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Transcript of ©2005 David F. Lobach Showing Health Information Value in a Community Network David F. Lobach, MD,...
©2005 David F. Lobach©2005 David F. Lobach
Showing Showing Health Information Value in Health Information Value in
a Community Networka Community Network
David F. Lobach, MD, PhD, MSDavid F. Lobach, MD, PhD, MS
Division of Clinical Informatics Division of Clinical Informatics Department of Community and Family MedicineDepartment of Community and Family MedicineDuke University Medical Center, Durham, North Duke University Medical Center, Durham, North
CarolinaCarolina
Contact Information: [email protected] Information: [email protected]
©2005 David F. Lobach©2005 David F. Lobach
AHRQ Health Information Technology ConferenceAHRQ Health Information Technology Conference June 9, 2005June 9, 2005AHRQ Health Information Technology ConferenceAHRQ Health Information Technology Conference June 9, 2005June 9, 2005
©2005 David F. Lobach©2005 David F. Lobach
Presentation OverviewPresentation Overview
Project DescriptionProject Description Community Network (COACH)Community Network (COACH) Decision Support Tool (SEBASTIAN)Decision Support Tool (SEBASTIAN) Data-Driven InterventionsData-Driven Interventions
Selection of Evaluation MetricsSelection of Evaluation Metrics Study DesignStudy Design Obtaining and Using DataObtaining and Using Data Project ChallengesProject Challenges Practical IssuesPractical Issues
©2005 David F. Lobach©2005 David F. Lobach
Community Information Community Information NetworkNetwork
Need for Information InfrastructureNeed for Information Infrastructure CCommunity-ommunity-OOriented riented AApproach to pproach to
CCoordinated oordinated HHealthcareealthcare Goal: Supporting the information needs Goal: Supporting the information needs
of the network of providers serving of the network of providers serving Medicaid beneficiariesMedicaid beneficiaries
©2005 David F. Lobach©2005 David F. Lobach
Network PartnersNetwork Partners
1 Care Management Team1 Care Management Team 7 Primary Care Clinics7 Primary Care Clinics
(1 FM, 3 Peds, 1 IM, 1 Ob-Gyn, 1 (1 FM, 3 Peds, 1 IM, 1 Ob-Gyn, 1 FQHC)FQHC)
3 Urgent Care Facilities 3 Urgent Care Facilities 2 Emergency Departments2 Emergency Departments 2 Hospitals2 Hospitals 2 Government Agencies (HD, DSS)2 Government Agencies (HD, DSS)
A system designed for and used by line workers at A system designed for and used by line workers at partner sitespartner sites
©2005 David F. Lobach©2005 David F. Lobach
Current Status of Current Status of COACH ISCOACH IS
16,964 Active Patients16,964 Active Patients 69,786 Total Patients 69,786 Total Patients 193,146 Encounters (Internal + 193,146 Encounters (Internal +
External)External) 124 User Accounts124 User Accounts 49 Active Users49 Active Users
©2005 David F. Lobach©2005 David F. Lobach
SebastiaSebastiann
SSystem for ystem for EEvidence-vidence-BBased ased AAdvice by dvice by SSimultaneous imultaneous
TTransmission or an ransmission or an IIntelligent ntelligent AAgent across a gent across a
NNetworketwork
©2003 David F. Lobach©2003 David F. Lobach
©2005 David F. Lobach©2005 David F. Lobach
Project GoalsProject Goals
Population Management - Population Management - Asynchronous recommendations Asynchronous recommendations generated though a rule-based generated though a rule-based intelligent agent running on a intelligent agent running on a clinical data repositoryclinical data repository
Patient Management - Interactive, Patient Management - Interactive, evidence-based recommendations evidence-based recommendations delivered to the point of caredelivered to the point of care
©2005 David F. Lobach©2005 David F. Lobach
Showing HIT ValueShowing HIT Value
Collaborators and PartnersCollaborators and Partners Specific Aims and ObjectivesSpecific Aims and Objectives Intervention OverviewIntervention Overview Study MeasuresStudy Measures Study DesignStudy Design Data SourcesData Sources
This work was funded in part by a grant fromThis work was funded in part by a grant from
©2005 David F. Lobach©2005 David F. Lobach
Partner OrganizationsPartner Organizations
Organization Type Partner Organization
Hospitals Duke University Hospital (DUH)Durham Regional Hospital (DRH)
Clinics Duke Primary Care ClinicsDuke Affiliated Primary Care PracticesPrivate Primary Care ClinicsLincoln Community Health Center (LCHC)Duke Specialty Care Clinics
Urgent Care Facilities Duke Urgent CareLincoln Community Health Center (LCHC)
Government Agencies Durham County Health Department (DCHD)Durham County Department of Social Services (DSS)NC Medicaid
Community Organizations Durham Community Health Network (DCHN)
©2005 David F. Lobach©2005 David F. Lobach
Specific AimsSpecific Aims
To evaluate the clinical, To evaluate the clinical, organizational and financial value of organizational and financial value of HIT in a community network from a HIT in a community network from a societal perspective. societal perspective.
