Developing a State-of-the-art Web Site to Teach Population-based Care

Partnerships for Quality EducationHenry Ford Health System, Dept. of Family Practice

Susan Schooley, MD

Lois Lamerato

Roger Tuttleman

Farouk Rassam

Outline • Background of our project

– COPC framework for population management– Applying COPC framework to “at risk” population

• “Web Readiness” exercise• Website development

– Advantages of web-based technology– Web site basics

• Web site teaching• Building a web site

– Design considerations– Components– Hosting– Data on web sites

The New “Community Medicine”• Multiple providers and

sites

• Multiple institutions

• Managed care – data driven

– resource stewardship

• Population health curriculum

• Health status goals

Our Goal….

To provide members of the health care team with the skills and tools necessary to prioritize and reduce health risks and improve health outcomes in their population of patients.

Physicians, nurses, case managers

Resource utilizationPrevention

Defined community

Community Medicine Curriculum

• Health care (population) Epidemiology

• Informatics

• Risk assessment & behavior change

• Community resources

• Applied “COPC” projects

• Multidisciplinary learners, faculty

• Multiple clinical contexts

COPC Model - Framework for Population Management

Steps of COPCS

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STAGES OF COMMUNITY ORIENTED PRIMARY CARE ACTIVITIES

Defining andcharacterizing thecommunity

Identifying communityhealth problems

Modifying the health careprogram

Monitoring the effectiveness ofprogram modifications

Stage 0 No effort to define orcharacterize the community

No effort to understand thehealth status or health needs ofthe community

No program modifications madein response to community healthneeds

No effort to determine the impact ofmodifications in the health careprogram

Stage I Community is characterizedfrom the subjectiveimpressions of thepractitioners and/orconsumer representatives

Health problems identifiedthrough general consensus ofthe providers and/or consumergroups

Modifications are made more inresponse to a national ororganization wide initiative

Estimates of program effectivenessare based on subjective impressions ofthe practitioners and/or consumergroups

Stage II Community is characterizedby extrapolation fromsecondary data - census orlarge area epidemiologicdata

Health problems identified byextrapolation from systematicreview of secondary data

Modifications are consistent withthe particular guidelines of thefunding source or agency

Program effectiveness is estimated byextrapolation from secondary data

Stage III Individuals within thecommunity can beenumerated andcharacterized through theuse of a data base specificto the community

Health problems examinedthrough the use of data setsspecific to the community

Modifications in the health careprogram are tailored to uniqueneeds of the community

Program effectiveness is determinedby systematic examination of acommunity-specific data set

Stage IV Systematic efforts assure acurrent and completeenumeration of allindividuals in thecommunity, includingpertinent demographic andsocioeconomic data

Formal mechanisms used toidentify and set prioritiesamong a broad range ofpotential health problems inthe community

Modifications in the programinvolve both primary care andcommunity/public healthcomponents and are targeted tospecific high risk individualswithin the community

Program effectiveness is determinedby techniques that are specific to theprogram objectives and account fordifferential impact among risk groups

COPC Model - Framework for Population Management

Steps of COPCS

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Information System for Population Health

Example of Application of COPC Model - Management of

Diabetes

STAGES OF COMMUNITY ORIENTED PRIMARY CARE ACTIVITIES – Diabetes example

Defining andcharacterizing thecommunity

Identifying communityhealth problems

Modifying the health careprogram

Monitoring the effectiveness ofprogram modifications

Stage 0 Nothing known orspeculated about DMpopulation in communityor practice

No effort is made tounderstand the healthproblems of the community

No programmatic efforts aremade to improve the health ofthe community

No programmatic efforts toevaluate

Stage I Physicians have a sensethat diabetes is prevalentamong the patientspresenting to their clinicfor care

Physicians have a sense thatglycemic control is a problem for many of theirdiabetic patients

Physician education of theimportance of glycemic controlmake physicians more awareof the need for periodic HA1Cscreening

Physicians try to sense whetherthey are seeing patients in poorcontrol less often

Stage II Local health departmentdata shows that diabetesis among the top fivecauses of death forpersons age 55 and older

Local health departmentdata shows that AfricanAmericans age 55 and olderexperience significantlyhigher mortality fromdiabetes than Caucasians

Public service addressees andoutreach activities in thecommunity are used to raisethe awareness of diabetesmanagement

Mortality trends for diabetes aretracked

Stage III Administrative billingdata shows that 1,696patients paneled to theDNW center have adiagnostic code for DM

Persons with elevatedHA1C are identified usingcomputerized clinicallaboratory data

Nurse care managers contactpatients to enroll in diabetesmanagement classes

Participants in diabetesmanagement classes are monitoredfor change in glycemic control

