Using Technology to Improve Quality

Charles DeShazer, MDVP, Quality, Medical Informatics & Transformation

Dean Health System

Madison, WI

Key Industry Assumptions

Current cost inflation curve is unsustainable

Payers are moving towards paying for value rather than volume

EHR will become a standard tool

Quality will become not only the “ticket to play” but also one basis of competition (value = quality/cost)

Primary care will be the engine for quality

Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

    AUS CAN GER NETH NZ UK US

OVERALL RANKING (2010) 3 6 4 1 5 2 7

Quality Care 4 7 5 2 1 3 6

Effective Care 2 7 6 3 5 1 4

Safe Care 6 5 3 1 4 2 7

Coordinated Care 4 5 7 2 1 3 6

Patient-Centered Care 2 5 3 6 1 7 4

Access 6.5 5 3 1 4 2 6.5

Cost-Related Problem 6 3.5 3.5 2 5 1 7

Timeliness of Care 6 7 2 1 3 4 5

Efficiency 2 6 5 3 4 1 7

Equity 4 5 3 1 6 2 7

Long, Healthy, Productive Lives 1 2 3 4 5 6 7

Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290

Overall Rank Ordering of Health System Characteristics 2010

Country Rankings

1.00–2.33

2.34–4.66

4.67–7.00

ACO model represents a shift of COST RISK to Providers through payment mechanisms…

% ofPopulation

1%

15%

70%

14%

25%

15%

10%

50%

Population vs. Costs vs. Interventions

1000 Lives 14,000

Lives

15,000 Lives

70,000 Lives

Complex Case Management

Disease/Demand Management

Health

Mgmt

% of

Cost

Example of 100,000 People in a Population

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, 2006

Yarnall 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)

Therefore, managing costs (risk) means managing chronic and complex conditions (especially in the short term)

• Quality initially will be the ticket to play and later become a key competitive measure

• You will have to fix the PCP’s day in the process

Kaiser Permanente Diabetes Care

Ohio region 2006

Large population of diabetic patients

Recently implemented EHR

No infrastructure for care management

Poor quality scores on HEDIS diabetic care

Creation of Diabetic Care Model

Primary care restructuring as medical home

Added care management resources

Outsourced health coaching and outreach

Leveraged EHR for process management and communication

Created quality measurement dashboard with actionable drill-down, filtering and sorting capabilities

Developed standardized workflows aligned with Clinical Decision Support

Better leveraged non-physician staff

Enhanced patient engagement via education, PHR, email, behavioral health integration and outreach

Results

Statistically significant improvement in 6 of 9 commercial and all Medicare HEDIS metrics within 1 year

Became one on the top performing regions in Diabetic care

3 years after implementation beginning to see decreased cost secondary to decreased strokes, heart attacks and amputations consistent with modeling (Achimedes)

Source: http://www.rwjf.org/files/research/72480af4qehr201106.pdf (Accessed 7/8/2011)Better Health Greater Cleveland: http://www.betterhealthcleveland.org/

Does Use of EHRs Help Improve Quality?

“For patients with diabetes, 51 percent of those receiving care in an EHR practice received all the recommended care, as compared with 7 percent of those who received care in a paper-based practice.”

Leverage Meaningful Use as a Springboard

Criteria Opportunity

Problem List Define system-wide standards and policies, improve accuracy of documentation, infrastructure for CDS, use for shared care plan

AVS & PHR Enhance quality, consistency and usefulness of content (esp. for chronic condition management), fully operationalize PHR, enhance patient engagement, use for shared care plan, leverage to engage family & caregivers

Medication List Improve medication reconciliation and management of transitions of care.

Patient Lists & Structured Data

Enhance analytics, create robust registries and dashboards, infrastructure for CDS

Clinical Decision Support

Create governance structure, establish standards, focus them on key areas of improvement opportunity, avoid alert fatigue

Quality Measures Expect to be held accountable for results, create improvement strategies now

Number of doctors seen

Percent reporting in past two years: Any 1 to 2 3+

After medical test, no one called or wrote you about results, or you had to call repeatedly to get results

27 21 36

Doctors failed to provide important information about your medical history or test results to other doctors or nurses you think should have it

23 22 26

Test results or medical records were not available at the time of scheduled appointment

18 14 29

Your primary care physician did not receive a report back from a specialist you saw

15 11 24

Your specialist did not receive basic medical information from your primary care doctor

12 9 18

Any of the above 47 42 55

Key System Challenge is to address FRAGMENTATION Poor Coordination of Care Is Common,

Especially If Multiple Doctors Are Involved

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2011.** On average, Medicare beneficiaries see 6.4 MDs and fill 20 prescriptions annually. Beneficiaries with 5+ chronic conditions see 14 MDs and fill 57 prescriptions annually (Source: N Engl J Med 2007;356:1130-9)

Key Technical Functions for Next Level Quality Management

Focus Area Key Technical Functions

Care Coordination HIE, Workflow Management, Shared Care Plan, Referral tracking

Chronic Condition Management & Complex Care Management

CRM, Workflow Management, Shared Care Plan, Predictive Modeling, CDS, Telehealth, Registries

Population Health Management CRM, HRA, Predictive Modeling, Workflow Management, CDS, Population analytics, Registries

Patient Engagement & Activation CRM, Shared Decision Making, Telehealth, PHR

Evidence-Based Medicine Practice

CDS, Workflow Management, Population analytics

Real-Time Connectivity HIE, Telehealth, mobile technology, unified messaging

EHR is necessary but not sufficient. The next level of quality management will require a Health Information Technology (HIT) “ecosystem” especially a robust analytic infrastructure. Standalone EHR may not be able to provide all of these functions.

Provider Organizational Cultural Shifts

Critical Success Factors for Transformation

Now Future

Volume Focus Value Focus

Physician Autonomy

Independence

Physician Captain

Accountability External

HIT optional

My data is my data

Organizational Standards

Interdependence

Physician Coach & Mgr

Accountability Internal

HIT Core to Strategy

TRANSPARENCY!!

Looking Ahead…

MU Stage 2 & 3

ICD-10

ACO development (success or flop?)

Evolution of Value-Based Reimbursement

Genomics

QUESTIONS?