neale chumbler regenstrief 2007 presentation

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

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

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Page 1: Neale Chumbler Regenstrief 2007 Presentation

Implementation of Health Implementation of Health Information Technology in VHA to Information Technology in VHA to Support Transformational Change: Support Transformational Change:

Improved Access and Patient Improved Access and Patient Centered CareCentered Care

Neale R. Chumbler, PhDNeale R. Chumbler, PhDResearch Scientist & Associate ProfessorResearch Scientist & Associate Professor

Department of Department of Health Services Health Services

Research, Research, Management and Management and

PolicyPolicy

Page 2: Neale Chumbler Regenstrief 2007 Presentation

Bobby Knight

IU Head Coach: 1971 - 2000

Page 3: Neale Chumbler Regenstrief 2007 Presentation

IOM’s IOM’s Crossing the Quality Crossing the Quality ChasmChasm

Six “Aims for Improvement”Six “Aims for Improvement” 1. Safety 1. Safety

(as safe at home as in health care (as safe at home as in health care facilities)facilities)

2. Effectiveness 2. Effectiveness (avoid overuse of ineffective care and (avoid overuse of ineffective care and

under use of effective care)under use of effective care)

3. Patient-centeredness 3. Patient-centeredness (respect patient needs; communication (respect patient needs; communication

& education for patients; coordination & education for patients; coordination of care)of care)

Page 4: Neale Chumbler Regenstrief 2007 Presentation

Six Aims for Improvement Six Aims for Improvement (cont’d)(cont’d)

4. Timeliness 4. Timeliness (care should reduce waiting times)(care should reduce waiting times)

5. Efficiency 5. Efficiency (reduction of waste; reduction of total cost (reduction of waste; reduction of total cost

of care)of care)

6. Equity 6. Equity (access to care regardless of income, (access to care regardless of income,

ethnicity, and insurance) ethnicity, and insurance) Berwick, Berwick,

20022002

Page 5: Neale Chumbler Regenstrief 2007 Presentation

Changes at Microsystems Changes at Microsystems of Careof Care

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

where the work actually happenswhere the work actually happens 2. To achieve six aims---three wide-2. To achieve six aims---three wide-

ranging redesign principlesranging redesign principles Knowledge-based care (best scientific Knowledge-based care (best scientific

evidence available in service of patient)evidence available in service of patient) Patient-centered care (patient in control Patient-centered care (patient in control

of his/her care)of his/her care) Systems-minded care (coordination of Systems-minded care (coordination of

care across disciplines; avert care across disciplines; avert fragmented care; relevance to patients fragmented care; relevance to patients with chronic illnesses)with chronic illnesses)

Berwick, 2002

Page 6: Neale Chumbler Regenstrief 2007 Presentation

Enhancement of Enhancement of Effectiveness of Effectiveness of MicrosystemsMicrosystems ““10 simple Rules”10 simple Rules”

1. 1. Care --- continuous healing relationshipCare --- continuous healing relationship Access to care --- internet; telephone, etc.Access to care --- internet; telephone, etc.

2. Care --- tailored according to patients’ 2. Care --- tailored according to patients’ needs and values.needs and values.

3. Patient --- exercises control over own health 3. Patient --- exercises control over own health Shared Decision Making.Shared Decision Making.

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

information.information.Berwick, 2002Berwick, 2002

Page 7: Neale Chumbler Regenstrief 2007 Presentation

Changes in Health Care Changes in Health Care OrganizationsOrganizations

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

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

Page 8: Neale Chumbler Regenstrief 2007 Presentation

VHA Care CoordinationVHA Care Coordination

Late 2003Late 2003 Espoused IOM Aims for Improvement Espoused IOM Aims for Improvement

(especially patient centeredness)(especially patient centeredness) Wagner’s Model of Chronic Care Wagner’s Model of Chronic Care

--- pt. self-management--- pt. self-management Address fragmented care --- affect pt. Address fragmented care --- affect pt.

safetysafety Health informatics, telehealth, & DMHealth informatics, telehealth, & DM

Darkins, 2006

Page 9: Neale Chumbler Regenstrief 2007 Presentation

CCHT ComponentsCCHT Components Use telehealth --- coordinate care---pts. Use telehealth --- coordinate care---pts.

