Making Excellent Care Automatic: Linking Records to Improve Preventive Services

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Making Excellent Care AutomaticLinking Records
toImprove Preventive Services

• Every system is perfectly designed to get the
  results it is getting. Paul Betalden
• or No-Design is your Design
• Yvette Williams MD MPH
• VA Southeast Network

The Tyranny of the Urgent
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Data Information Knowledge

• DATA Account balance 1234567.89
• INFORMATION
• My goodness my bank balance has jumped 8087 to
  more than 12 million dollars!"
• KNOWLEDGE
• That cant be right, nobody owes me that much
  money"

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Data Information Knowledge

• Data (a collection of facts) on its own has no
  meaning
• Information is data that has been assessed and
  processed (by humans or computers) to allow it to
  take on meaning.
• Knowledge (awareness or understanding) is
  Information that has been interpreted and put
  into context (cross-matched with other related
  information) and checked for patterns.
• Knowledge is a prerequisite to good decision
  making.
• Although we fool ourselves every day, for chronic
  disease this process CAN NOT take place in the 20
  minute unplanned consultation!

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Data Information Knowledge

• Database
• An organized body of related information arranged
  for ease and speed of search and retrieval.
• Disease Registry
• A regularly updated database that includes all
  clinically relevant data points on all active
  patients with a condition of interest, and is
  used for management and or feedback
• Medical Data points (or datum an item of
  information derived from measurement or research)
• Pharmacy
• Lab results
• Encounters (visits CPT, ICD data)

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Data Information Knowledge

• Knowledge Management
• the technologies involved in creating,
  disseminating, and utilizing knowledge data also
  any enterprise involved in this

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Making Excellent Care AutomaticLinking Records
toImprove Preventive Services
Diabetes is the Model Chronic Disease

• Prevalent
• Lethal
• Long Asymptomatic Timeline
• Modifiable Outcomes
• Cost Effective Plan of Care
• Patient Self Management is Essential for Success
• Medical Consensus
• ? Societal Consensus

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Making Excellent Care AutomaticLinking Records
toImprove Preventive Services
Diagnosis Treat
monitor control

• Chronic disease management does not fit easily
  into the traditional VA (or US) health care model
  that was designed for acute and tertiary care

This is a System Problem to solve it we need a
System Solution
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VA Southeast Network(VISN 7)
VISN Director (Ms Linda Watson)
Atlanta V A Medical Center (FY04 57,000 unique
patients, 554,000 outpatient visits) 8
Hospital-Based PC Teams 4 Community Based
Outpatient Clinics (CBOC)
Dublin
CAVHCS
Atlanta
Charleston
Birmingham
Augusta
Columbia
Tuscaloosa
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The Chronic Disease Challenge in VISN 7

• Pros
• Well Defined National Standards of Care
• Good theoretical buy-in to the guidelines
• Unified System
• Single Pharmacy and Lab Package
• Electronic Medical Record
• Availability of comprehensive Corporate Database
  (CDB)

• Cons
• Large numbers of patients
• 251,781 Patients in Primary Care
• gt50of these patients are over the age of 60
• 53 K (gt20) of these patients are Diabetic
• Many models of care
• Resident Clinics, Staff Model Group Practices

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Four Diabetes Performance Measures

• Percent of Panel Patients with
• Measure 1 A1C in the last year and most recent
  A1C lt 9
• Measure 2 Most recent BP this year lt 140/90
• Measure 3 Retinal Eye Exam in the last 2 years
• (or last year if A1C gt 8 or known retinopathy)
• Measure 4 LDL in the last year and most recent
  LDL lt 100

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Adjusting the Playing FieldProfiling Patients
Prospectively

• This project began as a Provider Profiling
  project .
• Initial attempts were to develop reports for
  clinicians in Atlanta. These reports were
  disseminated and discussed but ultimately these
  data were not as actionable as we would have
  liked.

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Unsuccessful Initial Attempts at Provider
Profiling by Audit and Feedback

• Provider Morale excuses, excuses!
• Provider time constraints More excuses
• Lack of system for Chronic disease Management
• Just plain did not achieve the results that we
  required

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The Chronic Care Model

• Edward Wagner MD http//www.nicsl.com.au/Present
  ations/EdWagnerJune04/player.html
• Director of the MacColl Institute for Healthcare
  Innovation
• Leader of the Improving Chronic Illness Care
  Program of the Robert Wood Johnson Foundation.
• Dr Wagner's area of interest is restructuring
  health services to deliver effective and
  efficient care for people with chronic illness

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The Chronic Disease ParadigmWagners Chronic
Care Model

• Wagner advocated a systems approach to Chronic
  Illness Management in which

Interacts with
Prepared Proactive Practice Team
Informed Activated Patient
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The Chronic Care Model

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Making Excellent Care AutomaticLinking Records
toImprove Preventive Services

• Wagners Chronic Care Model
• Delivery System Redesign Care Management
  roles Team practice
• Care delivery coordination Proactive follow up
• Planned visits Visit system change
• Self management Support Patient
  education Guidelines available to patients
• Patient activation Collaborative decision
  making with patients
• Self management assessment Self management
  resources and tools
• Decision Support Provider education
  Expert consultation support
• Institutionalization of guidelines
• Clinical Info. Systems Patient
  Registry Systems Use of information for care
  management
• Feedback of performance data

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Profiling Our Patients Prospectively

• In December 2003, we shifted our emphasis from
  retrospective reporting on the previous months
  performance measures to a prospective system in
  which we use the CDB to forecast a clinicians
  patients chronic disease screening needs for the
  following months.