Stage IV A Diabetes Registry isdeveloped as acomputerized surveillancesystem to track allpatients with DM paneledto the DNW clinic

Diabetes Registry tracks allappointments and clinicallaboratory of DNW diabeticpatients

Patient and physician remindersystems notify patients andproviders when HA1C’s aredue based on last test date andlast result date

Pre and post HA1C levels trackeffectiveness of surveillancesystem

Necessary Requirements for Advancing in COPC Framework

• Data

• Analytic tools

• Skills

Data

• Community level– Census– National, state and local level health data

Detroit Catchment Areas

Data

• Patient level– Population– Utilization care patterns– Illness patterns– Clinical patterns– Risk factors

Patient Panel - Age and Gender Distribution

0

5

10

15

20

25

30

35

0-5mo.

6-23mo.

2-4 5-12 13-18 19-39 40-54 55-64 65-74 75+

Males

Females

% of pts

Patient Panel - Utilization of Services, 1998

0

1000

2000

3000

4000

5000

6000

OPD ED IPD IPD DAYS

Adults

Pediatrics

encounters per 1000 pts.

Patient Panel - Prevalence Rates of Selected Dx, Adults

0 5 10 15 20

HTN

GYN Dis.

Conn Tissue Dis

URI

Back prob.

Chest pain

DM wo. Comp

Skin disorders

Abd pain

Bronchitis

rate/100

Patient Panel - Average Charges for Patients With Selected Dx, Adults

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Cor.Atherosc.

CHF COPD Asthma DM woComp

DM wComp

HTN

$

Diabetes Registry - Population Definition

1696

Panel pts. with 2 or more DM encounters between1-1-96 and 6-30-98

711

- 985 patients with DM visits since 7-1-98

- 427 pts with non-DM PC visits since 7-1-98

284

“At risk” population

Diabetes Registry - Age and Gender Distribution

0

5

10

15

20

25

30

35

40

< 20 20-29 30-39 40-49 50-59 60-69 70+

FemalesMales

# of pts.

Diabetes Registry - HA1C Testing Patterns Within Past Year

0 50 100 150 200

No tests

1 test

2 or moretests

# of pts.

Diabetes Registry - HA1C Control (at Last Test)

0

20

40

60

80

100

120

< 8 8-10 > 10-12

> 12-14

>14 Notstated

Norecord

# of pts.

Self-reportedFamily History of Health Problems

0

10

20

30

40

50

60

HTN Colon Ca. Breast Ca. DM Heart attack

% of response

Analytic Tools

• Data management software

• Analytic software

Learning to Use MS AccessLinking Tables in a Query

Learning to Use Epi Info

Skills

• Analytic/research– Research design– Measurement– Literature searching

• Clinical

Intro to Epi PrinciplesFundamental Assumptions

Where Are You?

Professional Expertise

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Low Medium High

Low

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Question #1: What Is the Level of Sophistication of the End-user(s)?

0 5 10

Can’t find “ON” button

Basic skills in Windows,Web, common officesoftware

Programmedmissiles inKuwait

Question #2: How Many Dollars Are Available to This Project?

0 5 10

Shareware until I win the lottery

Webmaster, server, etc.

Existing hardware, one person team

Question #3: What Hardware Is Currently Available for Web Development and Hosting?

0 5 10

486 processorWindows 3.11

Internet connections,modem (56K/sec)

Server, T-1 connection,(1.5MB/sec)

Question #4: What Hardware Is Available to the User(s)?

0 5 10

PCmodemWeb browser

Sound and graphicscards, Pentium/ Power PC

225Mhz, fastinternetconnections,plug-ins,Java capablebrowser

Question #5: What Expertise Does Developer Have?

0 5 10

My cousin is a computernerd

Can use commercialweb-authoring & mgmt.tools

Professionaldeveloper/programmer

Question #6:how Accessible Is Data?

0 5 10

Paper reports,summaries

Billing & encounterdatabase

Specificenumerationof population(clinical,demographic,risk), dynamicreal-time updates

Question #7: How “Relational” Is Existing Data?

0 5 10

No commonidentifier

Compatibleformats,programmed links

Download andimport capability

Question #8: How Capable Are You for “Interactivity”?

0 5 10

Users canread

Navigational,(can includelinks, hotspots,arrows)

Java,dynamic HTMLprogramming

Question #9: How Capable Are You for “Multimedia”?

0 5 10

Can paste clipart & photos

Video clips,animationsound clips

Holographic companionwith alternativescenarios responsive to personal preferences

Question #10: What Capability Exists to Maintain and Work With

Databases?

