QI and the EMR: Identifying and Addressing Disparities in Chronic Disease Management

Transcription

1 QI and the EMR: Identifying and Addressing Disparities in Chronic Disease Management Thomas D. Sequist, MD, MPH Assistant Professor of Medicine and Health Care Policy at Brigham and Women's Hospital and Harvard Medical School Louis J. Capponi, MD, Chief Medical Informatics Officer at New York City Health and Hospital Corporation Rand David, MD Director of the Department of Ambulatory Care and Associate Professor of Medicine at Mount Sinai School of Medicine Joseph R. Betancourt, MD, MPH Director, The Disparities Solutions Center at Massachusetts General Hospital Moderator

2 Racial Disparities in Diabetes Care: Physician Performance Reporting Thomas D. Sequist, MD MPH Brigham and Women s Hospital Harvard Vanguard Medical Associates Harvard Medical School

3 Harvard Vanguard Medical Associates Multi-specialty group practice 14 ambulatory health centers 300,000 adult patients - 15,000 diabetic patients 130 primary care physicians

4 HVMA Diabetes Care Model Clinical Information Systems Electronic medical record Computerized alerts Population Management Centralized patient mailings Diabetes dashboards Patient Engagement Primary care teams Chronic disease visits Improved Diabetes Care

5 Diabetes Dashboard

6 Annual LDL Cholesterol Monitoring 100 % Receiving Annual LDL Testing White Black Sequist; Arch Intern Med 2006

7 LDL Cholesterol Control 100 % Acheiving LDL < 130 mg/dl White Black Sequist; Arch Intern Med 2006

8 Why Focus on Physicians? In the trenches Importance of patient experiences and relationships Lack of awareness

9 Lurie N, Circulation 2005 The Not Me Phenomenon Do racial disparities exist in % Yes Health care Cardiac care Your hospital Your patients

10 Intervention Design Improve collection of race data Increase awareness Provider performance reports Provide tools Cultural competency training

11 Collecting Patient Race and Ethnicity

12 Provider Performance Report

13 Cultural Competency Training 2 day course for nurse practitioners 1 day course for physicians Small group discussions Community tours

14 Evaluation Plan Randomized, controlled trial 95 primary care doctors 35 nurse practitioners and physician assistants 8 health centers 6,000 patients 12 month intervention period (06/2007 to 05/2008)

15 Funding Acknowledgement Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation

16 New York City Health & Hospitals Corporation 11 Hospitals 6 DTC s 4 LTC s 80 Clinics Home Care MetroPlus

17 Business Case Heavy burden of chronic illness at HHC 60,000 Diabetics 11,000 Heart Failure Morbidity High 40% to 80% diabetics poorly controlled Blindness, kidney failure, amputations Mortality in symptomatic Heart Failure 20%/year Financial Averted Asthma Admission: $4,500 Averted Diabetes Admission: $8,000

18 Potential Quality of life benefits of RAND Study Diabetes Management Program 1 : 59% reduction in days spent sick in bed 53% reduction in school days lost 25% reduction in work days lost Clinical benefits from a Diabetes Management Program that results in a one percent reduction in HbA1C values 2 : 14% decrease in all cause mortality 21% decrease in diabetes-related deaths 14% decrease in myocardial infarction 12% decrease in strokes 43% decrease in amputations 24% decrease in renal failure A Diabetes Management Program can have a significant effect on both quality of life and clinical outcomes for diabetes patients Source: 1 J. Bigelow et al. Analysis of Healthcare Interventions That Change Patient Trajectories. (Santa Monica, CA: RAND, 2005). 2 Accelerating Change Today, May 2002, National Coalition on Health Care; Institute for Healthcare Improvement.

19 Strategic Approach Diabetes and Heart Failure Collaborative: 17 Interdisciplinary teams Specific Goals Institute for Healthcare Improvement methods Board of Directors Strategic Plan: Increase use of Chronic Care Model Develop Registries across HHC

20 The Chronic Care Model

21 Data Warehousing QA and Management Reports Data Warehouse Registries P 4 P

22 Clinical Information Systems Organize patient and population data to facilitate efficient and effective care. Provide timely reminders for providers and patients. Identify relevant subpopulations for proactive care. Facilitate individual patient care planning. Share information with patients and providers to coordinate care. Monitor performance of practice team and care system.

23 Create Clear and Simple Measurements

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27 Timeline Pilot Stand Alone Warehouse Add Patients Application Development Spread & Implementation Support

28 Spreading Change

29 Improving Diabetes Care Elmhurst Hospital Center Rand David, M.D. Director, Ambulatory Care and Internal Medicine Residency Program Associate Professor of Medicine Mount Sinai School of Medicine

30 Team Marlon Brewer, M.D. Nancy Tarlin, M.D. Huajun Huang, M.D. Sandra Alayo, RN, CDE Ruth Rooney, RN,CDE Bernadette Dilig, Dietician Rosalind DeGasperi, Social Worker James Friedman, NP, CDE Prajakta Vagal, Associate Director Rand David, M.D.

