Chumbler Regenstrief 2007 Presentation 2007 10 03 07

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Information about Chumbler Regenstrief 2007 Presentation 2007 10 03 07

Published on October 6, 2007

Author: ShawnHoke

Source: slideshare.net

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Implementation of Health Information Technology in VHA to Support Transformational Change: Improved Access and Patient Centered Care

Implementation of Health Information Technology in VHA to Support Transformational Change: Improved Access and Patient Centered Care Neale R. Chumbler, PhD Research Scientist & Associate Professor Department of Health Services Research, Management and Policy

Bobby Knight IU Head Coach: 1971 - 2000

IOM’s Crossing the Quality Chasm Six “Aims for Improvement” 1. Safety (as safe at home as in health care facilities) 2. Effectiveness (avoid overuse of ineffective care and under use of effective care) 3. Patient-centeredness (respect patient needs; communication & education for patients; coordination of care)

Six “Aims for Improvement”

1. Safety

(as safe at home as in health care facilities)

2. Effectiveness

(avoid overuse of ineffective care and under use of effective care)

3. Patient-centeredness

(respect patient needs; communication & education for patients; coordination of care)

Six Aims for Improvement (cont’d) 4. Timeliness (care should reduce waiting times) 5. Efficiency (reduction of waste; reduction of total cost of care) 6. Equity (access to care regardless of income, ethnicity, and insurance) Berwick, 2002

4. Timeliness

(care should reduce waiting times)

5. Efficiency

(reduction of waste; reduction of total cost of care)

6. Equity

(access to care regardless of income, ethnicity, and insurance)

Berwick, 2002

Changes at Microsystems of Care 1. Small units of work---the care that the patient experiences where the work actually happens 2. To achieve six aims---three wide-ranging redesign principles Knowledge-based care (best scientific evidence available in service of patient) Patient-centered care (patient in control of his/her care) Systems-minded care (coordination of care across disciplines; avert fragmented care; relevance to patients with chronic illnesses) Berwick, 2002

1. Small units of work---the care that the patient experiences

where the work actually happens

2. To achieve six aims---three wide-ranging redesign principles

Knowledge-based care (best scientific evidence available in service of patient)

Patient-centered care (patient in control of his/her care)

Systems-minded care (coordination of care across disciplines; avert fragmented care; relevance to patients with chronic illnesses)

Enhancement of Effectiveness of Microsystems “ 10 simple Rules” 1. Care --- continuous healing relationship Access to care --- internet; telephone, etc. 2. Care --- tailored according to patients’ needs and values. 3. Patient --- exercises control over own health Shared Decision Making. 4. Patient --- unlimited access to their own medical information. Berwick, 2002

“ 10 simple Rules”

1. Care --- continuous healing relationship

Access to care --- internet; telephone, etc.

2. Care --- tailored according to patients’

needs and values.

3. Patient --- exercises control over own health

Shared Decision Making.

4. Patient --- unlimited access to their own medical

information.

Berwick, 2002

Changes in Health Care Organizations IT --- improve access to information & support clinical decision making. Better coordination of care among services, especially for care of people with chronic illnesses.

IT --- improve access to information & support clinical decision making.

Better coordination of care among services, especially for care of people with chronic illnesses.

VHA Care Coordination Late 2003 Espoused IOM Aims for Improvement (especially patient centeredness) Wagner’s Model of Chronic Care --- pt. self-management Address fragmented care --- affect pt. safety Health informatics, telehealth, & DM Darkins, 2006

Late 2003

Espoused IOM Aims for Improvement (especially patient centeredness)

Wagner’s Model of Chronic Care

--- pt. self-management

Address fragmented care --- affect pt. safety

Health informatics, telehealth, & DM

CCHT Components Use telehealth --- coordinate care---pts. Home Patient Centered Care Pt. --- locus of control; care environment shifted to home Disease Management Symptom; knowledge; behavior Care/Case Management Across the VHA continuum

Use telehealth --- coordinate care---pts. Home

Patient Centered Care

Pt. --- locus of control; care environment shifted to home

Disease Management

Symptom; knowledge; behavior

Care/Case Management

Across the VHA continuum

CCHT Components Self management of chronic disease Facilitate medication changes Early interventions Technology delivers components Integrate information and communication technologies through communication services (messaging devices; videophones) Allows veteran and care coordinator maintain direct communication

Self management of chronic disease

Facilitate medication changes

Early interventions

Technology delivers components

Integrate information and communication technologies through communication services (messaging devices; videophones)

Allows veteran and care coordinator maintain direct communication

Home Telehealth Technology To support self-care and non-institutional long-term care needs of older veterans with disabling chronic disease.

