Implementation Research: Lessons Learned in OKPRN

James W. Mold, M.D., M.P.H.

Department of Family and Preventive Medicine

University of Oklahoma Health Sciences Center

Oklahoma City

Objectives

Define quality improvement research Describe OKPRN Review what we have learned Discuss unanswered questions Speculate about next steps

Oklahoma Physicians Resource/Research Network Established in 1994 (HRSA Grant) Emphasis on both resources and research

(More like R&D) Emphasis on information technologies

Now a 501c3 non-profit organization but closely aligned with the OU DFPM

110 practices; 235 clinician members Members care for 10% of the state’s pop.



OKPRN Practices

Basic Research

Human Research

Practice-and

Community-Based

Research

Practiceand

CommunityT1 T2 T3=QI

Not ready for humans Not ready for patients Not ready for practice

Cells Diseases People Practices

Bio

chem

istry

Cells/T

issues

Exp

. A

nim

als

Ph

ase I T

rials

Ph

ase II T

rials

Ph

ase III Trials

Meta-an

alysis G

uid

elines

Imp

lemen

tation

D

issemin

ation

Ph

ase IV

Trials

Co

st-effectiveness

Best P

ractices

Train

ing

Facilitatio

n

Re-en

gin

eering

What’s possible?

Can it work?

Will it work?

Is it worth it?

Diffu

sion

Basic Research

Human Research

Practice- and

Community-Based

Research

Practiceand

Community

T1 T2 T3=QI

DisseminationResearch

ImplementationResearch

GuidelinesDevelopment

Meta-analyses;Systematic

Reviews

Not ready for humans Not ready for patients Not ready for practice

Cells Diseases People Practices

Research Pipeline

T=Translation

OKPRN Practice-Based Research Studies

Patient access to computers and e-mail 1997 and 2007

Brown recluse spider bites Epidemiology and management

Night sweats Epidemiology, associations, and consequences

Peripheral neuropathy in older patients Epidemiology and consequences

Why older patients change doctors Diagnosing influenza Exemplar studies (discussed later)

The Challenge It has been estimated to take an average of 17

years before 14% of biomedical innovations make it into generalized practice.

Primary care must convert to a model or models of care better suited to the current and emerging health needs of the population

Innovations are happening at an increasing rate

Implementation Research Projects

Pneumococcal immunization Before - After

Diabetes care Prospective, uncontrolled Cluster RCT

Smoking during pregnancy Before - After

Implementation Research Projects Mammography RCT

Cluster RCT

Preventive Services Delivery Cluster RCT

Prescription for Health (Unhealthy Behaviors) Phased/staggered Intervention in Practice Clusters

How the Process Works For researchers and funders: Studies of specific

QI strategies; development of products (software, guidebooks)

For practices, these projects look like QI Clinician education (education, training, CME) Practice receives tangible support (e.g. facilitator, $$)

Funding sources: Agency for Healthcare Research and Quality, Oklahoma Foundation for Medical Quality, Robert Wood Johnson Foundation, QIO, Medicaid

Which Practices Are Successful

The QI initiative is a high priority for the practice

The practice is able to change The practice is able to implement the

critical components of the new process

Solberg LI. Improving medical practice:A conceptual framework. Annals Fam. Med. 2007; 5(3): 251-256.

Priority

Administration is behind it Clinicians are behind it Staff are behind it Competing priorities are less important than the

desired change and won’t interfere with it.

Change Capacity

Shared quality of care mission Collaborative, cohesive environment Well-organized, non-chaotic Clear lines of authority/decision-making Well-developed QI process Regular QI meetings Stable workforce and administration Stable finances/financial management Effective policies and procedures

Change Process Content

Care management capabilities Patient self-management support Capable staff Patient tracking and registry functions EHR functionality Decision support options Test and referral tracking Task management systems Performance Tracking/Reporting

TimeThe time that it takes to implement an

innovation in committed practices depends upon:

1. The complexity of the intervention2. The magnitude of the changes required3. The number of people in the practice who must

change their methods

It generally takes about 6 months.

