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Management Using Health Information System George Mason University April 27, 2007 Syed Tirmizi, MD Medical Informatic

Management Using Health Information System George Mason University April 27, 2007 Syed Tirmizi, MD Medical Informatician Veterans Health Administration. Veterans Health Administration. 5.3 million patients, ~ 7.7 million enrollees 1,400 Sites-of-Care

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Management Using Health Information System George Mason University April 27, 2007 Syed Tirmizi, MD Medical Informatic

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  1. Management Using Health Information System George Mason UniversityApril 27, 2007Syed Tirmizi, MDMedical InformaticianVeterans Health Administration

  2. Veterans Health Administration • 5.3 million patients, ~ 7.7 million enrollees • 1,400 Sites-of-Care • 198,500 Employees (~14,500 MD , 58,000 Nurses, 33,000 AHP) • Affiliations with 107 Academic Health Systems

  3. Who Are VA Patients ? • Older • 49% over age 65 • Sicker • Compared to Age-Matched Americans • 3 Additional Non-Mental Health Diagnoses • 1 Additional Mental Health Diagnosis • Poorer ~ 70% with annual incomes < $26,000 ~ 40% with annual incomes < $16,000 • Changing Demographics • 7.0% female overall • Females: 22.5% of outpatients less than 50 years of age

  4. Toward a “Virtual Health System” • Electronic Health Records (EHRs) • Robust, Widespread Use of High Performance Electronic Health Records (EHRs) • Personal Health Records (PHRs) • Full copy of one’s own health information along with personalized services based on that information • Standards • Health Data & Communication Standards • Health Information Exchange • Connectivity Among the EHRs, PHRs, and related health entities

  5. Electronic Health Records &Computerized Provider Order Entry • Computerized Provider Order Entry (CPOE) is one of the Leapfrog Group’s “Top 3 Safety Strategies” • Outside of VA, CPOE < 15% nationally • < 30% among Academic Medical Centers • Nationally, 94% of all VA prescriptions are entered directly by providers • Ultimate Goal: 100% • VA is the Benchmark for CPOE

  6. Uses a Chart Metaphor -Combining Text and Images • Single longitudinal health record is immediately available in • Outpatient • Inpatient & • Long-term care settings

  7. Links Reminder With Actions With Documentation

  8. Bar-Code Medication Administration (BCMA) BCMA Assures: Right Medication Right Dose Right Patient Right Provider Right Time Virtually Eliminates Errors at the Point of Administration . . . Coming Soon: Bar-Coded Lab Specimen, Blood Administration, & more

  9. However This is NOT about technology… It is about RESULTS: • Improved Health Care Quality • Improved Health Outcomes

  10. How Do We Compare to non-VA Providers?VHA Continues to exceed HEDIS in the vast majority of 17 common measures HEDIS = Health Plan Employer Data & Information Set From the National Committee on Quality Assurance (NCQA)

  11. How Do We Compare to non-VA Providers?VHA Continues to exceed HEDIS in the vast majority of 17 common measures

  12. Amputations per 1000 patients FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among Patients With Diabetes

  13. Vaccine Cuts Pneumonia Risk in High-Risk Patients* • 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. • VA Medical Center study of 1,900 elderly patients with chronic lung disease; 2/3 vaccinated against pneumonia. • Pneumococcal vaccination: • 43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death. • Pneumonia and Influenza vaccination: • 72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes. • Pneumococcal vaccination saved an average of $294 per vaccine recipient over the 2-year period. *Archives of Internal Medicine 1999;159:2437-2442 Dr. Kristin Nichol, VAMC / Minneapolis

  14. Pneumococcal Vaccination Rates in VHA --BRFSS 90th-- --BRFSS-- • Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz • HHS: National Health Interview Survey, >64

  15. 50% 40% 30% 20% 10% 0% -10% -20% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 - -0.3% 0.8% -6.2% -8.6% -6.5% -7.3% -9.1% -4.6% 0.8% VHA Cost Per Patient 6.4% 14.9% 14.9% 12.8% 14.9% 25.5% 31.9% 40.4% 44.7% Avg. Medicare Payment/Enrollee - 3.3% 5.9% 9.8% 13.5% 18.4% 23.7% 29.5% 34.7% 39.4% Medical CPI VHA Cost Per Patient Avg. Medicare Payment/Enrollee Medical CPI Ten Year Cumulative Percent Change in Costs - VA, Medicare, CPI • VHA Cost per Patient– Total Medical Care Obligations per Total Unique Patients (including non Veterans) • Average Medicare Payment per Enrollee—Medicare Program Benefits per Enrollee (www.cms.hhs.gov/researchers/pubs/datacompendium) • Medical Consumer Price Index--