CCHT Implementation System-wide; programs in all 21 regional administrative units (VISNs) 7/31/07 --- 27,637 veterans have been provided CCHT Predominantly CHF, COPD, diabetes, & PTSD Darksins, 2006

System-wide; programs in all 21 regional administrative units (VISNs)

7/31/07 --- 27,637 veterans have been provided CCHT

Predominantly CHF, COPD, diabetes, & PTSD

CCHT Findings Rigorously tested the effectiveness of the CCHT intervention to determine if there were reductions in service use for veterans with diabetes. Propensity scores --- help ensure comparability of the treatment and comparison group on observable covariates Difference-in-differences was used to control for cross-sectional selection bias and intervening time factors

Rigorously tested the effectiveness of the CCHT intervention to determine if there were reductions in service use for veterans with diabetes.

Propensity scores --- help ensure comparability of the treatment and comparison group on observable covariates

Difference-in-differences was used to control for cross-sectional selection bias and intervening time factors

CCHT Findings Diabetes 1. Monitored wkly, w/more intensive evaluations vs. daily, but less intensively Hospital admissions decreased in daily monitoring group & increased in weekly monitoring group 2. Improvement in HRQL --- SF36V physical functioning; bodily pain; social functioning 3. Significant reductions (by 25%, p = .02) ---hospitalizations (24-mos). Chumbler et al., 2005a; 2005b; Barnett et al., 2006

Diabetes

1. Monitored wkly, w/more intensive evaluations vs. daily, but less intensively

Hospital admissions decreased in daily monitoring group & increased in weekly monitoring group

2. Improvement in HRQL --- SF36V

physical functioning; bodily pain; social functioning

3. Significant reductions (by 25%, p = .02) ---hospitalizations (24-mos).

Chumbler et al., 2005a; 2005b; Barnett et al., 2006

Tested Cost-Utility of Diabetes Program One third of program participants were deemed cost-effective Cost-effectiveness varied by marital status and VAMC implemented site Targeting the intervention differently in future work, may be more cost-effective for a greater % of patients. CCHT Findings Barnett et al., 2007

Tested Cost-Utility of Diabetes Program

One third of program participants were deemed cost-effective

Cost-effectiveness varied by marital status and VAMC implemented site

Targeting the intervention differently in future work, may be more cost-effective for a greater % of patients.

Cancer CCHT Findings HRQL --- 6.5-point increase in HRQL between baseline and end of treatment. Clinically meaningful difference Better management of nervousness/worry over time + HRQL. Case-control study: Matched by Tumor Type and Cancer Stage. Fewer hospitalizations and fewer clinic visits. Chumbler et al., 2007a; 2007b

HRQL --- 6.5-point increase in HRQL between baseline and end of treatment.

Clinically meaningful difference

Better management of nervousness/worry over time + HRQL.

Case-control study: Matched by Tumor Type and Cancer Stage.

Fewer hospitalizations and fewer clinic visits.

Chumbler et al., 2007a; 2007b

My HealteVet (MHV) Online Personal Health Record Secure Web-based portal 1. View medical records 2. Prescription Refills 3. Self-enter information & share it w/providers 4. Appointments 5. Disease Management (assessment tools) 5. Laboratory Values Track personal BP, weight, HR, etc.

Online Personal Health Record

Secure Web-based portal

1. View medical records

2. Prescription Refills

3. Self-enter information & share it w/providers

4. Appointments

5. Disease Management (assessment tools)

5. Laboratory Values

Track personal BP, weight, HR, etc.

 

 

MHV Stored in a secure & private environment eVA ault; d ata encrypted Share with providers in & out of VHA Identify clinical studies to enroll Kupersmith et al., 2007

Stored in a secure & private environment

eVA ault; d ata encrypted

Share with providers in & out of VHA

Identify clinical studies to enroll

MHV “ Research Health” Diseases & Conditions MHV currently pilot tested in 9 VAMCs . No Findings published

“ Research Health”

Diseases & Conditions

MHV currently pilot tested in 9 VAMCs .