To evaluate the value of HIT in a To evaluate the value of HIT in a community network from the community network from the perspective of specific stakeholder perspective of specific stakeholder groups, including patients, providers, groups, including patients, providers, hospitals, payers, and purchasers. hospitals, payers, and purchasers.
©2005 David F. Lobach©2005 David F. Lobach
Intervention OverviewIntervention Overview
SEBASTIANCDSS
COACHClinical
Database
FeedbackReports
COACHQuery
Database
Data from CommunityPartners
Patient Entered Data via eHealth KioskSystem
EmailAlerts
PatientReminders
Patients
CareProviders
ClinicManagers
Interventions
©2005 David F. Lobach©2005 David F. Lobach
Sample EventsSample EventsFocus Care Issue
Clinical Outcomes Three ED encounters within 90 daysLow severity ED encounter ED encounter for asthmaED encounter for diabetesHospitalization for asthmaHospitalization for diabetes
Care Quality No mammogram in 2 yearsNo Pap smear in 3 yearsNo Chlamydia screening in 1 yearNo post-partum visit after delivery in 21 to 56 daysNo glycated hemoglobin test in 1 yearNo lipid panel in 1 yearNo urine protein/albumin test in 1 yearNo dilated eye examination in 1 yearOne or fewer well child visits in 1 yearNo well child visits in 1 year
Care Coordination Two missed appointments in 60 daysNo Follow-up appointment after ear infection in 2 wks
©2005 David F. Lobach©2005 David F. Lobach
Sample Events Sample Events (Pending)(Pending)
Focus Care Issue
Clinical Outcomes Medication incompatibility
Care Quality No staging of asthmaNo asthma action plan in 2 yearsPatient-reported health risk: new onset pregnancyPatient-reported health risk: missed >10 days of school/yearPatient-reported health risk: no blood test for lead poisoning in past yearPatient-reported health risk: no blood test for lead poisoning everPatient-reported health risk: signs or symptoms of vision problemsPatient-reported health risk: signs or symptoms of hearing problemsPatient-reported health risk: high risk of TB exposurePatient-reported health risk: concern about weightPatient-reported health risk: recreational drug usePatient-reported health risk: alcohol abusePatient-reported care barrier: need assistance to get care servicesPatient-reported barrier: need assistance to get medical equipmentPatient-reported care barrier: need assistance to get medications
Care Coordination Pending appointment and h/o missed appointments in last 60 days
©2005 David F. Lobach©2005 David F. Lobach
Frequency of Frequency of InterventionsInterventions
ALERTS FEEDBACK REMINDERS
Care Issue Frequency Target Group Frequency Frequency
ED encounter for asthma / diabetes / low severity / 3rd in 90 days daily CHW, CLM, PCP monthly weekly
Hospitalization for asthma / diabetes daily CHW, CLM, PCP monthly weekly
No follow-up appointment after ear infection daily CHW, CLM, PCP monthly weekly
Two missed appointments in 60 days daily CHW, CLM, PCP monthly weekly
One or fewer well child visits for 1-2 yo /no well child visits for 3-6 yo monthly CHW, CLM monthly quarterly
No mammogram / Pap smear / Chlamydia testing monthly CHW, CLM monthly quarterly
No post-partum visit after delivery weekly CHW, CLM, PCP monthly biweekly
No HgbA1c / lipid panel / urine microalbumin / dilated eye exam monthly CHW, CLM monthly quarterly
