Research Into Care: Identifying Barriers and Gaps in Care AAFP National Research Network Robert Graham Center Wilson D. Pace, MD
AAFP National Research Network The AAFP National Research Network is a nationwide practice-based research network with primary care clinician members representing 48 U.S States and 4 Canadian provinces. Affiliations with 11 other research networks It does studies to describe and improve upon the phenomenon of primary care practice.
The Robert Graham Center Improve individual and population health by enhancing the delivery of primary care The Center aims to achieve this mission through the generation or synthesis of evidence that brings a family medicine and primary care perspective to health policy deliberations
Dupont Circle Washington, DC Peer-reviewed Research Policy Briefs Health Policy Fellowship Scholars Program (10-12/year) Primary Care Forum
Physician Medicare payment cuts 2008
NRN + RGC Collaborations Patient Safety Errors in Primary Care Patient Laboratory Investigations Medication Safety DARTNet AHRQ funded research Relating Community and Practice Evaluating Medical Homes
2008
DARTNet: Distributed Ambulatory Research in Therapeutics Network Pilot Research Project: DARTNet Phase I Patterns of Use, Comparative Effectiveness, and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes: A Retrospective Cohort Study AHRQ Contract #HHSA29020050037I TO2
What is DARTNet? A prototype system of 2-way data exchange with practice electronic health records Research, quality improvement and practice comparisons historically and at the point of care--at the practice level An infrastructure of human resources and HIT to support the dual mission of DARTNet
DARTNet s Mission DARTNet s mission is to explore how currently available EHR data can be used to supplement data from other large datasets in order to answer questions concerning the safety and effectiveness of medications and medical devices
DARTNet s Aims Support the Concept of the Patient Centered Medical Home: To engage community-based primary care practices in local, regional, state, and national quality improvement activities via benchmarking and interactive learning Enhance the State of the Art in Effectiveness Research: To use the by-product of quality improvement activities to benefit policymakers in health care delivery and financing decisions Advance practice-based research capabilities Explore HIT capabilities within ambulatory care
Partnership (CO-DEcIDE DEcIDE) University of Colorado SNOCAP PBRNs School of Medicine (Family Medicine and Internal Medicine) School of Pharmacy American Academy of Family Physicians National Research Network (PBRN) Robert Graham Center
Other DARTNet Partners University of Minnesota Center for Excellence in Primary Care Infrastructure required for EHR queries (NIH and AHRQ support) Houses the distributed information technology operations Clinical Integration Networks of America, Inc. (CINA) Provides point of care clinical decision support tools to all DARTNet practices Standardizes EHR data elements at each practice Transfers standardized data to a second database where they are de-identified and available for study
The Unique Contributions of DARTNet Creation of Federated Data collection and analysis core to address the traditional frailties of centralized database research The fusion of PBRN Research and Clinical Effectiveness studies NLP capability While not Part of AHRQ Work Evaluation of Point of Care Data Collection (Card study on hypoglycemia)
DARTNet We have constructed a prototype system and infrastructure with the capability of an analytic one two punch! Exploration of issues critical to stakeholders/policymakers using secondary data Results to guide real-time EHR queries
Single Practice Perspective Translation interface Univ of MN Billing DARTNet Rx CINA Data CCR Hospital Lab EHR Gateway Queries and Data Transfers Web services Clinical tools Disease registries Quality improvement reports
Single Practice Perspective Translation interface Univ of MN Billing DARTNet Rx CINA Data CCR Hospital Lab EHR Gateway Queries and Data Transfers Web services Clinical tools Disease registries Quality improvement reports
Single Practice Perspective Translation interface Univ of MN Billing DARTNet Rx CINA Data CCR Hospital Lab EHR Gateway Queries and Data Transfers Web services Clinical tools Disease registries Quality improvement reports
Single Practice Perspective Translation interface Univ of MN Billing DARTNet Rx CINA Data CCR Hospital Lab EHR Gateway Queries and Data Transfers Web services Clinical tools Disease registries Quality improvement reports
Single Practice Perspective Translation interface Univ of MN Billing DARTNet Rx CINA Data CCR Hospital Lab EHR Gateway Queries and Data Transfers Web services Clinical tools Disease registries Quality improvement reports