No Findings published

Future Steps --- Telehealth Void in literature on importance of organizational characteristics in telehealth effectiveness Care coordinator staffing ratio Education level of care coordinators Management oversight of programs Hospital characteristics; Resources Number and type of patients

Void in literature on importance of organizational characteristics in telehealth effectiveness

Care coordinator staffing ratio

Education level of care coordinators

Management oversight of programs

Hospital characteristics; Resources

Number and type of patients

Future Steps CCHT Implementation Randomized Controlled Trials Tele-rehabilitation to improve access to care for stroke patients Cost-effectiveness How CCHT impacts broader care processes (e.g., extent to which diagnoses are made; medicines ordered; and referrals made) Jaana & Pare, 2007

CCHT Implementation

Randomized Controlled Trials

Tele-rehabilitation to improve access to care for stroke patients

Cost-effectiveness

How CCHT impacts broader care processes

(e.g., extent to which diagnoses are made; medicines ordered; and referrals made)

Further Investigation Assessment of Attitude of Providers Telehealth providers (RNs) Staffing-impact on nursing workload hours (set up, monitoring, follow-up; respond to technical issues) Referring physicians want more information on how it will be used for patient care. Identification of patients most likely to benefit Hopp et al., 2007

Assessment of Attitude of Providers

Telehealth providers (RNs)

Staffing-impact on nursing workload hours (set up, monitoring, follow-up; respond to technical issues)

Referring physicians want more information on how it will be used for patient care.

Identification of patients most likely to benefit

Further Investigation Usability of Home-Telehealth Technology Identification & Follow-up on technical issues Disease Mgt. Modules Type & Frequency of Questions answered by pts. Flexibility in asking additional questions Hopp et al., 2007

Usability of Home-Telehealth Technology

Identification & Follow-up on technical issues

Disease Mgt. Modules

Type & Frequency of Questions answered by pts.

Flexibility in asking additional questions

Future Steps More efficient manner of integrating the data from home telehealth devices into CPRS Vital sign data --- vital sign package to be electronically tagged to count for EPRP Clinical Reminder --- who is enrolled in the CCHT? Early stages of a national reminder

More efficient manner of integrating the data from home telehealth devices into CPRS

Vital sign data --- vital sign package to be electronically tagged to count for EPRP

Clinical Reminder --- who is enrolled in the CCHT?

Early stages of a national reminder

Future Steps More efficient manner of integrating the data from home telehealth devices into CPRS Develop effective strategies to integrate these practices to better support provider decision making Feasibility Frequency Urgency flag?

More efficient manner of integrating the data from home telehealth devices into CPRS

Develop effective strategies to integrate these practices to better support provider decision making

Feasibility

Frequency

Urgency flag?

MHV Future Steps Research Issues in implementation Usability of MHV Identify ways MHV enhanced (human factors associated with implementation & adherence) Identify characteristics of veterans who are not using it and offer suggestions Role of providers in MHV Work settings; sustainability

Research Issues in implementation

Usability of MHV

Identify ways MHV enhanced (human factors associated with implementation & adherence)

Identify characteristics of veterans who are not using it and offer suggestions

Role of providers in MHV

Work settings; sustainability

CCHT & MHV Disease management protocols for MHV (survey section) Vet answer just like CCHT CCHT re-designed --- MHV more applicable 1) improve access 2) shared decision-making 3) encouraged patient self-management

Disease management protocols for MHV (survey section)

Vet answer just like CCHT

CCHT re-designed --- MHV more applicable

1) improve access

2) shared decision-making

3) encouraged patient self-management

Transformational Change Re-alignment of values, methods, and structures Flow out of planned action & disruptive environmental influences VHA’s CCHT and MHV Cross-cutting innovations that contribute to transformative organizational improvement across the 6 IOM aims. Gamm et al., 2007

Re-alignment of values, methods, and structures

Flow out of planned action & disruptive environmental influences

VHA’s CCHT and MHV

Cross-cutting innovations that contribute to transformative organizational improvement across the 6 IOM aims.

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