David Haggstrom Regenstrief Conference Slides
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Experience and Potential for Transformational Change in
Cancer Care Delivery
David A. Haggstrom, MD, MAS
Regenstrief Conference
October 3, 2007
Tranformational change• “Together we can transform the American health care
system into one that provides the highest quality of care for all of its citizens.”– Carolyn Clancy, AHRQ
• Connect the System. Through electronic health records, standards, and information exchange.
• Measure and Publish Quality. Work with doctors and hospitals to define benchmarks for what constitutes quality care.
• Measure and Publish Price. Agreement is needed on what procedures are covered in each "episode of care."
• Create Positive Incentives. Reward those who offer & those who purchase high-quality, competitively priced health care.
RAND quality report
• Individuals receive 55% of recommended care
• “A key component of any solution…is the routine availability of information on performance at all levels. Making such information available will require a major overhaul of our current health information systems, with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality.”
McGlynn E et al., NEJM, 2003.
Cancer policy statementsInstitute of Medicine, April 1999:
“A cancer data system is needed that can provide quality benchmarks for use by systems of care: hospitals, provider groups, and managed care systems”
National Cancer Institute, cancer.gov, 2002:“Work is underway to make cancer a working model for quality of care research and the translation of this research into practice”
Regenstrief Cancer Care Engineering, May 2007:“Develop an hierarchical system-based approach to improving cancer care: establishing an Indiana prototype for colorectal cancer care”
National Initiative for Cancer Care Quality– Development of quality measures:
• Literature review of existing indicators, guidelines, RCTs• Subsequent expert review (clinical, health services researchers,
nurses, patients)
– Method: patient survey & medical record review• 47% of eligible patients enrolled
– Proportion of patients who received recommended care• 86% of breast cancer patients
– Adherence less than 85% for 18/36 breast cancer measures• 78% of colorectal cancer patients
– Adherence less than 85% for 14/25 colorectal ca measures
– Colorectal cancer post-treatment surveillance: 50%– Appropriate referral: 13-59%– Respect for patient preferences: 57-71%
Schneider E et al., Jnl Clin Onc, 2005.
Outline• How do we measure quality?• With what data do we measure quality?• What technologies can transform our use of quality data?
– health information exchange– clinical decision support– personal health records
• How do we study technology implementation?• Who is accountable for quality?
– provider-level– system-level– patient-level
Data
Quality measureTransformative
technology Provider
Patient
System
Health care quality and Overutilization
Unmeasured quality gap
Good Quality Poor Quality
Good Quality
UnderuseOveruse
• Application of medical interventions without known medical benefit, or worse, with known lack of benefit
• Overtreated: Why too much medicine is making us sicker and poorer, Shannon Brownlee, 2007
• Cancer examples:• bone marrow transplant for
breast cancer• PSA screening• surveillance testing
Unmeasured quality gap
Good Quality Poor Quality
Health care quality and Uncertainty
Uncertainty
Certainty
• Clinical uncertainty• Risk adjustment
• Decision-making uncertainty• Patient preferences &
values vary• Measure “informed” or
“good decisions” in concordance with patient preferences, Mulley et al.
Other dimensions of quality
Patient satisfaction Patient-provider communication
Quality-of-life Symptom control
Importance of measurement
Act Plan
Study Do
PDSA cyclesPDSA cycles
Act Plan
Study Do
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
General population Cancer
population Longitudinal care
How do we measurecancer care quality?
Recurrence
Surveillance
General population SEER
cancer registries
Medicare
With what data do we measure quality?United States
Haggstrom DA et al., Cancer. 2005.
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
General population
Medicare/Medicaid
With what data do we measure quality?Michigan
State cancer registry
Bradley CJ et al., Cancer, 2005.
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
General population
With what data do we measure quality?Iowa
Private claimsState
cancer registry
Doebbeling BN et al., Med Care,1999.
