Collaborative care for chronic illness and

information technology

IntroductionAcademyHealth 2005David A. Dorr, MD MS

OHSU

Objectives State of collaborative and chronic physical

and mental illness care Framework for collaborative care and

Information Technology (IT) use Successes and challenges

Chronic illness care: problems Underuse

Effective treatments for chronic illness care only given 54% of the time.

Misuse Preventable, injurious outpatient AEs occur in 1-

9% of patients. Overuse

Up to 30% of treatments provided for some illnesses (low back pain) are inappropriate.

Terms from Chassin MR. JAMA. 1998; Sources: EA McGlynn, NEJM; Rothman, Annals; Wennberg; Forster, 2003; Dorr 2004.

Chronic illness care: VA transformation

Chronic disease

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Root causes of problems with chronic illness care

Culture / History “Tyranny of the urgent” Art and craft of medicine

Complexity Individual versus

population focused Financial

Root causes: information based Information/knowledge

needed is Enormous

Challenging to find

Lacking

In the wrong form

Difficult to communicate

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Chassin, Mark R. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4)

first RCT published: 1952 (Daniels and Hill in the British Medical Journal, comparing treatments for tuberculosis)

(Medline search as of 1 June 98)

first five years (66-70): 1% of all RCTs published from 1966-1995

last five years (91-95): 49% of all RCTs published from 1966-1995

Information system: definition Any system to store / retrieve / display /

aggregate / or otherwise touch information

Not just computers or charts in broad sense

Our focus is primarily on computer-supported information systems

Information System domains (IOM) Health information /

data

Results management

Order entry

Decision support

Communication and connectivity

Patient support

Administrative process

Reporting and population health

More successes Results management

Patient worksheet

Order entry Corollary orders and

order sets improve safety, can reduce cost, and improve outcomes.

Savings of up to $44 billion dollars per year.

Pertinent labs

Preventive care summaryMedications

Chronic conditions

Pertinent exams

Passive remindersOrganized by illness

Wilcox 2005; CITL report 2003.

Individual categories: successes Decision support

30-66% improvement in adherence to preventive care and acute care guidelines.

But … chronic illness has mixed results.

Patient support Congestive heart failure

IT and domains: hierarchy Access

Best Practices

Communication

Health information / data Results management Order entry Decision support Communication and

connectivity Patient support Administrative process Reporting and population

health

Care management packages to Improve Quality of Care: Information System focus

Chronic Care Model Hartford / Intermountain Health Care generalist

care management

Disease management

Veterans’ Administration transformation QUERI (reTIDES, EQUIP, PAS, CHIACC)

Improving Care for Chronic Illness

Community Health System Resources and Policies ------ Organization of Health Care

Self-Management

Support

Delivery System Design

Decision Support

Clinical Information

Systems

Informed, Activated Patients & Caregivers

Prepared, Proactive

Practice Team

Collaborative Care

Functional and Clinical Outcomes

From: E.H. Wagner & RWJF Improving Chronic Illness Care Initiative

Generalist care management system

Improvement in diabetes, depression, and congestive heart failure outcomes.

Care management

Referral- For any condition or need- Focus on certain conditions

Care manager- Assess & plan- Catalyze- Enact

Technology- Access- Best Practices- Communication

Evaluation- Ongoing with feedback- Based on key process and outcome measures

Dorr et al, HSR, in press; Dorr et al, Disease management, in press.

Disease management Companies external to health workers

provide Technology (e.g. monitoring devices)

System (e.g. 24 hour nursing support)

To reduce utilization and cost.

Final thoughts IS use can help solve chronic illness

performance issues.

Advanced information system use only 15-25% in US, and still difficult to know what will work.

Financial, implementation, and workflow barriers significant.

Thanks! Amy Cohen, PhD Adam Wilcox, PhD Laurie Burns Paul D. Clayton, PhD Larry Casalino, MD PhD