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ClinicalClinical InformationInformation
SystemsSystems
ClinicalClinical InformationInformation
SystemsSystemsSacopee Valley Health CenterSacopee Valley Health Center
August 16, 2007August 16, 2007
Session AimSession Aim
Brief overview of the Chronic Care ModelBrief overview of the Chronic Care Model
Cost of chronic disease Cost of chronic disease
Using clinical information systems to improve Using clinical information systems to improve outcomes of patients suffering chronic disease outcomes of patients suffering chronic disease with pre planning and identifying patients at with pre planning and identifying patients at risk.risk.
Chronic DiseaseChronic Disease
A chronic condition lasts a year or longer, A chronic condition lasts a year or longer, limits what one can do and may require limits what one can do and may require ongoing care. More than 125 million ongoing care. More than 125 million Americans have at least one chronic Americans have at least one chronic condition and 60 million (21% of the condition and 60 million (21% of the population) have more than one condition. population) have more than one condition.
The number of people with chronic The number of people with chronic conditions is projected to increase from 125 conditions is projected to increase from 125 million in 2000 to 171 million in the year million in 2000 to 171 million in the year 2030. 2030.
What accounts for this What accounts for this dramatic growth in chronic dramatic growth in chronic
conditions?conditions? The large population of baby boomers is aging, and their The large population of baby boomers is aging, and their
health is beginning to deteriorate.health is beginning to deteriorate. Advances in medical science have helped extended our life Advances in medical science have helped extended our life
span, leaving more people vulnerable to age related chronic span, leaving more people vulnerable to age related chronic illness such as cancer, Alzheimer's disease, osteoporosis, illness such as cancer, Alzheimer's disease, osteoporosis, heart disease.heart disease.
10% of patients in one survey reported that in the last year 10% of patients in one survey reported that in the last year they were not able to see a primary care physician when they they were not able to see a primary care physician when they felt it was necessary. felt it was necessary.
22% of those who have insurance report that it does not cover 22% of those who have insurance report that it does not cover all the types of care they need. This percentage represents an all the types of care they need. This percentage represents an estimated 21 million Americans with chronic conditionsestimated 21 million Americans with chronic conditions
In a recent survey 16% of respondents (an estimated 16 In a recent survey 16% of respondents (an estimated 16 million people) have been warned by a pharmacist about a million people) have been warned by a pharmacist about a possibly harmful interaction between medications they were possibly harmful interaction between medications they were prescribed by one or more physicians.prescribed by one or more physicians.
Prevalence of Chronic Prevalence of Chronic ConditionsConditions
Current 2000 Projected 2020
125 M
157 M
Multiple Chronic ConditionsMultiple Chronic Conditions
2000 2020
60 Million
81 Million
Out-of-Pocket CostsOut-of-Pocket Costs
$182
$369
$621
$1,106
None
1 Chronic Condition
2 Chronic Conditions
>3 Chronic Conditions
Direct CostsDirect Costs
2000 2020
$510
Billion
$1.07
Trillion
Current deficiencies in Current deficiencies in management of chronic illnessmanagement of chronic illness
Rushed practitioners not following Rushed practitioners not following established practice guidelines established practice guidelines
Lack of care coordination Lack of care coordination Lack of active follow-up to ensure the Lack of active follow-up to ensure the
best outcomes best outcomes Patients inadequately trained to Patients inadequately trained to
manage their illnesses manage their illnesses
How to improve the systemHow to improve the system
The crucial factor in improving chronic illness care is a clinical database that has the critical information that a provider needs to have for a productive interaction with a patient
Clinical information systems such as registries (PECS) and electronic health records (EHR) enhance the quality, safety, and efficiency of patient care and office workflow
A registry or list of patients and their related data is a tool for tracking individual and population clinical care information
Definition
A registry is a computer application that stores disease-condition specific individual and population-based information to support care management, outreach, quality improvement, and outcome research.
Planning for a registryPlanning for a registry WHOWHO
Will be entering it? Will be entering it? WHATWHAT
Data do I need to get my reports?Data do I need to get my reports? WHENWHEN
Will it be entered? Will it be entered? WHEREWHERE
Will it be entered?Will it be entered? WHYWHY
When what I do works so well? When what I do works so well?