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
With what data do we measure quality?Indiana
‘Connect the System’
Cancer population Longitudinal care
IN State cancer registry
SPINVA cancer
registryLINK
VA-INPC
longitudinal care• Medicare• Medicaid• Private claims• Regenstrief EMR• VA admin. claims• VA EMR
New possibilities
with EMR• Test results
– Laboratory
– Radiology•Free text query
Add new quality measures in EMR
• Satisfaction• Communication• Quality-of-life• Symptoms
• Proportion of patients who underwent screening – primary care• Adequate lymph node retrieval & evaluation - surgery• Proportion receiving radiation therapy/chemotherapy - oncology• Proportion who underwent follow-up of abnormal test – who?• Proportion receiving postoperative surveillance – who is responsible?
VA-INPCCancer
population Longitudinal data
Primary care – quality measure
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
• Proportion of patients who underwent screening – primary care• Adequate lymph node retrieval & evaluation - surgery• Proportion receiving radiation therapy/chemotherapy - oncology• Proportion who underwent follow-up of abnormal test – who?• Proportion receiving postoperative surveillance – who is responsible?
Cancer population Longitudinal data
VA/INPC
Surgery treatment – quality measure
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
• Proportion of patients who underwent screening – primary care• Adequate lymph node retrieval & evaluation - surgery• Receipt of radiation therapy/chemotherapy - oncology• Proportion who underwent follow-up of abnormal test – who?• Proportion receiving postoperative surveillance – who is responsible?
Cancer population Longitudinal data
VA/INPC
Oncology treatment – quality measure
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
Transformative technology #1:Health information exchange
Primary care Surgery Oncology
timely quality performance reports
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Transformative technology #2:Clinical decision support
High riskAve risk / Follow-up of abnormal tests Surveillance colonoscopy
ONCWATCH REMINDERS
real-time quality performance
Cancer screening
Control
hospitals
β site
No CDS
Active system re-design
5 more hospitals
Passive dissemination5 regional hospitals
Learning system
1. CLINICAL PROCESSES
a. Cancer screening
b. Diagnostic colonoscopy
c. Surveillance colonoscopy
2. Organizational surveys• Culture• Teamwork• Leadership
New CDS
Implementation Plan
Qualitative data–Workflow–Usability
Control
hospitals
Implementation researchof health information technology
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Transformative technology #2:Clinical decision support
High riskLow risk / Follow-up of abnormal tests Surveillance colonoscopy
Physician
specialtyGeneral internist +/- gastroenterologist +/- surgeon
real-time quality performance
Cancer screening
REMINDERS
• Proportion who underwent follow-up of abnormal test
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Uncertain accountability
Primary careRadiologist
Proceduralist
Who is responsible?
Information exchange
• Proportion receiving postoperative surveillance
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Uncertain accountability
Primary careSurgery
Oncology
Who is responsible?
Information exchange
Approaches touncertain accountability
Promoting continuity infragmented health care system
1. System approach:• Assign provider accountability to larger organizations/units
than single provider
2. Patient-centered approach• Share accountability through personal health records
‘Extended medical staff’definition
• Data source: Assigned physicians & patients using Medicare claims (2002-2004)
• Physicians extended medical staff– Inpatient MDs: assign MD to hospital where they
provided care to most inpatients– Outpatient MDs: assigned MD to hospital where
admitted most patients• Patients extended medical staff
– Inpatients: assigned based on plurality of discharges over specific period
– Outpatients: assigned to physician (primary or specialty care) who provided most of their care in outpatient setting
• then assigned to physicians’ primary hospital
Fisher E et al., Health Affairs,2006
Concentration of patients among extended medical staff
% of physician inpatient work at primary hospital
90%
% of patient received services from extended medical staff
73%
Patient panel size Individual providers Extended medical staff
0-49 50% <1%
50-499 48% 2%
>500 2% 98%
Advantages of ‘extended medical staff’ as locus of accountability
‘Positive incentives’• Performance measurement