HomeHome

Patient Centered CarePatient Centered Care Pt. --- locus of control; care environment shifted to Pt. --- locus of control; care environment shifted to

homehome

Disease ManagementDisease Management Symptom; knowledge; behaviorSymptom; knowledge; behavior

Care/Case ManagementCare/Case Management Across the VHA continuumAcross the VHA continuum

Page 10: Neale Chumbler Regenstrief 2007 Presentation

CCHT ComponentsCCHT Components Self management of chronic diseaseSelf management of chronic disease

Facilitate medication changesFacilitate medication changes Early interventionsEarly interventions

Technology delivers componentsTechnology delivers components Integrate information and communication Integrate information and communication

technologies through communication technologies through communication services (messaging devices; videophones)services (messaging devices; videophones)

Allows veteran and care coordinator Allows veteran and care coordinator maintain direct communicationmaintain direct communication

Page 11: Neale Chumbler Regenstrief 2007 Presentation

Home Telehealth Home Telehealth TechnologyTechnology

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

Page 12: Neale Chumbler Regenstrief 2007 Presentation

CCHT ImplementationCCHT Implementation

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

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

Predominantly CHF, COPD, Predominantly CHF, COPD, diabetes, & PTSDdiabetes, & PTSD Darksins, 2006

Page 13: Neale Chumbler Regenstrief 2007 Presentation

CCHT FindingsCCHT Findings Rigorously tested the effectiveness of Rigorously tested the effectiveness of

the CCHT intervention to determine if the CCHT intervention to determine if there were reductions in service use there were reductions in service use for veterans with diabetes.for veterans with diabetes. Propensity scores --- help ensure Propensity scores --- help ensure

comparability of the treatment and comparability of the treatment and comparison group on observable covariatescomparison group on observable covariates

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

Page 14: Neale Chumbler Regenstrief 2007 Presentation

CCHT FindingsCCHT Findings

DiabetesDiabetes 1. Monitored wkly, w/more intensive evaluations vs. 1. Monitored wkly, w/more intensive evaluations vs.

daily, but less intensivelydaily, but less intensively

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

2. Improvement in HRQL --- SF36V2. Improvement in HRQL --- SF36V physical functioning; bodily pain; social functioningphysical functioning; bodily pain; social functioning

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

Chumbler et al., 2005a; Chumbler et al., 2005a; 2005b; Barnett et al., 2005b; Barnett et al., 20062006

Page 15: Neale Chumbler Regenstrief 2007 Presentation

Tested Cost-Utility of Diabetes Tested Cost-Utility of Diabetes ProgramProgram One third of program participants One third of program participants

were deemed cost-effective were deemed cost-effective Cost-effectiveness varied by marital Cost-effectiveness varied by marital

status and VAMC implemented sitestatus and VAMC implemented site Targeting the intervention Targeting the intervention

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

CCHT Findings

Barnett et al., 2007

Page 16: Neale Chumbler Regenstrief 2007 Presentation

Cancer CCHT FindingsCancer CCHT Findings HRQL --- 6.5-point increase in HRQL HRQL --- 6.5-point increase in HRQL

between baseline and end of between baseline and end of treatment.treatment. Clinically meaningful differenceClinically meaningful difference Better management of Better management of

nervousness/worry over time + HRQL.nervousness/worry over time + HRQL. Case-control study: Matched by Case-control study: Matched by

Tumor Type and Cancer Stage.Tumor Type and Cancer Stage. Fewer hospitalizations and fewer clinic Fewer hospitalizations and fewer clinic

visits.visits.

Chumbler et al., 2007a; Chumbler et al., 2007a; 2007b2007b

Page 17: Neale Chumbler Regenstrief 2007 Presentation

My HealteVet (MHV)My HealteVet (MHV) Online Personal Health RecordOnline Personal Health Record Secure Web-based portalSecure Web-based portal

1. View medical records1. View medical records 2. Prescription Refills2. Prescription Refills 3. Self-enter information & share it 3. Self-enter information & share it

w/providersw/providers 4. Appointments4. Appointments 5. Disease Management (assessment 5. Disease Management (assessment

tools)tools) 5. Laboratory Values 5. Laboratory Values

Track personal BP, weight, HR, etc.Track personal BP, weight, HR, etc.

Page 18: Neale Chumbler Regenstrief 2007 Presentation
Page 19: Neale Chumbler Regenstrief 2007 Presentation
Page 20: Neale Chumbler Regenstrief 2007 Presentation

MHVMHV

Stored in a secure & private Stored in a secure & private environmentenvironment eVAeVAault; dault; data encryptedata encrypted

Share with providers in & out of Share with providers in & out of VHAVHA

Identify clinical studies to enrollIdentify clinical studies to enrollKupersmith et al., 2007

Page 21: Neale Chumbler Regenstrief 2007 Presentation

MHVMHV

““Research Health”Research Health” Diseases & ConditionsDiseases & Conditions

MHV currently pilot tested in 9 MHV currently pilot tested in 9 VAMCsVAMCs..