Pending appt. and h/o missed appt. in last 60 days n/a n/a n/a daily
No staging of asthma / no asthma action plan monthly CHW, CLM monthly quarterly
Reported health risk: new onset pregnancy weekly CHW, CLM monthly n/a
Reported health risk: missed >10 days of school/year monthly CHW, CLM monthly n/a
Reported health risk: no blood test for lead poisoning monthly CHW, CLM monthly quarterly
Reported health risk: signs or symptoms of vision or hearing problems / weight concerns / recreational drug use / alcohol abuse
monthly CHW, CLM monthly n/a
Reported health risk: high risk of TB exposure daily CHW, CLM, PCP monthly daily
Reported barrier: assistance to get care services / assistance to get medical equipment / assistance to get medications
weekly CHW, CLM monthly n/a
Medication incompatibility daily CHW, CLM, PCP monthly daily
©2005 David F. Lobach©2005 David F. Lobach
Choosing Study Choosing Study MeasuresMeasures
Optimal Measures:Optimal Measures: Solid clinical outcomes of Solid clinical outcomes of significance to health care (e.g. mortality)significance to health care (e.g. mortality)
Will any true clinical outcomes be impacted Will any true clinical outcomes be impacted by the intervention that can be detected by the intervention that can be detected during the study period?during the study period?
Can a change in surrogate clinical measures Can a change in surrogate clinical measures be detected during the study period?be detected during the study period?
Will any process measures be impacted by Will any process measures be impacted by the intervention?the intervention?
What are the cost implications of the What are the cost implications of the intervention?intervention?
Will any descriptive/qualitative measures be Will any descriptive/qualitative measures be effected by the study intervention?effected by the study intervention?
©2005 David F. Lobach©2005 David F. Lobach
Selecting & Defining Selecting & Defining MeasuresMeasures
How will you know that your How will you know that your intervention is a success?intervention is a success?
1.1. Fewer ED visits for ambulatory Fewer ED visits for ambulatory care sensitive conditionscare sensitive conditions
2.2. Higher quality careHigher quality care
3.3. Better coordination of care Better coordination of care servicesservices
4.4. Lower costsLower costs
5.5. Patients will be more satisfied Patients will be more satisfied with the care they receivewith the care they receive
©2005 David F. Lobach©2005 David F. Lobach
Selecting & Defining Selecting & Defining MeasuresMeasures
How can that endpoint be How can that endpoint be measured*?measured*?
1.1. Relative number of ED visitsRelative number of ED visits2.2. HEDIS quality metricsHEDIS quality metrics3.3. Rates of follow-up appointmentsRates of follow-up appointments4.4. Costs of care providedCosts of care provided5.5. Satisfaction surveysSatisfaction surveys
*Consider what has been measured in similar *Consider what has been measured in similar studies. Don’t re-invent the wheel!studies. Don’t re-invent the wheel!
©2005 David F. Lobach©2005 David F. Lobach
Selecting & Defining Selecting & Defining MeasuresMeasures
What data are needed to assess What data are needed to assess these measures?these measures?