0 5 10

Can read andinterpretsummary data

Acquainted withquery functions in commercialdatabase software

Custom design newinterfacesfor unsophisticatedusers

Question #11: What Is Available for Communication?

0 5 10

E-mail

Client serverapplications,customizedfor real-timeshared worksessions

Electronicdiscussion groups

Where Are You?

Professional Expertise

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Low Medium High

Low

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Where Are You?

Professional Expertise

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Low Medium High

Low

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Hig

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This box represents the chart here and will appear on other pages.

What Is a Web Site?

It is a location on the world wide web made up of web pages that use the internet as their transport mechanism. These pages can contain text, graphics, audio, video, and other dynamic and static materials.

What Is a Web-based Teaching Web Site?

It is a teaching program that is delivered over the internet or intranet. The program is accessed using a web browser, such as Microsoft Internet Explorer or Netscape Navigator.

Where Is a Web-based Teaching Web Site Delivered?

To any computer that can access the internet or intranet. This includes a computer at work, on the road, and at home.

Types of Web-based Teaching Web Sites

• Plain text and graphics.

• Interactive.

• Interactive multimedia.

Plain Text and Graphics

Example of a text and graphic web-based teaching web site

Characteristics

• These are like paper-based course material placed on the web and accessed in electronic format.

• You select items by clicking the forward or backward arrow, a hyperlink, or a graphic hot spot.

• Many contain hyperlinks to other related web sites.

Characteristics (Continued)

• Might be an appropriate solution for a given need.

• Provides a lower level of interactivity, although not necessarily a low level of information.

• This is the model many people start with creating web sites.

Interactive

• Sample Sites:– Calendar– Quiz

• Sample Interactive web site:– Example

Characteristics

• Interactivity is the means by which people learn, by having their brain engaged and interacting with the contents.

• Use of good interactivity can enhance the learning experience provided by teaching programs.

• Ensure that the users respond to the contents and do not just read their way through successive information screens.

Characteristics (Continued)

• Interactivity allows the instructor to ensure learning is taking place, track a user’s progress, provide remedial strategies, and, by tracking responses, gain understanding about the success of the teaching program.

Interactive Multimedia

Example of an interactive multimedia web-based teaching web site

Characteristics

• Elements of multimedia are added to enhance and upgrade the learning environment.

• Video, sound, animation, and graphics encourage users to learn with more of their senses than just the eyes.

• Opens the way for conversion of video-delivered teaching courses to a web-based format which improves the convenience of distribution for these materials.

Characteristics (Continued)

• The more engaging nature of multimedia has been a hit in the CBIT market.

• Interactive multimedia teaching programs are usually realized with CD-ROM technology, which allows the large audio and video files to be stored on a CD and presented nicely on the computer screen, without the wait times of the internet.

Characteristics (Continued)

• The web is following close behind with improved bandwidths, and is a major improvement on the CD-ROM format in terms of ease of update.

• The interactive multimedia type of web-based teaching programs are usually authored with a software tool that allows the programming of multimedia and managing the high levels of interactivity.

Characteristics (Continued)

• Although Java applets can be built to manage the high levels of interactivity, most authors prefer full scale authoring tools, such as Authorware which has plug-ins for delivery over the internet.

Advantages of Web-based Teaching Web Sites

• Widely available connections and browsers.

• Flexible, accessible, convenient.

• Cost and time savings.

• Inexpensive worldwide distribution.

• Ease of updating.

• Cross platform compatibility.

Other Technologies Used for Teaching

• Computer-Based Interactive Teaching (CBIT).

• Distance learning.

• Video conferencing.

• Self-paced teaching.

Why Use Web-based Teaching Web Sites

• Need for less expensive ways to deliver teaching.

• New demands in organizations.

• Convenience for users.

• Engaging nature of multimedia delivery.

• Centralized nature of web-delivered teaching.

• Very easy to update.

Is It Worth Investing in Web-based Teaching Web Sites?

Yes. The web can provide the most efficient delivery of information because of its ability to be accessible from anywhere, anytime, and to disseminate a standardized, updateable version to multiple users.

Factors Determining Whether Web-based Teaching Is Right

for Your Organization.

• Management support.

• Potential users to justify the cost.

• Users are computer literate.

• Does the web-based teaching provide a method of instruction that is easier, faster, cheaper, or more engaging than the alternatives?

Some Criteria Used in Evaluating Web-based Teaching.

• Contents.

• Instructional design.

• Interactivity.

• Navigation.

• Use of multimedia.

• Evaluation.

Web Site Design Considerations

Web Site Design Considerations

• Skill Level of your audience.

• Equipment of your audience.

• Content.

• Cost.

• Planning of the web site.

Skill Level of Your Audience

• Who is your audience?

