Neale Chumbler Regenstrief 2007 Presentation


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Implementation of Health Information Technology in VHA to Support Transformational Change: Improved Access and Patient Centered Care

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Neale Chumbler Regenstrief 2007 Presentation

  1. 1. 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
  2. 2. Bobby Knight IU Head Coach: 1971 - 2000
  3. 3. IOM’s Crossing the Quality Chasm <ul><li>Six “Aims for Improvement” </li></ul><ul><li>1. Safety </li></ul><ul><ul><li>(as safe at home as in health care facilities) </li></ul></ul><ul><li>2. Effectiveness </li></ul><ul><ul><li>(avoid overuse of ineffective care and under use of effective care) </li></ul></ul><ul><li>3. Patient-centeredness </li></ul><ul><ul><li>(respect patient needs; communication & education for patients; coordination of care) </li></ul></ul>
  4. 4. Six Aims for Improvement (cont’d) <ul><li>4. Timeliness </li></ul><ul><ul><li>(care should reduce waiting times) </li></ul></ul><ul><li>5. Efficiency </li></ul><ul><ul><li>(reduction of waste; reduction of total cost of care) </li></ul></ul><ul><li>6. Equity </li></ul><ul><ul><li>(access to care regardless of income, ethnicity, and insurance) </li></ul></ul><ul><li>Berwick, 2002 </li></ul>
  5. 5. Changes at Microsystems of Care <ul><li>1. Small units of work---the care that the patient experiences </li></ul><ul><ul><li>where the work actually happens </li></ul></ul><ul><li>2. To achieve six aims---three wide-ranging redesign principles </li></ul><ul><ul><li>Knowledge-based care (best scientific evidence available in service of patient) </li></ul></ul><ul><ul><li>Patient-centered care (patient in control of his/her care) </li></ul></ul><ul><ul><li>Systems-minded care (coordination of care across disciplines; avert fragmented care; relevance to patients with chronic illnesses) </li></ul></ul>Berwick, 2002
  6. 6. Enhancement of Effectiveness of Microsystems <ul><li>“ 10 simple Rules” </li></ul><ul><li>1. Care --- continuous healing relationship </li></ul><ul><ul><li>Access to care --- internet; telephone, etc. </li></ul></ul><ul><li>2. Care --- tailored according to patients’ </li></ul><ul><li>needs and values. </li></ul><ul><li>3. Patient --- exercises control over own health </li></ul><ul><ul><li>Shared Decision Making. </li></ul></ul><ul><li>4. Patient --- unlimited access to their own medical </li></ul><ul><li>information. </li></ul><ul><li>Berwick, 2002 </li></ul>
  7. 7. Changes in Health Care Organizations <ul><li>IT --- improve access to information & support clinical decision making. </li></ul><ul><li>Better coordination of care among services, especially for care of people with chronic illnesses. </li></ul>
  8. 8. VHA Care Coordination <ul><li>Late 2003 </li></ul><ul><li>Espoused IOM Aims for Improvement (especially patient centeredness) </li></ul><ul><li>Wagner’s Model of Chronic Care </li></ul><ul><ul><li>--- pt. self-management </li></ul></ul><ul><li>Address fragmented care --- affect pt. safety </li></ul><ul><li>Health informatics, telehealth, & DM </li></ul>Darkins, 2006
  9. 9. CCHT Components <ul><li>Use telehealth --- coordinate care---pts. Home </li></ul><ul><li>Patient Centered Care </li></ul><ul><ul><li>Pt. --- locus of control; care environment shifted to home </li></ul></ul><ul><li>Disease Management </li></ul><ul><ul><li>Symptom; knowledge; behavior </li></ul></ul><ul><li>Care/Case Management </li></ul><ul><ul><li>Across the VHA continuum </li></ul></ul>
  10. 10. CCHT Components <ul><li>Self management of chronic disease </li></ul><ul><ul><li>Facilitate medication changes </li></ul></ul><ul><ul><li>Early interventions </li></ul></ul><ul><li>Technology delivers components </li></ul><ul><ul><li>Integrate information and communication technologies through communication services (messaging devices; videophones) </li></ul></ul><ul><li>Allows veteran and care coordinator maintain direct communication </li></ul>
  11. 11. Home Telehealth Technology To support self-care and non-institutional long-term care needs of older veterans with disabling chronic disease.