1.1. # of ED visits, billing diagnoses for # of ED visits, billing diagnoses for visit, severity level of visit visit, severity level of visit
2.2. Claims data with ICD9 and CPT Claims data with ICD9 and CPT Codes, plan enrollment historyCodes, plan enrollment history
3.3. # of appointments kept and missed# of appointments kept and missed
4.4. Estimates of care costs Estimates of care costs
5.5. Satisfaction survey dataSatisfaction survey data
©2005 David F. Lobach©2005 David F. Lobach
Selecting & Defining Selecting & Defining MeasuresMeasures
How can one obtain these data?How can one obtain these data?1.1. State Medicaid claims dataState Medicaid claims data
2.2. Chart audits (electronic or manual)Chart audits (electronic or manual)
3.3. Clinic encounter recordsClinic encounter records
4.4. Claims data and Medicare Claims data and Medicare reimbursement ratesreimbursement rates
5.5. Satisfaction surveysSatisfaction surveys
©2005 David F. Lobach©2005 David F. Lobach
Selecting & Defining Selecting & Defining MeasuresMeasures
What type of comparison needs to What type of comparison needs to be made between control and be made between control and intervention groups to detect a intervention groups to detect a significant difference?significant difference?1.-5.1.-5. Compare differences between Compare differences between
groups – Wilcoxon rank sum groups – Wilcoxon rank sum statisticstatistic
©2005 David F. Lobach©2005 David F. Lobach
Outcome MeasuresOutcome MeasuresMeasurement Focus Measures
Clinical Outcomes. ED EncountersHospitalizations
ED encounters per 1000 pt yearsHospitalizations per 1000 pt yearsPrimary care encounters per 1000 pt yearsHgbA1c levels
Care Quality.Preventive ServicesChronic Disease
Management for Asthma & Diabetes
HEDIS scores for mammograms, Pap smears, Chlamydia screeningHEDIS scores for asthma staging, recording action plans, prescribing inhaled
corticosteroids HEDIS scores for performing glycated hemoglobin, microalbumin, lipid panel,
dilate eye examHEDIS scores for well child visitsAHRQ PQI for asthmaAHRQ PQI for uncontrolled diabetes, short- & long-term complications
Care Coordination. Missed AppointmentsF/U Appointments
Missed appointments per 1000 patient yearsRate of f/u after ear infection per 1000 patient years
Costs/Revenues. ED costsHospitalization Costs
Costs of HIT interventions including personnel/hardware/software costsCo-pay costsProfessional feesTechnical feesPharmaceutical reimbursement ED costsHospitalization costs
Satisfaction.Patient SatisfactionPatient Quality of LifeProvider Opinions
Patient satisfaction surveyEuroQoLProvider opinion surveys
©2005 David F. Lobach©2005 David F. Lobach
Choosing a Study Choosing a Study DesignDesign
Optimal Design:Optimal Design: Double-blinded Double-blinded Randomized Control Trial Randomized Control Trial
Can a simultaneous control group be Can a simultaneous control group be established?established?
Can individuals be randomly assigned Can individuals be randomly assigned to a group?to a group?
Is a placebo available?Is a placebo available? Can the use of the intervention be Can the use of the intervention be
hidden from the study subjects?hidden from the study subjects? Can the use of the intervention be Can the use of the intervention be
hidden from the study team?hidden from the study team?
©2005 David F. Lobach©2005 David F. Lobach
Design & Randomization Design & Randomization PlanPlan
Care Group
Run-in CYCLE 1 CYCLE 2 CYCLE 3 CYCLE 4 CYCLE 5
Months 0-3
Months 4-9
Months 10-15
Months 16-21
Months 22-27
Months 28-33
HighLevel
1 Alerts AlertsFeedback
AlertsFeedbackPt Reminders
AlertsFeedbackPt Reminders
AlertsFeedbackPt Reminders
2 Feedback FeedbackPt Reminders
FeedbackPt Reminders Alerts
FeedbackPt Reminders Alerts
FeedbackPt Reminders Alerts
3 Pt Reminders Pt RemindersAlerts
Pt Reminders AlertsFeedback
Pt RemindersAlertsFeedback
Pt Reminders AlertsFeedback
LowLevel
4 Alerts AlertsFeedback
5 Feedback FeedbackPt Reminders
6 Pt Reminders Pt Reminders Alerts
©2005 David F. Lobach©2005 David F. Lobach
Data Analysis IntervalsData Analysis Intervals
Month0-3
Months 4-9
Months 10-15
Months 16-21
Months 22-27
Months 28-33
OverallComparison
Comparisons of the six clinical/organizational and three economic endpoints. Strategies 1-3 are compared with strategies 4-6.
