integrated care coordination information system: primary care redesign through care coordination and...
TRANSCRIPT
Integrated Care Coordination Information System: primary care redesign through care coordination and population management
David A. Dorr, MD, MSAssociate Professor
Department of Medical Informatics & Clinical EpidemiologyGeneral Internal Medicine & Geriatrics
OHSU
Funding for this research from The John A. Hartford Foundation, AHRQ, Intermountain Healthcare, and the National Library of
Medicine
More information at caremanagementplus.org
Overview
• Care Management Plus: ICCIS need and trial• Prioritized functions• Unintended consequences• Sustainability: Free take one vs. thoughtful
partnership
A.k.a – How to build a better system of care for your most at-risk primary care patients
Becomes
4
Arm 1: Coordination of Care-Complete assessment/care plan-Education-Goal setting and follow up-Communication-Motivation/coaching-Completing CM services
Evaluation (Aim 4):Outcomes (health/satisfaction) and their relationship to
implementation and use of IT
Needs assessment / Build system (1 year + )Train clinics and care managers
Randomly assigned goals for IT use
Arm 2: Quality-choose 5 of 20 quality measures: prevention, diabetes, vulnerable elderly, asthma, congestive hearth failure
Data from ICCIS, Payers
Needs assessment
Referra
l
Care Plan
ning
Educa
tion
Follo
w Up
Syste
m
Reminders
Communication
Population
0
5
10
15
20
25
30
Additional Care Management elements requested from 7 teams with EHRs
Behkami, Proc AMIA, 2009
ICCIS Care Coordination Workflow
A centralized reminder list of tasks and communications that were proactively planned but incomplete allows population-based tasks to be merged with individual encounter tasks.
Quality measure dashboard
Dashboard can be run by clinic, team, or individual PCP
The abilities to document exclusions at multiple levels and generate targeted population-based review cycles avoid the problems caused by static quality reports and allow providers to efficiently focus outreach efforts on high risk populations.
ICCIS Interactive Quality Reports
(1)Wilcox, Proc of AMIA Symp, 2005
Patient Worksheet
When working with persons with multiple illnesses or complex illness, a clinical summary that captures a core set of information improves patient outcomes (1). Care coordination and behavioral modification (goal setting) elements often require special effort and the quality summary requires more advanced monitoring and implementation than most standard EHRs provide.
It worked! (see our poster)
Figure 3: Absolute adherence change for Arms and Clinics
Arms reimbursed
Table 1. Care coordination activities
Unintended consequences: Errors / fixes
• 278 fixes of systemic errors in first 6 months of study
• Sources : – data (multiple EHRs, minimal standards); – workflow/usability; – Understanding/naming to reduce confusion
Sustainability - ‘Free, take one’ – dissemination to 208 teams
SFDPH (12 sites)
Intermountain (16 teams)
OHSU (9 teams)
PeaceHealth (20 teams)
Daughters of Charity (5 teams)
Colorado Access (16 teams)
HealthCare Partners (2 sites)
Sustainability: Thoughtful partnership
• Readiness assessment : define benefit up front– E.g., Medical Home care coordination; ACO
reduction in hospitalizations and shared savings• Partner on achievement of goals• Share savings or benefit together– Example: intensive care management
demonstrations; SNP plans
• Oregon Health & Science University– David Dorr, PI– Kelli Radican– Susan Butterworth– Nima Behkami– Marsha Pierre-Jacques Williams– Gwenivere Olsen– Molly King– Kristin Dahlgren
• Columbia University– Adam Wilcox
• Intermountain Healthcare– Cherie Brunker, Co-PI (UU)– Liza Widmier– Mary Carpenter– Bryan Gardner– Ann Larsen
• Advisory Board– K. John McConnell– Tom Bodenheimer– Eric Coleman – Cheryl Schraeder– Heather Young– Steven Counsell– Larry Casalino
Thank you & Main lessonsTopic Tool AssessmentWorkflow Tickler as CDSS and
single workflowNeeds assessment and requirements; usability
Patient-centered Care
Patient Worksheet Accuracy, usefulness from clinical staff
Unintended consequences
Error tracking with clinical consequences
Fixes needed
Sustainability “Free, take one” v.Thoughtful partnership
Need has to be clearly assessed and targeted
[email protected]://www.caremanagementplus.org
Sticky problemsProblem Explanation ICCIS Result
Data in many different EHRs
EHRs have different data structures
Extracted data from 4 different EHRs
Functions in HIT systems siloed
Many functions are in separate EHR settings
Create universal workflows in separate application
EHRs have variable standard implementations
Although a standard vocabulary is available, it isn’t used
NOT EASY – manual mappings, many errors until it is solved
Population management is an analytic, not transactional issue
Reports take a long time to run and are static
Create interactive views of the reports (e.g., quality measure performance) with associated tables
Usability
Log metrics: click throughs (<5 seconds on page): 62% ; loops/ repeated actionsInterviews: Use / workflow / challenges / errors