Transitions and Health Information Technology

Transcription

1 Transitions and Health Information Technology David A. Dorr, MD, MS ( dorrd@ohsu.edu ) Associate Professor / Vice Chair Department of Medical Informatics & Clinical Epidemiology General Internal Medicine & Geriatrics OHSU Funding for this research from The Gordon and Betty Moore Foundation, The John A. Hartford Foundation, AHRQ, Intermountain Healthcare, and the National Library of Medicine More information at caremanagementplus.org A year in a life Ms. Viera a 75-year-old woman with diabetes, systolic hypertension, mild congestive heart failure, arthritis and recently diagnosed dementia. What does her health and life look like over a year? 1

2 The Past: Heroism in the face of multiple illnesses Multiple diseases increase risk and coordination exponentially (5+ : 90 x risk of hospitalization; 10x prescriptions; 13 providers vs. 2) Patients with multiple illnesses better process quality scores but worse preventable hospitalizations Bodenheimer, JAMA;C. Boyd, JAMA; Wolff, JAGS; Dorr, JAGS The Norm: Uncoordinated giver Specialists (7 ongoing) spouse Ms. Viera 1 Primary Team BP Pain Chol. Bones Diabetes Dorr 2009, Frontiers of Engineering 2

3 Ms. Viera is HOSPITALIZED giver Current Medication List to Hospital Team giver with handwritten list Specialists (7 ongoing) spouse Ms. Viera 1 Primary Team Hospital Team AND request by phone or fax to primary care team!! BP Pain Chol. Bones Diabetes STOP Dorr 2009, Frontiers of Engineering Ms. Viera is DISCHARGED giver plan back to patient and Primary Specialists (7 ongoing) Hospital Team Handwritten discharge form Ms. Viera giver with handwritten list!! 1 Primary Team Faxed discharge summary to Primary ; Call if Hospital Team exceptional Discharge summary: +7 days; Appt time +3 days BP Pain Chol. Bones Diabetes Dorr 2009, Frontiers of Engineering 3

4 Ms. Viera DEVELOPS SYMPTOMS ED Team giver ED needs immediate treat decision giver with handwritten list!! Specialists (7 ongoing) Ms. Viera 1 Primary Team Call on-call physician for practice Is Electronic Health Record list up to date? BP Pain Chol. Bones Diabetes Dorr 2009, Frontiers of Engineering OUTCOME: (RE)Hospitalization due to system failure Ms. Viera SEES 3 SPECIALISTS Specialists (7 ongoing) giver Ms. Viera 2 of 3 send reports to the PCP office with plan; these reports are duly filed. When seen by the PCP, she can t remember treatment changes. 1 Primary Team BP Pain Chol. Bones Diabetes Dorr 2009, Frontiers of Engineering 4

5 Problems identified with the old system Lack of collaboration between patient/family and health care team Lack of reliable, completed communication 50% of the time... Patients don t understand the plan Can t identify what was communicated Don t feel included in the plan Failure to prioritize needs Bodenheimer, 2008 Intervention: Management Plus Dissemination to over 350 clinical teams Larger infrastructure: Electronic Health Record, quality focus Ander, 2004 ; Woolf, 2002; Baron, 2007, 2010; Werner

6 Cognition HTN CHF Aches Diabetes giver Specialists (7 ongoing) Primary Team spouse Ms. Viera Primary Team Manager giver Ms. Viera HIT spouse Specialists (7 ongoing) Cognition HTN CHF Aches Diabetes Summary of studies from CM+ The TRIPLE aim of health care Improved diabetes, depression outcomes Improved patient, care manager, and provider experience Reduction in hospitalizations, cost 6

7 Dissemination: 750 people in >350 clinical teams SEARHC OHSU (9 teams) PeaceHealth (20 teams) NEQCA Intermountain (16 teams) SFHP ( sites) Colorado Access (16 teams) Health Partners (2 sites) Daughters of Charity (5 teams) Health Information Technology at transitions 1. HIT is 20% of the solution / 80% is team and system redesign (socio- part of sociotechnical) 2. Identify the low-hanging fruit (e.g., complex care / high risk transitions / established relationships) 3. Be aware of the lazy busy user model 4. Design your systems to quickly provide SOMETHING useful (not everything at once) 5. COLLABORATE with users (shared teaching / iteration of design and keeping it simple) 7

8 Integrated Coordination Information System (ICCIS) Randomized Trial Needs and requirements; build ICCIS Management Training Randomize by clinic Goals for IT use All clinics participate; both quality measurement and coordination of care taught Medical Home Based Arm1. Coordination of care 1.1 Complete assessment / care plan 1.2 Education (self-management, etc) 1.3. Goal setting and follow-up 1.4 Communication 1.5 Motivation / Coaching 1.6 Completing CM services Data for patients with complex healthcare needs Arm2. Quality Choose 5 of 20 quality measures Prevention, Diabetes, Vulnerable Elderly, Asthma, Congestive Heart Failure PCPI/NQF approved Evaluation: Cost of patient illness / Patient Satisfaction and Relationship to implementation and use of information technology People can create HIT that implements flexible algorithms in a USEFUL way Additional Management elements requested from 7 teams with EHRs Combine the peral targeted and flexible based on values Make it efficient population management functions Help remind me about the highest priorities 8

9 IT component Provides a means to track and enroll high risk patients. The tickler is a centralized reminder list of tasks and communications that were proactively planned, but incomplete, which allows population-based tasks to be merged with individual encounter tasks into one easy-to-use list. 9

