Driving Higher Rates of Influenza Vaccine Administration: Education, Intervention and Impact at Central Texas VA Healthcare System

Transcription

1 Office of Continuing Medical Education Center for Collaborative and Interactive Technologies In partnership with: The Central Texas VA Healthcare System Twine Clinical, LLC Medical Impact Ventures Driving Higher Rates of Influenza Vaccine Administration: Education, Intervention and Impact at Central Texas VA Healthcare System Introduction/Background/History: Please indicate any relevant information that may be helpful for others to understand this initiative. The toll taken in lives lost, lost work days, and expenditures for medical treatment of influenza each year is staggering; estimated by the CDC at $8.7 billion in direct medical care costs, with indirect costs associated with lost work days accounting for an additional $6.2 billion annually. However, while the effectiveness of influenza vaccine varies from year to year based on the strains of the virus that predominate and the degree of vaccine match to predominate strains, there is clear evidence that influenza vaccination can help in curtailing the spread of the disease, reduce the severity of disease in persons exposed to the virus, and reduce the numbers of deaths and the aggregate costs associated with treating influenza. As a consequence major health policy and health service organizations, like the CDC and the Veterans Health Administration (VHA), respectively, strongly endorse yearly influenza vaccination as a strategy for promoting individual and public health and reducing risks from a potentially fatal disease. Data from the larger VHA system indicate that rates of influenza vaccination for targeted age groups 65% for the age age group and 77% for the 65 age group approximates performance levels for the Central Texas VA Healthcare system. Using electronic medical record (EMR) data, the Central Texas VA Healthcare System realized flu vaccination rates of 66% and 81% for the two age groupings of interest less than earlier established VA targets of 85% and 95%, respectively for these two groups. These data point to a substantive performance gap that is costly to both individuals and society, and that suggests a good deal of room for improvement. Precise reasons for and factors involved in these gaps in adherence to influenza vaccination recommendations within the VA system have not been investigated thoroughly, and at present only anecdotal data are available to suggest the reasons why higher rates of influenza vaccination rates are not documented in medical records of VA patients. Among the reasons for lower-than-targeted immunization rates suggested through anecdotal reports are: Patient concerns about the safety of the vaccines themselves; Provider reports of lack of visibility of vaccine history information in often very dense online medical record reports; Provider focus on presenting problems, often with inadequate attention to preventive services the sick patient visit; Absent or insufficient documentation of patient reasons for declining the influenza vaccine; Incomplete documentation of vaccination at outside facilities; and Time constraints that hinder efforts to explore fully the preventive health care needs of patients who often present with co-morbidities. Although these anecdotal data suggest factors that come into play with regard to deficiencies in performance around influenza vaccinations in the VA system, they do not provide evidence at a level of rigor sufficient to guide educational and/or quality improvement (QI)/performance improvement (PI) efforts designed to result in sustained performance change over time. As a result an initial aspect of this project will involve completing formative research using a mixed methods (i.e., a combination of qualitative and quantitative investigatory approaches) to identify barriers to change, as well as potential facilitating or mitigating factors, that will be a primary focus of the educational component and QI/PI component of the proposed project. Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 1

2 Initiative Goal: Please describe the overall goal of this initiative, including the patient population or disease area that this initiative will address. This activity is designed to improve VA clinicians (and when appropriate clinical support staff): awareness of system-wide targets for influenza vaccinations among veterans age 50 and older understanding of the potential seriousness of health risks posed by influenza in populations that often present with co-morbidities and complications typical of populations served through VHA facilities applications of strategies for overcoming patient resistance to influenza vaccination in the absence of clinical evidence contraindicating vaccine use application of strategies for managing work flow to overcome barriers to patient vaccination adoption of techniques for performance self-monitoring using extant reporting systems and technologies knowledge about sources of tested patient resources that can be used in promoting acceptance of influenza vaccine in resistant patients. Target Learners: Please describe the intended participants of this educational initiative, as well as the estimated number of learners. Clinicians working in clinical settings in the Central Texas VA Healthcare system will be the primary target learners for this initiative. This group is comprised primarily of 518 physicians, nurse practitioners, and physician assistants who, in 2011, processed over one million office visits made by 85,000 unique patients served through the system. The learner group is made up mostly of primary care providers (e.g., family medicine and internal medicine clinicians), but will be available to specialist physicians (e.g., pulmonologists, cardiologists, infectious disease specialists) who may see patients at risk from influenza. In the event that the results demonstrate expected improvements in influenza rates, a plan is being developed to expand