Collaborative care for chronic illness and information technology Introduction AcademyHealth 2005 David A. Dorr, MD MS OHSU.
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Collaborative care for chronic illness and
information technology
IntroductionAcademyHealth 2005David A. Dorr, MD MS
OHSU
Objectives State of collaborative and chronic physical
and mental illness care Framework for collaborative care and
Information Technology (IT) use Successes and challenges
Chronic illness care: problems Underuse
Effective treatments for chronic illness care only given 54% of the time.
Misuse Preventable, injurious outpatient AEs occur in 1-
9% of patients. Overuse
Up to 30% of treatments provided for some illnesses (low back pain) are inappropriate.
Terms from Chassin MR. JAMA. 1998; Sources: EA McGlynn, NEJM; Rothman, Annals; Wennberg; Forster, 2003; Dorr 2004.
Chronic illness care: VA transformation
Chronic disease
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Diabetes testing Diabetes control Hypertensioncontrol
% a
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ere
nt
VA
Medicare
Jha 2003.
Root causes of problems with chronic illness care
Culture / History “Tyranny of the urgent” Art and craft of medicine
Complexity Individual versus
population focused Financial
Root causes: information based Information/knowledge
needed is Enormous
Challenging to find
Lacking
In the wrong form
Difficult to communicate
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Chassin, Mark R. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4)
first RCT published: 1952 (Daniels and Hill in the British Medical Journal, comparing treatments for tuberculosis)
(Medline search as of 1 June 98)
first five years (66-70): 1% of all RCTs published from 1966-1995
last five years (91-95): 49% of all RCTs published from 1966-1995
Information system: definition Any system to store / retrieve / display /
aggregate / or otherwise touch information
Not just computers or charts in broad sense
Our focus is primarily on computer-supported information systems
Information System domains (IOM) Health information /
data
Results management
Order entry
Decision support
Communication and connectivity
Patient support
Administrative process
Reporting and population health
More successes Results management
Patient worksheet
Order entry Corollary orders and
order sets improve safety, can reduce cost, and improve outcomes.
Savings of up to $44 billion dollars per year.
Pertinent labs
Preventive care summaryMedications
Chronic conditions
Pertinent exams
Passive remindersOrganized by illness
Wilcox 2005; CITL report 2003.
Individual categories: successes Decision support
30-66% improvement in adherence to preventive care and acute care guidelines.
But … chronic illness has mixed results.
Patient support Congestive heart failure
IT and domains: hierarchy Access
Best Practices
Communication
Health information / data Results management Order entry Decision support Communication and
connectivity Patient support Administrative process Reporting and population
health
Care management packages to Improve Quality of Care: Information System focus
Chronic Care Model Hartford / Intermountain Health Care generalist
care management
Disease management
Veterans’ Administration transformation QUERI (reTIDES, EQUIP, PAS, CHIACC)
Improving Care for Chronic Illness
Community Health System Resources and Policies ------ Organization of Health Care
Self-Management
Support
Delivery System Design
Decision Support
Clinical Information
Systems
Informed, Activated Patients & Caregivers
Prepared, Proactive
Practice Team
Collaborative Care
Functional and Clinical Outcomes
From: E.H. Wagner & RWJF Improving Chronic Illness Care Initiative
Generalist care management system
Improvement in diabetes, depression, and congestive heart failure outcomes.
Care management
Referral- For any condition or need- Focus on certain conditions
Care manager- Assess & plan- Catalyze- Enact
Technology- Access- Best Practices- Communication
Evaluation- Ongoing with feedback- Based on key process and outcome measures
Dorr et al, HSR, in press; Dorr et al, Disease management, in press.
Disease management Companies external to health workers
provide Technology (e.g. monitoring devices)
System (e.g. 24 hour nursing support)
To reduce utilization and cost.
Final thoughts IS use can help solve chronic illness
performance issues.
Advanced information system use only 15-25% in US, and still difficult to know what will work.
Financial, implementation, and workflow barriers significant.
Thanks! Amy Cohen, PhD Adam Wilcox, PhD Laurie Burns Paul D. Clayton, PhD Larry Casalino, MD PhD
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