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Indian Health Service Using Decision Support Effectively: Lessons from the Field. Lisa Dolan-Branton, RN Indian Health Service Office of Information Technology/Chronic Care Initiative AHRQ 2007 Annual Meeting. Indian Health System Setting IHS Resource and Patient Management System

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indian health service using decision support effectively lessons from the field
Indian Health ServiceUsing Decision Support Effectively: Lessons from the Field
  • Lisa Dolan-Branton, RN
  • Indian Health Service
  • Office of Information Technology/Chronic Care Initiative
  • AHRQ 2007 Annual Meeting
presentation overview
Indian Health System Setting
  • IHS Resource and Patient Management System
  • Clinical Decision Support in RPMS
  • Key Elements of a responsive HIS
  • (so clinicians use it with every patient)
Presentation Overview
mission and goal
Mission: to raise the physical, mental, social, and spiritual health of American Indians and Alaska natives to the highest level.
  • Goal: to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people.
Mission and Goal
the indian health system
IHS
    • 33 Hospitals
    • 49 Health Centers
    • 46 Health Stations
  • Tribal
    • 15 Hospitals
    • 198 Health Centers
    • 121 Health Stations
    • 180 Alaska Village Clinics
  • 34 Urban health care services and resource centers
  • 1.8 million users (Federally Recognized Tribes)
  • 56% AIAN rely primarily on IHS funded care (2000 census)
  • $3.1 billion from FY 2006 Appropriations
  • $628 million from Third-Party collections (2004)
The Indian Health System
ihs appropriations per capita compared to other federal health expenditure benchmarks

6,168

5,454

Forecast to 2004

5,184

1999

2004

2001

3,965

3,832

3,753

IHS

2003

1999

1999

2,101

Year of Last Published Data

2004

Medical Care

500

Non-medical

IHS APPROPRIATIONS PER CAPITA COMPARED TO OTHER FEDERAL HEALTH EXPENDITURE BENCHMARKS
american indian and alaska native population by state

* Census 2000, One race (AI/AN) alone

WA

NH

VT

ME

MT

ND

MN

OR

ID

SD

WI

NY

MI

WY

CA

IA

PA

NV

NE

NJ

OH

IL

IN

UT

WV

DE

CO

KS

MO

VA

MD

KY

NC

TN

AZ

NM

OK

AR

SC

AI/AN Population

by State, 2000

AL

GA

TX

MS

100,00 to 333,400

LA

FL

50,000 to 99,999

AK

10,000 to 49,999

1,713 to 9,999

HI

American Indian and Alaska Native Population By State
slide7

COMMUNITY ORIENTED

PRIMARY CARE

Cultural & Spiritual

Behavioral & Social

Medical Care

Public Health

Water & Sanitation

The Indian health care system is built on a broad spectrum approach to health. It starts with a base of fundamental public health and sanitation infrastructure. It provides inpatient and ambulatory medical services. It also integrates community-oriented programs promoting healthy behaviors and lifestyles.

community oriented primary care has reduced ai an mortality

American Indians

& Alaska Natives

US All Races

US White

COMMUNITY ORIENTED PRIMARY CARE HAS REDUCED AI/AN MORTALITY

Infant Mortality Rates

1973 – 2002

(25.0 to 8.5/1,000)

66% Reduction

%Decrease in Mortality

Rates since 1973

indian health system spectrum of cis use
No RPMS

RPMS PCC with paper charts and centralized data entry

PCC+ with centralized data entry

Partial use of EHR or other Electronic Medical Records

Fully implemented EHR

Indian Health System Spectrum of CIS Use
decision support in ehr
Order Checks
    • Med orders are checked for drug-drug interactions and allergies
    • All orders are checked for duplicate orders
  • Prescribing Restrictions / Guidance
    • Prescribing guidelines in pharmacy package accessible to prescribers (see screenshot)
Decision Support in EHR
decision support in ehr cont d
Info Button
    • Customizable links to web pages from POV (diagnosis) and Patient Ed components
    • Can be configured to insert selected text into web site’s search function
  • Reminders
    • National or locally created
    • Health maintenance or condition-driven
    • Reminder Dialogs enable simultaneous resolution of reminders (orders, education, etc.) and documentation
Decision Support in EHR (cont’d)
ehr physician study setting
26 IHS health centers implementing EHR between June 2003 and December 2005
  • 69% federally operated, 31% tribal health centers
  • Mountain – 58%Pacific – 19%West south central – 12%South atlantic – 8%West north central – 4%
  • Median number of physicians per clinic: 5.0 (IQR 2-19)Median number of NP/PA per clinic: 2.0 (IQR 1-6)
EHR Physician Study Setting
impact of ehr on quality
Impact of EHR on Quality

* At least 4 on a 5 point Likert scale

rpms behavioral health applications functions
Documentation of individual and group encounters
      • DSM IV-TR Axis I – V Diagnostic Coding
    • Treatment Plans
    • Case Management Information
    • Suicide data collection
    • Ability to document non-direct patient care activities such as community education, Performance Improvement, clinical supervision, training, etc.
    • Robust reports module: workload, case management, condition-specific
RPMS Behavioral Health Applications Functions
key elements of responsive cds
HIT solution can drive improvement at each patient visit
  • Vision of a HIT system that provides you with the ability to manage patients, communities and populations within your mission context
  • Value of requirements development with Clinicians
    • Clear and specific requirements that put the clinical and public health needs at the center of the specification and programming process
  • Rapid cycle development
  • Like a good community organizer—becomes background noise
    • It’s not about IT
Key Elements of Responsive CDS