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1 New Strategies for Using Advanced Technology and Care Models for Safer, More Effective, More Humane Health Services No One Grows Old Saying, Gee, I Hope I End Up in a Nursing Home ! New Strategies for Using Advanced Technology and Care Models for Safer, More Effective, More Humane Health Services Jonathan B. Perlin, MD, PhD, MSHA, FACP Deputy Under Secretary for Health Veterans Health Administration Department of Veterans Affairs SPRY Foundation Conference Computer-Based Technology & Caregiving for Older Adults Washington, DC October 2, 2003

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j. Perlin, Veterans Health Administration - October, 2003 2 Patients dont seek care just to be safe Expect effectiveness in maintaining & improving health, managing disease & distress Goal: Safety & Effectiveness, To Close to Chasm Gap between care scientific evidence defines as best and the care most Americans receive Goal: To provide Patient-Centered, Coordinated Care Patient is locus of control Seamless across environments Integrates disease-specific and general health and social needs To Err is Human: 98,000 Patients The Quality Chasm: Every Patient Crossing the Quality Chasm 2001: IOM Safety: Only the Tip of the Iceberg

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j. Perlin, Veterans Health Administration - October, 2003 3 From Health Care Delivery To Patient-Centered Care Safety: Avoid Getting it Wrong Quality: Get it Right... Consistently Patient-Centered Care Support patients with safe, high-quality care, in health and disease, at the time & place, and in the manner patient desires Care extends from hospital & clinic to home & community Using Information Technologies for Creating Effective Relationships between Patients, Caregivers and the Health System

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j. Perlin, Veterans Health Administration - October, 2003 4 2003: Who is VA Veterans Health Administration VHA is agency of the Department of Veterans Affairs 3 Administrations: Veterans Health, Veterans Benefits, National Cemetery 4.9 million patients, ~ 6.9 million enrollees Increased from 2.5 million patients / enrollees in 1995 (+96% / 7 yrs) ~ 1,300 Sites-of-Care, including 162 medical centers or hospitals, > 700 clinics, long-term care, domiciliaries, home-care programs 51 million Ambulatory Care visits, 600,000 hospitalizations ~ $25 Budget: ~ $19B from 1995 1999 (+ 32% / 7 yrs) ~185,000 Employees (~15,000 MD, 50,000 Nurses, 33,000 AHP) 21,000 fewer employees than 1995 Affiliations with 107 Academic Health Systems Additional 25,000 affiliated MDs; 100,000 trainees / year 60% (70% MDs) US health professionals have some training in VA

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j. Perlin, Veterans Health Administration - October, 2003 5 Who Are Our Patients ? Older 49 % over age 65 Sicker Compared to Age-Matched Americans 3 Additional Non-Mental Health Diagnoses 1 Additional Mental Health Diagnosis Poorer ~ 70% with annual incomes < $26,000 ~ 40% with annual incomes < 16,000 Changing Demographics 4.5% female overall Females: 22.5% of outpatients less than 50 years of age

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j. Perlin, Veterans Health Administration - October, 2003 6 Veterans 85 & Over, Number in 1,000s Between today and 2010, VAs Veterans aged 85 and over will increase from 380,000 to ~ 1.2 million No one grows older saying, Gee, I hope I end up in a nursing home !

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j. Perlin, Veterans Health Administration - October, 2003 7 Long-Term Care Costs as Percent of per capita GDP

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j. Perlin, Veterans Health Administration - October, 2003 8 Wagner Model of Chronic Care Community Informed, Activated Patient Productive Interaction Optimal Patient Outcomes Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design

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j. Perlin, Veterans Health Administration - October, 2003 9 Wagner Model of Chronic Care: Extended Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Optimal Patient Outcomes

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j. Perlin, Veterans Health Administration - October, 2003 10 Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes

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j. Perlin, Veterans Health Administration - October, 2003 11 Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes

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j. Perlin, Veterans Health Administration - October, 2003 12 VAs Computerized Patient Record System... Every VA Medical Center has Electronic Health Records !