ComparisonsAmong HITTreatments
Comparisons of the six clinical/organizational and three economic endpoints. Indicator variables are used to denote the three highlighted strategies: provider alerts, feedback reports, and patient reminders.
DoseResponse
Comparisons
ONEIntervent.vs. noAddedIntervent.
TWOinterventionsvs. noAddedintervention
THREEinterventions vs.no interventions
THREEIntervent.vs. ONEIntervent.
THREEIntervent.vs. TWOIntervent
©2005 David F. Lobach©2005 David F. Lobach
Choosing Data SourcesChoosing Data Sources
Optimal Data:Optimal Data: Coded clinical data Coded clinical data entered electronically by the data entered electronically by the data generating sourcegenerating source
What coded data is available?What coded data is available? What clinical data is available?What clinical data is available? What claims data is available?What claims data is available? Is there a data dictionary for Is there a data dictionary for
interpreting the data?interpreting the data? What is required to make the data What is required to make the data
available?available? Will chart audits be required?Will chart audits be required?
©2005 David F. Lobach©2005 David F. Lobach
Project ChallengesProject Challenges
Controlling ExpectationsControlling Expectations Avoiding “Scope Creep”Avoiding “Scope Creep” Start up FundingStart up Funding Operational FundingOperational Funding Obtaining Data from PartnersObtaining Data from Partners HIPAA ImplicationsHIPAA Implications
©2005 David F. Lobach©2005 David F. Lobach
Practical IssuesPractical Issues
How to work with community How to work with community partnerspartners
Challenges working in the Challenges working in the community settingcommunity setting
How to navigate the academic How to navigate the academic institutioninstitution
©2005 David F. Lobach©2005 David F. Lobach
Open House @ Duke Open House @ Duke UniversityUniversity
Learn more about the AHRQ-funded Duke HIT Learn more about the AHRQ-funded Duke HIT Value Project at Duke University Medical CenterValue Project at Duke University Medical Center
Friday, August 12, 2005Friday, August 12, 2005 9:00 AM to 4:00 PM9:00 AM to 4:00 PM Detailed project presentationsDetailed project presentations Onsite demonstrationsOnsite demonstrations Cost: ~$25 for lunch, snacks and local Cost: ~$25 for lunch, snacks and local
transportationtransportation For more information and registration:For more information and registration:
Call 919.684.6421Call 919.684.6421 Email Email [email protected]@duke.edu Visit: http://dmi-www.mc.duke.edu/Visit: http://dmi-www.mc.duke.edu/
©2005 David F. Lobach©2005 David F. Lobach
AcknowledgmentsAcknowledgments
DCIDCI Jennifer M. Macri, MSJennifer M. Macri, MS Garry SilveyGarry Silvey Allen MayersAllen Mayers Kensaku KawamotoKensaku Kawamoto Jan Willis, MSJan Willis, MS
DCHDCH Susan Yaggy, MPASusan Yaggy, MPA Fred Johnson, MBAFred Johnson, MBA Jessica SimoJessica Simo Pam PhillipsPam Phillips
Other Duke GroupsOther Duke Groups Eric Eisenstein, DBAEric Eisenstein, DBA Kevin Anstrom, PhDKevin Anstrom, PhD Vic Hasselblad, PhD David Crosslin, MS Bob Rezzarday Bob Rezzarday
Outside Collaborators Richard Low (Topsail Richard Low (Topsail
Technologies)Technologies)
©2005 David F. Lobach©2005 David F. Lobach
Questions?Questions?
Contact Information: [email protected] Information: [email protected]
Questions?Questions?
Contact Information: [email protected] Information: [email protected]