  12. 12. CCHT Implementation <ul><li>System-wide; programs in all 21 regional administrative units (VISNs) </li></ul><ul><li>7/31/07 --- 27,637 veterans have been provided CCHT </li></ul><ul><li>Predominantly CHF, COPD, diabetes, & PTSD </li></ul>Darksins, 2006
  13. 13. CCHT Findings <ul><li>Rigorously tested the effectiveness of the CCHT intervention to determine if there were reductions in service use for veterans with diabetes. </li></ul><ul><ul><li>Propensity scores --- help ensure comparability of the treatment and comparison group on observable covariates </li></ul></ul><ul><li>Difference-in-differences was used to control for cross-sectional selection bias and intervening time factors </li></ul>
  14. 14. CCHT Findings <ul><li>Diabetes </li></ul><ul><li>1. Monitored wkly, w/more intensive evaluations vs. daily, but less intensively </li></ul><ul><ul><li>Hospital admissions decreased in daily monitoring group & increased in weekly monitoring group </li></ul></ul><ul><li>2. Improvement in HRQL --- SF36V </li></ul><ul><ul><li>physical functioning; bodily pain; social functioning </li></ul></ul><ul><li>3. Significant reductions (by 25%, p = .02) ---hospitalizations (24-mos). </li></ul><ul><ul><ul><ul><ul><li>Chumbler et al., 2005a; 2005b; Barnett et al., 2006 </li></ul></ul></ul></ul></ul>
  15. 15. <ul><li>Tested Cost-Utility of Diabetes Program </li></ul><ul><ul><li>One third of program participants were deemed cost-effective </li></ul></ul><ul><ul><li>Cost-effectiveness varied by marital status and VAMC implemented site </li></ul></ul><ul><li>Targeting the intervention differently in future work, may be more cost-effective for a greater % of patients. </li></ul>CCHT Findings Barnett et al., 2007
  16. 16. Cancer CCHT Findings <ul><li>HRQL --- 6.5-point increase in HRQL between baseline and end of treatment. </li></ul><ul><ul><li>Clinically meaningful difference </li></ul></ul><ul><ul><li>Better management of nervousness/worry over time + HRQL. </li></ul></ul><ul><li>Case-control study: Matched by Tumor Type and Cancer Stage. </li></ul><ul><ul><li>Fewer hospitalizations and fewer clinic visits. </li></ul></ul><ul><ul><ul><ul><ul><li>Chumbler et al., 2007a; 2007b </li></ul></ul></ul></ul></ul>
  17. 17. My HealteVet (MHV) <ul><li>Online Personal Health Record </li></ul><ul><li>Secure Web-based portal </li></ul><ul><ul><li>1. View medical records </li></ul></ul><ul><ul><li>2. Prescription Refills </li></ul></ul><ul><ul><li>3. Self-enter information & share it w/providers </li></ul></ul><ul><ul><li>4. Appointments </li></ul></ul><ul><ul><li>5. Disease Management (assessment tools) </li></ul></ul><ul><ul><li>5. Laboratory Values </li></ul></ul><ul><ul><ul><li>Track personal BP, weight, HR, etc. </li></ul></ul></ul>
  18. 20. MHV <ul><li>Stored in a secure & private environment </li></ul><ul><ul><li>eVA ault; d ata encrypted </li></ul></ul><ul><li>Share with providers in & out of VHA </li></ul><ul><li>Identify clinical studies to enroll </li></ul>Kupersmith et al., 2007
  19. 21. MHV <ul><li>“ Research Health” </li></ul><ul><ul><li>Diseases & Conditions </li></ul></ul><ul><li>MHV currently pilot tested in 9 VAMCs . </li></ul><ul><li>No Findings published </li></ul>
  20. 22. Future Steps --- Telehealth <ul><li>Void in literature on importance of organizational characteristics in telehealth effectiveness </li></ul><ul><ul><li>Care coordinator staffing ratio </li></ul></ul><ul><ul><li>Education level of care coordinators </li></ul></ul><ul><ul><li>Management oversight of programs </li></ul></ul><ul><ul><li>Hospital characteristics; Resources </li></ul></ul><ul><ul><li>Number and type of patients </li></ul></ul>