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j. Perlin, Veterans Health Administration - October, 2003 14 Health Care is a Team Sport ! Health Care is a Team Sport !

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j. Perlin, Veterans Health Administration - October, 2003 15 Vaccine Cuts Pneumonia Risk in High-Risk Patients Archives of Internal Medicine 1999;159:2437-2442 Dr. Kristin Nichol, VAMC / Minneapolis 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. VAMC study of 1,900 elderly patients with chronic lung disease ; 2/3 vaccinated against pneumonia. Pneumococcal vaccination: 43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death. Pneumonia and Influenza vaccination: 72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes. Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period.

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j. Perlin, Veterans Health Administration - October, 2003 16 Pneumococcal Vaccination Rates Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz HHS: National Health Interview Survey, >64 --BRFSS-- --BRFSS 90th--

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j. Perlin, Veterans Health Administration - October, 2003 18 Reducing Variation: From Evidence to Practice Patient With Need Patient Need Met Possess Knowledge Operationalize Knowledge Pneumococcal Pneumonia Vaccination Indications Performance Measurement + Accountability + Supporting Technologies Computerized Health Information System System Changes Closing the Quality Chasm

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j. Perlin, Veterans Health Administration - October, 2003 19 Clinical Reminders Contemporary Expression of Practice Guidelines Time & Context Sensitive Reduce Negative Variation Create Standard Data Acquire health data beyond care delivered in VA

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j. Perlin, Veterans Health Administration - October, 2003 20 Immunizations +/- Mental Health Diagnosis (FY 2001) Effective Equitable Efficient

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j. Perlin, Veterans Health Administration - October, 2003 21 Pneumonia: Acute Inpatient DRG89-90 VHA Data - Unadjusted 9,500 fewer bed days 8,000 fewer discharges

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j. Perlin, Veterans Health Administration - October, 2003 22 Quality: Prevention Index, 1996 2002 * Sampling methodology more stringent

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j. Perlin, Veterans Health Administration - October, 2003 23 Performance Measures for Lipid Screening & Mgmt in Patients with Diabetes

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j. Perlin, Veterans Health Administration - October, 2003 29 Computerized Provider Order Entry (CPOE), one of the Leapfrog Groups Top 3 Safety Strategies Outside of VA, CPOE < 8% nationally, < 30% among Academic Medical Centers Nationally, 92% of all VA Rxs Now CPOE Ultimate Goal: 100% VA is the Benchmark for CPOE

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j. Perlin, Veterans Health Administration - October, 2003 31 CMOPs: Technology at Work Consolidated Mail Outpatient Pharmacy ~200 Million 30-Day Equivalent Prescriptions / Year (40K per shift per CMOP) Medication Deficiencies: 5.8 sigma Wrong Medication: 0.0009% Labeling problem: 0.0001% Damage in Mails: 0.0014% Delays in Delivery: 0.0178% Patient Satisfaction Rating: 90% VG/E

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j. Perlin, Veterans Health Administration - October, 2003 32 2001 Satisfaction with Pharmacy Services Prescriptions by Mail vs. In-person Received Meds by Mail Waited In-person < 30 Minutes Waited In-person > 30 Minutes

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j. Perlin, Veterans Health Administration - October, 2003 33 Performance Measurement Closing The Quality Chasm

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j. Perlin, Veterans Health Administration - October, 2003 34 2002: Leadership by Example recognizes VAs: Clinical Performance Improvement Performance Measurement Information Technologies Health Services Research Patient Safety Evidence, Measurement, Technology & Accountability

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j. Perlin, Veterans Health Administration - October, 2003 35 Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes

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j. Perlin, Veterans Health Administration - October, 2003 36 My Health e Vet Internet-based, secure Personal Health Record. Provides veterans with copies of key parts of their VA health information Veterans can view, retain, and update their personal health data (BP, Blood Sugar, Wt, etc.) Comprehensive, Personalized Health Education Information Personalized Health Assessments Activate & Empower patients as partners with health care providers in achieving optimal health, through the sharing of health information

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j. Perlin, Veterans Health Administration - October, 2003 42 Hey, Doc, I have Diabetes, Shouldnt I be on an ACE Inhibitor ?

