Haggstrom Regenstrief Conf2

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Information about Haggstrom Regenstrief Conf2

Published on October 6, 2007

Author: ShawnHoke

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Experience and Potential for Transformational Change in Cancer Care Delivery

Experience and Potential for Transformational Change in Cancer Care Delivery David A. Haggstrom, MD, MAS Regenstrief Conference October 3, 2007

Tranformational change “ Together we can transform the American health care system into one that provides the highest quality of care for all of its citizens. ” Carolyn Clancy, AHRQ Connect the System. Through electronic health records, standards, and information exchange. Measure and Publish Quality. Work with doctors and hospitals to define benchmarks for what constitutes quality care. Measure and Publish Price. Agreement is needed on what procedures are covered in each "episode of care." Create Positive Incentives.   Reward those who offer & those who purchase high-quality, competitively priced health care.

“ Together we can transform the American health care system into one that provides the highest quality of care for all of its citizens. ”

Carolyn Clancy, AHRQ

Connect the System. Through electronic health records, standards, and information exchange.

Measure and Publish Quality. Work with doctors and hospitals to define benchmarks for what constitutes quality care.

Measure and Publish Price. Agreement is needed on what procedures are covered in each "episode of care."

Create Positive Incentives.   Reward those who offer & those who purchase high-quality, competitively priced health care.

RAND quality report Individuals receive 55% of recommended care “ A key component of any solution…is the routine availability of information on performance at all levels . Making such information available will require a major overhaul of our current health information systems , with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality.” McGlynn E et al., NEJM, 2003.

Individuals receive 55% of recommended care

“ A key component of any solution…is the routine availability of information on performance at all levels . Making such information available will require a major overhaul of our current health information systems , with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality.”

Cancer policy statements Institute of Medicine , April 1999: “ A cancer data system is needed that can provide quality benchmarks for use by systems of care: hospitals, provider groups, and managed care systems ” National Cancer Institute, cancer.gov , 2002: “ Work is underway to make cancer a working model for quality of care research and the translation of this research into practice ” Regenstrief Cancer Care Engineering , May 2007: “ Develop an hierarchical system-based approach to improving cancer care: establishing an Indiana prototype for colorectal cancer care ”

Institute of Medicine , April 1999:

“ A cancer data system is needed that can provide quality benchmarks for use by systems of care: hospitals, provider groups, and managed care systems ”

National Cancer Institute, cancer.gov , 2002:

“ Work is underway to make cancer a working model for quality of care research and the translation of this research into practice ”

Regenstrief Cancer Care Engineering , May 2007:

“ Develop an hierarchical system-based approach to improving cancer care: establishing an Indiana prototype for colorectal cancer care ”

National Initiative for Cancer Care Quality Development of quality measures : Literature review of existing indicators, guidelines, RCTs Subsequent expert review (clinical, health services researchers, nurses, patients) Method : patient survey & medical record review 47% of eligible patients enrolled Proportion of patients who received recommended care 86% of breast cancer patients Adherence less than 85% for 18/36 breast cancer measures 78% of colorectal cancer patients Adherence less than 85% for 14/25 colorectal ca measures Colorectal cancer post-treatment surveillance: 50% Appropriate referral: 13-59% Respect for patient preferences: 57-71% Schneider E et al., Jnl Clin Onc, 2005.

Development of quality measures :

Literature review of existing indicators, guidelines, RCTs

Subsequent expert review (clinical, health services researchers, nurses, patients)

Method : patient survey & medical record review

47% of eligible patients enrolled

Proportion of patients who received recommended care

86% of breast cancer patients

Adherence less than 85% for 18/36 breast cancer measures

78% of colorectal cancer patients

Adherence less than 85% for 14/25 colorectal ca measures

Colorectal cancer post-treatment surveillance: 50%

Appropriate referral: 13-59%

Respect for patient preferences: 57-71%

Outline How do we measure quality? With what data do we measure quality? What technologies can transform our use of quality data? health information exchange clinical decision support personal health records How do we study technology implementation? Who is accountable for quality? provider-level system-level patient-level Data Quality measure Transformative technology Provider Patient System

How do we measure quality?

