ClinicalClinical InformationInformation

SystemsSystems

ClinicalClinical InformationInformation

SystemsSystemsSacopee Valley Health CenterSacopee Valley Health Center

August 16, 2007August 16, 2007

Session AimSession Aim

Brief overview of the Chronic Care ModelBrief overview of the Chronic Care Model

Cost of chronic disease Cost of chronic disease

Using clinical information systems to improve Using clinical information systems to improve outcomes of patients suffering chronic disease outcomes of patients suffering chronic disease with pre planning and identifying patients at with pre planning and identifying patients at risk.risk.

Chronic DiseaseChronic Disease

A chronic condition lasts a year or longer, A chronic condition lasts a year or longer, limits what one can do and may require limits what one can do and may require ongoing care. More than 125 million ongoing care. More than 125 million Americans have at least one chronic Americans have at least one chronic condition and 60 million (21% of the condition and 60 million (21% of the population) have more than one condition. population) have more than one condition.

The number of people with chronic The number of people with chronic conditions is projected to increase from 125 conditions is projected to increase from 125 million in 2000 to 171 million in the year million in 2000 to 171 million in the year 2030. 2030.

What accounts for this What accounts for this dramatic growth in chronic dramatic growth in chronic

conditions?conditions? The large population of baby boomers is aging, and their The large population of baby boomers is aging, and their

health is beginning to deteriorate.health is beginning to deteriorate. Advances in medical science have helped extended our life Advances in medical science have helped extended our life

span, leaving more people vulnerable to age related chronic span, leaving more people vulnerable to age related chronic illness such as cancer, Alzheimer's disease, osteoporosis, illness such as cancer, Alzheimer's disease, osteoporosis, heart disease.heart disease.

10% of patients in one survey reported that in the last year 10% of patients in one survey reported that in the last year they were not able to see a primary care physician when they they were not able to see a primary care physician when they felt it was necessary. felt it was necessary.

22% of those who have insurance report that it does not cover 22% of those who have insurance report that it does not cover all the types of care they need. This percentage represents an all the types of care they need. This percentage represents an estimated 21 million Americans with chronic conditionsestimated 21 million Americans with chronic conditions

In a recent survey 16% of respondents (an estimated 16 In a recent survey 16% of respondents (an estimated 16 million people) have been warned by a pharmacist about a million people) have been warned by a pharmacist about a possibly harmful interaction between medications they were possibly harmful interaction between medications they were prescribed by one or more physicians.prescribed by one or more physicians.

Prevalence of Chronic Prevalence of Chronic ConditionsConditions

Current 2000 Projected 2020

125 M

157 M

Multiple Chronic ConditionsMultiple Chronic Conditions

2000 2020

60 Million

81 Million

Out-of-Pocket CostsOut-of-Pocket Costs

$182

$369

$621

$1,106

None

1 Chronic Condition

2 Chronic Conditions

>3 Chronic Conditions

Direct CostsDirect Costs

2000 2020

$510

Billion

$1.07

Trillion

Current deficiencies in Current deficiencies in management of chronic illnessmanagement of chronic illness

Rushed practitioners not following Rushed practitioners not following established practice guidelines established practice guidelines

Lack of care coordination Lack of care coordination Lack of active follow-up to ensure the Lack of active follow-up to ensure the

best outcomes best outcomes Patients inadequately trained to Patients inadequately trained to

manage their illnesses manage their illnesses

How to improve the systemHow to improve the system

The crucial factor in improving chronic illness care is a clinical database that has the critical information that a provider needs to have for a productive interaction with a patient

Clinical information systems such as registries (PECS) and electronic health records (EHR) enhance the quality, safety, and efficiency of patient care and office workflow

A registry or list of patients and their related data is a tool for tracking individual and population clinical care information

Definition

A registry is a computer application that stores disease-condition specific individual and population-based information to support care management, outreach, quality improvement, and outcome research.

Planning for a registryPlanning for a registry WHOWHO

Will be entering it? Will be entering it? WHATWHAT

Data do I need to get my reports?Data do I need to get my reports? WHENWHEN

Will it be entered? Will it be entered? WHEREWHERE

Will it be entered?Will it be entered? WHYWHY

When what I do works so well? When what I do works so well?