the initiative to other VA facilities, possible expanding the benefits to reach thousands of clinicians and hundreds of thousands of patients. Collaborators: Please include a brief description of the role of each collaborator in the initiative. Baylor College of Medicine: develop and deliver the online CME content, evaluate educational outcomes, and issue CME credit to learners Twine Clinical, LLC: develop and implement the QI/PI project component, gather performance data, and analyze QI/PI data to characterize outcomes Central Texas VA Healthcare System: provide implementation site, recruit/support learners, facilitate educational and QI/PI component implementation, and assist or perform programming on the VA EHR platform if internal staff are required to do so Medical Impact Ventures: install and customize the QI/PI data platform, provide technical support for the platform, report on operational issues Educational Design: Please describe how this initiative will be designed, as well as the approximate time span of this initiative. This project will involve implementation of two components an educational component and a quality improvement/performance improvement (QI/PI) component that will be developed to operate in tandem to promote change in clinician performance in realizing system-wide targets for influenza vaccines among patients age 50 and older. The educational component will be based on formative investigation using focus groups of patients and key informant interviews of clinicians including lower performers. The educational component will be developed by Baylor College of Medicine (BCM) to address the educational needs of clinicians with regard to influenza and the health risks that it poses to patients, the importance of annual vaccines targeted to specific viral strains, understanding of factors that might suggest caution in administering a vaccine, and strategies for overcoming clinic system and patient barriers to vaccination. In addition, the learning content will focus on engaging patients in their own care, providing resources for use in increasing patient understanding of the potential benefits and harms associated with influenza vaccination, and supporting shared decision making involving the patient and the clinician in determining a course of action related to vaccination. The educational component will be designed for delivery via the Internet, and the learning components will be structured in a manner that facilitates access by desktop or laptop computer, smartphone, or other Web-enabled device (e.g., tablet). Through collaboration with the partners, the learning components will be integrated into the QI/PI component of the project in ways that prompt the clinician about opportunities for learning and learning resources for clinicians and Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 2

3 patients at the point of care or at other times and locales convenient to the learner. The QI/PI component will entail: 1) Implementing a clinical logic-driven automated point-of-care decision support tool within the electronic work flow of the system in a manner that is compatible with and operates seamlessly within the existing electronic medical record system (EMR); 2) initiating alerts within the EMR dashboard at the point-of-care when the patient is due for influenza immunization, individualizing alert activation based on EMR data and pointing clinicians to relevant learning and resource materials developed through the educational component; 3) completing, on a monthly basis EMR-derived performance assessments (based on EMR-derived performance metrics to be described later in this document) at the system, office, and individual clinician level and available to clinicians via computer, smartphone, tablet, etc. ; 4) linking clinicians to CME credit-bearing educational content tailored to help bridge performance gaps; and 5) using data from the EMR, and accessed only by authorized VA employees, to create registry lists of patients not identified as having been vaccinated for purposes of supporting outreach efforts, including deploying mobile vaccination teams to specific service sites and using media to inform patients about vaccinations and their importance. Assessment Project assessment will include evaluations of clinician learning and performance using Moore s levels up to 4 (competence), 5 (performance) and where possible 6 (patient health), 1 care unit performance, and Central Texas VA Healthcare System performance in influenza vaccination performance based on actual documentation of service delivery or documented reasons for non-delivery extracted from medical record data. The assessment of the educational component will begin with formative research (mentioned above) designed to determine what factors are important in influencing physician behaviors with regard to influenza vaccinations, what physicians identify as barriers to improving their performance in this area, and what they view as support services that would help them improve. Although some formative data will be drawn from the electronic medical record (EMR) in the form of current performance measures that will allow for establishing the current performance baseline before implementation begins, much of the data gathered for formative purposes will involve one-on-one interviews with clinicians and focus groups with patients. Once the intervention is underway, evaluation of learning and of application of learning in practice will be done using methods that have been developed and refined over more than a decade. These involve: Learner knowledge testing using short answer tests administered upon CME completion and developed with appropriate testing of the test items to accurately gauge knowledge mastery; Assessment of learner attitudes about influenza vaccinations using Likert scales and mechanisms to identify learner perceptions of the importance of influenza vaccinations and their administration to patients with specific characteristics (e.g., age, health