  16. Over 16,000 veterans now using home telehealth devices Home Telehealth Technologies

  17. PHRPersonal Health Record

  18. Research – Harris Interactive • Two in five adults in the US keep their own personal and family health records. • 13% keep them electronically • 40% planning to do so in the future • More women (45%) than men (38%) kept records. • 58% of the over-65s filed information about their treatment. • 84% of all surveyed welcomed the Personal Health Record (PHR) concept. • Out of the 13% in the Harris survey who kept electronic records, only one in thirteen kept them online at a health record website. Source: Harris Interactive, August 2004 22

  19. What Do Patients Value in a PHR? Angst, C. M., & Agarwal, R. (2004) “Patients Take Control: Individual Empowerment with Personal Health Records,” Center for Health Information and Decision Systems.

  20. Predictors of PHR Use or Desire for Use • Convenience is a strong predictor of desire for PHR1 • Compliance is a predictor of PHR use2 • Connectedness is a predictor of PHR use2 • Age and Chronic Illness were not predictors but Education and Knowledge of PHRs were predictors of desire for PHR3 • 1Angst, C. M., & Agarwal, R. (Working Paper). “Getting Personal About Electronic Health Records: Modeling the beliefs of personal health record users and non-users,” • 2Agarwal, R., & Angst, C. M. (2006). “Technology-Enabled Transformations in U.S. Health Care: Early Findings on Personal Health Records and Individual Use,” In D. Galletta & P. Zhang (Eds.), Human-Computer Interaction and Management Information Systems: Applications (Vol. 5). Armonk, NY: M.E. Sharpe, Inc. • 3Angst, C.M., Agarwal, R., & Downing, J. (Working Paper). “An Empirical Examination of the Importance of Defining the PHR for Research and for Practice,” Under Review. 24

  21. How comfortable would you be if an PHR was provided, sponsored, and/or maintained by: 25

  22. The Chronic Disease Care Model Community HealthSystem Resources and Policies Organization of Health Care Self-Management Support VistA DeliverySystem Design Decision Support Productive Interactions Informed, Empowered Patient and Family Prepared, Proactive Practice Team My HealtheVet Improved Outcomes

  23. What do people with Chronic Disease need? • A continuous healing relationship. • Regular assessments of how they are doing. • Effective clinical management. • Information and on-going support for self-management. • Shared care plan. • Active, sustained follow-up. * Ed Wagner – presentation “Beyond the Basics: Another Look at the Care Model”

  24. Benefits to Providers • Transfer the “ownership” of chronic disease management to the patient. • Offers more complete picture of patient’s health conditions and health care, including non-VA care. • Reallocation of time in practice to more complex cases. • Ability to communicate and collaborate with patients more easily. • A study by McKay et al* found that patients who participated in an online diabetes education and support group lowered their blood glucose levels significantly more than controls did. *McKay HG, King D, Eakin EG, Seeley JR, Glasgow RE. The diabetes network Internet-based physical activity intervention: randomized pilot study. Diabetes Care 2001 Aug;24(8):1328-1334.

  25. 2006 Innovations in American Government Award Winner Visit www.innovations.va.gov

  26. VA ‘s Use of Health IT Technology “[VA has] adopted aculture of patient safety and qualitythat is pervasive," says Karen Davis, president of Commonwealth Fund, which studies health-care issues. The centerpiece of that culture is VistA, the VA's much praised electronic medical-records system.… VistA has also turned out bea powerful force for quality control.” Business Week July 17, 2006

  27. VA ‘s Use of Health IT Technology “Veterans’ hospitals used to be a byword for second-rate care or worse. Now they’re national leaders in efficiency and quality. What cured them? A large dose of technology.” Fortune May 15, 2006