With what data do we measure quality?

What technologies can transform our use of quality data?

health information exchange

clinical decision support

personal health records

How do we study technology implementation?

Who is accountable for quality?

provider-level

system-level

patient-level

Health care quality and Overutilization Application of medical interventions without known medical benefit, or worse , with known lack of benefit Overtreated: Why too much medicine is making us sicker and poorer , Shannon Brownlee, 2007 Cancer examples : bone marrow transplant for breast cancer PSA screening surveillance testing Unmeasured quality gap Good Quality Poor Quality Good Quality Underuse Overuse

Application of medical interventions without known medical benefit, or worse , with known lack of benefit

Overtreated: Why too much medicine is making us sicker and poorer , Shannon Brownlee, 2007

Cancer examples :

bone marrow transplant for breast cancer

PSA screening

surveillance testing

Clinical uncertainty Risk adjustment Decision-making uncertainty Patient preferences & values vary Measure “informed” or “good decisions” in concordance with patient preferences, Mulley et al. Unmeasured quality gap Good Quality Poor Quality Health care quality and Uncertainty Uncertainty Certainty

Clinical uncertainty

Risk adjustment

Decision-making uncertainty

Patient preferences & values vary

Measure “informed” or “good decisions” in concordance with patient preferences, Mulley et al.

Other dimensions of quality Patient satisfaction Patient-provider communication Quality-of-life Symptom control

Patient satisfaction

Patient-provider communication

Quality-of-life

Symptom control

Importance of measurement PDSA cycles Act Plan Study Do Act Plan Study Do

How do we measure cancer care quality? Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care General population Cancer population Longitudinal care Recurrence Surveillance

With what data do we measure quality? United States Haggstrom DA et al., Cancer . 2005. General population SEER cancer registries Medicare Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Haggstrom DA et al., Cancer . 2005.

With what data do we measure quality? Michigan Bradley CJ et al., Cancer , 2005. General population Medicare/Medicaid State cancer registry Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Bradley CJ et al., Cancer , 2005.

With what data do we measure quality? Iowa Doebbeling BN et al., Med Care, 1999. General population Private claims State cancer registry Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Doebbeling BN et al., Med Care, 1999.

With what data do we measure quality? Indiana ‘Connect the System’ Cancer population Longitudinal care IN State cancer registry SPIN VA cancer registry VA-INPC longitudinal care Medicare Medicaid Private claims Regenstrief EMR VA admin. claims VA EMR New possibilities with EMR Test results Laboratory Radiology Free text query Add new quality measures in EMR Satisfaction Communication Quality-of-life Symptoms LINK

VA-INPC

longitudinal care

Medicare

Medicaid

Private claims

Regenstrief EMR

VA admin. claims

VA EMR

New possibilities

with EMR

Test results

Laboratory

Radiology

Free text query

Add new quality measures in EMR

Satisfaction

Communication

Quality-of-life

Symptoms

Proportion of patients who underwent screening – primary care Adequate lymph node retrieval & evaluation - surgery Proportion receiving radiation therapy/chemotherapy - oncology Proportion who underwent follow-up of abnormal test – who? Proportion receiving postoperative surveillance – who is responsible? Primary care – quality measure VA-INPC Cancer population Longitudinal data Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Proportion of patients who underwent screening – primary care

Adequate lymph node retrieval & evaluation - surgery

Proportion receiving radiation therapy/chemotherapy - oncology

Proportion who underwent follow-up of abnormal test – who?

Proportion receiving postoperative surveillance – who is responsible?

