CrossRoads
Post on 13-Jun-2015
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CrossroadsTransforming Health Care Delivery with
Informatics: A perspective from the Massachusetts General Hospital (MGH)
Henry C. Chueh, MD, MS
Coming up...
Introduce the problem
Suggest a theme to solutions to the problem
Provide a brief description of MGH
Describe our path through stories about tools
Revisit the theme
One Day in the Life of a PCP
10.6
7.4
6.0
Hours needed to manage 2,500 patients...
Chronic disease (10 Dx) Prevention FreeYarnall 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
“Computerized clinical information systems will help physicians close this quality gap
by performing many of the repetitive, protocol-driven tasks.” (McDonald, 1976)"the burden of harm conveyed by the
collective impact of all of our health care quality problems is
staggering" (Chassen et al., 1998)“The current care systems cannot do the job...trying harder will not work...changing
care systems will.” (IOM, 2001) "Our recovery plan will invest in electronic health records and new technology that will
reduce errors, bring down costs, ensure privacy, and save lives." (Obama, Feb 2009)
Lack of time Flawed process
demand
supply
CDSS
MDs = 178 • FTEs = 101 • Practices = 15 • Patients = 155,590
MGH Primary Care
(at MGH)IMA
WHABMGMWI
(near MGH)DowntownBeacon Hill
MGMGSenior Health
Back BayNECHC
Charlestown
Everett
Chelsea (2)
MGH WestRevere (2)
IT infrastructure at MGH
Online registration and scheduling
Outpatient electronic health records and e-prescribing
Clinical data repository for results and reports
Inpatient provider order entry
Patient portal
Information “push”
patient
nurse care manager
primary care provider
1
2
Decision support in diabetes(A1C, SBP, LDL) Visit
Modest improvements in process outcomes only
info
info
reco
mm
end
Patients don’t always come in for clinic visits.
Clinic visits are busy.
Providers are good at deciding, but bad at doing.
Getting there from here
Loyalty cohort: Connectedness
FastTrack: Enhanced CDSS/SSCD outside visits
ACCORD: Involving patients
Who are my patients?
Visit to registered PCP
Repeated visits to a specific practice
Age and home address as variables
Connection Status
59%
34%
6%
PCP connected Practice connected Not connected
n = 155,590
MGH Preventive Metrics
0
17
34
51
68
85
Mammography (n=35,865)
Pap Test(n=65,860)
CRC Screening(n=37,605)
Per
cent
age
(%)
P<0.0001 P<0.0001 P<0.0001
PCP Linked Practice Linked
MGH Disease Metrics
0
18
36
54
72
90
Diabetes A1C(n=9,632)
Diabetes LDL(n=9,632)
CAD LDL(n=6,612)
Per
cent
age
(%)
PCP Linked Practice Linked
P<0.0001 P<0.0001 P<0.0001
A patient-tailored information letter
A hard copy Rx, to be signed
Automatic electronic documentation
A 6-week reminder timer
Results
64%
15%
9%
11%
PCP/screened Practice/screenedPractice/overdue PCP/overdue
Breast cancer screening
patients
care delegate
primary care physician
Decision support in breastcancer prevention
Outside the Visit
population info
Mammography FastTrack
action
0
7.5
15.0
22.5
30.0
All Patients MD-Linked Practice-Linked
Intervention Control
P = 0.01
P = 0.01
P = 0.02
Mammography FastTrack: 6-month results
Com
plet
ion
rate
(%)
Awareness of Issue
Risk assessment
Plan for care
Follow-up
Complete care
?
A Fragile Loop
1/3 have no system, <1/3 satisfied with system
Patients want communication
Lack of documentation
Lack of patient understanding
Follow-up
ACCORDAmbulatory Care Compact to Organize Risk and Decision-making
ACCORD characteristics
Patient-Provider preferences
Explicit agreement with documentation
Fail-safe monitoring
High visibility
CDSS
CDSS
Population-based
Continuous, not visit-based
Patient-provider preferences
challenges. tools.
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