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j. Perlin, Veterans Health Administration - October, 2003 44 Patient begins to tie together diet & weight with nutrition information & blood sugar & Understanding of disease from health education & Begins to take control of health Process changes from Transactional (making appointments) TO Transformational (Changing Health Behaviors & Health)

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j. Perlin, Veterans Health Administration - October, 2003 45 Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes

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j. Perlin, Veterans Health Administration - October, 2003 46 From Health Care Delivery To Patient-Centered Care Patient-Centered Care Coordination Support patients with safe, high-quality care, in health and disease, at the time & place, and in the manner patient desires Patient is locus of control and care is seamless across diseases and locations Care extends from hospital & clinic to home & community Imperative to Care for an Aging Population

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j. Perlin, Veterans Health Administration - October, 2003 47 CARE COORDINATION The Clinic (Care Coordinator) Becomes Aware that the Patient Is Beginning to Get Into Trouble, Proactively, The Patient Is Called To Come Into Clinic... Or Visited at Home! Before S/He Crashes

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j. Perlin, Veterans Health Administration - October, 2003 48 San Juan Gainesville Lake City West Palm Beach Miami Bay Pines Ft. Myers VISN 8 Community Care Coordination Service Program Sites Orlando Patient (not provider) centric Designed to fill gaps in system Collaboration with providers. Expands patient and provider relationship into the home (home- telehealth technologies) Successful in Doms and State Nursing Homes Positive med/psyc/soc Outcomes Expandable & Reproducible

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Home-Telehealth Technologies

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j. Perlin, Veterans Health Administration - October, 2003 50 The Health Buddy: Demonstrated Uses Single Dialogues HTN, COPD, DM, CHF, Cancer Care, Depression, Chronic pain, HIV, Hep C, Anticoagulation, Bi-polar Disorder Dual Dialogues HTN/COPD DM/CHF DM/HTN CAD/Angina HTN/Hyperlipidemia (Spanish) CHF/Hyperlipidemia (Spanish) Trialogue HTN/CHF/DM

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j. Perlin, Veterans Health Administration - October, 2003 51 iCare Desktop Software

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j. Perlin, Veterans Health Administration - October, 2003 52 VISN8 Blood Pressure Medication Compliance In the past 24 hours, have you taken all of your blood pressure medicines as your doctor has ordered them?

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j. Perlin, Veterans Health Administration - October, 2003 53 VISN8: Diabetes Care Have you checked your blood sugar in the last 24 hours? Have you taken your diabetes pill or insulin in the last 24 hours?

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j. Perlin, Veterans Health Administration - October, 2003 54 Utilization Outcomes ServicesCare Coordination Usual care Clinic visits+30%+15% ER visits-36%+11% Admissions-46%+7% BDOC-61%+8% Ext Admissions-47%+65% BDOC-81%+68%

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j. Perlin, Veterans Health Administration - October, 2003 55 Functional Status: SF-36V

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j. Perlin, Veterans Health Administration - October, 2003 56 Clinical Outcomes Compared to Usual Care, Care Coordination Resulted in... Blood Pressure Improvement: 62% greater reduction in systolic bp (p=0.015) 38% greater reduction in diastolic bp (p=0.050) Diabetes Care (HbA1c) Improvement: Regression analysis showed significantly greater decrease in HbA1c

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j. Perlin, Veterans Health Administration - October, 2003 58 Future Vision Technology is a means, not an end, An enabler, not a goal The goal is safe, coordinated, high- quality, patient-centered health care