– focus on longitudinal experience of patient & address fragmentation of care by pooling accountability
• Local organizational accountability– influence resource distribution, IF measured on BOTH
quality & cost– larger organizations have capacity to invest in
improving quality & lowering costs
Patient-centered approachPromoting continuity in
fragmented cancer care system
Survivorship Care Plan
1.Cancer type, treatment received, & potential toxicities
2.Tailored information about timing & content of recommended follow-up
3.Recommendations regarding preventive practices & how to maintain health & well-being
4.Availability of psychosocial services in community
Personal health record
1.Diagnosis, treatment received, & potential side-effects
2.Tailored information about timing & content of recommended follow-up
3.Recommendations regarding preventive practices & how to maintain health & well-being
4.Availability of psychosocial services in community
RiskAssessment
Screening Diagnosis Treatment Surveillance
Provider -Oncologist-Radiationtherapist-Surgeon
-PrimaryCare-Radiologist-Proceduralist
-PrimaryCare
-PrimaryCare-Oncologist-Surgeon-Radiologist-Proceduralist
PHR
Transformative technology #3:Personal health records
Palliativecare
Patient/
caregiver
Longitudinal care
• Current functions:– Patient education– Self-management tools– Pharmacy refills
• Functions in near future:– on-line appointments– patient/provider messaging
• Pilot program:– full access to VA electronic health record
Study/project designs
Appropriate care
Clinical processes
Quality
personal health record
no personal health record
Patient perceptionsquality of cancer care
• Population: population-based survey of 1,067 patients with colorectal cancer nine months after diagnosis
• Mean problem score (in descending order):– Health information 48– Treatment information 32– Psychosocial care 32– Coordination of care 21– Access to care 12
Ayanian J et al., Jnl Clin Onc, 2005.
Racial/ethnic differencespatient perceptions of quality of care
Health care quality and AccessUnmeasured quality gap
Good Quality Poor Quality
Population with access
to health care system
• “Chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”,
New York Times,
September 23, 2007
No
access
Transformationtechnology & implementation
Transformative technologiesInformation exchange
timely performance feedbackClinical decision support
real-time peformance feedbackPersonal health records
patient-centered decision support
Implementation science Better understand adoption of technology with multiple methods & designs
Transformationaccountability
Solitary episodes of care delivery accountability for multiple episodes of care
shared among multiple providers• Large organizations have capacity to act
give health information and recommendations to patient in personal health record
• Patient is willing to act – patient health is at stake
Transformationwhat we measure is what we change (at least on purpose)
Leverage ‘system connectedness’
Measure quality in many dimensionsUnderuseOveruseAccessPatient experience
Act Plan
Study Do
Act Plan
Study Do
Indy quality performance measure the right things
at the right time
Act Plan
Study Do
Act Plan
Study Do
Thank you
Health care quality and Overutilization
Unmeasured quality gap
Good Quality Poor Quality
Good Quality
UnderuseOveruse
• Application of medical interventions without known medical benefit, or worse, with known lack of benefit
• “Avoiding the unintended consequences of growth in medical care: how might more be worse?” 1999, JAMA, Fisher E, Welch G
• Overtreated: Why too much medicine is making us sicker and poorer, Shannon Brownlee, 2007
• Cancer examples:• bone marrow transplant for breast
cancer• PSA screening• surveillance testing
Health care quality and AccessUnmeasured quality gap
Good Quality Poor Quality
Population with access
to health care system
• African Americans more frequently than whites
• lost medical insurance coverage after cancer diagnosis
• denied coverage after changing jobs
• reached their insurance spending limits
• “CMS - chemotherapy cost not covered for illegal immigrants because does not qualify as emergency”,
New York Times,September 23, 2007
No
access
Implementation research
• Measuring context…
• Organizational surveys:– Teamwork– Leadership– Culture
• Qualitative methods
• Human factors engineering
What is measured targets what is changed
Approporiate clinical use Overuse Risk-adjusted use Preference-concordant use Patient experience Patient symptoms Access
• Proportion of care delivered outside the VA for CRC care? Denise Hynes?
