Indian Health ServiceIndian Health Service

Using Decision Support Using Decision Support Effectively: Effectively: Lessons from the FieldLessons from the Field

Lisa Dolan-Branton, RNIndian Health Service

Office of Information Technology/Chronic Care Initiative

AHRQ 2007 Annual Meeting

Lisa Dolan-Branton, RNIndian Health Service

Office of Information Technology/Chronic Care Initiative

AHRQ 2007 Annual Meeting

Presentation OverviewPresentation Overview

•Indian Health System SettingIndian Health System Setting

•IHS Resource and Patient Management IHS Resource and Patient Management SystemSystem

•Clinical Decision Support in RPMSClinical Decision Support in RPMS

•Key Elements of a responsive HIS Key Elements of a responsive HIS (so clinicians use it with every patient) (so clinicians use it with every patient)

Mission and GoalMission and Goal

Mission: to raise the physical, mental, social, and Mission: to raise the physical, mental, social, and spiritual health of American Indians and Alaska spiritual health of American Indians and Alaska natives to the highest level.natives to the highest level.

Goal: to assure that comprehensive, culturally Goal: to assure that comprehensive, culturally acceptable personal and public health services are acceptable personal and public health services are available and accessible to American Indian and available and accessible to American Indian and Alaska Native people.Alaska Native people.

The Indian Health The Indian Health SystemSystem

IHSIHS33 Hospitals33 Hospitals49 Health Centers49 Health Centers46 Health Stations46 Health Stations

TribalTribal15 Hospitals15 Hospitals198 Health Centers198 Health Centers121 Health Stations121 Health Stations180 Alaska Village Clinics180 Alaska Village Clinics

34 Urban health care services and resource centers34 Urban health care services and resource centers

1.8 million users (Federally Recognized Tribes)1.8 million users (Federally Recognized Tribes)

56% AIAN rely primarily on IHS funded care (2000 census)56% AIAN rely primarily on IHS funded care (2000 census)

$3.1 billion from FY 2006 Appropriations $3.1 billion from FY 2006 Appropriations $628 million from Third-Party collections (2004)$628 million from Third-Party collections (2004)

IHS APPROPRIATIONS PER CAPITA IHS APPROPRIATIONS PER CAPITA COMPARED TO OTHER FEDERAL HEALTH COMPARED TO OTHER FEDERAL HEALTH

EXPENDITURE BENCHMARKSEXPENDITURE BENCHMARKS

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

MedicareExpenditures per

Enrollee

Medical Care forVeterans

AdministrationUsers

US Per CapitaExpenditures forPersonal Medical

Services

Medical Care forFederal Prison

Inmates

Medical Care forMedicaid Enrollees

FEHB Medical CareBenchmark per IHS

User

IHS Appropriations& Collections Per

User

IHS

20042001

20031999

1999

2004

Forecast to 2004

1999

Year of Last Published Data

2,101

3,7533,965 3,832

5,1845,454

6,168

500Medical

Care

Non-medical

AI/AN Population by State, 2000

100,00 to 333,400

50,000 to 99,999

10,000 to 49,999

1,713 to 9,999

WA

OR

CA

NV

ID

MT

WY

UTCO

AZ NM

TX

OK

ND

KS

NE

SD

AR

MO

IA

MN

GA

TN

MSAL

LA

MI

OHINIL

WI

FL

PA

VA

ME

NY

WV

NC

KY

SC

AK

NHVT

NJ

DE

MD

HI

American Indian and Alaska Native Population By State

* Census 2000, One race (AI/AN) alone

COMMUNITY ORIENTEDPRIMARY CARE

Cultural & Cultural & SpiritualSpiritual

Behavioral & Behavioral & SocialSocial

Medical Medical CareCare

Public HealthPublic Health

Water & SanitationWater & Sanitation

The Indian health care system is built on a broad spectrum approach to health. It starts with a base of fundamental public health and sanitation infrastructure. It

provides inpatient and ambulatory medical services. It also integrates community-oriented programs promoting healthy behaviors and lifestyles.

COMMUNITY ORIENTED PRIMARY CARE COMMUNITY ORIENTED PRIMARY CARE HAS REDUCED AI/AN MORTALITYHAS REDUCED AI/AN MORTALITY

0

5

10

15

20

25

%% Decrease in MortalityRates since 1973

American Indians & Alaska Natives

US All RacesUS All Races

US WhiteUS White

Infant Mortality Rates1973 – 2002(25.0 to 8.5/1,000)

66% Reduction

80.8

56.4

54.3

31.2

27.2

25.9

12.8

76.0

66.0

64.0

0 20 40 60 80 100

Tuberculosis

Cervical Cancer

Infant Deaths

Maternal Deaths

Accidental

Homicide

Cerebrovascular

Alcohol-Related

Pneumonia & Influenza

Suicide

Resource Patient Management Resource Patient Management System (RPMS)System (RPMS)