Use the registry to provide clinical support

Registries support physicians by providing printed patients reports,

Identifying patients that are overdue Generate reminders and care-planning tools

for individual patients Provide feedback to care team, leaders and

affiliated organizations Help identify potential medication interactions A formulary can reduce out of pocket

expenses

Workflow Analysis: Workflow Analysis: Who/WhenWho/When

Do Registries WorkDo Registries Work

In the VA, programs with improved In the VA, programs with improved HbA1c results, had computerized HbA1c results, had computerized diabetes reminders, engaged patients diabetes reminders, engaged patients with self management, and involved the with self management, and involved the providers in quality improvement.providers in quality improvement.11

Use of physician reminders, performance Use of physician reminders, performance feedback, and structured care feedback, and structured care management were all associated with management were all associated with improved diabetes process, but not improved diabetes process, but not improved outcomes.improved outcomes.22

Clinician’s responses to a survey assessing Clinician’s responses to a survey assessing their use of CCM components was their use of CCM components was significantly correlated to improvements in significantly correlated to improvements in HbA1c values and ratios of total cholesterol HbA1c values and ratios of total cholesterol to HDL cholesterol. Clinician’s responses to HDL cholesterol. Clinician’s responses were also associated with patient reported were also associated with patient reported measures of improved care processes.measures of improved care processes.33

1. Jackson GL, Yano EM, Edelman D et al. Veterans Affairs primary care organizational characteristics 1. Jackson GL, Yano EM, Edelman D et al. Veterans Affairs primary care organizational characteristics associated with better diabetes control. Am J Manag Care 2005; 11(4):225-37.associated with better diabetes control. Am J Manag Care 2005; 11(4):225-37.

2. Mangione CM, Gerzoff RB, Williamson DF et al. The association between quality of care and the 2. Mangione CM, Gerzoff RB, Williamson DF et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006; 145(2):107-16.intensity of diabetes disease management programs. Ann Intern Med 2006; 145(2):107-16.

3. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE. Use of 3. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE. Use of Chronic Care Model Elements Is Associated with Higher- Quality Care. Annals of Family Medicine 2007; Chronic Care Model Elements Is Associated with Higher- Quality Care. Annals of Family Medicine 2007; 5(1):14-20.5(1):14-20.

Measuring ProgressMeasuring Progress

MeasurementMeasurement is a critical part of is a critical part of testing and implementing changestesting and implementing changes

Measures tell a team whether the Measures tell a team whether the changes they are making actually changes they are making actually lead to improvementlead to improvement

Measurement for improvement Measurement for improvement should not be confused with should not be confused with measurement for researchmeasurement for research

Measurement for Measurement for ResearchResearch

Measurement for Measurement for Learning and Learning and Process Process ImprovementImprovement

PurposePurpose To discover new To discover new knowledge knowledge

To bring new knowledge To bring new knowledge into daily practice into daily practice

TestsTests One large "blind" test One large "blind" test Many sequential, Many sequential, observable testsobservable tests

BiasesBiases Control for as many Control for as many biases as possible biases as possible

Stabilize the biases from Stabilize the biases from test to test test to test

DataData Gather as much data as Gather as much data as possible, "just in case" possible, "just in case"

Gather "just enough" Gather "just enough" data to learn and data to learn and complete another cycle complete another cycle

DurationDuration Can take long periods of Can take long periods of time to obtain results time to obtain results

"Small tests of "Small tests of significant changes" significant changes" accelerates the rate of accelerates the rate of improvement improvement

PDSAPDSA

VariablesVariables

CHANGE:CHANGE: A deliberate introduction A deliberate introduction into into a process in order to a process in order to achieve achieve a higher level of a higher level of performanceperformance

EVENT:EVENT: Something that happens Something that happens which may affect which may affect

performance of the process.performance of the process.

TRACKINGTRACKING

The Improvement Tracker allows you to track any of The Improvement Tracker allows you to track any of the measures currently available in the Topics area of the measures currently available in the Topics area of IHI.org. Just select the measure you want to track (or IHI.org. Just select the measure you want to track (or create your own custom measure), set your aim, and create your own custom measure), set your aim, and enter your data. The Improvement Tracker enter your data. The Improvement Tracker automatically graphs your data. It lets you create automatically graphs your data. It lets you create reports, and even customize them for various reports, and even customize them for various audiences — your team, your CEO, your community.audiences — your team, your CEO, your community.

Improvement Tracker allows you to track predefined Improvement Tracker allows you to track predefined standard measures in several topic areas, with more standard measures in several topic areas, with more being added periodically. Additionally, you can create being added periodically. Additionally, you can create your own custom measures to track any data you your own custom measures to track any data you want!want!

http://www.ihi.org/ihi/workspace/tracker/http://www.ihi.org/ihi/workspace/tracker/