Indian Health ServiceIndian Health Service
Using Decision Support Using Decision Support Effectively: Effectively: Lessons from the FieldLessons from the Field
Lisa Dolan-Branton, RNIndian Health Service
Office of Information Technology/Chronic Care Initiative
AHRQ 2007 Annual Meeting
Lisa Dolan-Branton, RNIndian Health Service
Office of Information Technology/Chronic Care Initiative
AHRQ 2007 Annual Meeting
Presentation OverviewPresentation Overview
•Indian Health System SettingIndian Health System Setting
•IHS Resource and Patient Management IHS Resource and Patient Management SystemSystem
•Clinical Decision Support in RPMSClinical Decision Support in RPMS
•Key Elements of a responsive HIS Key Elements of a responsive HIS (so clinicians use it with every patient) (so clinicians use it with every patient)
Mission and GoalMission and Goal
Mission: to raise the physical, mental, social, and Mission: to raise the physical, mental, social, and spiritual health of American Indians and Alaska spiritual health of American Indians and Alaska natives to the highest level.natives to the highest level.
Goal: to assure that comprehensive, culturally Goal: to assure that comprehensive, culturally acceptable personal and public health services are acceptable personal and public health services are available and accessible to American Indian and available and accessible to American Indian and Alaska Native people.Alaska Native people.
The Indian Health The Indian Health SystemSystem
IHSIHS33 Hospitals33 Hospitals49 Health Centers49 Health Centers46 Health Stations46 Health Stations
TribalTribal15 Hospitals15 Hospitals198 Health Centers198 Health Centers121 Health Stations121 Health Stations180 Alaska Village Clinics180 Alaska Village Clinics
34 Urban health care services and resource centers34 Urban health care services and resource centers
1.8 million users (Federally Recognized Tribes)1.8 million users (Federally Recognized Tribes)
56% AIAN rely primarily on IHS funded care (2000 census)56% AIAN rely primarily on IHS funded care (2000 census)
$3.1 billion from FY 2006 Appropriations $3.1 billion from FY 2006 Appropriations $628 million from Third-Party collections (2004)$628 million from Third-Party collections (2004)
IHS APPROPRIATIONS PER CAPITA IHS APPROPRIATIONS PER CAPITA COMPARED TO OTHER FEDERAL HEALTH COMPARED TO OTHER FEDERAL HEALTH
EXPENDITURE BENCHMARKSEXPENDITURE BENCHMARKS
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
MedicareExpenditures per
Enrollee
Medical Care forVeterans
AdministrationUsers
US Per CapitaExpenditures forPersonal Medical
Services
Medical Care forFederal Prison
Inmates
Medical Care forMedicaid Enrollees
FEHB Medical CareBenchmark per IHS
User
IHS Appropriations& Collections Per
User
IHS
20042001
20031999
1999
2004
Forecast to 2004
1999
Year of Last Published Data
2,101
3,7533,965 3,832
5,1845,454
6,168
500Medical
Care
Non-medical
AI/AN Population by State, 2000
100,00 to 333,400
50,000 to 99,999
10,000 to 49,999
1,713 to 9,999
WA
OR
CA
NV
ID
MT
WY
UTCO
AZ NM
TX
OK
ND
KS
NE
SD
AR
MO
IA
MN
GA
TN
MSAL
LA
MI
OHINIL
WI
FL
PA
VA
ME
NY
WV
NC
KY
SC
AK
NHVT
NJ
DE
MD
HI
American Indian and Alaska Native Population By State
* Census 2000, One race (AI/AN) alone
COMMUNITY ORIENTEDPRIMARY CARE
Cultural & Cultural & SpiritualSpiritual
Behavioral & Behavioral & SocialSocial
Medical Medical CareCare
Public HealthPublic Health
Water & SanitationWater & Sanitation
The Indian health care system is built on a broad spectrum approach to health. It starts with a base of fundamental public health and sanitation infrastructure. It
provides inpatient and ambulatory medical services. It also integrates community-oriented programs promoting healthy behaviors and lifestyles.