No Findings publishedNo Findings published

Page 22: Neale Chumbler Regenstrief 2007 Presentation

Future Steps --- Future Steps --- TelehealthTelehealth

Void in literature on importance Void in literature on importance of organizational characteristics of organizational characteristics in telehealth effectivenessin telehealth effectiveness Care coordinator staffing ratioCare coordinator staffing ratio Education level of care coordinatorsEducation level of care coordinators Management oversight of programsManagement oversight of programs Hospital characteristics; ResourcesHospital characteristics; Resources Number and type of patientsNumber and type of patients

Page 23: Neale Chumbler Regenstrief 2007 Presentation

Future StepsFuture Steps

CCHT ImplementationCCHT Implementation Randomized Controlled TrialsRandomized Controlled Trials

Tele-rehabilitation to improve access to Tele-rehabilitation to improve access to care for stroke patientscare for stroke patients

Cost-effectiveness Cost-effectiveness How CCHT impacts broader care How CCHT impacts broader care

processes processes (e.g., extent to which diagnoses are (e.g., extent to which diagnoses are

made; medicines ordered; and referrals made; medicines ordered; and referrals made)made) Jaana & Pare, 2007

Page 24: Neale Chumbler Regenstrief 2007 Presentation

Further InvestigationFurther Investigation

Assessment of Attitude of ProvidersAssessment of Attitude of Providers Telehealth providers (RNs)Telehealth providers (RNs)

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

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

Identification of patients most likely Identification of patients most likely to benefitto benefit

Hopp et al., 2007

Page 25: Neale Chumbler Regenstrief 2007 Presentation

Further InvestigationFurther Investigation

Usability of Home-Telehealth Usability of Home-Telehealth TechnologyTechnology Identification & Follow-up on Identification & Follow-up on

technical issuestechnical issues

Disease Mgt. ModulesDisease Mgt. Modules Type & Frequency of Questions answered Type & Frequency of Questions answered

by pts.by pts.

Flexibility in asking additional questionsFlexibility in asking additional questions

Hopp et al., 2007

Page 26: Neale Chumbler Regenstrief 2007 Presentation

Future StepsFuture Steps

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

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

Clinical Reminder --- who is enrolled in Clinical Reminder --- who is enrolled in the CCHT?the CCHT? Early stages of a national reminderEarly stages of a national reminder

Page 27: Neale Chumbler Regenstrief 2007 Presentation

Future StepsFuture Steps

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

Develop effective strategies to integrate Develop effective strategies to integrate these practices to better support provider these practices to better support provider decision makingdecision making FeasibilityFeasibility FrequencyFrequency Urgency flag?Urgency flag?

Page 28: Neale Chumbler Regenstrief 2007 Presentation

MHV Future StepsMHV Future Steps

Research Issues in implementationResearch Issues in implementation Usability of MHVUsability of MHV Identify ways MHV enhanced (human Identify ways MHV enhanced (human

factors associated with implementation factors associated with implementation & adherence)& adherence)

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

Role of providers in MHVRole of providers in MHV Work settings; sustainabilityWork settings; sustainability

Page 29: Neale Chumbler Regenstrief 2007 Presentation

CCHT & MHVCCHT & MHV

Disease management protocols Disease management protocols for MHV (survey section)for MHV (survey section) Vet answer just like CCHTVet answer just like CCHT

CCHT re-designed --- MHV more CCHT re-designed --- MHV more applicableapplicable 1) improve access1) improve access 2) shared decision-making2) shared decision-making 3) encouraged patient self-3) encouraged patient self-

managementmanagement

Page 30: Neale Chumbler Regenstrief 2007 Presentation

Transformational ChangeTransformational Change

Re-alignment of values, methods, and Re-alignment of values, methods, and structuresstructures

Flow out of planned action & Flow out of planned action & disruptive environmental influences disruptive environmental influences

VHA’s CCHT and MHVVHA’s CCHT and MHV Cross-cutting innovations that contribute Cross-cutting innovations that contribute

to transformative organizational to transformative organizational improvement across the 6 IOM aims.improvement across the 6 IOM aims.Gamm et al., 2007