Proportion of patients who underwent screening – primary care Adequate lymph node retrieval & evaluation - surgery Proportion receiving radiation therapy/chemotherapy - oncology Proportion who underwent follow-up of abnormal test – who? Proportion receiving postoperative surveillance – who is responsible? Surgery treatment – quality measure Cancer population Longitudinal data VA/INPC Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Proportion of patients who underwent screening – primary care

Adequate lymph node retrieval & evaluation - surgery

Proportion receiving radiation therapy/chemotherapy - oncology

Proportion who underwent follow-up of abnormal test – who?

Proportion receiving postoperative surveillance – who is responsible?

Proportion of patients who underwent screening – primary care Adequate lymph node retrieval & evaluation - surgery Receipt of radiation therapy/chemotherapy - oncology Proportion who underwent follow-up of abnormal test – who? Proportion receiving postoperative surveillance – who is responsible? Oncology treatment – quality measure Cancer population Longitudinal data VA/INPC Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Proportion of patients who underwent screening – primary care

Adequate lymph node retrieval & evaluation - surgery

Receipt of radiation therapy/chemotherapy - oncology

Proportion who underwent follow-up of abnormal test – who?

Proportion receiving postoperative surveillance – who is responsible?

Transformative technology #1: Health information exchange Primary care Surgery Oncology timely quality performance reports Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Primary care

Transformative technology #2: Clinical decision support Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Ave risk / Follow-up of abnormal tests Surveillance colonoscopy ONCWATCH REMINDERS real-time quality performance Cancer screening

Control hospitals Implementation research of health information technology β site No CDS Active system re-design 5 more hospitals Passive dissemination 5 regional hospitals Learning system 1. CLINICAL PROCESSES Cancer screening Diagnostic colonoscopy Surveillance colonoscopy 2. Organizational surveys Culture Teamwork Leadership New CDS Implementation Plan Qualitative data Workflow Usability Control hospitals

Control

hospitals

1. CLINICAL PROCESSES

Cancer screening

Diagnostic colonoscopy

Surveillance colonoscopy

2. Organizational surveys

Culture

Teamwork

Leadership

Qualitative data

Workflow

Usability

Transformative technology #2: Clinical decision support Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Low risk / Follow-up of abnormal tests Surveillance colonoscopy Physician specialty General internist +/- gastroenterologist +/- surgeon real-time quality performance Cancer screening REMINDERS

Proportion who underwent follow-up of abnormal test Uncertain accountability Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Primary care Radiologist Proceduralist Who is responsible? Information exchange

Proportion who underwent follow-up of abnormal test

Proportion receiving postoperative surveillance Uncertain accountability Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Primary care Surgery Oncology Who is responsible? Information exchange

Proportion receiving postoperative surveillance

Approaches to uncertain accountability Promoting continuity in fragmented health care system System approach: Assign provider accountability to larger organizations/units than single provider Patient-centered approach Share accountability through personal health records

System approach:

Assign provider accountability to larger organizations/units than single provider

Patient-centered approach

Share accountability through personal health records

‘ Extended medical staff’ definition Data source : Assigned physicians & patients using Medicare claims (2002-2004) Physicians  extended medical staff Inpatient MDs : assign MD to hospital where they provided care to most inpatients Outpatient MDs : assigned MD to hospital where admitted most patients Patients  extended medical staff Inpatients : assigned based on plurality of discharges over specific period Outpatients : assigned to physician (primary or specialty care) who provided most of their care in outpatient setting then assigned to physicians’ primary hospital Fisher E et al., Health Affairs, 2006

Data source : Assigned physicians & patients using Medicare claims (2002-2004)

Physicians  extended medical staff

Inpatient MDs : assign MD to hospital where they provided care to most inpatients

Outpatient MDs : assigned MD to hospital where admitted most patients

Patients  extended medical staff

Inpatients : assigned based on plurality of discharges over specific period

Outpatients : assigned to physician (primary or specialty care) who provided most of their care in outpatient setting

then assigned to physicians’ primary hospital

Concentration of patients among extended medical staff 73% % of patient received services from extended medical staff 90% % of physician inpatient work at primary hospital 98% 2% >500 2% 48% 50-499 <1% 50% 0-49 Extended medical staff Individual providers Patient panel size

