Designing for ACCORD with Patients Henry C. Chueh, MD, MS Massachusetts General Hospital

AHRQ 2008

Promoting Quality …

Partnering for Change

Bethesda, MDSep 8, 2008

Designing for ACCORDwith Patients

Henry C. Chueh, MD, MSMassachusetts General Hospital

Boston, MA

MGH Laboratory of Computer Science Innovative Designs for Informatics

MGH PCP Network – Adult and FPs Only

MDs = 178 • FTEs = 101 • Practices = 15 • Patients = 155,590

At MGHIMA

WHABMGMWI

Near MGHMGH Downtown MGH Beacon Hill

MGMGSenior Health

MGH Back Bay NECHC

Charlestown

Everett

Chelsea2 sites

Waltham

MGH Primary Care Network

Revere2 sites


Quality Chasm


24 hours in the life of a PCP

“The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care,” a report from the American College of Physicians, 2006Yarnall KS, et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635 Ostbye T, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005; 3:209

Preventive care (7.4 hrs)

Chronic care (10.6 hrs)

Leftover (6 hrs)


“Computerized clinical information systems will help physicians close this quality gap by

performing many of the repetitive, protocol-driven tasks.”

-- Clement McDonald, 1976

The Promise of Information Technology


MGH Quality Measures By Linkage Status

0%

25%

50%

75%

100%

Mammography(n=35,865)

Pap Test(n=65,860)

CRC Screening(n=37,605)

Percentage

PCP Linked Practice Linked


Our Challenge

How do we design, build and implement the health information technology (HIT) tools to support and encourage busy practitioners and

patients to “do the right thing?”

…and that they’ll use.


Preliminary work

• Patient-provider linkage is important• Inter-visit workflow acceptable• Providers will use well-designed tools• Diversity of care processes can impact

outcomes


Focus on Follow-up

• Consumes time inappropriately• Failure can result in poor outcomes1

• Fastest growing area of claims2 • Patients have interest3

1 Earnest 20042 Shaefer 2000, Boohaker et al 1996, Murff HJ et al 20033 IOM 2001, WSJ Poll 2006


A Fragile Loop

Awareness of Issue

Risk assessment

Plan for care

Follow-up

Complete care

?


What about Clinical Decision Support Systems?

• Tend to be physician-oriented and visit-based

• Minimal effect for interventions that cannot be completed at the point of care

• Patient-centered approaches rare• Often lack the ability to “close the loop”


Redesign for Systems to Support Clinical Decisions

Zapka et al 2003, 2004

“Ecologic Framework”


Doctor and Patient Clarity

• Adjusted for age and insurance status• 2 factors associated with appropriate

follow-up care:– MD documentation of follow-up plan– Patient understanding of need for follow-up

Poon, Haas, Puopolo 2004


ACCORD

Ambulatory Care Compact to Organize Risk and Decision Making

AHRQ Ambulatory Safety and QualityProgram: Health IT


“Make Clear Decisions Together”


Figure 8


Characteristics

• Patient-provider centered, informed decisions

• Preference and choice• Self-documenting• Explicit agreements with high visibility• Fail-safe monitoring


Focus Groups

• Patients• Providers• Patients with Providers• Assess concept and initial design

directions• Identify incentives and barriers


Focus Group Lessons

• Doctors worried about workflow intrusion• Patients worried about doctors• Patients concerned about potential

barriers to access to their doctor• Should enhance/increase face time with

patients• Flexibility needed for ACCORD creation


Specific Aims

• Design models for Partnership• Develop systems for Tracking• Evaluate impact on Patient experience,

quality


Create

QuickTime™ and a decompressor

are needed to see this picture.




Elements of an ACCORD

• Option• Action• Observation• Time


Propose




Review


Study Design


Systems to Supportthe

Clinical Decision.


ACCORD Team

• Steven Atlas, MD, MPH• Jeanhee Chung, MD, MS• Richard Grant, MD, MPH• Susan Edgman-Levitan, PA• Robin Weinick, PhD• Yu Chiao Chang, PhD

• Greg Estey• David Berkowicz, MD• Michael Yebba• Mark Wylie• Jeff Ashburner• Alicia Wong

Designing for ACCORD with Patients Henry C. Chueh, MD, MS Massachusetts General Hospital

Documents

Transcript of Designing for ACCORD with Patients Henry C. Chueh, MD, MS Massachusetts General Hospital