history, co-morbidities); Assessment of learner confidence in implementing the performance change activities gauged using either a Likert-type or visual analog scale; Assessment of learner intentions to implement practice changes consistent with evidence-based recommendations, including anticipated barriers to change; and Follow-up assessment of self-reported actual changes in practices behaviors gathered via a two-month follow-up survey delivered using Follow-up assessments of anticipated barriers to change and those that were realized in practice. Assessment of QI/PI impacts will be done using methods developed and refined by personnel at Twine Clinical and their partners. These assessments primarily involve gathering data from the EMR that allow for determinations about the numbers of patients age 50 and above who are potential recipients of influenza vaccines, how many are receiving vaccines, and reasons cited (or not cited) in the EMR for not administering a vaccination. Using data from these sources, performance profiles will be developed for each clinician, each care unit (e.g., clinic or office where outpatient services are provided), and for the overall Central Texas VA Healthcare System. The data, which will not allow for identification of individual providers by anyone not authorized within the VA system, will allow individual clinicians to assess their own performance, compare their performance with that other clinicians within their unit, compare their performance with Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 3

4 that of the overall Central Texas system, and compare their performance to that of the larger VHA health care enterprise, including identification of clinician performance in light of overall performance targets established for the system. These comparisons were selected because they provide targeted clinicians with information relevant to their roles within the VHA system. Performance measures of this type are used in professional evaluations within the VHA system that influence promotions, advancements in federal grade, and ultimately earning potential within the VHA system. Data from other sources (e.g., the CDC) on influenza vaccination performance in other health care milieus will be shared with clinicians through learning activities available online, but these are not likely to have as large an impact on performance as are comparisons with peers within the VHA system. Assessment of the overall impact of the project will involve analyses of the data over project period and comparison against baseline data gathered before any intervention is implemented. For purposes of example, data from the flu season were used to indicate how these data will be used in assessing, in a summative fashion, the overall impact of these efforts in enhancing influenza vaccination rates within the Central Texas VA Healthcare System. In addition to providing graphic representations of project results and their impacts on vaccination rates, the data will be used in conjunction with accepted economic forecast data gleaned from the clinical and economics literature to project results in terms of: 1) numbers of patients vaccinated; 2) doses of vaccine delivered; 3) infections avoided; 4) hospitalizations avoided; 5) deaths avoided; and 6) aggregate dollars saved. These estimates will be generated for the Central Texas VA Healthcare System to include a projection of the change in performance across each of these parameters associated with the intervention described here. Interventions The interventions that will be implemented through this project include the following: Formative research with stakeholders within the Central Texas VA Healthcare System to gather data for use in educational content development; Creation of learning content specific to the needs (e.g., patient characteristics, system requirements, identified barriers) of targeted learners; Development of the Web-based delivery system for bringing learning opportunities to clinicians at diverse locales using varied access devices; Creation of a QI/PI process that capitalizes on extant technologies to bring relevant performance data directly to targeted users regardless of locale; Development and installation of a QI/PI platform that will be integrated into the extant EMR architecture in order to facilitate performance monitoring; Implementation of a reporting system that provides clinicians with regular updates, reinforcing learning and performance messaging identifying opportunities for improvement; Preparation and online accessibility to patient resources that can be used by clinicians on supporting shared decision making regarding the need for and potential benefits and harms associated with receiving an influenza vaccine; Outreach to patients using EMR-based data to target those in relevant age groupings who appear to have not had influenza vaccines and promoting awareness through media campaigns, and outreach including expanding access through use of a mobile service delivery unit; Data gathering relative to clinician performance over time in making progress toward targeted vaccination goals for the Central Texas location and for the larger VHA system; Assessment of learning achievements over time, including self-reported efforts to implement change in practice and barriers anticipated and realized to such change within the targeted practice settings; and Development of strategies and resources for promoting adoption of successful performance change strategies and resource support in other VA settings nationally, taking advantage of the common EMR resource and other shared resources to promote replication of strategies that work. Reassessment Reassessment is an integral component of all BCM-sponsored CME activities, and it involves follow-up with learners at two months post-participation in a learning activity to assess progress in implementing practice changes targeted through the educational activity. This provides one measure of longer-term Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 4