• What is their knowledge level of your topic?

• What is their computer skills level?

Equipment of Your Audience

• What type of computers are they using?

• What operating systems are they using?

• What browsers are they using?

• What are their sound and multimedia capability?

Content of Your Web Site

• Lectures.

• Tutorials.

• Education and population management.

• Communications links (discussion groups).

• Other links.

Cost of Your Web Site

• Cost of developing a web site is completely variable. You can spend as little or as much as you want.

Planning Your Web Site

• Develop an overview of your web site.

• Develop a plan with incremental steps.

• Reevaluate your site as each of the steps are completed.

• Don’t be too rigid. Listen to your audience’s feedback.

Planning of the Web Site

Web Site Design Considerations Conclusions

Balance your design between information, equipment, and audience.

Components Required for Web Site Design and Generation

Hardware Needed for Design(Click Here to See a List of Products)

• Computer.

• Internet connection.

• Scanner (optional).

• Digital camera (optional).

Software Needed for Design (Click Here to See a List of Products)

• Web page design program.

• FTP program.

• Clip-art.

• Graphics manipulation programs.

• Multimedia programs.

• Database.

• Statistical analysis program.

Design and Development Team

• Project manager.• Web page designer.• Graphics designer.• Multimedia developer.• Script writer.• Database administrator.• Programmer.• Epidemiologist.

Design and Development Team

• Actually, you team will be made up of however many people you can afford. This could be a single person working part-time all the ways to a large budget interactive movie with professional actors and screen writers.

Hosting Your Web Site

Hosting Your Web Site

• Using a free site.

• Using your own computer.

• Using your company’s information system platform.

• Using a commercial host.

• Using your own web server.

• Registering your web site.

Using a Free Site

• Advantages:– No hosting costs.

• Disadvantages:– Advertising on every page.– Typically slower access.– Little or no security.– “Funny” internet address.

Using Your Own Computer

• Advantages:– You can do what you want.– Easy to set up security.

• Disadvantages:– Robs performance from your computer.– Must protect from internet attacks.– Must have a permanent IP address.– Takes up additional disk space.

Using Your Company’s Information System Platform

• Advantages:– Little or no cost.– May be fast (or possibly slow).

• Disadvantages:– Politics.– Must have someone else set security.– Limitations on type of enhancements available

(multimedia, databases, etc.).

Using a Commercial Host

• Advantages:– You have good control.– Normally pretty fast.– Free of politics.

• Disadvantages:– Moderately expensive.– Harder to set up security.– More difficult getting started.

Using Your Own Server

• Advantages:– You can do what you want.– Easy to set up security.

• Disadvantages:– Need a spare computer.– Must protect from internet attacks.– Must have a permanent IP address.– Must maintain computer.

Registering Your Web Site

• By registering your web site (at www.networksolutions.com), you can have a domain name like all the popular sites (e.g., www.microsoft.com). It cost $70 for the first 2 years plus a service fee. Most web hosting services will do this for you.

• You will need a DNS setup to link your new domain name to the internet.

Delivering Data on the Web Site

Delivering Data on the Web Site

• Common identifiers.

• Kinds of data.

• Security issues.

• Hardware needs.

• Software needs.

• Updating databases.

• Querying.

Common Identifiers

• Need to develop or use a set of common identifiers for the data.– At Henry Ford Health System, we use our Medical

Record Number as the key.

Kinds of Data

• Community level.

• Encounter level.

• Patient level.

• Summary.

Community Level Data

Encounter Level Data

Patient Level Data

Summary Data

Security Issues

• Protect your web pages from being changed.– Turn on security and set good passwords.

• Limit access.– Set security for confidential documents.

• Stop viruses.– Install antivirus program & keep updated.

• Stop attacks.– Install latest system patches. Consider a firewall.

Hardware Needs (Click Here to See a List of Products)

• Server.

• Internet connection with a minimum speed of 128 kbs and a permanent connection.

Software Needs

• Web Serving software.

• Database engine.

• Scripting language.

• Multimedia serving software.

Updating Databases

• It is possible to work on a “live” database where the data is added as patients are seen.

• At most locations, you will need to massage the data and import it into your databases. This requires a major effort that you need to plan.

Querying

• Levels of capacity.– Program’s normal query, customized queries.

• Query result presentation.– Standard results, customized views, graphics.

• Interactive querying.– automatically run queries.

• Analytic issues.– The amount of analysis that you want to include.

Customized Query Form

Querying

• Levels of capacity.– Program’s normal query, customized queries.

• Query result presentation.– Standard results, customized views, graphics.

• Interactive querying.– automatically run queries.

• Analytic issues.– The amount of analysis that you want to include.

In Summation

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