Importance of measurement
Act Plan
Study Do
PDSA cyclesPDSA cycles
XX
Act Plan
Study Do
XX
Subspecialty care
Primary care
Unmeasured quality gap
Poor QualityGood Quality
Shared care
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Transformative technology #2:Clinical decision support
Oncwatch
High riskLow risk / Follow-up of abnormal tests Surveillance colonoscopy
REMINDERS
Physician
specialtyGeneral internist +/- gastroenterologist +/- surgeon
real-time feedback
Cancer screening
Sample sizes
Patient population size
Assessment of providers as individuals
Assessment of providers as group (extended medical staff)
0-49 50% <1%
50-499 48% 2%
>500 2% 98%
Cancer examples of use of non-evidence-based interventions
Bone marrow transplant for breast cancer
PSA Surveillance tests among cancer
survivors
Atlanta measures
• More detail about measures???
Control
sites
α/β site
Non-OncWatch
Active implementation
5 more sites
Passive diffusion5 regional sites
Learning system
1. CLINICAL PROCESSES
a. Cancer screening
b. Diagnostic colonoscopy
c. Surveillance colonoscopy
2. Organizational surveys• Culture• Teamwork• Leadership
OncWatch
Implementation Plan
•Qualitative data–Workflow–Usability
Control
sites
• If a man will begin with certainties, he will end in doubts; but if he will be content to begin with doubts, he will end in certainties. -Francis Bacon (1561-1626),_
Cancer quality/performance measures
• Measuring the Quality of Breast Cancer Care in Women– Evidence Report/Technology Assessment No. 105. (University of
Ottawa Evidence-based Practice Center) AHRQ. October 2004.
• Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal Cancer
– (Duke Evidence-based Practice Center) AHRQ. May 2006.
• Process measures• Outcome measures
Survivorship care plan
Survivorship care planPersonal health record
Types of uncertainty
ERROR: Measure quality of physician performance only by measuring clinical processes.
UNINTENDED CONSEQUENCE: Patients making informed and shared decisions with their physicians not to undergo screening or treatment are labeled as receiving poor quality care. Sick patients who would not benefit from aggressive screening or treatment may also be labeled as receiving poor quality care.
RESEARCH NEED: In areas of clinical uncertainty, measure quality by measuring the presence of “good decisions”, not only what decision is made. Take into account patient illness or preferences when measuring quality, otherwise, the measures may create incentives for inappropriate or unwanted clinical care.
• “The only man who behaves sensibly is my tailor; he takes my measurements anew every time he sees me, while all the rest go on with their old measurements and expect me to fit them”– George Bernard Shaw
General population
Medicaid
How do we measure performance?Michigan
State cancer registry
Bradley CJ, Gardiner J, Given CW, Roberts C. Cancer, Medicaid enrollment, and survival disparities. Cancer. 2005 Apr 15;103(8):1712-8.
Bradley CJ, Principal Investigator, “In-Depth Examination of Disparities in Cancer Outcomes.” $1,630,646. Funding Source: National Cancer Institute. 2004-2008.
