Integrated Care Coordination Information System: primary care redesign through care coordination and...

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

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

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

Care Plan

Reminders

Communication

Population

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

dorrd@ohsu.eduhttp://www.caremanagementplus.org

Thank you!

• dorrd@ohsu.edu• http://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

Integrated Care Coordination Information System: primary care redesign through care coordination and...

Documents

Making Connections: Strategies for Strengthening Care ... · Making Connections: Strengthening Care Coordination for Children & Adolescents 1 Introducing Care Coordination Strategies

Care Coordination Handbook

Coordination of Care with Primary Care Physicians (PCP)

a history of dorr-oliver - Dorr-Oliver Alumni History/History/2008 - Dorr-Oliver... · FLSmidth Dorr-Oliver Eimc:o Inc:. 609 Hamilton Street, Suite 2, Allentown, PA 18101 Tel: 610-740-1015·

Minnesota Health Care Home Care Coordination Cost Study

Longitudinal Coordination of Care

Care Coordination Monthly Webinar

Care Coordination Delegation Guidelines for Community Members · Care Coordination Delegation Guidelines for Blue Plus MSHO Community Members 1 | P a g e Care Coordination Delegation

Care Coordination & Caregiver Training

Quality Improvement and Care Coordination: Implementing ...depts.washington.edu/anesth/care/pain/telepain/... · Quality Improvement and Care Coordination: Implementing CDC’s Opioid

Care Coordination Implementation Guide

Patient Care Coordination Variance Reporting - Stratis … · Section 4.8 Implement–Patient Care Coordination Variance Reporting - 2 Overview of Patient Care Coordination Variance

Patient Care Coordination Variance Reports Template · Web viewSection 4.8.2 Implement–Patient Care Coordination Variance Reports Template - 1 Patient Care Coordination Variance

Care Coordination - Welcome to SCAN Health Plan! · 2018-04-13 · Care Coordination . Improving the Patient Experience . Office Staff Training . Introduction \爀屲Care Coordination

Office of Care Coordination Newsletter - Orange County, CA · OFFICE OF CARE COORDINATION NEWSLETTER NOVEMBER 2017 Office of Care Coordination Newsletter NOVEMBER 2017 VOLUNTEERS

1 Care Coordination Through the Use of Home TeleHealth Technologies VHA Care Coordination Program VHA Care Coordination Program VA Healthcare Network of

HL7 Coordination of Care Service Functional ModelHL7 PCWG Coordination of Care Service Functional Model Page 4 HL7 Service Functional Model; Coordination of Care Service (CCS), STU

Improving Care With an Integrated Care Coordination Program

Care Coordination for California’s Children and Youth with ... · Care coordination under the CCS program is done by medical professionals while care coordination under managed

SDS Care Coordination Guide