10 ICCIS Interactive Quality Reports Offers the ability to document exclusions at multiple levels and generate targeted population-based review cycles, which avoid the problems caused by static quality reports and allow providers to efficiently focus outreach efforts on high risk populations. Core catalyst : how ICCIS solves a particular challenge in Health Information Exchange Many Health Information Exchange efforts falter at the value proposition versus technical and legal requirements With ICCIS, we mapped 7 different EHRs to a population management system / registry (PracticePartner, Epic, Centricity, TouchWorks, Intergy, CPRS, eclinicalworks) We limited the exchange to targeted areas and pragmatic approaches to maximize value Starting as research, legal issues may be easier but operations for care coordination and quality improvement are covered under HIPAA 10

11 Were the incentives effective? Absolute adherence change for study arms Length of intervention (quarters) Incentives: Coordination activities Arms reimbursed Both Arm 1 only Arm 2 only Activity All clinics Coord to Quality ratio managed patients :1 Sharing patient summaries 819 1:3 Completed encounters :1 Assessment :1 Education :1 Goals 202 1:1.3 Communication :1 Motivational Interviewing :3 Quality encounters :1 Quality measure query runs 03 2:1 Quality measure increases 119 1:1.3 11

12 What did we learn and what is next? People will use an IT system for coordination if the incentives are right and it meets their needs (ICCIS) Next: Health Reform and incentive programs are COMPLETELY changing the way you could use HIT for transitions Meaningful Use Coordination requirements Transitions and the CCD -> CCDA Incentives for Coordination Health Reform changes Meaningful Use Coordination Stage 1: Be able to exchange a Continuity of Document (but don t do anything with it) Attest to exchanging for certain public health functions (immunizations, surveillance) Stage 2: EHRs must be able to produce and interpret structured document in Consolidated Clinical Document Architecture (CCDA)

13 Continuity of Document -> CCDA Structured clinical document partially machine interpretable Main categories of patient data represented Specified coding for MU Stage 2 Demographics Allergies Medications Diagnoses Results, Interventions, Plan, etc Transitions and the CCD Transitions has the most models / initiatives for Hospital to Home IT was a late addition to the effort Most newer models focus on the CCD but try to solve Who will receive it? - Team What should they do? Coleman, CHCF What should be in it? Massachusetts HIE How can it help with prioritization? 13

14 Ms. Viera is DISCHARGED and HAS FOLLOW-UP VISIT giver Specialists (7 ongoing) Hospital Team Adapted from Coleman, CHCF Printed discharge form Ms. Viera Visit within x days 1 Primary Team Continuity of Document Sent Primary Visit Post-discharge Planning Red flags from hospitalization (undone tests, self monitoring) Elicitation of Goals and Values; short-term goal setting Medication reconciliation and consideration of in-home review Prioritization of needs ; step outside normal medical Review and revise care plan Social support and safety; community connections What should be in CCDA and who should receive it? 175 elements for CCDA from IMPACT in MAHEALTH Depends on Context / need %20Garber,%20O'Malley.pdf 28 14

15 Need to create use cases like LAND and SEE (MA HEALTH) pdf Incentives for Coordination Complex Coordination fees At transitions For longitudinal Patient Centered Medical Home models New era of taking risk and rewarding for outcomes Accountable Organizations Bundled payments for surgery Shared Savings in Comprehensive Primary 15

16 Coordination Incentives: New codes for posthospital care coordination fees giver Call within 48 hours Specialists (7 ongoing) Hospital Team Day 0: Discharge + 48 hours: call Printed discharge form HIT: ADT to PCP team Ms. Viera Visit within x days +7 or +30 days: visit 1 Primary Team Send D/C summary Primary team NEEDS IT notification ASAP HIT: EHR track call and visit for billing Dorr 2009, Frontiers of Engineering HIT and Health Reform Goals of health reform are the triple aim: improved population health, improved patient experience, reduced costs Has it been shown? Large integrated systems, in nonrandomized trials, have shown substantial savings - $1.5 to $3 / $1 invested (Geisinger, GroupHealth, Intermountain Healthcare CM+) 1 but other trials have shown mixed effects National Demonstration Project mixed outcomes 2 Physician Group Practice CMS demonstration (University of Michigan, Marshfield clinic cost savings, others mixed) 3 How can HIT help us to replicate the successes? 4 1 Reid, Health Affairs, May 2010; Dorr, JAGS, 2008; 2 Nutting, AFM, 2009; Crabtree, AFM, 2010; 3 PGP: 4 Fields, Health Affairs,

17 Health Reform efforts involving HIT: replicating successes The amount of technical assistance needed is usually far more than provided At-the-elbow support Practice facilitation focused on team engagement Collaboration with users and peers Encourage transformation Focus on high value elements Less from previous studies Voice of your users This area - Dissemination and Implementation science - is still in its infancy Transforming Outcomes for Patients through Medical home Evaluation and redesign (TOPMED) Cluster Randomized Controlled Trial in 8 clinics Patient Centered Primary Home evaluation, Training Intervention Incentives with multiplier Focused Practice Support Rapid cycle IT improvement Control Same incentives without multiplier General Practice Support Same IT components Funded by the Gordon and Betty Moore Foundation 17

18 Oregon Health & Science University David Dorr, PI ( dorrd@ohsu.edu ) Susan Butterworth Marsha Pierre-Jacques Williams Kimberley Gray Jesse Wagner Doug Rhoton Intermountain Healthcare Cherie Brunker, Co-PI (UU) Liza Widmier Ann Larsen Iona Thraen For more information: ICCIS demo: 18