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
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
Harvard Vanguard Medical Associates Multi-specialty group practice 14 ambulatory health centers 300,000 adult patients - 15,000 diabetic patients 130 primary care physicians
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
Diabetes Dashboard
Annual LDL Cholesterol Monitoring 100 % Receiving Annual LDL Testing 90 80 70 60 50 40 30 20 10 0 43 29 46 35 51 40 63 65 62 53 White Black 1997 1998 1999 2000 2001 Sequist; Arch Intern Med 2006
LDL Cholesterol Control 100 % Acheiving LDL < 130 mg/dl 90 80 70 60 50 40 30 20 10 0 18 9 21 13 29 19 40 30 45 39 White Black 1997 1998 1999 2000 2001 Sequist; Arch Intern Med 2006
Why Focus on Physicians? In the trenches Importance of patient experiences and relationships Lack of awareness
Lurie N, Circulation 2005 The Not Me Phenomenon Do racial disparities exist in. 70 60 50 % Yes 40 30 20 10 0 Health care Cardiac care Your hospital Your patients
Intervention Design Improve collection of race data Increase awareness Provider performance reports Provide tools Cultural competency training
Collecting Patient Race and Ethnicity
Provider Performance Report
Cultural Competency Training 2 day course for nurse practitioners 1 day course for physicians Small group discussions Community tours
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)
Funding Acknowledgement Finding Answers: Disparities Research for Change A National Program of the Robert Wood Johnson Foundation
New York City Health & Hospitals Corporation 11 Hospitals 6 DTC s 4 LTC s 80 Clinics Home Care MetroPlus http://www.nyc.gov/hhc
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
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.
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
The Chronic Care Model
Data Warehousing QA and Management Reports Data Warehouse Registries P 4 P
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.
Create Clear and Simple Measurements
Timeline 2004 2005 2006 2007 Pilot Stand Alone Warehouse Add Patients Application Development Spread & Implementation Support
Spreading Change
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
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.
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
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%
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
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
Diabetes Disease Management Program Resources to support Delivery System Retinal Camera in MPC clinic for Annual Eye Exam:
Program Highlights Decision Support: Integrate evidence-based diabetes guidelines into daily practice Creating Diabetes Protocol Screen
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% - 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 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.
Diabetes Disease Management Program Example of Misys- Decision Support Tool Diabetes Protocol Screen on the EMR:
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
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
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
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-06 4510 49.02% 50.91% 46.99% 80.04% 41.17% 84.25% 5.05% 2.42% Feb-06 4499 48.41% 51.90% 46.99% 80.55% 45.12% 85.30% 4.11% 2.26% Mar-06 4485 47.23% 52.22% 47.00% 80.49% 47.23% 85.51% 5.26% 2.51% Apr-06 4540 44.96% 51.30% 46.00% 79.52% 50.75% 85.64% 4.31% 1.85% May-06 4490 44.63% 52.34% 47.46% 79.91% 53.10% 86.50% 4.77% 2.03% Jun-06 4506 45.07% 52.40% 47.83% 80.60% 55.22% 86.73% 9.89% 3.88% 1.66% Jul-06 4423 45.51% 52.34% 47.91% 81.12% 56.84% 86.89% 21.61% 2.14% 0.90% Aug-06 4483 46.75% 53.09% 48.56% 81.49% 59.62% 87.53% 32.03% 4.35% 1.92% Sep-06 4410 48.25% 53.90% 49.18% 84.15% 63.24% 90.23% 41.97% 3.45% 1.81% Oct-06 4479 50.39% 54.01% 47.85% 82.30% 63.18% 87.90% 47.96% 4.33% 1.90% Nov-06 4503 51.79% 54.74% 47.66% 82.61% 64.45% 88.34% 53.61% 3.98% 1.87% Dec-06 4506 51.71% 54.75% 47.43% 82.87% 65.53% 88.46% 57.77% 3.73% 1.78% Jan-07 4535 51.13% 54.41% 47.61% 83.20% 66.62% 88.49% 61.48% 4.52% 2.03 Feb-07 4462 51.42% 54.20% 47.15% 83.12% 67.86% 88.25% 64.43% 3.56% 1.77 Mar-07 4571 51.60% 55.02% 46.23% 83.85% 69.46% 88.42% 66.70% 4.44% 2.01 Apr-07 4466 50.34% 55.44% 47.34% 85.29% 71.59% 89.68% 69.84% 4.46% 2.08 May-07 4523 47.09% 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
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 177 47% 64% 48% 81% 39% 3% 89% 2nd Quarter 180 50% 62% 47% 84% 46% 7% 92% 3rd Quarter 175 53% 58% 50% 86% 59% 41% 95% 4th Quarter 170 61% 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
Attending Physicians Profile Comparison between HbA1c control achievement in Quarter 1, 2003 Vs Quarter 4, 2006 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Quarter 1, 2003 Quarter 4, 2006
Achievement of HBA1c Control from Q1 2003 to Q1 2007 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
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
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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
www.mghdisparitiessolutions.org To receive email 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.