31 Backdrop Medical Primary Care Over 4500 diabetic patients in the medical clinic Over 12, 700 visits per year (24% of total visits) 10% DM patients with HbA1c< 7% in 2002 Participation in IHI Collaborative in 2002 Participation in HHC Chronic Disease Collaborative in 2005

32 Elmhurst Hospital Center Western Queens Population: Over 1 Million In Primary Catchment Area. New Meaning for the Word Disparate, Distinct but Not Separate African American 11% Caucasian 9% Chinese 10% South Asian 15% Hispanic 55%

33 Diabetes Management Initiative Aim: Provide comprehensive, evidence-based, quality diabetes care to all diabetic patients in the Medical Primary Care Encourage patients to be proactive in their care through education and self-management support Improve measurable outcomes by maximizing access to multidisciplinary team of care givers The program is based on the Chronic Care Model developed by Ed Wagner, MD, MPH

34 Program Highlights Delivery System Design: Target patients Newly diagnosed, and/or with HbA1c > 7.0% Diabetes education: Individual and group classes English, Spanish Dietician consultation based on different culture and psychosocial support Psychosocial Support Intense care management for patients who need more support Retinal camera into the clinic for annual eye exam Depression screening, treatment of mild to moderately depressed patients and follow up

35 Diabetes Disease Management Program Resources to support Delivery System Retinal Camera in MPC clinic for Annual Eye Exam:

36 Program Highlights Decision Support: Integrate evidence-based diabetes guidelines into daily practice Creating Diabetes Protocol Screen

37 Elmhurst Hospital Center Diabetes Disease Management Program Medical Primary Care Diabetic Patients with HbA1c <7.0% (New and Old patients) Interventions: Visit to the clinic - every 6 months HbA1c levels - every 6 months Annual tests for LDL, Microalbumin, Monofilament, Eye exam Depression Screening Diabetes Education Individual/ Group classes for all newly diagnosed diabetics + reinforcement for the old patients as needed Nutritional Counseling Individual/ Group classes for all newly diagnosed diabetics + reinforcement for the old patients as needed Psychosocial Support - Visit to a social worker for all newly diagnosed diabetics + revisits for the old patients as needed Diabetic Patients with HbA1c between 7.0% % (New and Old Patients) Interventions: Visit to the clinic every 3 months HbA1c levels every 3 months Annual tests for LDL, Microalbumin, Monofilament, Eye exam Depression Screening Diabetes Education Individual/ Group classes for all newly diagnosed diabetics + reinforcement for the old patients as needed Insulin teaching at home Referral to Health and home care nurse for insulin teaching if patient is advised insulin therapy Nutritional Counseling - Individual/ Group classes for all newly diagnosed diabetics + reinforcement for the old patients as needed Psychosocial Support - Visit to a social worker for all newly diagnosed diabetics + revisits for the old patients as needed Care management Intensive one-on-one /telephonic care management/ self management support to the patient for 3-6 months followed by need based follow up Diabetic Patients with HbA1c >10.0% (New and Old patients) Interventions: Visit to the clinic every 3 months HbA1c levels every 3 months Annual tests for LDL, Microalbumin, Monofilament, Eye exam Depression Screening Diabetes Education Self Care Management, a series of group classes+ individual reinforcement as needed Insulin teaching at home Referral to Health and home care nurse for insulin teaching if patient is advised insulin therapy Nutritional Counseling - Individual/ Group classes for all newly diagnosed diabetics + reinforcement for the old patients as needed Psychosocial Support - Visit to a social worker for all newly diagnosed diabetics + revisits for the old patients as needed Care management Intensive one-on-one /telephonic care management/ self management support to the patient for 3-6 months followed by need based follow up. Referral to the Diabetes clinic as needed.

38 Diabetes Disease Management Program Example of Misys- Decision Support Tool Diabetes Protocol Screen on the EMR:

39 Program Highlights Self-Management Support: Self-management support by assessment for readiness and documented selfmanagement goal Discussion and emphasis on self management occurs during education sessions and one to one sessions with care manager

40 Program Highlights Clinical Information System: Diabetes education materials in all languages on the QHN Intranet Develop web-based diabetes registry Deliver clinical outcome measure reports to individual providers in a timely fashion

41 Disease Management Registry Queens Health Network Disease Management Registry is an indispensable, web-based decision support tool of the Network s Disease Management Program It organizes patient and population data to: Identify relevant subpopulations for proactive care Facilitate individual patient care planning Provide timely reminders for providers Facilitate performance monitoring of Individual providers, practice team and care system