Risk Assessm
ent
Diagnosis
Cancer Treatm
ent
Screening
Palliative Care
Recurrence
Surveillance
Health care quality improvement or implementation research
Poor
Quality
Health
Care
Good QualityPoor QualityGood Quality
Measurement of Cancer Care Measurement of Cancer Care QualityQuality
OrganizationOrganizationss
ProvidersProviders
Pathway 1:Pathway 1:IMPLEMENTATIOIMPLEMENTATIO
NN
Quality improvement framework
GoodGood PoorPoor
•PatientsPatients•Referring Referring CliniciansClinicians•PurchasersPurchasers INCENTIVE TO INCENTIVE TO
CHANGECHANGE
Pathway 2:Pathway 2:SELECTIONSELECTION
REPORTREPORTSS
PPUUBBLLIICC
Berwick D, Institute for Healthcare Improvement, Berwick D, Institute for Healthcare Improvement, Medical CareMedical Care
Measurement of Cancer Care Measurement of Cancer Care QualityQuality
OrganizationOrganizationss
ProvidersProviders
Pathway 1:Pathway 1:IMPLEMENTATIOIMPLEMENTATIO
NN
Quality improvement framework
GoodGood PoorPoor
•PatientsPatients•Referring Referring CliniciansClinicians•PurchasersPurchasers INCENTIVE TO INCENTIVE TO
CHANGECHANGE
Pathway 2:Pathway 2:SELECTIONSELECTION
REPORTREPORTSS
PPUUBBLLIICC
Berwick D, Institute for Healthcare Improvement, Berwick D, Institute for Healthcare Improvement, Medical CareMedical Care
Measurement of Cancer Care Measurement of Cancer Care QualityQuality
OrganizationOrganizationss
ProvidersProviders
Pathway 1:Pathway 1:IMPLEMENTATIOIMPLEMENTATIO
NN
Quality improvement framework
GoodGood PoorPoor
Measurement of Cancer Care Measurement of Cancer Care QualityQuality
OrganizationOrganizationss
ProvidersProviders
Pathway 1:Pathway 1:IMPLEMENTATIOIMPLEMENTATIO
NN
Quality improvement framework
GoodGood PoorPoor
•PatientsPatients•Referring Referring CliniciansClinicians•PurchasersPurchasers INCENTIVE TO INCENTIVE TO
CHANGECHANGE
Pathway 2:Pathway 2:SELECTIONSELECTION
REPORTREPORTSS
PPUUBBLLIICC
Berwick D, Institute for Healthcare Improvement, Berwick D, Institute for Healthcare Improvement, Medical CareMedical Care
Uncertain accountability
• Cheesy?
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
• When Mrs. Hewitt sued Habana over her mother’s death, for example, she found that its owners and managers had spread control of Habana among 15 companies and five layers of firms.
• As a result, Mrs. Hewitt’s lawyer, like many others confronting privately owned homes, has been unable to establish definitively who was responsible for her mother’s care.
• New York Times, September 23, 2007
• The limits of health services research:– Public health
– Chemotherapy for immigrants not covered
IOM: Crossing the Quality Chasm
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable
• Safe
Tranformational change• “Together we can transform the American health care system into
one that provides the highest quality of care for all of its citizens.”– Carolyn Clancy, AHRQ
• Connect the System. Every medical provider will have some system for electronic health records. Standards need to be set so all health information systems can quickly and securely communicate and exchange data.
• Measure and Publish Quality. Every case, every procedure has an outcome. Some are better than others. To measure quality, we must work with doctors and hospitals to define benchmarks for what constitutes quality care.
• Measure and Publish Price. Price information is useless unless cost is calculated for identical services. Agreement is needed on what procedures are covered in each "episode of care."
• Create Positive Incentives. All parties—providers, patients, insurance plans, and payers—must be subject to contractual arrangements that reward those who offer and those who purchase high-quality, competitively priced health care.