Advantages of ‘extended medical staff’ as locus of accountability ‘Positive incentives’ Performance measurement focus on longitudinal experience of patient & address fragmentation of care by pooling accountability Local organizational accountability influence resource distribution, IF measured on BOTH quality & cost larger organizations have capacity to invest in improving quality & lowering costs

Performance measurement

focus on longitudinal experience of patient & address fragmentation of care by pooling accountability

Local organizational accountability

influence resource distribution, IF measured on BOTH quality & cost

larger organizations have capacity to invest in improving quality & lowering costs

Patient-centered approach Promoting continuity in fragmented cancer care system Survivorship Care Plan Cancer type, treatment received, & potential toxicities Tailored information about timing & content of recommended follow-up Recommendations regarding preventive practices & how to maintain health & well-being Availability of psychosocial services in community Personal health record Diagnosis, treatment received, & potential side-effects Tailored information about timing & content of recommended follow-up Recommendations regarding preventive practices & how to maintain health & well-being Availability of psychosocial services in community

Survivorship Care Plan

Cancer type, treatment received, & potential toxicities

Tailored information about timing & content of recommended follow-up

Recommendations regarding preventive practices & how to maintain health & well-being

Availability of psychosocial services in community

Personal health record

Diagnosis, treatment received, & potential side-effects

Tailored information about timing & content of recommended follow-up

Recommendations regarding preventive practices & how to maintain health & well-being

Availability of psychosocial services in community

Transformative technology #3: Personal health records Risk Assessment Screening Diagnosis Treatment Surveillance Provider -Oncologist -Radiation therapist -Surgeon -Primary Care -Radiologist -Proceduralist -Primary Care -Primary Care -Oncologist -Surgeon -Radiologist -Proceduralist PHR Palliative care Patient/ caregiver Longitudinal care

Current functions : Patient education Self-management tools Pharmacy refills Functions in near future : on-line appointments patient/provider messaging Pilot program : full access to VA electronic health record

Current functions :

Patient education

Self-management tools

Pharmacy refills

Functions in near future :

on-line appointments

patient/provider messaging

Pilot program :

full access to VA electronic health record

Study/project designs Appropriate care Clinical processes Quality personal health record no personal health record

Patient perceptions quality of cancer care Population : population-based survey of 1,067 patients with colorectal cancer nine months after diagnosis Mean problem score (in descending order): Health information 48 Treatment information 32 Psychosocial care 32 Coordination of care 21 Access to care 12 Ayanian J et al., Jnl Clin Onc, 2005.

Population : population-based survey of 1,067 patients with colorectal cancer nine months after diagnosis

Mean problem score (in descending order):

Health information 48

Treatment information 32

Psychosocial care 32

Coordination of care 21

Access to care 12

Racial/ethnic differences patient perceptions of quality of care

Health care quality and Access “ Chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”, New York Times , September 23, 2007 Unmeasured quality gap Good Quality Poor Quality Population with access to health care system No access

“ Chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”,

New York Times ,

September 23, 2007

Transformation technology & implementation Transformative technologies Information exchange  timely performance feedback Clinical decision support  real-time peformance feedback Personal health records  patient-centered decision support Implementation science Better understand adoption of technology with multiple methods & designs

Transformative technologies

Information exchange

 timely performance feedback

Clinical decision support

 real-time peformance feedback

Personal health records

 patient-centered decision support

Implementation science

Better understand adoption of technology with multiple methods & designs

Transformation accountability Solitary episodes of care delivery  accountability for multiple episodes of care shared among multiple providers Large organizations have capacity to act  give health information and recommendations to patient in personal health record Patient is willing to act – patient health is at stake

Solitary episodes of care delivery

 accountability for multiple episodes of care shared among multiple providers

Large organizations have capacity to act

 give health information and recommendations to patient in personal health record

Patient is willing to act – patient health is at stake

Transformation what we measure is what we change (at least on purpose) Leverage ‘system connectedness’ Measure quality in many dimensions Underuse Overuse Access Patient experience

