severson H, Biglan A, Lichtenstein E. The Tobacco Reduction and Cancer Control program (TRACC): team approaches to counseling in medical and dental settings. In: Tobacco and the Clinician: Interventions for Medical and Dental Practice. Washington, DC: US Dept of Health and Human Services, Public Health Service; 1994. NIH publication 94-3693. NCI Smoking and Control Monograph 5.

10. Appel, LJ, Moore TJ, Obarzanek E, et al, DASH Collaborative Research Group. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med. 1997;336:1117-1124.

11. Moore TJ, Jenkins M. The DASH Diet for Hypertension: Lower Your Blood Pressure in 14 Days—Without Drugs. New York, NY: The Free Press; 2001.

12. Friedman GD, Collen MF, Fireman BH. Multiphasic Health Checkup Evaluation: a 16-year follow-up. J Chronic Dis. 1986;39(6):453-463.

13. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289:1106-1116.

14. Ownby DR, Johnson CC, Peterson EL. Exposure to dogs and cats during the first year of life and the risk of allergic sensitization at 6 to 7 years of age. JAMA. 2002;288:963-972.

15. Flamm BL, Lim OW, Jones C, Fallon D, Newman LA, Mantis JK. Vaginal birth after cesarean section: results of a multicenter study. Am J Obstet Gynecol. 1988;158:1079-1084.

16. Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320:569-571.

17. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries: a case-control study. JAMA. 1996;276:1968-1973.

18. Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;334:1362-1366.

19. Maciosek MV, Coffield AB, McGinnis JM, et al. Methods for priority setting among clinical preventive services. Am J Prev Med. 2001;21:10-19.

20. Coffield AB, Maciosek MV, McGinnis JM, et al. Priorities among recommended clinical preventive services. Am J Prev Med. 2001;21:1-9.

21. Vogt TM, Aickin M, Ahmed F, Schmidt M. The Prevention Index: using technology to improve quality assessment. Health Serv Res. 2004;39:511-530.

22. Nerenz DR, Bonham VL, Green-Weir R, Joseph C, Gunter M. Eliminating racial/ethnic disparities in health care: can health plans generate reports? Health Aff (Millwood). 2002;21(3):259-263.

23. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic. J Am Geriatr Soc. 1997;45:543-549.

24. Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor Intervention Trial: risk factor changes and mortality results. JAMA. 1982;248:1465-1477.

25. Perry HM Jr, Smith WM, McDonald RH, et al. Morbidity and mortality in the Systolic Hypertension in the Elderly Program (SHEP) pilot study. Stroke. 1989;20:4-13.

26. Bauer DC, Gluer CC, Cauley JA, et al, Study of Osteoporotic Fractures Research Group. Broadband ultrasound attenuation predicts fractures strongly and independently of densitometry in older women: a prospective study. Arch Intern Med. 1997;157:629-634.

27. Stevens VJ, Corrigan SA, Obarzanek E, et al, TOHP Collaborative Research Group. Weight loss intervention in phase 1 of the Trials of Hypertension Prevention. Arch Intern Med. 1993;153:849-858.

28. Beta-Blocker Heart Attack Study Group. The Beta-Blocker Heart Attack Trial. JAMA. 1981;246:2073-2074.

29. Shumaker SA, Reboussin BA, Espeland MA, et al. The Women's Health Initiative Memory Study (WHIMS): a trial of the effect of estrogen therapy in preventing and slowing the progression of dementia. Control Clin Trials. 1998;19:604-621.

30. Field TS, Cernieux J, Buist D, et al. Retention of enrollees following a cancer diagnosis within health maintenance organizations in the Cancer Research Network. J Natl Cancer Inst. 2004;96:148-152.

31. Kennedy D. When the price is wrong [editorial]. Science. 2003;301:895.

32. Bloom F. Science as a way of life: perplexities of a physician-scientist. Science. 2003;300:1680-1685.

33. Feldman PH, Kane RL. Strengthening research to improve the practice and management of long-term care. Milbank Q. 2003;81:179-220.

34. Mechanic RE, Dobson A. The impact of managed care on clinical research: a preliminary investigation. Health Aff (Millwood). 1996;15(3):72-89.