• “Changing what is possible”
MedicareMedicaid
Private
Insurance Uninsured
Indiana Network for Patient Care
Regenstrief Medical Record System (RMRS)
General population
Cancer population
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
VA
INPC
StateRegistry
SPIN
Risk Assessm
ent
TimelyDiagnos
is
Cancer Treatme
nt
Screening
Surveillance for
Recurrence
Genomics
Risk of Cancer Death
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population Cancer
population (xx%)
SEER(20% US)
StateRegistries(Indiana)
VA
Cancer registriesD
A
T
A
S
O
U
R
C
E
Primary care practice
• VA• IU-MG
VA Medicare Medicaidprivate
insurance Uninsured
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Cancer population
SEER(20% US)
StateRegistries(Indiana)
VA
Cancer registriesD
A
T
A
S
O
U
R
C
E
VA Medicare Medicaidprivate
insurance Uninsured
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
Cancer population
SEER(20% US)
StateRegistries(Indiana)
VA
Cancer registriesD
A
T
A
S
O
U
R
C
E
SPIN
RiskAssessment
Screening Diagnosis Treatment Surveillance
Patient/caregiver
Patient/caregiver
Provider ProviderProviderProvider Provider
Follow-up of abnormal tests may be improved by coordination
Survivorship care may be improved by coordination
Patient/caregiver
Patient/caregiver
Patient/caregiver
Patient/caregiver
PHR
Transformative technology #3:Personal health records
Patient/caregiver
Patient/caregiver
Palliativecare
Patient/
caregiver
Longitudinal care
VA
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population Cancer
population
(xx%)
RE
S
E
A
R
C
H
QU
E
S
T
I
O
N
Genomic risk
Health Services Research
SEER(20% US)
StateRegistries(Indiana)
VA
Cancer registries
Fragmented health care delivery = fragmented data
age
insurance coverage
location65
VA MedicareMedicaid
private
insuranceUninsured
SEER
SEER-Medicare
MedicareWellpoint
UnitedHealth Medicaid
medical record
VA INPC
Fragmented health care delivery = fragmented data
age
insurance coverage
location65
VA MedicareMedicaid
private
insuranceUninsured
SEER
SEER-Medicare
Fragmented health care delivery = fragmented data
age
insurance coverage
location65
VA MedicareMedicaid
private
insuranceUninsured
SEER
SEER-Medicare
RiskAssessment
Screening Diagnosis Treatment Surveillance
PatientPatient
Provider ProviderProviderProvider Provider
Follow-up of abnormal FOBTs may be improved by coordination
Survivorship care may be improved by coordination
PatientPatient Patient/caregiver
Patient/caregiver
PatientPatient
Coordination of careacross the continuum
PHR
65
insurance coverage
location
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population Cancer
population
(xx%)
RE
S
E
A
R
C
H
QU
E
S
T
I
O
N
Genomic risk
Health Services Research
SEER(20% US)
StateRegistries(Indiana)
VA
Cancer registries
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population Cancer
population
SEER(20% US)
StateRegistries(Indiana)
VA
Cancer registriesD
A
T
A
S
O
U
R
C
E
Unmeasured quality gap
Health Care
Good Quality Poor Quality
Certainty
Clinical uncertainty
Health Care Quality and Uncertainty
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population Cancer
populationSEER MedicareLongitudinal careState
cancer registry
Medicaid
How do we measure performance?
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population State
cancer registry
Private claims
• Proportion of patients who underwent screening – primary care• Adequate lymph node retrieval & evaluation - surgery• Proportion receiving radiation therapy/chemotherapy - oncology• Proportion who underwent follow-up of abnormal test – who?• Proportion receiving postoperative surveillance – who is responsible?
• Proportion of patients who underwent screening – primary care• Adequate lymph node retrieval & evaluation - surgery• Proportion receiving radiation therapy/chemotherapy - oncology• Proportion who underwent follow-up of abnormal test – who?• Proportion receiving postoperative surveillance – who is responsible?
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population Cancer
population Longitudinal data
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population
MedicareState
cancer registry
How do we measure performance?Virginia?
Penberthy L, McClish D, Manning C, Retchin S, Smith T. The added value of claims for cancer surveillance: results of varying case definitions. Med Care. 2005 Jul;43(7):705-12.
Risk Assessm
ent
Diagnosis
Cancer Treatme
nt
Screening
Recurrence
Surveillance
General population
• Proportion of patients who underwent screening – primary care• Adequate lymph node retrieval & evaluation - surgery• Proportion receiving radiation therapy/chemotherapy - oncology• Proportion who underwent follow-up of abnormal test – who?• Proportion receiving postoperative surveillance – who is responsible?
Cancer population Longitudinal data
RiskAssessment
Screening Diagnosis Treatment Surveillance
Patient/caregiver
Patient/caregiver
Provider ProviderProviderProvider Provider
Follow-up of abnormal FOBTs may be improved by coordination
Survivorship care may be improved by coordination
Patient/caregiver
Patient/caregiver
Patient/caregiver
Patient/caregiver
Patient/caregiver
Patient/caregiver
Coordination of careacross the continuum
PHR
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