Leverage ‘system connectedness’

Measure quality in many dimensions

Underuse

Overuse

Access

Patient experience

Act Plan Study Do Act Plan Study Do

Indy quality performance measure the right things at the right time Act Plan Study Do Act Plan Study Do

Thank you

Thank you

Health care quality and Overutilization Application of medical interventions without known medical benefit, or worse , with known lack of benefit “ Avoiding the unintended consequences of growth in medical care: how might more be worse?” 1999, JAMA, Fisher E, Welch G Overtreated: Why too much medicine is making us sicker and poorer , Shannon Brownlee, 2007 Cancer examples : bone marrow transplant for breast cancer PSA screening surveillance testing Unmeasured quality gap Good Quality Poor Quality Good Quality Underuse Overuse

Application of medical interventions without known medical benefit, or worse , with known lack of benefit

“ Avoiding the unintended consequences of growth in medical care: how might more be worse?” 1999, JAMA, Fisher E, Welch G

Overtreated: Why too much medicine is making us sicker and poorer , Shannon Brownlee, 2007

Cancer examples :

bone marrow transplant for breast cancer

PSA screening

surveillance testing

Health care quality and Access African Americans more frequently than whites lost medical insurance coverage after cancer diagnosis denied coverage after changing jobs reached their insurance spending limits “ CMS - chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”, New York Times , September 23, 2007 Unmeasured quality gap Good Quality Poor Quality Population with access to health care system No access

African Americans more frequently than whites

lost medical insurance coverage after cancer diagnosis

denied coverage after changing jobs

reached their insurance spending limits

“ CMS - chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”,

New York Times ,

September 23, 2007

Implementation research Measuring context… Organizational surveys: Teamwork Leadership Culture Qualitative methods Human factors engineering

Measuring context…

Organizational surveys:

Teamwork

Leadership

Culture

Qualitative methods

Human factors engineering

What is measured targets what is changed Approporiate clinical use Overuse Risk-adjusted use Preference-concordant use Patient experience Patient symptoms Access

Approporiate clinical use

Overuse

Risk-adjusted use

Preference-concordant use

Patient experience

Patient symptoms

Access

Proportion of care delivered outside the VA for CRC care? Denise Hynes?

Proportion of care delivered outside the VA for CRC care? Denise Hynes?

Importance of measurement PDSA cycles X X Act Plan Study Do Act Plan Study Do

Subspecialty care Primary care Unmeasured quality gap Poor Quality Good Quality Shared care

Transformative technology #2: Clinical decision support Oncwatch Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Low risk / Follow-up of abnormal tests Surveillance colonoscopy REMINDERS Physician specialty General internist +/- gastroenterologist +/- surgeon real-time feedback Cancer screening

Sample sizes 98% 2% >500 2% 48% 50-499 <1% 50% 0-49 Assessment of providers as group (extended medical staff) Assessment of providers as individuals Patient population size

Cancer examples of use of non-evidence-based interventions Bone marrow transplant for breast cancer PSA Surveillance tests among cancer survivors

Bone marrow transplant for breast cancer

PSA

Surveillance tests among cancer survivors

Atlanta measures More detail about measures???

More detail about measures???

Control sites α / β site Non-OncWatch Active implementation 5 more sites Passive diffusion 5 regional sites Learning system 1. CLINICAL PROCESSES Cancer screening Diagnostic colonoscopy Surveillance colonoscopy 2. Organizational surveys Culture Teamwork Leadership OncWatch Implementation Plan Qualitative data Workflow Usability Control sites

Control

sites

1. CLINICAL PROCESSES

Cancer screening

Diagnostic colonoscopy

Surveillance colonoscopy

2. Organizational surveys

Culture

Teamwork

Leadership

Qualitative data

Workflow

Usability

If a man will begin with certainties, he will end in doubts; but if he will be content to begin with doubts, he will end in certainties. -Francis Bacon (1561-1626),_

