Partners HealthCare Innovation in Service to the Mission. Gary L. Gottlieb, MD, MBA

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1 Partners HealthCare Innovation in Service to the Mission Gary L. Gottlieb, MD, MBA

2 The Mission Patient Care Discovery Teaching Community

3 Our Clinical Objectives To provide the best health care to patients by: - Delivering the appropriate intervention - Doing so in the best way possible - Avoiding costly unnecessary activities But how can we learn which are the most appropriate interventions and the best way to deliver them?

4 Measuring Successful Clinical Care We want to optimize length and quality of life Save lives Measurable Improve quality of life Symptoms Functional Status How do we measure these? Mental Health

5 Measuring the Outcomes that Matter Most We have to ask the patient These are Patient Reported Outcomes We need to record them electronically To Quantify, Trend, Aggregate and Compare outcomes Analog capture as a Note insufficient Must be numerical Paper/pencil PROMs insufficient Interferes too much with workflow Must be in the EHR and in a database We need to use validated tools (PROMs) Interpretable/actionable Can be compared across providers/institutions

6 Partners PROMs Platform Next generation platform currently in production at The Center for Connected Health

7

8 Functional Status PROMIS-10 Physical Function Score

9 Symptoms and Quality of Life Seattle Angina Questionnaire (SAQ) Rose Dyspnea Scale Knee Injury and Osteoarthritis Scale (KOOS) International Prostate Symptom Score (IPSS) Sexual Health in Men (SHIM) Inflammatory Bowel Disease Questionnaire (IBDQ)

10 Mental Health Depression: PHQ2 PHQ9 Anxiety: GAD2 GAD7 PROMIS-10 Mental Health Score

11 Patient Response These are the questions I should have been asked all along. -- Patient after her first PROM Snapshot

12 The Story of Ms. L 60W with history of treated endometrial cancer, morbidly obese and recently diagnosed diabetes (April of this year) Frequent Flier across the continuum of care multiple specialties multiple visits per month Multiple musculoskeletal complaints, intractable pain ED visits for these complaints, Radiology, Labs ALL-STAR team of physicians BUT very little progress on improving her health Won t check her blood sugar Can t lose weight Can t seem to get control over her physical complaints

13 A Frequent Flier Primary Care Gynecologic Oncology Urology General Surgery Orthopedics Renal Ophthalmology Physical Therapy ED

14 Ms. L (continued) Partners patient for life (earliest notes 1991) morbidly obese back then Hundreds of encounters, hundreds of notes Demonstrated inability to maintain care plan Readily answers that she has clear mental health problems The BEST physicians, surgeons, nurses, case managers, physical therapists our system has to offer How many visits with a mental health professional? Psychiatrist: Zero Therapist: Zero Social Worker: Zero How many times was Depression or Anxiety on her problem list or addressed in her assessment and plan? Depression : Zero Anxiety : Zero How many mentions of mental health in her notes in any way? Zero

15 Improving Care for Individual Patients PROMs Principle Example in Diabetes Consistently ask the right questions Send answers to the clinician best suited to respond Monitor a patient whether they present to care or not PHQ9 Depression screening every 6 months Depression results automatically sent to practice social worker Web/Phone system collects PROMs every 6 months if not in clinic

16 strength, Patient-Reported or endurance. Outcomes A higher score Snapshot is better. Most people report a score between 15 and 78 with an average of Thank you for completing the Patient-Reported Outcomes Snapshot. Below are scores calculated from your answers. Your approximately score is reported in 50. comparison to the national average which includes people of all ages and all levels of health. Most people score between 15 and 78 Physical Function is one's ability to carry out various activities, ranging from everyday self-care to more challenging activities Mental that require health greater mobility, strength, or endurance. A higher score is better. Most people report a score between 15 and 78 with an average of approximately 50. refers to emotional symptoms including depression, anxiety or irritability, as well as joyfulness. It also refers to your satisfaction with social interactions and your impressions of yourself. A higher score is better. Most people report a score between 19 and 82 with an average of approximately 50. Mental health refers to emotional symptoms including depression, anxiety or irritability, as well as joyfulness. It also refers to your satisfaction with social interactions and your impressions of yourself. A higher score is better. Most people report a score between 19 and 82 with an average of approximately 50. Most people score between 15 and Most people score between 19 and 82 for Patients with Diabetes Most people score between 19 and 82 Anxiety is described as self-reported fear (fearfulness, panic), anxious misery (worry, dread), hyperarousal (tension, nervousness, restlessness). Most people report a score between 17 and 100 with Most people score above 17 an average of approximately 50 for normal level of anxiety. Anxiety is described as self-reported fear (fearfulness, panic), anxious misery (worry, dread), hyperarousal (tension, nervousness, restlessness). Most people report a score between 17 and 100 with an average of approximately 50 for normal level of anxiety Your view of your health is your own assessment of health status on a scale from 0 to 100. A higher score is better. Most people report a score between 40 and Most people score above 17 Most people score between 40 and 80