Indian Health System Indian Health System Spectrum of CIS UseSpectrum of CIS Use

• No RPMSNo RPMS

• RPMS PCC with paper charts and RPMS PCC with paper charts and centralized data entrycentralized data entry

• PCC+ with centralized data entryPCC+ with centralized data entry

• Partial use of EHR or other Electronic Partial use of EHR or other Electronic Medical RecordsMedical Records

• Fully implemented EHRFully implemented EHR

Decision Support in EHRDecision Support in EHR

•Order ChecksOrder Checks•Med orders are checked for drug-drug Med orders are checked for drug-drug interactions and allergiesinteractions and allergies•All orders are checked for duplicate All orders are checked for duplicate ordersorders•Prescribing Restrictions / GuidancePrescribing Restrictions / Guidance•Prescribing guidelines in pharmacy Prescribing guidelines in pharmacy package accessible to prescribers (see package accessible to prescribers (see screenshot)screenshot)

Oral Contraceptive HelpOral Contraceptive Help

Decision Support in EHR Decision Support in EHR (cont’d)(cont’d)

•Info ButtonInfo Button•Customizable links to web pages from POV Customizable links to web pages from POV (diagnosis) and Patient Ed components(diagnosis) and Patient Ed components•Can be configured to insert selected text into web Can be configured to insert selected text into web site’s search functionsite’s search function•RemindersReminders•National or locally createdNational or locally created•Health maintenance or condition-drivenHealth maintenance or condition-driven•Reminder Dialogs enable simultaneous resolution Reminder Dialogs enable simultaneous resolution of reminders (orders, education, etc.) and of reminders (orders, education, etc.) and documentationdocumentation

EHR v1.1EHR v1.1

Supports Web Link Information button on POV Supports Web Link Information button on POV and Education componentsand Education components

Patient Wellness Patient Wellness HandoutHandout

Immunizations dueWeight, Height, BMIBlood pressureAllergiesCurrent medications

Patient Wellness Patient Wellness HandoutHandout

EHR Physician Study EHR Physician Study SettingSetting

26 IHS health centers implementing EHR between 26 IHS health centers implementing EHR between June 2003 and December 2005June 2003 and December 2005

69% federally operated, 31% tribal health centers69% federally operated, 31% tribal health centers

Mountain – 58%Mountain – 58%Pacific – 19%Pacific – 19%West south central – 12%West south central – 12%South atlantic – 8%South atlantic – 8%West north central – 4%West north central – 4%

Median number of physicians per clinic: 5.0 (IQR 2-19)Median number of physicians per clinic: 5.0 (IQR 2-19)Median number of NP/PA per clinic: 2.0 (IQR 1-6)Median number of NP/PA per clinic: 2.0 (IQR 1-6)

Impact of EHR on QualityImpact of EHR on Quality

Agreed (%)*

EHR helps to improve quality of care

EHR helps to improve patient safety

EHR decreases quality of physician-patient interaction

EHR creates less time to talk with patients in the office

35

36

39

60

* At least 4 on a 5 point Likert scale

Use of Key EHR Use of Key EHR FunctionalityFunctionality

iCare: Population Management iCare: Population Management GUIGUI

iCare - Pre-PlanningiCare - Pre-Planning

iCare - Patient PanelsiCare - Patient Panels

iCare - FlagsiCare - Flags

iCare - Panel OutcomesiCare - Panel Outcomes

RPMS Behavioral Health RPMS Behavioral Health Applications FunctionsApplications Functions

•Documentation of individual and group encountersDocumentation of individual and group encounters

•DSM IV-TR Axis I – V Diagnostic CodingDSM IV-TR Axis I – V Diagnostic Coding

•Treatment PlansTreatment Plans

•Case Management Information Case Management Information

•Suicide data collection Suicide data collection

•Ability to document non-direct patient care activities such Ability to document non-direct patient care activities such as community education, Performance Improvement, as community education, Performance Improvement, clinical supervision, training, etc.clinical supervision, training, etc.

•Robust reports module: workload, case management, Robust reports module: workload, case management, condition-specificcondition-specific

Future Clinical Decision Future Clinical Decision SupportSupport

Key Elements of Responsive CDSKey Elements of Responsive CDS

• HIT solution can drive improvement at each patient visit HIT solution can drive improvement at each patient visit

• Vision of a HIT system that provides you with the ability to Vision of a HIT system that provides you with the ability to manage patients, communities and populations within your manage patients, communities and populations within your mission contextmission context

• Value of requirements development with Clinicians Value of requirements development with Clinicians

• Clear and specific requirements that put the clinical and Clear and specific requirements that put the clinical and public health needs at the center of the specification and public health needs at the center of the specification and programming processprogramming process

• Rapid cycle developmentRapid cycle development

• Like a good community organizer—becomes background Like a good community organizer—becomes background noisenoise

• It’s not about ITIt’s not about IT

Lisa Dolan-Branton, RNLisa Dolan-Branton, RNlisa.dolan@ihs.govlisa.dolan@ihs.gov

• QUESTIONS?QUESTIONS?QUESTIONS?