If a man will begin with certainties, he will end in doubts; but if he will be content to begin with doubts, he will end in certainties. -Francis Bacon (1561-1626),_

Cancer quality/performance measures Measuring the Quality of Breast Cancer Care in Women Evidence Report/Technology Assessment No. 105. (University of Ottawa Evidence-based Practice Center) AHRQ. October 2004. Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal Cancer (Duke Evidence-based Practice Center) AHRQ. May 2006. Process measures Outcome measures

Measuring the Quality of Breast Cancer Care in Women

Evidence Report/Technology Assessment No. 105. (University of Ottawa Evidence-based Practice Center) AHRQ. October 2004.

Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal Cancer

(Duke Evidence-based Practice Center) AHRQ. May 2006.

Process measures

Outcome measures

Survivorship care plan Survivorship care plan Personal health record

Survivorship care plan

Types of uncertainty ERROR : Measure quality of physician performance only by measuring clinical processes. UNINTENDED CONSEQUENCE : Patients making informed and shared decisions with their physicians not to undergo screening or treatment are labeled as receiving poor quality care. Sick patients who would not benefit from aggressive screening or treatment may also be labeled as receiving poor quality care. RESEARCH NEED : In areas of clinical uncertainty, measure quality by measuring the presence of “good decisions”, not only what decision is made. Take into account patient illness or preferences when measuring quality, otherwise, the measures may create incentives for inappropriate or unwanted clinical care.

ERROR : Measure quality of physician performance only by measuring clinical processes.

UNINTENDED CONSEQUENCE : Patients making informed and shared decisions with their physicians not to undergo screening or treatment are labeled as receiving poor quality care. Sick patients who would not benefit from aggressive screening or treatment may also be labeled as receiving poor quality care.

RESEARCH NEED : In areas of clinical uncertainty, measure quality by measuring the presence of “good decisions”, not only what decision is made. Take into account patient illness or preferences when measuring quality, otherwise, the measures may create incentives for inappropriate or unwanted clinical care.

“ The only man who behaves sensibly is my tailor; he takes my measurements anew every time he sees me, while all the rest go on with their old measurements and expect me to fit them” George Bernard Shaw

“ The only man who behaves sensibly is my tailor; he takes my measurements anew every time he sees me, while all the rest go on with their old measurements and expect me to fit them”

George Bernard Shaw

How do we measure performance? Michigan Bradley CJ, Gardiner J, Given CW, Roberts C. Cancer, Medicaid enrollment, and survival disparities. Cancer . 2005 Apr 15;103(8):1712-8. Bradley CJ, Principal Investigator, “In-Depth Examination of Disparities in Cancer Outcomes.”  $1,630,646.  Funding Source:  National Cancer Institute.  2004-2008. General population Medicaid State cancer registry Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care Recurrence Surveillance

Bradley CJ, Gardiner J, Given CW, Roberts C. Cancer, Medicaid enrollment, and survival disparities. Cancer . 2005 Apr 15;103(8):1712-8.

Bradley CJ, Principal Investigator, “In-Depth Examination of Disparities in Cancer Outcomes.”  $1,630,646.  Funding Source:  National Cancer Institute.  2004-2008.

Health care quality improvement or implementation research Poor Quality Health Care Good Quality Poor Quality Good Quality

Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor Patients Referring Clinicians Purchasers INCENTIVE TO CHANGE Pathway 2: SELECTION REPORTS PUBLIC Berwick D, Institute for Healthcare Improvement, Medical Care

Patients

Referring Clinicians

Purchasers

Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor Patients Referring Clinicians Purchasers INCENTIVE TO CHANGE Pathway 2: SELECTION REPORTS PUBLIC Berwick D, Institute for Healthcare Improvement, Medical Care

Patients

Referring Clinicians

Purchasers

Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor

Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor Patients Referring Clinicians Purchasers INCENTIVE TO CHANGE Pathway 2: SELECTION REPORTS PUBLIC Berwick D, Institute for Healthcare Improvement, Medical Care

Patients

Referring Clinicians

Purchasers

Uncertain accountability Cheesy?