Use the registry to provide clinical support
Registries support physicians by providing printed patients reports,
Identifying patients that are overdue Generate reminders and care-planning tools
for individual patients Provide feedback to care team, leaders and
affiliated organizations Help identify potential medication interactions A formulary can reduce out of pocket
expenses
Workflow Analysis: Workflow Analysis: Who/WhenWho/When
Do Registries WorkDo Registries Work
In the VA, programs with improved In the VA, programs with improved HbA1c results, had computerized HbA1c results, had computerized diabetes reminders, engaged patients diabetes reminders, engaged patients with self management, and involved the with self management, and involved the providers in quality improvement.providers in quality improvement.11
Use of physician reminders, performance Use of physician reminders, performance feedback, and structured care feedback, and structured care management were all associated with management were all associated with improved diabetes process, but not improved diabetes process, but not improved outcomes.improved outcomes.22
Clinician’s responses to a survey assessing Clinician’s responses to a survey assessing their use of CCM components was their use of CCM components was significantly correlated to improvements in significantly correlated to improvements in HbA1c values and ratios of total cholesterol HbA1c values and ratios of total cholesterol to HDL cholesterol. Clinician’s responses to HDL cholesterol. Clinician’s responses were also associated with patient reported were also associated with patient reported measures of improved care processes.measures of improved care processes.33
1. Jackson GL, Yano EM, Edelman D et al. Veterans Affairs primary care organizational characteristics 1. Jackson GL, Yano EM, Edelman D et al. Veterans Affairs primary care organizational characteristics associated with better diabetes control. Am J Manag Care 2005; 11(4):225-37.associated with better diabetes control. Am J Manag Care 2005; 11(4):225-37.
2. Mangione CM, Gerzoff RB, Williamson DF et al. The association between quality of care and the 2. Mangione CM, Gerzoff RB, Williamson DF et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006; 145(2):107-16.intensity of diabetes disease management programs. Ann Intern Med 2006; 145(2):107-16.
3. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE. Use of 3. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE. Use of Chronic Care Model Elements Is Associated with Higher- Quality Care. Annals of Family Medicine 2007; Chronic Care Model Elements Is Associated with Higher- Quality Care. Annals of Family Medicine 2007; 5(1):14-20.5(1):14-20.
Measuring ProgressMeasuring Progress
MeasurementMeasurement is a critical part of is a critical part of testing and implementing changestesting and implementing changes
Measures tell a team whether the Measures tell a team whether the changes they are making actually changes they are making actually lead to improvementlead to improvement
Measurement for improvement Measurement for improvement should not be confused with should not be confused with measurement for researchmeasurement for research
Measurement for Measurement for ResearchResearch
Measurement for Measurement for Learning and Learning and Process Process ImprovementImprovement
PurposePurpose To discover new To discover new knowledge knowledge
To bring new knowledge To bring new knowledge into daily practice into daily practice
TestsTests One large "blind" test One large "blind" test Many sequential, Many sequential, observable testsobservable tests
BiasesBiases Control for as many Control for as many biases as possible biases as possible
Stabilize the biases from Stabilize the biases from test to test test to test
DataData Gather as much data as Gather as much data as possible, "just in case" possible, "just in case"
Gather "just enough" Gather "just enough" data to learn and data to learn and complete another cycle complete another cycle
DurationDuration Can take long periods of Can take long periods of time to obtain results time to obtain results
"Small tests of "Small tests of significant changes" significant changes" accelerates the rate of accelerates the rate of improvement improvement
PDSAPDSA
VariablesVariables
CHANGE:CHANGE: A deliberate introduction A deliberate introduction into into a process in order to a process in order to achieve achieve a higher level of a higher level of performanceperformance
EVENT:EVENT: Something that happens Something that happens which may affect which may affect
performance of the process.performance of the process.
TRACKINGTRACKING
The Improvement Tracker allows you to track any of The Improvement Tracker allows you to track any of the measures currently available in the Topics area of the measures currently available in the Topics area of IHI.org. Just select the measure you want to track (or IHI.org. Just select the measure you want to track (or create your own custom measure), set your aim, and create your own custom measure), set your aim, and enter your data. The Improvement Tracker enter your data. The Improvement Tracker automatically graphs your data. It lets you create automatically graphs your data. It lets you create reports, and even customize them for various reports, and even customize them for various audiences — your team, your CEO, your community.audiences — your team, your CEO, your community.
Improvement Tracker allows you to track predefined Improvement Tracker allows you to track predefined standard measures in several topic areas, with more standard measures in several topic areas, with more being added periodically. Additionally, you can create being added periodically. Additionally, you can create your own custom measures to track any data you your own custom measures to track any data you want!want!
http://www.ihi.org/ihi/workspace/tracker/http://www.ihi.org/ihi/workspace/tracker/