Chumbler Regenstrief 2007 Presentation 2007 10 03 07

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

Bobby Knight IU Head Coach: 1971 - 2000

IOM’s Crossing the Quality Chasm
Six “Aims for Improvement”
1. Safety
(as safe at home as in health care facilities)
2. Effectiveness
(avoid overuse of ineffective care and under use of effective care)
3. Patient-centeredness
(respect patient needs; communication & education for patients; coordination of care)

Six Aims for Improvement (cont’d)
4. Timeliness
(care should reduce waiting times)
5. Efficiency
(reduction of waste; reduction of total cost of care)
6. Equity
(access to care regardless of income, ethnicity, and insurance)
Berwick, 2002

Changes at Microsystems of Care
1. Small units of work---the care that the patient experiences
where the work actually happens
2. To achieve six aims---three wide-ranging redesign principles
Knowledge-based care (best scientific evidence available in service of patient)
Patient-centered care (patient in control of his/her care)
Systems-minded care (coordination of care across disciplines; avert fragmented care; relevance to patients with chronic illnesses)
Berwick, 2002

Enhancement of Effectiveness of Microsystems
“ 10 simple Rules”
1. Care --- continuous healing relationship
Access to care --- internet; telephone, etc.
2. Care --- tailored according to patients’
needs and values.
3. Patient --- exercises control over own health
Shared Decision Making.
4. Patient --- unlimited access to their own medical
information.
Berwick, 2002

Changes in Health Care Organizations
IT --- improve access to information & support clinical decision making.
Better coordination of care among services, especially for care of people with chronic illnesses.

VHA Care Coordination
Late 2003
Espoused IOM Aims for Improvement (especially patient centeredness)
Wagner’s Model of Chronic Care
--- pt. self-management
Address fragmented care --- affect pt. safety
Health informatics, telehealth, & DM
Darkins, 2006

CCHT Components
Use telehealth --- coordinate care---pts. Home
Patient Centered Care
Pt. --- locus of control; care environment shifted to home
Disease Management
Symptom; knowledge; behavior
Care/Case Management
Across the VHA continuum

CCHT Components
Self management of chronic disease
Facilitate medication changes
Early interventions
Technology delivers components
Integrate information and communication technologies through communication services (messaging devices; videophones)
Allows veteran and care coordinator maintain direct communication

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

CCHT Implementation
System-wide; programs in all 21 regional administrative units (VISNs)
7/31/07 --- 27,637 veterans have been provided CCHT
Predominantly CHF, COPD, diabetes, & PTSD
Darksins, 2006

CCHT Findings
Rigorously tested the effectiveness of the CCHT intervention to determine if there were reductions in service use for veterans with diabetes.
Propensity scores --- help ensure comparability of the treatment and comparison group on observable covariates
Difference-in-differences was used to control for cross-sectional selection bias and intervening time factors

CCHT Findings
Diabetes
1. Monitored wkly, w/more intensive evaluations vs. daily, but less intensively
Hospital admissions decreased in daily monitoring group & increased in weekly monitoring group
2. Improvement in HRQL --- SF36V
physical functioning; bodily pain; social functioning
3. Significant reductions (by 25%, p = .02) ---hospitalizations (24-mos).
Chumbler et al., 2005a; 2005b; Barnett et al., 2006

Tested Cost-Utility of Diabetes Program
One third of program participants were deemed cost-effective
Cost-effectiveness varied by marital status and VAMC implemented site
Targeting the intervention differently in future work, may be more cost-effective for a greater % of patients.
CCHT Findings Barnett et al., 2007

Cancer CCHT Findings
HRQL --- 6.5-point increase in HRQL between baseline and end of treatment.
Clinically meaningful difference
Better management of nervousness/worry over time + HRQL.
Case-control study: Matched by Tumor Type and Cancer Stage.
Fewer hospitalizations and fewer clinic visits.
Chumbler et al., 2007a; 2007b

My HealteVet (MHV)
Online Personal Health Record
Secure Web-based portal
1. View medical records
2. Prescription Refills
3. Self-enter information & share it w/providers
4. Appointments
5. Disease Management (assessment tools)
5. Laboratory Values
Track personal BP, weight, HR, etc.

MHV
Stored in a secure & private environment
eVA ault; d ata encrypted
Share with providers in & out of VHA
Identify clinical studies to enroll
Kupersmith et al., 2007

MHV
“ Research Health”
Diseases & Conditions
MHV currently pilot tested in 9 VAMCs .
No Findings published

Future Steps --- Telehealth
Void in literature on importance of organizational characteristics in telehealth effectiveness
Care coordinator staffing ratio
Education level of care coordinators
Management oversight of programs
Hospital characteristics; Resources
Number and type of patients

Future Steps
CCHT Implementation
Randomized Controlled Trials
Tele-rehabilitation to improve access to care for stroke patients
Cost-effectiveness
How CCHT impacts broader care processes
(e.g., extent to which diagnoses are made; medicines ordered; and referrals made)
Jaana & Pare, 2007

Further Investigation
Assessment of Attitude of Providers
Telehealth providers (RNs)
Staffing-impact on nursing workload hours (set up, monitoring, follow-up; respond to technical issues)
Referring physicians want more information on how it will be used for patient care.
Identification of patients most likely to benefit
Hopp et al., 2007

Further Investigation
Usability of Home-Telehealth Technology
Identification & Follow-up on technical issues
Disease Mgt. Modules
Type & Frequency of Questions answered by pts.
Flexibility in asking additional questions
Hopp et al., 2007

Future Steps
More efficient manner of integrating the data from home telehealth devices into CPRS
Vital sign data --- vital sign package to be electronically tagged to count for EPRP
Clinical Reminder --- who is enrolled in the CCHT?
Early stages of a national reminder

Future Steps
More efficient manner of integrating the data from home telehealth devices into CPRS
Develop effective strategies to integrate these practices to better support provider decision making
Feasibility
Frequency
Urgency flag?

MHV Future Steps
Research Issues in implementation
Usability of MHV
Identify ways MHV enhanced (human factors associated with implementation & adherence)
Identify characteristics of veterans who are not using it and offer suggestions
Role of providers in MHV
Work settings; sustainability

CCHT & MHV
Disease management protocols for MHV (survey section)
Vet answer just like CCHT
CCHT re-designed --- MHV more applicable
1) improve access
2) shared decision-making
3) encouraged patient self-management

Transformational Change
Re-alignment of values, methods, and structures
Flow out of planned action & disruptive environmental influences
VHA’s CCHT and MHV
Cross-cutting innovations that contribute to transformative organizational improvement across the 6 IOM aims.
Gamm et al., 2007

Chumbler Regenstrief 2007 Presentation 2007 10 03 07

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Chumbler Regenstrief 2007 Presentation 2007 10 03 07 — Presentation Transcript