Cheesy?

Diagnosis Cancer Treatment Screening Recurrence Surveillance

When Mrs. Hewitt sued Habana over her mother’s death, for example, she found that its owners and managers had spread control of Habana among 15 companies and five layers of firms. As a result, Mrs. Hewitt’s lawyer, like many others confronting privately owned homes, has been unable to establish definitively who was responsible for her mother’s care. New York Times, September 23, 2007

When Mrs. Hewitt sued Habana over her mother’s death, for example, she found that its owners and managers had spread control of Habana among 15 companies and five layers of firms.

As a result, Mrs. Hewitt’s lawyer, like many others confronting privately owned homes, has been unable to establish definitively who was responsible for her mother’s care.

New York Times, September 23, 2007

The limits of health services research: Public health Chemotherapy for immigrants not covered

The limits of health services research:

Public health

Chemotherapy for immigrants not covered

IOM: Crossing the Quality Chasm Effective Patient-centered Timely Efficient Equitable Safe

Effective

Patient-centered

Timely

Efficient

Equitable

Safe

Tranformational change “ Together we can transform the American health care system into one that provides the highest quality of care for all of its citizens. ” Carolyn Clancy, AHRQ Connect the System. Every medical provider will have some system for electronic health records.  Standards need to be set so all health information systems can quickly and securely communicate and exchange data. Measure and Publish Quality. Every case, every procedure has an outcome.  Some are better than others.  To measure quality, we must work with doctors and hospitals to define benchmarks for what constitutes quality care. Measure and Publish Price. Price information is useless unless cost is calculated for identical services.  Agreement is needed on what procedures are covered in each &quot;episode of care.&quot; Create Positive Incentives.   All parties—providers, patients, insurance plans, and payers—must be subject to contractual arrangements that reward those who offer and those who purchase high-quality, competitively priced health care. “ Changing what is possible”

“ Together we can transform the American health care system into one that provides the highest quality of care for all of its citizens. ”

Carolyn Clancy, AHRQ

Connect the System. Every medical provider will have some system for electronic health records.  Standards need to be set so all health information systems can quickly and securely communicate and exchange data.

Measure and Publish Quality. Every case, every procedure has an outcome.  Some are better than others.  To measure quality, we must work with doctors and hospitals to define benchmarks for what constitutes quality care.

Measure and Publish Price. Price information is useless unless cost is calculated for identical services.  Agreement is needed on what procedures are covered in each &quot;episode of care.&quot;

Create Positive Incentives.   All parties—providers, patients, insurance plans, and payers—must be subject to contractual arrangements that reward those who offer and those who purchase high-quality, competitively priced health care.

“ Changing what is possible”

Medicare Medicaid Private Insurance Uninsured Indiana Network for Patient Care Regenstrief Medical Record System (RMRS) General population Cancer population VA INPC State Registry SPIN Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance

Risk Assessment Timely Diagnosis Cancer Treatment Screening Surveillance for Recurrence Genomics Risk of Cancer Death

Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E Primary care practice VA IU-MG VA Medicare Medicaid private insurance Uninsured

Primary care practice

VA

IU-MG

Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E VA Medicare Medicaid private insurance Uninsured

Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E SPIN

Transformative technology #3: Personal health records Risk Assessment Screening Diagnosis Treatment Surveillance Patient/ caregiver Provider Provider Provider Provider Provider Follow-up of abnormal tests may be improved by coordination Survivorship care may be improved by coordination Patient/ caregiver Patient/ caregiver PHR Patient/ caregiver Palliative care Patient/ caregiver Longitudinal care

VA

Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) R E S E A R C H Q U E S T I O N Genomic risk Health Services Research SEER (20% US) State Registries (Indiana) VA Cancer registries