5 impact of the educational component. In addition, ongoing reassessment over the project period will be achieved through bi-monthly individualized performance reports, as well as reports based on service units and the larger Central Texas VA service system. These ongoing assessments (audit and feedback) are designed to reinforce learning and change. Summative assessment conducted at the end of the project will provide yet another assessment of overall performance, and it will identify specific interventions components that were most associated with success in fostering practice change, as well as aspects of the educational component and PI/QI component that may not have operated as planned. Systems Improvement Systems improvement is a major focus of this initiative. QI/PI activities will be implemented across primary care settings of the Central Texas VA Healthcare System. The QI process will be modeled after a similar and very successful initiative led by Twine Clinical and focusing on management of risk from venous thromboembolism (VTE) in patients with specific health conditions that place them at higher risk for VTE. The systems improvement approach to be employed in this project draws upon proven methods for fostering improvement, including capitalizing on technology-based clinical logic-driven performance information systems; conducting ongoing performance monitoring (auditing) and providing feedback on a routine basis to foster change and/or reinforce desired clinical behaviors; and optimizing access to performance data and educational resources by clinicians who can benefit from this information and these resources through use of technologies that are not platform dependent, but that allow for interaction with the data and the learning resources at times and in places convenient to targeted learners. The systems improvement methods developed for this project are based on similar successful initiatives that have been shown to produce desired results and that can be replicated and adjusted to accommodate the needs of the Central Texas VA Healthcare System. Patient Improvement Improved delivery of services to patients in the form of higher rates of influenza vaccine administration is the primary focus of this initiative. Tracking of influenza vaccination rates across all participating clinical service sites will be done in an ongoing basis using data captured in the EMR to assess the extent to which improved rates are realized. These data will represent actual reports of services delivered, and as such will provide a very reliable measure of patient improvement over the project duration. However, in addition to the quantitative data on patient improvement as reflected in increased rates of influenza vaccinations in the targeted populations, patient improvement efforts will involve creating resources that can be used to support patient-provider shared decision making relative to influenza vaccination. Development of these materials will be informed by formative research conducted in the early phases of the project. Follow-up with clinicians who work with patients will be done to determine if the resources were helpful in fostering patient engagement in discussions of influenza vaccination, if the resources were perceived as helping patient express concerns about taking the vaccine and/or allaying patient fears related to vaccine use, and if the resources might be improved through changes in message content, formatting or presentation, or other aspects of the resources themselves or the way in which they are used with specific groups of patients. Data around patient resources and their effectiveness will be gathered through interviews with clinicians and with patients during summative evaluation activities. Institutional Review Board (IRB) approval will be obtained from both the BCM and the Central Texas VA Healthcare System before any data collection involving interaction with patients is undertaken. If and as possible patient health as documented by influenza related disease and admissions will be examined to estimate change. Time Span Funding is requested to support 24 months of project activity. Activities related to promoting replication of project components, dissemination of outcomes and resources, and publication of results will be ongoing beyond the 24-month funding cycle, with the partners assuming the costs associated with these extended activities. Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 5

6 Publication Strategy: Please describe how educational outcomes results from this initiative will be disseminated. Dissemination is a major focus of all online CME activities developed and delivered through where this CME activity and related resources will be housed. The educational components, once developed, tested, and refined, will be made available to other clinicians in the VA system and in other health service delivery environments. After the project is completed and evaluation results are reported, the materials will remain posted on the Web site, and information about the availability of the resources will be posted prominently on Web site. Also, as discussed at some length in the application, the Central Texas VA Healthcare System is firmly committed to the fostering adoption of successful components of the VA project by the larger VA system. The leadership of the Central Texas VA Healthcare system has indicated willingness to champion adoption of the project by the larger system, and mechanisms are in place in the VHA system to facilitate broader adoption of clinical service enhancement mechanisms that have been shown to work. Also, deliberate actions will be taken to ensure that the results of the project are published in at least one peer reviewed journal. The partners in the project are experienced in developing manuscripts for consideration by peer-reviewed journals. In addition candidate journals like Health Services Research (HSR) that focus on investigations of health service improvement initiatives, logical