COMMUNITY ORIENTED PRIMARY CARE COMMUNITY ORIENTED PRIMARY CARE HAS REDUCED AI/AN MORTALITYHAS REDUCED AI/AN MORTALITY
0
5
10
15
20
25
%% Decrease in MortalityRates since 1973
American Indians & Alaska Natives
US All RacesUS All Races
US WhiteUS White
Infant Mortality Rates1973 – 2002(25.0 to 8.5/1,000)
66% Reduction
80.8
56.4
54.3
31.2
27.2
25.9
12.8
76.0
66.0
64.0
0 20 40 60 80 100
Tuberculosis
Cervical Cancer
Infant Deaths
Maternal Deaths
Accidental
Homicide
Cerebrovascular
Alcohol-Related
Pneumonia & Influenza
Suicide
Resource Patient Management Resource Patient Management System (RPMS)System (RPMS)
Indian Health System Indian Health System Spectrum of CIS UseSpectrum of CIS Use
• No RPMSNo RPMS
• RPMS PCC with paper charts and RPMS PCC with paper charts and centralized data entrycentralized data entry
• PCC+ with centralized data entryPCC+ with centralized data entry
• Partial use of EHR or other Electronic Partial use of EHR or other Electronic Medical RecordsMedical Records
• Fully implemented EHRFully implemented EHR
Decision Support in EHRDecision Support in EHR
•Order ChecksOrder Checks•Med orders are checked for drug-drug Med orders are checked for drug-drug interactions and allergiesinteractions and allergies•All orders are checked for duplicate All orders are checked for duplicate ordersorders•Prescribing Restrictions / GuidancePrescribing Restrictions / Guidance•Prescribing guidelines in pharmacy Prescribing guidelines in pharmacy package accessible to prescribers (see package accessible to prescribers (see screenshot)screenshot)
Oral Contraceptive HelpOral Contraceptive Help
Decision Support in EHR Decision Support in EHR (cont’d)(cont’d)
•Info ButtonInfo Button•Customizable links to web pages from POV Customizable links to web pages from POV (diagnosis) and Patient Ed components(diagnosis) and Patient Ed components•Can be configured to insert selected text into web Can be configured to insert selected text into web site’s search functionsite’s search function•RemindersReminders•National or locally createdNational or locally created•Health maintenance or condition-drivenHealth maintenance or condition-driven•Reminder Dialogs enable simultaneous resolution Reminder Dialogs enable simultaneous resolution of reminders (orders, education, etc.) and of reminders (orders, education, etc.) and documentationdocumentation
EHR v1.1EHR v1.1
Supports Web Link Information button on POV Supports Web Link Information button on POV and Education componentsand Education components
Patient Wellness Patient Wellness HandoutHandout
Immunizations dueWeight, Height, BMIBlood pressureAllergiesCurrent medications
Patient Wellness Patient Wellness HandoutHandout
EHR Physician Study EHR Physician Study SettingSetting
26 IHS health centers implementing EHR between 26 IHS health centers implementing EHR between June 2003 and December 2005June 2003 and December 2005
69% federally operated, 31% tribal health centers69% federally operated, 31% tribal health centers
Mountain – 58%Mountain – 58%Pacific – 19%Pacific – 19%West south central – 12%West south central – 12%South atlantic – 8%South atlantic – 8%West north central – 4%West north central – 4%
Median number of physicians per clinic: 5.0 (IQR 2-19)Median number of physicians per clinic: 5.0 (IQR 2-19)Median number of NP/PA per clinic: 2.0 (IQR 1-6)Median number of NP/PA per clinic: 2.0 (IQR 1-6)
Impact of EHR on QualityImpact of EHR on Quality
Agreed (%)*
EHR helps to improve quality of care
EHR helps to improve patient safety
EHR decreases quality of physician-patient interaction
EHR creates less time to talk with patients in the office
35
36
39
60
* At least 4 on a 5 point Likert scale
Use of Key EHR Use of Key EHR FunctionalityFunctionality
iCare: Population Management iCare: Population Management GUIGUI
iCare - Pre-PlanningiCare - Pre-Planning
iCare - Patient PanelsiCare - Patient Panels
iCare - FlagsiCare - Flags
iCare - Panel OutcomesiCare - Panel Outcomes
RPMS Behavioral Health RPMS Behavioral Health Applications FunctionsApplications Functions
•Documentation of individual and group encountersDocumentation of individual and group encounters
•DSM IV-TR Axis I – V Diagnostic CodingDSM IV-TR Axis I – V Diagnostic Coding
•Treatment PlansTreatment Plans
•Case Management Information Case Management Information
•Suicide data collection Suicide data collection
•Ability to document non-direct patient care activities such Ability to document non-direct patient care activities such as community education, Performance Improvement, as community education, Performance Improvement, clinical supervision, training, etc.clinical supervision, training, etc.
•Robust reports module: workload, case management, Robust reports module: workload, case management, condition-specificcondition-specific
Future Clinical Decision Future Clinical Decision SupportSupport
Key Elements of Responsive CDSKey Elements of Responsive CDS
• HIT solution can drive improvement at each patient visit HIT solution can drive improvement at each patient visit
• Vision of a HIT system that provides you with the ability to Vision of a HIT system that provides you with the ability to manage patients, communities and populations within your manage patients, communities and populations within your mission contextmission context
• Value of requirements development with Clinicians Value of requirements development with Clinicians
• Clear and specific requirements that put the clinical and Clear and specific requirements that put the clinical and public health needs at the center of the specification and public health needs at the center of the specification and programming processprogramming process
• Rapid cycle developmentRapid cycle development
• Like a good community organizer—becomes background Like a good community organizer—becomes background noisenoise
• It’s not about ITIt’s not about IT
Lisa Dolan-Branton, RNLisa Dolan-Branton, [email protected]@ihs.gov
• QUESTIONS?QUESTIONS?QUESTIONS?