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Profiling Our Patients Prospectively

• For instance in December 2003 we are able to
  provide each primary care provider with
  patient-specific lists of the labs, eye exams and
  BP measurements that will be needed before the
  end of March 2004 to keep each veteran in
  compliance with these four measures of
  compliance.

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Profiling Our Patients Prospectively

• This report includes detailed information
  regarding compliance with four key measures on
  all of the providers diabetic patients.

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Activating our patients and engaging our
clinicians

• We then developed and implemented
• A format for reaching patients directly outside
  of the traditional patient visit
• The Diabetes Resource Center self-scheduled DM
  teaching, patients can walk-in for assistance
  with getting labs and exams
• Monthly Virtual Chronic Disease Clinics that
  allowed clinicians scheduled time to address
  chronic disease

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Activating our patients

• We used the Mail-merge function in Office XP to
  produce detailed patient-specific letters that
  notified patients of
• The current diabetes guidelines, and their
  specific BP, LDL and A1C goals
• The patients personal test results with
  annotation as to whether he/she is meeting these
  goals
• What tests are Due Now and how the patient
  could obtain the needed tests without the need
  for a specific scheduled clinic appointment

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Activating our Patients by allowing them to self
schedule

• Development of the Diabetes Resource Center in
  the Atlanta VLC one stop shopping for diabetes.
• Comprehensive diabetes teaching every Monday
  morning MD, RN and RD
• Group foot exams
• Follow up by MD, PharmD and RN every Tuesday
  morning
• Walk-in to VLC for information on diabetes
  self-management any morning MTW
• Walk-in to Lab and Eye clinic with letter for
  labs and eye photos.

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Engaging the Primary Care Provider -- Chronic
Disease Virtual Clinics

• Since measures that have grades of compliance,
  they may be stratified to allow the operator the
  choice of either printing lists of all patients
  with HbA1c above 8 or simply printing only those
  above 11 that may need an appointment to the
  physician or referral to the Diabetes clinic.
• Detailed outline of duties for each team member
  (Clerks, Medical Assistants, Nurses and
  Clinicians) during the Virtual Chronic Disease
  Clinic
• Two-Page Patient Letter
• One-Page Patient Letter

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Results

• How does this translate into practice?

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Green Team compliance with Diabetes Measures
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Green Team compliance with Diabetes Measures
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Dr SHs Performance Dec 03 / Aug 04
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Potential Benefits to the Institution

• An organized system to match labs ordered to
  guideline requirements should ultimately result
  in less duplication of labs
• Better Chronic Disease/ EPRP scores
• More patients self scheduling labs several days
  prior to their appointments and fewer patients
  receiving stat labs on the day of the
  appointment
• Fewer patients arriving to lab non-fasting
• Improved patient satisfaction scores
• Better use of scheduled appointments and fewer
  overall face-to-face appointments  

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Prospective Patient-Centered Diabetes Care

• Automatically populates fields with required labs
• Automatically populates fields that advise
  patient to call to schedule a group visit
• Automatically mailed out if patient is
  non-compliant

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• Our New Improved Letter
• Automatically mailed out on veterans birth month
• Labs automatically ordered every year with view
  alerts to primary care provider

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Key Elements

• Patients Receive
• Periodic letters informing them of
• Guidelines and Goals
• Personal compliance status 0, 1, 2, 3 or 4 of
  the recommended diabetes measures
• Tests due now
• Actions needed now to reach compliance on all 4
  measures
• Ability to self-schedule recommended lab and
  other ancillary tests at time convenient to the
  patient
• Reliable periodic feedback on their chronic
  disease.
• Access to education and self-management support
  in the Diabetes Resource Center

• The Primary Care Team Receives
• Web based reporting on compliance with measures.
• Detailed graphs and spreadsheets containing
  demographics of patients not meeting each
  measure.
• Dedicated time and an organized format for
  addressing chronic disease
• A shift in focus from punitive profiling to
  prospective disease management

Deployment of these systems tools and explicit
organizational support for chronic disease
management result in a Prepared and Proactive
Practice team
Patient education and improved self-management
skills result in an Informed and Activated Patient
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Making Excellent Care AutomaticLinking Records
toImprove Preventive Services

• Summary
• Delivery System Redesign
• Visit system change
• Team practice
• Proactive follow up
• Planned visits
• Self management Support
• Patient activation
• Patient education
• Guidelines available to patients
• Collaborative decision making with patients
• Self management assessment
• Self management resources and tool
• Decision Support
• Institutionalization of guidelines
• Provider education
• Expert consultation support

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Data Information Knowledge

• DATA Account balance 1234567.89
• INFORMATION
• My goodness my bank balance has jumped 8087 to
  more than 12 million dollars!"
• KNOWLEDGE
• That cant be right, nobody owes me that much
  money"
• WISDOM"I'd better talk to the bank before I
  spend it".

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Department of Homeland Security flow sheet