42 Registry Reports as Decision Support Tool Monthly Summary Diabetes Reports for MPC EHC MEDICAL PRIMARY CARE (Clinic Code 337) Diabetes Monthly Report Percent of Active Patients by Each Indicator Time Active Period Patients* HbA1c<7.0 LDL<100 BP<130/80 Microalbumin** Monofilament*** Eye Depression ER IP Exam Screening Visits Visits Jan % 50.91% 46.99% 80.04% 41.17% 84.25% 5.05% 2.42% Feb % 51.90% 46.99% 80.55% 45.12% 85.30% 4.11% 2.26% Mar % 52.22% 47.00% 80.49% 47.23% 85.51% 5.26% 2.51% Apr % 51.30% 46.00% 79.52% 50.75% 85.64% 4.31% 1.85% May % 52.34% 47.46% 79.91% 53.10% 86.50% 4.77% 2.03% Jun % 52.40% 47.83% 80.60% 55.22% 86.73% 9.89% 3.88% 1.66% Jul % 52.34% 47.91% 81.12% 56.84% 86.89% 21.61% 2.14% 0.90% Aug % 53.09% 48.56% 81.49% 59.62% 87.53% 32.03% 4.35% 1.92% Sep % 53.90% 49.18% 84.15% 63.24% 90.23% 41.97% 3.45% 1.81% Oct % 54.01% 47.85% 82.30% 63.18% 87.90% 47.96% 4.33% 1.90% Nov % 54.74% 47.66% 82.61% 64.45% 88.34% 53.61% 3.98% 1.87% Dec % 54.75% 47.43% 82.87% 65.53% 88.46% 57.77% 3.73% 1.78% Jan % 54.41% 47.61% 83.20% 66.62% 88.49% 61.48% 4.52% 2.03 Feb % 54.20% 47.15% 83.12% 67.86% 88.25% 64.43% 3.56% 1.77 Mar % 55.02% 46.23% 83.85% 69.46% 88.42% 66.70% 4.44% 2.01 Apr % 55.44% 47.34% 85.29% 71.59% 89.68% 69.84% 4.46% 2.08 May % 54.41% 46.74% 84.41% 71.39% 87.97% 70.11% 4.58% 2.19 GOAL**** 60.00% 60.00% 60.00% 90.00% 90.00% * Active patients are those who have had at least two visits to the defined clinic since January 1, 2003, with at least one visit to the defined clinic occurring in the past 12 months (in relation to each successive month) ** Microalbuminuria - Percent of active patients tested for microalbuminuria ***Monofilament - Percent of active patients tested for monofilament foot exam ****Goals defined by HHC Chronic Disease Collaborative

43 Registry Reports as Both Decision Support Tools and Ongoing Professional Practice Evaluation Provider Specific Report: Quarterly Report for Diabetes Oucome Measures for CY 2006 Clinic EHC - MPC 337 ABC Active Patients* HbA1c < 7.0% LDL < 100 BP < 130/80 Microalbumin** Monofilament** Depression Screening** Eye Exam** 1 st Quarter % 64% 48% 81% 39% 3% 89% 2nd Quarter % 62% 47% 84% 46% 7% 92% 3rd Quarter % 58% 50% 86% 59% 41% 95% 4th Quarter % 65% 51% 90% 69% 63% 96% * Active patients are those who have had at least two visits to the defines clinic since January 1, 2003, with at least one visit to the defined clinic occuring in the past 12 months (in relation to each successive month) ** Percent of active patients tested for the measure Source: QHN Disease Mangement Registry

44 Attending Physicians Profile Comparison between HbA1c control achievement in Quarter 1, 2003 Vs Quarter 4, % 60% 50% 40% 30% 20% 10% 0% Quarter 1, 2003 Quarter 4, 2006

45 Achievement of HBA1c Control from Q to Q All EHC-MPC Diabetic Patients 60% 50% 40% 30% 20% 10% 0% Q1 03 Q2 03 Q3 03 Q4 03 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07

46 What We Have Learned and Where We Need to Go Caring for patients with chronic conditions involves a team approach, including physicians, nurses, educators, nutritionists, social workers and patient care associates Effective chronic illness care is virtually impossible without information systems that assure ready access to key clinical data on individual as well as populations of patients IT is an absolute requirement for driving care in population-based management. Opportunities for application to disparate populations abound. Types of Available Registries: Elmhurst Hospital Diabetes CHF Depression Pediatric Diabetes Commonweath Fund Grant: Comparing care management to standard care with respect to both quality and cost of care

47 Question and Answer Period Type your question in the chat box on the lower right of your screen, select host and presenters and click on send to submit your question.

48 QI and the EMR: Identifying and Addressing Disparities in Chronic Disease Management Thomas D. Sequist, MD, MPH Assistant Professor of Medicine and Health Care Policy at Brigham and Women's Hospital and Harvard Medical School Louis J. Capponi, MD, Chief Medical Informatics Officer at New York City Health and Hospital Corporation Rand David, MD Director of the Department of Ambulatory Care and Associate Professor of Medicine at Mount Sinai School of Medicine Joseph R. Betancourt, MD, MPH Director, The Disparities Solutions Center at Massachusetts General Hospital Moderator

49 To receive notifications of upcoming free web seminars and other future activities at the Disparities Solutions Center, please go to our website and click on the sign up link on our homepage. Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane. Dr. Martin Luther King, Jr.