Implementation Strategies Tested

Feedback Benchmarking Identification of exemplars/exemplar methods

Academic Detailing Literature review Exemplary practices (positive deviants)

Practice facilitation HIT support Local Learning Collaboratives

Feedback and Benchmarking

Must be accurate and believable (trusted) Measures must be relevant/agreed upon Must be repeated at least monthly during

implementation

Exemplars and Exemplar Practices

Okarche, Oklahoma 1998Okarche, Oklahoma 1998

““It doesn’t help when the QIO comes in, It doesn’t help when the QIO comes in, audits my charts, and tells me what a lousy audits my charts, and tells me what a lousy job I am doing. If they would tell me who is job I am doing. If they would tell me who is doing a good job, maybe I could talk with doing a good job, maybe I could talk with them and find out how to do it better.”them and find out how to do it better.”

Mark Gregory, M.D.Mark Gregory, M.D.

What Mark Didn’t Say

If they would just tell me: What the literature says I should do. What the specialists say I should do. What the guidelines say I should do. What my academic colleagues say I should do. What CME resources are available.

Performance DistributionsPerformance Distributions Virtually always presentVirtually always present Wider than you would expectWider than you would expect Within practices and between practicesWithin practices and between practices High performers are often High performers are often notnot the “usual the “usual

suspects”suspects” Highest performers in one area aren’t Highest performers in one area aren’t

necessarily the highest performers in other necessarily the highest performers in other areasareas Some true exemplars (quest for excellence) Some true exemplars (quest for excellence)

0

10

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40

50

60

70

80

90

100

Percent

E O J V U H W C L M A E G Y B S P D T Q R I N K

Clinician

CRC Screening

0

10

20

30

40

50

60

70

80

90

100

Percent

J D H E P I G B L Q C F M A N K O

Clincian

Dtap#4

No Show Rates

0

20

40

60

80

100

70 137 136 19 14 4 18 92 121 105

Number of Residencies

Percent

CPCI Accumulated Knowledge

0

10

20

30

40

50

60

70

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90

100

35 4 34 6 30 15 12 24 5 3 1 2 10 22 37 28 7 9 18 39 8 29 36 38

Clinician

Percent

CPCI Comprehensiveness of Care

82

84

86

88

90

92

94

96

98

100

35 4 34 6 30 15 12 24 5 3 1 2 10 22 37 28 7 9 18 39 8 29 36 38

Clinician

Percent

What’s the best way to …What’s the best way to … Manage laboratory test results?Manage laboratory test results? Deliver preventive services?Deliver preventive services? Improve my care for patients with Improve my care for patients with

diabetes?diabetes? Handle prescription refills?Handle prescription refills? Help patients remember to bring their Help patients remember to bring their

medications with them to appointments?medications with them to appointments? Help overweight patients lose weight and Help overweight patients lose weight and

keep it off?keep it off?

What Do Exemplars Know? Principles Techniques Scripts

From a High School Math Quiz

Academic Detailing

Respectful sharing of information Discussion of current methods Discussion of how the principles and

techniques might apply within that practice Plan for improvement

Practice Facilitation

One-half day per week for about 6 months

Relationship with clinicians and staff is key; takes several months

Key functions include: assessment and feedback, coaching, team-building, technical and hands-on, assistance, training, coordination of PDSA cycles, and cross-pollination

PEAPEAPEAPEA

PEAPEA

OKPRNOKPRNBoard of DirectorsBoard of Directors

Dept. of Dept. of Family Family

and and Preventive Preventive MedicineMedicine

PEAPEA

*PEA = Practice Enhancement Assistant

NE OK

SW OK

NW OK

SE OK

HIT Support

Generation of reports Template development Database development Implementation of registries Clinical decision support systems Communication systems