EHR Rx Billing Billing Other EHR Rx CLINICAL DATA SYSTEMS (Labs, Billing) Internet CINA CDR Exports CCR QUALITY IMPROVEMENT Audit and Feedback Benchmarks Reminder Systems CINA CDR Exports CCR RSA dual authentication Clinical Trial Website Health System 1 Gateway Health System 2 Gateway CLINIC 1 Gateway CLINIC 2 Gateway CLINIC 3 Gateway Trial bank Clinicaltrials.gov OGSA-DAI Tools Security, authentication, linkage, manage processes IRB Evaluation RESEARCH Trial design Eligibility and recruitment Trial management DARTNet
EHR Rx Billing Billing Other EHR Rx CLINICAL DATA SYSTEMS (Labs, Billing) Internet CINA Exports QUALITY IMPROVEMENT Audit and Feedback Benchmarks Reminder Systems CINA Exports RSA dual authentication Clinical Trial Website Health System 1 Gateway Health System 2 Gateway CLINIC 1 Gateway CLINIC 2 Gateway CLINIC 3 Gateway Trial bank Clinicaltrials.gov OGSA-DAI Tools Security, authentication, linkage, manage processes IRB Evaluation RESEARCH Trial design Eligibility and recruitment Trial management DARTNet
EHR Rx Billing Billing Other EHR Rx CLINICAL DATA SYSTEMS (Labs, Billing) Internet CINA CDR Exports CCR QUALITY IMPROVEMENT Audit and Feedback Benchmarks Reminder Systems CINA CDR Exports CCR RSA dual authentication Clinical Trial Website Health System 1 Gateway Health System 2 Gateway CLINIC 1 Gateway CLINIC 2 Gateway CLINIC 3 Gateway Trial bank Clinicaltrials.gov OGSA-DAI Tools Security, authentication, linkage, manage processes DARTNet IRB Evaluation RESEARCH Trial design Eligibility and recruitment Trial management
DARTNet Capabilities
DARTNet Prototype Size Number of Practices 79 Number of clinicians - ~ 500 (two Universities) Organizations 9 Largest 124 clinicians Smallest solo clinician Patients Seen in last 48 months 416,552
Membership Requirements EMR must have lab and imaging electronic interfaces Use EMR for prescribing Commit to full electronic prescribing Use point of care clinical decision support (CDS) Agree to benchmarking and to share clinical practices if top performer
Learning Community Organizations and practices join to find and share best practices All data analyzed at practice level All practices agree to quality reporting and benchmarking Highest performers agree to be identified and to share methods Central staff agree to develop information sharing methods
Feedback Reports Percentage of patients with diabetes seen between 1/1/07 and 7/31/08 who have had A1c tested in prior 6 months 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Your Practice Average Practice PlainView Family Medicine HillView Family Medicine MountainView Family Medicine
AHRQ supported DARTNet Study Pilot project focused on Clinical Effectiveness for Oral Diabetes Medications for Adults with Type II Diabetes* * AHRQ Publication No. 07-EHC010-EF, July 2007
Specific Aims Aim 1: Examine the relative effectiveness of single drug and two or more drug combinations of oral hypoglycemic medications as measured by glycemic control. Aim 2: Examine medication related adverse events as measured by liver failure, liver injury and/or elevated hepatic enzymes and rates of hypoglycemic events. Aim 3: Examine patterns of drug utilization over time and by age and gender.
Study Design Phase 1: Claims based study Larger number, limited set of data elements Data source: Ingenix/ICHIS Impact database Phase 2: DARTNet replication Smaller number, broader range of data elements Data sources: Practice Data
Summary of Findings 80% started on monotherapy, 20% on combination therapy Persistence higher for Biguanides and TZDs vs. other monotherapies BIG+SU and BIG+TZD vs. other combination therapies Unadjusted HA1C reductions: Mono ~ 1%, 2-drug combos ~ 2%, 3-drug combos ~2.6% Adjusted HA1C reductions similar across drugs/combos vs. metformin monotherapy Predictive factors: persistence, compliance, baseline HA1C, # diabetes-related MD/education visits Crude rates of hypoglycemia, liver injury, and liver failure were relatively low
Graham Center/NRN Practice Geography Research How well do the characteristics of the population in a practice s service area reflect the characteristics of the practice patient population?
Patient Point Mapping
Clinic Patients and Poverty
Medical Home Evaluation The Graham Center and National Research Network are competing to collaborate on an evaluation of a clinic network that may represent one of the most mature Patient Centered Medical Home models currently operating.
Thank You The Graham Center and National Research Network have many other studies and projects underway that should help in practice transformation We are always happy to talk about potential collaborations