1. Clinical Information Systems Sacopee Valley Health Center August 16, 2007

2. Session Aim Brief overview of the Chronic Care Model Brief overview of the Chronic Care Model Cost of chronic disease Cost of chronic disease Using clinical information systems to improve outcomes of patients suffering chronic disease with pre planning and identifying patients at risk. Using clinical information systems to improve outcomes of patients suffering chronic disease with pre planning and identifying patients at risk.

4. Chronic Disease A chronic condition lasts a year or longer, limits what one can do and may require ongoing care. More than 125 million Americans have at least one chronic condition and 60 million (21% of the population) have more than one condition. A chronic condition lasts a year or longer, limits what one can do and may require ongoing care. More than 125 million Americans have at least one chronic condition and 60 million (21% of the population) have more than one condition. The number of people with chronic conditions is projected to increase from 125 million in 2000 to 171 million in the year 2030. The number of people with chronic conditions is projected to increase from 125 million in 2000 to 171 million in the year 2030.

5. What accounts for this dramatic growth in chronic conditions? The large population of baby boomers is aging, and their health is beginning to deteriorate. The large population of baby boomers is aging, and their health is beginning to deteriorate. Advances in medical science have helped extended our life span, leaving more people vulnerable to age related chronic illness such as cancer, Alzheimer's disease, osteoporosis, heart disease. Advances in medical science have helped extended our life span, leaving more people vulnerable to age related chronic illness such as cancer, Alzheimer's disease, osteoporosis, heart disease. 10% of patients in one survey reported that in the last year they were not able to see a primary care physician when they felt it was necessary. 10% of patients in one survey reported that in the last year they were not able to see a primary care physician when they felt it was necessary. 22% of those who have insurance report that it does not cover all the types of care they need. This percentage represents an estimated 21 million Americans with chronic conditions 22% of those who have insurance report that it does not cover all the types of care they need. This percentage represents an estimated 21 million Americans with chronic conditions In a recent survey 16% of respondents (an estimated 16 million people) have been warned by a pharmacist about a possibly harmful interaction between medications they were prescribed by one or more physicians. In a recent survey 16% of respondents (an estimated 16 million people) have been warned by a pharmacist about a possibly harmful interaction between medications they were prescribed by one or more physicians.

6. Prevalence of Chronic Conditions 125 M 157 M

7. Multiple Chronic Conditions 60 Million 81 Million

8. Out-of-Pocket Costs None 1 Chronic Condition 2 Chronic Conditions >3 Chronic Conditions

9. Direct Costs $510 Billion $1.07 Trillion

10. Current deficiencies in management of chronic illness Rushed practitioners not following established practice guidelines Rushed practitioners not following established practice guidelines Lack of care coordination Lack of care coordination Lack of active follow-up to ensure the best outcomes Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses Patients inadequately trained to manage their illnesses

11. How to improve the system The crucial factor in improving chronic illness care is a clinical database that has the critical information that a provider needs to have for a productive interaction with a patient

12. Clinical information systems such as registries (PECS) and electronic health records (EHR) enhance the quality, safety, and efficiency of patient care and office workflow A registry or list of patients and their related data is a tool for tracking individual and population clinical care information

13. Definition A registry is a computer application that stores disease-condition specific individual and population-based information to support care management, outreach, quality improvement, and outcome research.

14. Planning for a registry WHO WHO Will be entering it? Will be entering it? WHAT WHAT Data do I need to get my reports? Data do I need to get my reports? WHEN WHEN Will it be entered? Will it be entered? WHERE WHERE Will it be entered? Will it be entered? WHY WHY When what I do works so well? When what I do works so well?