17 Improving Care for Individual Patients Mental Health Issues identified by PROMs Goal HgA1c < HgA1c Since 4/1/2012: HgA1c at target Not depressed Seeing nutritionist Considering Bariatric Surgery Only 1 visit to ED (fell) 4/1/11 6/1/11 8/1/11 10/1/11 12/1/11 2/1/12 4/1/12 6/1/12 8/1/12 10/1/12 12/1/12 2/1/13 4/1/13

18 PROMs Detecting Symptoms The Story of Frank C Mid-60s, retired police officer Bicuspid aortic valve since birth Known aortic stenosis for many years Not a complainer = challenging when symptoms are the trigger for lifesaving surgery PROMs asks about chest pain, shortness of breath: Scores of 0 or 1 are acceptable. Some of his answers: How often do you have chest pain at rest? 2 - Some of the Time How often do you have chest pain when you exercise? 2 - Some of the Time How often are you short of breath when walking less than one block? 2 - Some of the Time 0 Never 1 A Little of the Time 2 Some of the Time 3 Most of the Time 4 Always

19 Symptoms as the Reason for Intervention Symptoms predict rapid demise for patients with AS. UpToDate Surgery is curative. But it is only appropriate if you have symptoms.

20 ss of breath Patient-Reported Most people Outcomes score between 40 Snapshot and 80 for Patients having a Cardiac Surgery Procedure is difficulty Thank you for completing the Patient Reported Outcomes Snapshot. Below are scores calculated from your answers. and it can occur when Your sitting, score is reported in comparison to the national average which includes people of all ages and all levels of health. n flat, or exerting yourself. A re means less shortness Physical of Function is one's ability Initial to carry PROMs Surgery means no shortness out various of breath, activities, 20 ranging from everyday self-care to more challenging aximum shortness activities of breath. that require greater mobility, 8/17/2012 8/21/2012 ple Name score : between strength, 0 and 6. or endurance. A higher score is FRANK better. J Most PANTALONEMost people score between 0 and 6 people report a score between 15 and 78 with an average of it Date: 05/21/2013 approximately 50. Most people score between 15 and 78 Name: in is discomfort MGH or Cox pain 630 that you el in the middle of Mental your chest, health refers but to emotional e felt in nearby areas symptoms when including depression, anxiety or atient-reported rest. A lower irritability, score Chest means as well Outcomes as joyfulness. pain It also Snapshot resolved. for Patients having a Cardiac Surgery refers to your satisfaction with social t pain. 0 means no chest pain, 20 interactions and your impressions of Procedure aximum chest pain. yourself. Most A people higher score is better. Most ween ou for 0 and completing 3. people the report Patient a score between Reported 19 and Outcomes 82 Snapshot. Below are scores calculated from your answers. with an average of approximately Most 50. people score between 0 and 3 Most people score between 19 and 82 ore is reported in comparison to the national average which includes people of all ages and all levels of health. Your Next Steps to Better Health Function ur physical is function one's ability has improved to carry since your last visit and is now well above average - you're doing great! Your view of your health is your own s ur activities, mental health ranging has from improved since your last visit and is similar to most people - good job. assessment of health status a scale self-care to more from challenging 0 to 100. A higher score is better. hat require greater Most mobility, Functional status people report a score between 40 or endurance. A higher and 80. score is st people report a score improved between markedly. Most people score between 40 and 80 with an average of tely 50. Most people score between 15 and 78 Shortness of breath is difficulty breathing and it can occur when sitting, lying down flat, or exerting yourself. A 13 alth refers to emotional Copyright 2012, Quality Data Management and Partners HealthCare lower score means less shortness of including depression, breath. anxiety 0 means or no shortness of breath, 20 as well as joyfulness. means It Mood maximum also shortness and of breath. social our satisfaction with Most social people score between 0 and 6. Most people score between 0 and 6 s and your impressions of higher score is better. functioning Most improved port a score between Chest 19 pain and is 82 discomfort or pain that you erage of approximately usually feel in the middle of your chest, but concurrently. 50. Most people score between 19 and 82 can also be felt in nearby areas when exercising or at rest. A lower score means less chest pain. 0 means no chest pain, 20 means maximum chest pain. Most people w of your health score is your between own 0 and 3. Most people score between 0 and 3 nt of health status on a scale 1

21 Quality at Scale & Finding Best Practices Not just Frank C Impressive results in aggregate: 94% of cardiac surgery patients are chest pain free at 3 months. 88% of patients can exercise without chest pain at 3 months. BUT one clinic had consistently better Chest Pain scores in the post-operative period. Why? Initial investigation suggests this might be post-operative chest wall pain related to the surgical wound. What activities in that clinic are making the difference? Different case mix Different closure techniques Different pain regimen Different patient education Further investigation may yield Best Practices to help all clinics improve

22 Conclusion Patient-Reported Outcome Measures capture some of the outcomes most important to patients. Innovation must not further stretch our providers. Mobile technology allows data capture and reporting that fits seamlessly into workflow Adding the Patient s Voice to our clinical data through PROMs allows us to Improve care through better monitoring. Demonstrate where we are effectively providing care. Learn from variation to determine best practices.

23 The Mission Patient Care Discovery Teaching Community

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