  21. 23. Future Steps <ul><li>CCHT Implementation </li></ul><ul><li>Randomized Controlled Trials </li></ul><ul><ul><li>Tele-rehabilitation to improve access to care for stroke patients </li></ul></ul><ul><li>Cost-effectiveness </li></ul><ul><li>How CCHT impacts broader care processes </li></ul><ul><ul><li>(e.g., extent to which diagnoses are made; medicines ordered; and referrals made) </li></ul></ul>Jaana & Pare, 2007
  22. 24. Further Investigation <ul><li>Assessment of Attitude of Providers </li></ul><ul><ul><li>Telehealth providers (RNs) </li></ul></ul><ul><ul><ul><li>Staffing-impact on nursing workload hours (set up, monitoring, follow-up; respond to technical issues) </li></ul></ul></ul><ul><ul><li>Referring physicians want more information on how it will be used for patient care. </li></ul></ul><ul><li>Identification of patients most likely to benefit </li></ul>Hopp et al., 2007
  23. 25. Further Investigation <ul><li>Usability of Home-Telehealth Technology </li></ul><ul><ul><li>Identification & Follow-up on technical issues </li></ul></ul><ul><ul><li>Disease Mgt. Modules </li></ul></ul><ul><ul><ul><li>Type & Frequency of Questions answered by pts. </li></ul></ul></ul><ul><ul><ul><li>Flexibility in asking additional questions </li></ul></ul></ul>Hopp et al., 2007
  24. 26. Future Steps <ul><li>More efficient manner of integrating the data from home telehealth devices into CPRS </li></ul><ul><ul><li>Vital sign data --- vital sign package to be electronically tagged to count for EPRP </li></ul></ul><ul><ul><li>Clinical Reminder --- who is enrolled in the CCHT? </li></ul></ul><ul><ul><ul><li>Early stages of a national reminder </li></ul></ul></ul>
  25. 27. Future Steps <ul><li>More efficient manner of integrating the data from home telehealth devices into CPRS </li></ul><ul><ul><li>Develop effective strategies to integrate these practices to better support provider decision making </li></ul></ul><ul><ul><ul><li>Feasibility </li></ul></ul></ul><ul><ul><ul><li>Frequency </li></ul></ul></ul><ul><ul><ul><li>Urgency flag? </li></ul></ul></ul>
  26. 28. MHV Future Steps <ul><ul><li>Research Issues in implementation </li></ul></ul><ul><ul><ul><li>Usability of MHV </li></ul></ul></ul><ul><ul><ul><li>Identify ways MHV enhanced (human factors associated with implementation & adherence) </li></ul></ul></ul><ul><ul><ul><li>Identify characteristics of veterans who are not using it and offer suggestions </li></ul></ul></ul><ul><ul><ul><li>Role of providers in MHV </li></ul></ul></ul><ul><ul><ul><ul><li>Work settings; sustainability </li></ul></ul></ul></ul>
  27. 29. CCHT & MHV <ul><li>Disease management protocols for MHV (survey section) </li></ul><ul><ul><li>Vet answer just like CCHT </li></ul></ul><ul><li>CCHT re-designed --- MHV more applicable </li></ul><ul><ul><li>1) improve access </li></ul></ul><ul><ul><li>2) shared decision-making </li></ul></ul><ul><ul><li>3) encouraged patient self-management </li></ul></ul>
  28. 30. Transformational Change <ul><li>Re-alignment of values, methods, and structures </li></ul><ul><li>Flow out of planned action & disruptive environmental influences </li></ul><ul><li>VHA’s CCHT and MHV </li></ul><ul><ul><li>Cross-cutting innovations that contribute to transformative organizational improvement across the 6 IOM aims. </li></ul></ul>Gamm et al., 2007