candidate journals for publishing project results and related outcomes include the Journal of Military and Veterans Health (JMVH) and Federal Practitioner, a journal specifically focused on the needs and interests of clinical professionals working in the Department of Defense, the Public Health Service, as well as the VHA and/or the Journal for Continuing Education in the Health Professions. Publication will be a high priority for the project. Lastly, BCM will actively seek out funding from other sources, including industry support, federal and other public grants, and funding from professional societies and other groups that are involved in health care quality improvement. The intent of such efforts is to build upon lessons learned from the project, and to extend the benefits of project to other groups and constituencies that face similar related to control of infectious disease. BCM has a strong track record in securing ongoing funding for successful efforts, and it is anticipated that the results from this project will open numerous additional opportunities to extend the project beyond the Central Texas VA Healthcare System. Educational Quality/ Professional Practice Gaps Data gathered directly from the electronic medical record (EMR) reflect rates of influenza vaccinations (including those provided in non-va settings [e.g., retail pharmacies, other clinical care facilities]) rates that are below desired/target levels for patients served within Strategies Used to Identify Gaps (e.g., peer-reviewed published data, national consensus sources for clinical performance/ quality measures, chart audit/ehr data, medical claims data, etc.) Retrieval of actual influenza vaccination rate data from the electronic medical record system for the Central Texas VA Healthcare System System-wide data published by the Veterans Health Learning Objectives Enable learners to: characterize their own performance with regard to percentages of at-risk patients receiving influenza vaccinations in light of established vaccination targets for the VA system. ABS MOC Process (Part I-IV) and/or Core Competencies Addressed (e.g., IOM, ACGME, ABMS) Five of the six ABMS MOC Core Competencies will be addressed through project activities: Patient Care and Procedural Skills Medical Knowledge Educational Outcomes/ Measures (Please include Moore Level when appropriate) The project is designed to result in changes coinciding with Levels 3 through 5 and possibly Level 6 of Moore s expanded CME framework. These levels include intended improvements in: Declarative knowledge Strategies Used to Measure Outcomes (e.g., direct and objective performance assessments, chart audits, medical claims data, EHR data, disease screening audits, patient surveys, etc.) Formative Assessments of facilitators and barriers to vaccination: Clinician formative investigation will be conducted by interviews and focus groups and patient formative investigation of barriers and facilitators will be conducted by Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 6

7 the Central Texas VA Healthcare System, that could be associated with increased morbidity, mortality, and higher care costs to patients and to public and private payers of health care (competence and performance) Administration and available online Health research and policy setting organization(e.g., the CDC) recommendations Anecdotal reports from Central Texas VA facility personnel that will be confirmed and expanded on through formative research activities conducted using mixed method techniques identify factors within their practice settings that influence their own behaviors with regard to administering influenza vaccine to at-risk patients. describe strategies for overcoming patientand clinician-centric knowledge and attitudinal barriers, as well as environmental and process barriers, to influenza vaccine administration in their practice. demonstrate rates of influenza vaccine administration that approximate more closely target rates established for the VA system. Practice-based Learning and Improvement Interpersonal & Communication Skills Systems-based Practice In addition four of the six core competencies identified by the Institute of Medicine will be addressed through this project: Provide patientcentered care Employ evidencebased practice Apply quality improvement Utilize informatics The initiatives are also in alignment with ABMS MOC Parts: Part II Medical Knowledge Part IV Performance in practice (Level 3A) Procedural knowledge (Level 3B) Competence (Level 4) Performance (Level 5) Patient health (Level 6) where possible In addition, data may be sufficient to address learning assessments that move into Level 7, community health, since information on a defined community and their overall rates of influenza vaccination and projected reductions in morbidity, avoidable deaths, and reduced costs will be projected. However, the extent to which this last component of the framework can addressed with rigor will depend on the quality of the data generated, and no firm commitment to Level 7 outcomes will be made at this stage. focus groups. Summative evaluations: This will involve mixed methods designed to gather information of both a quantitative and qualitative nature. Knowledge Measurement: This will involve objective tests using multiple choice questions, as well as and short case vignettes. Attitudes, intentions to change, anticipated barriers to vaccination, self-reported perceptions of change at 2 months post-education, and realized barriers to change: Measures across these areas will be done using survey methods that have been employed, refined, and updated over a period of more than a decade. Objectives Measures of Performance: EHR data will be collected on vaccination rates, reasons for not performing vaccination. Reference Cited 1. Moore DE, Jr., Green JS, Gallis HA. Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. Winter 2009;29(1):1-15. Submitted to GSK Center for Medical Education by Baylor College of Medicine June 14, 2013 Page 7