15. Use the registry to provide clinical support Registries support physicians by providing printed patients reports, Identifying patients that are overdue Generate reminders and care-planning tools for individual patients Provide feedback to care team, leaders and affiliated organizations Help identify potential medication interactions A formulary can reduce out of pocket expenses

16. Workflow Analysis: Who/When

18. Do Registries Work In the VA, programs with improved HbA1c results, had computerized diabetes reminders, engaged patients with self management, and involved the providers in quality improvement. 1 In the VA, programs with improved HbA1c results, had computerized diabetes reminders, engaged patients with self management, and involved the providers in quality improvement. 1 Use of physician reminders, performance feedback, and structured care management were all associated with improved diabetes process, but not improved outcomes. 2 Use of physician reminders, performance feedback, and structured care management were all associated with improved diabetes process, but not improved outcomes. 2

19. Clinician’s responses to a survey assessing their use of CCM components was significantly correlated to improvements in HbA1c values and ratios of total cholesterol to HDL cholesterol. Clinician’s responses were also associated with patient reported measures of improved care processes. 3 Clinician’s responses to a survey assessing their use of CCM components was significantly correlated to improvements in HbA1c values and ratios of total cholesterol to HDL cholesterol. Clinician’s responses were also associated with patient reported measures of improved care processes. 3 1. Jackson GL, Yano EM, Edelman D et al. Veterans Affairs primary care organizational characteristics associated with better diabetes control. Am J Manag Care 2005; 11(4):225-37. 1. Jackson GL, Yano EM, Edelman D et al. Veterans Affairs primary care organizational characteristics associated with better diabetes control. Am J Manag Care 2005; 11(4):225-37. 2. Mangione CM, Gerzoff RB, Williamson DF et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006; 145(2):107-16. 2. Mangione CM, Gerzoff RB, Williamson DF et al. The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med 2006; 145(2):107-16. 3. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE. Use of Chronic Care Model Elements Is Associated with Higher- Quality Care. Annals of Family Medicine 2007; 5(1):14-20. 3. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, Glasgow RE. Use of Chronic Care Model Elements Is Associated with Higher- Quality Care. Annals of Family Medicine 2007; 5(1):14-20.

20. Measuring Progress Measurement is a critical part of testing and implementing changes Measurement is a critical part of testing and implementing changes Measures tell a team whether the changes they are making actually lead to improvement Measures tell a team whether the changes they are making actually lead to improvement Measurement for improvement should not be confused with measurement for research Measurement for improvement should not be confused with measurement for research

21. Measurement for Research Measurement for Learning and Process Improvement Purpose To discover new knowledge To bring new knowledge into daily practice Tests One large "blind" test Many sequential, observable tests Biases Control for as many biases as possible Stabilize the biases from test to test Data Gather as much data as possible, "just in case" Gather "just enough" data to learn and complete another cycle Duration Can take long periods of time to obtain results "Small tests of significant changes" accelerates the rate of improvement

22. PDSA PDSA

23. Variables CHANGE:A deliberate introduction into a process in order to achieve a higher level of performance CHANGE:A deliberate introduction into a process in order to achieve a higher level of performance EVENT:Something that happens which may affect performance of the process. EVENT:Something that happens which may affect performance of the process.

24. TRACKING The Improvement Tracker allows you to track any of the measures currently available in the Topics area of IHI.org. Just select the measure you want to track (or create your own custom measure), set your aim, and enter your data. The Improvement Tracker automatically graphs your data. It lets you create reports, and even customize them for various audiences — your team, your CEO, your community. Improvement Tracker allows you to track predefined standard measures in several topic areas, with more being added periodically. Additionally, you can create your own custom measures to track any data you want! The Improvement Tracker allows you to track any of the measures currently available in the Topics area of IHI.org. Just select the measure you want to track (or create your own custom measure), set your aim, and enter your data. The Improvement Tracker automatically graphs your data. It lets you create reports, and even customize them for various audiences — your team, your CEO, your community. Improvement Tracker allows you to track predefined standard measures in several topic areas, with more being added periodically. Additionally, you can create your own custom measures to track any data you want! http://www.ihi.org/ihi/workspace/tracker/ http://www.ihi.org/ihi/workspace/tracker/ http://www.ihi.org/ihi/workspace/tracker/