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Using Technology to Improve Quality
Charles DeShazer, MDVP, Quality, Medical Informatics & Transformation
Dean Health System
Madison, WI
Key Industry Assumptions
Current cost inflation curve is unsustainable
Payers are moving towards paying for value rather than volume
EHR will become a standard tool
Quality will become not only the “ticket to play” but also one basis of competition (value = quality/cost)
Primary care will be the engine for quality
Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
AUS CAN GER NETH NZ UK US
OVERALL RANKING (2010) 3 6 4 1 5 2 7
Quality Care 4 7 5 2 1 3 6
Effective Care 2 7 6 3 5 1 4
Safe Care 6 5 3 1 4 2 7
Coordinated Care 4 5 7 2 1 3 6
Patient-Centered Care 2 5 3 6 1 7 4
Access 6.5 5 3 1 4 2 6.5
Cost-Related Problem 6 3.5 3.5 2 5 1 7
Timeliness of Care 6 7 2 1 3 4 5
Efficiency 2 6 5 3 4 1 7
Equity 4 5 3 1 6 2 7
Long, Healthy, Productive Lives 1 2 3 4 5 6 7
Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290
Overall Rank Ordering of Health System Characteristics 2010
Country Rankings
1.00–2.33
2.34–4.66
4.67–7.00
ACO model represents a shift of COST RISK to Providers through payment mechanisms…
% ofPopulation
1%
15%
70%
14%
25%
15%
10%
50%
Population vs. Costs vs. Interventions
1000 Lives 14,000
Lives
15,000 Lives
70,000 Lives
Complex Case Management
Disease/Demand Management
Health
Mgmt
% of
Cost
Example of 100,000 People in a Population
24 hours in the life of a PCP
“The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care,” a report from the American College of Physicians, 2006
Yarnall KS, et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635
Ostbye T, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005; 3:209
Preventive care (7.4 hrs)
Chronic care (10.6 hrs)
Leftover (6 hrs)
Therefore, managing costs (risk) means managing chronic and complex conditions (especially in the short term)
• Quality initially will be the ticket to play and later become a key competitive measure
• You will have to fix the PCP’s day in the process
Kaiser Permanente Diabetes Care
Ohio region 2006
Large population of diabetic patients
Recently implemented EHR
No infrastructure for care management
Poor quality scores on HEDIS diabetic care
Creation of Diabetic Care Model
Primary care restructuring as medical home
Added care management resources
Outsourced health coaching and outreach
Leveraged EHR for process management and communication
Created quality measurement dashboard with actionable drill-down, filtering and sorting capabilities
Developed standardized workflows aligned with Clinical Decision Support
Better leveraged non-physician staff
Enhanced patient engagement via education, PHR, email, behavioral health integration and outreach
Results
Statistically significant improvement in 6 of 9 commercial and all Medicare HEDIS metrics within 1 year
Became one on the top performing regions in Diabetic care
3 years after implementation beginning to see decreased cost secondary to decreased strokes, heart attacks and amputations consistent with modeling (Achimedes)
Source: http://www.rwjf.org/files/research/72480af4qehr201106.pdf (Accessed 7/8/2011)Better Health Greater Cleveland: http://www.betterhealthcleveland.org/
Does Use of EHRs Help Improve Quality?
“For patients with diabetes, 51 percent of those receiving care in an EHR practice received all the recommended care, as compared with 7 percent of those who received care in a paper-based practice.”
Leverage Meaningful Use as a Springboard
Criteria Opportunity
Problem List Define system-wide standards and policies, improve accuracy of documentation, infrastructure for CDS, use for shared care plan
AVS & PHR Enhance quality, consistency and usefulness of content (esp. for chronic condition management), fully operationalize PHR, enhance patient engagement, use for shared care plan, leverage to engage family & caregivers
Medication List Improve medication reconciliation and management of transitions of care.
Patient Lists & Structured Data
Enhance analytics, create robust registries and dashboards, infrastructure for CDS
Clinical Decision Support
Create governance structure, establish standards, focus them on key areas of improvement opportunity, avoid alert fatigue
Quality Measures Expect to be held accountable for results, create improvement strategies now
Number of doctors seen
Percent reporting in past two years: Any 1 to 2 3+
After medical test, no one called or wrote you about results, or you had to call repeatedly to get results
27 21 36
Doctors failed to provide important information about your medical history or test results to other doctors or nurses you think should have it
23 22 26
Test results or medical records were not available at the time of scheduled appointment
18 14 29
Your primary care physician did not receive a report back from a specialist you saw
15 11 24
Your specialist did not receive basic medical information from your primary care doctor
12 9 18
Any of the above 47 42 55
Key System Challenge is to address FRAGMENTATION Poor Coordination of Care Is Common,
Especially If Multiple Doctors Are Involved
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.** On average, Medicare beneficiaries see 6.4 MDs and fill 20 prescriptions annually. Beneficiaries with 5+ chronic conditions see 14 MDs and fill 57 prescriptions annually (Source: N Engl J Med 2007;356:1130-9)
Key Technical Functions for Next Level Quality Management
Focus Area Key Technical Functions
Care Coordination HIE, Workflow Management, Shared Care Plan, Referral tracking
Chronic Condition Management & Complex Care Management
CRM, Workflow Management, Shared Care Plan, Predictive Modeling, CDS, Telehealth, Registries
Population Health Management CRM, HRA, Predictive Modeling, Workflow Management, CDS, Population analytics, Registries
Patient Engagement & Activation CRM, Shared Decision Making, Telehealth, PHR
Evidence-Based Medicine Practice
CDS, Workflow Management, Population analytics
Real-Time Connectivity HIE, Telehealth, mobile technology, unified messaging
EHR is necessary but not sufficient. The next level of quality management will require a Health Information Technology (HIT) “ecosystem” especially a robust analytic infrastructure. Standalone EHR may not be able to provide all of these functions.
Provider Organizational Cultural Shifts
Critical Success Factors for Transformation
Now Future
Volume Focus Value Focus
Physician Autonomy
Independence
Physician Captain
Accountability External
HIT optional
My data is my data
Organizational Standards
Interdependence
Physician Coach & Mgr
Accountability Internal
HIT Core to Strategy
TRANSPARENCY!!
Looking Ahead…
MU Stage 2 & 3
ICD-10
ACO development (success or flop?)
Evolution of Value-Based Reimbursement
Genomics
QUESTIONS?