  28. Recent Praise for VistA… “Despite my private sector credentials and experience, it is my duty to tell you that the current, comprehensive electronic health environment of the Veterans Health Administration surpasses any capability available today on the planet, whether in the private sector, other departments of the U.S. government, or the highly profiled activities of other countries.” Jonathan C. Javitt, M.D., M.P.H.(former Co-Chair, Health Care Delivery and IT Subcommittee, President’s Information Technology Advisory Committee) Testimony before the House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations September 28, 2005

  29. VistA’s Contribution to the High Quality Care Provided By VA The “culture of quality” depended on the successful implementation of several innovations:a uniform data collection system facilitated by nationwide implementation of an electronic medical record system, systematic application of quality standards, and externally monitored local area networks to monitor quality.” Annals of Internal Medicine, Editorial, August 17, 2004

  30. Highest Quality of Care For Patients with Diabetes in VA “Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care.” Annals of Internal Medicine, August 17, 2004

  31. Highest Quality of Care For Patients in VA Measured Broadly “Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.” Annals of Internal Medicine, December 21, 2004

  32. (Still More) Praise . . . “The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the best in the world.” John Glaser, Ph.D., October 2003Vice President & CIOPartners (Harvard) HealthCare System

  33. Current State Facility-centric Data is not standardized from site to site, therefore it is not computable Automated Clinical Decision Support uses data only from the local VistA system (1 of 128) Future State Patient-centric (Veteran-centric) Standardization of data becomes the foundation for decision support functionality Automated Clinical Decision Support is available in real time across allsites of care HDR – How Is It Different Than Current State?

  34. Information Exchange

  35. DoD/VA Interoperability Solution Suite DoD VA One-way, enterprise exchange of text data FHIE FHIE BHIE Bidirectional, real-time exchange of text data BHIE Bidirectional, real-time, enterprise exchange of computable data CHDR CHDR

  36. The Goals of Standardization • Ensure consistent interpretation of clinical information • Support clinical decision-making • Support interoperability with health care partners • Support public health and bio-surveillance activities • Improve quality, safety, and cost-effectiveness of patient care

  37. The Information Challenge • Our ability to produce VA data has skyrocketed over the last 10 years: • proliferation of tools and technology for data collection and reporting • proliferation of measures and monitors for managing and improving organizational performance • The real challenge is not how to get data, but what data to focus on and how to best use data that is available.

  38. “Clinical Reminders” Performance Measures • Clinical Reminders • Real time decision support • Targeted to specific patient cohort • Targeted to specific clinic/clinicians • Reminder Dialogs • Standard documentation • Capture of data (HF, IMM, encounter data, etc) • Reminder Reports • Performance improvement/scheduled feedback • Identification of best practices • Targeting low scorers for educational intervention • Patient recall if missed intervention

  39. Clinical Reminder Reports • A menu of Reminder Reports that clinicians can use for summary or detailed level information about patients’ due and satisfied reminders

  40. Clinical Reminder Reports • Multiple Uses for Reminder Reports • Patient care: • Future Appointments • Which patients need an intervention? • Past Visits • Which patients missed an intervention? • Action Lists • Inpatients • Which patients need an intervention prior to discharge?

  41. Clinical Reminder Reports • Identify patients for case management • Diabetic patients with poor control • Identify patients with incomplete problem lists • Patients with (+) Hep C test but no PL entry • Identify high risk patients • on warfarin, amiodarone • Track annual PPD due (Employee Health)

  42. Clinical Reminder Reports • Quality Improvement: • Provide feedback (team/provider) • Identify (& share) best practices • Identify under-performers (develop action plan) • Track performance • Implementation of new reminders or new processes • Identify process issues early (mismatch of workload growth versus staffing) • Provide data for external review (JCAHO)

  43. Clinical Reminder Reports • Management Tool • Aggregate reports • Facility / Service • Team (primary care team) • Clinic / Ward • Provider-specific reports • Primary Care Provider • Encounter location • If one provider per clinic location

  44. Clinical Reminder Reports • Employee Performance & Evaluation • Re-credentialing data for providers • Annual Proficiency - Nursing • Support for Special Advancement • Support for Bonuses • Employee Rewards & Recognition

  45. Graph the Data Over Time

  46. Using Cube to Analyze New Patient GI Wait Times Problem is 32.84% at “Green” Facility

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