Fragmented health care delivery = fragmented data age insurance coverage location 65 VA Medicare Medicaid private insurance Uninsured SEER SEER-Medicare Medicare Wellpoint UnitedHealth Medicaid medical record VA INPC

age

Fragmented health care delivery = fragmented data age insurance coverage location 65 VA Medicare Medicaid private insurance Uninsured SEER SEER-Medicare

age

Fragmented health care delivery = fragmented data age insurance coverage location 65 SEER SEER-Medicare VA Medicare Medicaid private insurance Uninsured

age

Coordination of care across the continuum Risk Assessment Screening Diagnosis Treatment Surveillance Patient Provider Provider Provider Provider Provider Follow-up of abnormal FOBTs may be improved by coordination Survivorship care may be improved by coordination Patient Patient/ caregiver Patient PHR

65 insurance coverage location

65

 

 

Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) R E S E A R C H Q U E S T I O N Genomic risk Health Services Research SEER (20% US) State Registries (Indiana) VA Cancer registries

Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E

Unmeasured quality gap Health Care Good Quality Poor Quality Certainty Clinical uncertainty Health Care Quality and Uncertainty

How do we measure performance? Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population SEER Medicare Longitudinal care State cancer registry Medicaid

Proportion of patients who underwent screening – primary care Adequate lymph node retrieval & evaluation - surgery Proportion receiving radiation therapy/chemotherapy - oncology Proportion who underwent follow-up of abnormal test – who? Proportion receiving postoperative surveillance – who is responsible? Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population State cancer registry Private claims

Proportion of patients who underwent screening – primary care

Adequate lymph node retrieval & evaluation - surgery

Proportion receiving radiation therapy/chemotherapy - oncology

Proportion who underwent follow-up of abnormal test – who?

Proportion receiving postoperative surveillance – who is responsible?

Proportion of patients who underwent screening – primary care Adequate lymph node retrieval & evaluation - surgery Proportion receiving radiation therapy/chemotherapy - oncology Proportion who underwent follow-up of abnormal test – who? Proportion receiving postoperative surveillance – who is responsible? Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population Longitudinal data

Proportion of patients who underwent screening – primary care

Adequate lymph node retrieval & evaluation - surgery

Proportion receiving radiation therapy/chemotherapy - oncology

Proportion who underwent follow-up of abnormal test – who?

Proportion receiving postoperative surveillance – who is responsible?

How do we measure performance? Virginia? Penberthy L, McClish D, Manning C, Retchin S, Smith T. The added value of claims for cancer surveillance: results of varying case definitions. Med Care . 2005 Jul;43(7):705-12. Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Medicare State cancer registry

Penberthy L, McClish D, Manning C, Retchin S, Smith T. The added value of claims for cancer surveillance: results of varying case definitions. Med Care . 2005 Jul;43(7):705-12.

Proportion of patients who underwent screening – primary care Adequate lymph node retrieval & evaluation - surgery Proportion receiving radiation therapy/chemotherapy - oncology Proportion who underwent follow-up of abnormal test – who? Proportion receiving postoperative surveillance – who is responsible? Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population Longitudinal data

Proportion of patients who underwent screening – primary care

Adequate lymph node retrieval & evaluation - surgery

Proportion receiving radiation therapy/chemotherapy - oncology

Proportion who underwent follow-up of abnormal test – who?

Proportion receiving postoperative surveillance – who is responsible?

Coordination of care across the continuum Risk Assessment Screening Diagnosis Treatment Surveillance Patient/ caregiver Provider Provider Provider Provider Provider Follow-up of abnormal FOBTs may be improved by coordination Survivorship care may be improved by coordination Patient/ caregiver Patient/ caregiver Patient/ caregiver PHR

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Haggstrom Regenstrief Conf2 ... NITYA_BHARATH_WEDDING_PHOTOS. The Begining of the making of the bride also called the Mehindi (Henna cermony)
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