Local Learning Collaboratives

One-hour lunch meetings every 1 – 2 months

Review performance data from all practices Share successes and failures Share anecdotes Share effective methods

Performance Feedback

Academic Detailing

Facilitation

IT Support

Local Learning Collaboratives

Effective Implementation of Innovations in Primary Care

Practice Enhancement Assistant

Literature and Exemplar Methods

Priority

Proposed effects of the QI Interventions on Change Elements

Change Capacity Change Process Content

Performance Feedback

Academic Detailing

Practice Facilitation

HIT SupportLocal Learning Collaboratives

Disseminating the Implementation Process Longitudinal relationships Knowledge of local factors Travel time/cost Cross-practice collaboration

It Takes a Village Primary care can no longer be practiced in

relative isolation from public health, mental health, social services, and community organizations

Obesity, lack of exercise, smoking, and abuse of alcohol account for 37% of all premature deaths.

County Health Extension

Key functions: Performance monitoring/reporting Practice facilitation Local learning collaboratives HIT support PCMH capacities shared across practices

County Health ExtensionClosing gaps: Public health Mental Health Social Services and Community Resources

Cooperative Extension 1889: Dept of Agriculture began issuing Farmers’

Bulletins and the Yearbook of Agriculture; experimental farms issued research bulletins and “popular bulletins”; publications reached small proportion of farmers, many of whom distrusted “book farming”

1880 -1911: Widespread establishment of “farmers institutes” and even “mobile institutes” to reach more farmers

1906: S. A. Knapp hired the first county extension agent to develop a personal relationship with every farm family in the county and help them implement innovations

Cooperative Extension 1889: Dept of Agriculture began issuing Farmers’

Bulletins and the Yearbook of Agriculture; experimental farms issued research bulletins and “popular bulletins”; publications reached small proportion of farmers, many of whom distrusted “book farming”

1880 -1911: Widespread establishment of “farmers institutes” and even “mobile institutes” to reach more farmers

1906: S. A. Knapp hired the first county extension agent to develop a personal relationship with every farm family in the county and help them implement innovations

Cooperative Extension

Funding sources – 30% federal, 70% state and local Headquartered in the land-grant university Staffing – 1% federal, 32% university, 67% local in

nearly all of the 3,150 counties in the U.S.; plus more than 2 million volunteers

Goal is to maintain meaningful bi-directional communication between the university and the farmers and provide on-site training and assistance to farmers and farm families so they can stay abreast of advances in science

Taking the University to the People by Wayne D. Rasmussen; Iowa State University Press, 1989

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ The insurance companies alone (including

Medicare and Medicaid) are spending (mostly wasting) more than $5 billion a year on QI

Now add in the money spent by AHRQ, the NIH, the CDC, private foundations, advocacy organizations, professional associations, etc.

Pandemic influenza preparedness NHLBI asthma guidelines

Community Care of NC Regional 501c3 organizations; owned and

run by primary care clinicians; supported by Medicaid care management funds ($3 PMPM); charged with improving quality of care for Medicaid patients.

ROI $2 for every $1 invested Saved the state $60 million in Medicaid costs in

2003 and $120 million in 2004

Canadian County, Oklahoma Juvenile Justice System and community groups

anteed up $10,000 Matched through the Medicaid federal match to

pay for a ½ time care manager for children Linked to a matching contract with the OU DFPM

for $120,000 to improve well child care Drew the attention of a developmental

pediatrician, who obtain a grant from a foundation for $100,000 to improve developmental screening

Now approved by Medicaid as a HAN. Will receive $5 PMPM ($340,000 per year)

The University of New Mexico HEROs Program Health Extension Rural Offices (HEROs) Mission:

Generate better health at lower cost Increase community capacity to address local

problems in order to reduce health disparities Activities

Tele-health projects Training Workforce development

County health report cards

University of Wisconsin

Questions??????