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1 Marrying Technology to the Chronic Care Model Neil A. Solomon, MD President, NAS Consulting Services Faculty Director, Breakthroughs in Chronic Care.

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Presentation on theme: "1 Marrying Technology to the Chronic Care Model Neil A. Solomon, MD President, NAS Consulting Services Faculty Director, Breakthroughs in Chronic Care."— Presentation transcript:

1 1 Marrying Technology to the Chronic Care Model Neil A. Solomon, MD President, NAS Consulting Services Faculty Director, Breakthroughs in Chronic Care Program August 23, 2005

2 2 The Quality Chasm

3 3 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Improved Outcomes What Do We Do With the CCM?

4 4 Using Data to Promote Great Care Data Repositories Registries Electronic Health Records Personal Health Records

5 5 Data Repositories Link disparate databases Create patient level profiles Aggregate up to level of physician, practice, medical center Profile outcomes across providers and groups Utilize for patients care and system management

6 6

7 7 What is a Clinical Data Repository? Single, shared database to support quality and business improvements e.g. CAPG Clinical Data Repository Data aggregation - acquire, clean, and match Regularly scheduled reports Clinical quality, Resource utilization Ad hoc web-based reporting and viewing tool Remotely run analyses on subsets of data Physicians and patients can access their own data MD level feedback Patient intervention opportunities Support for point of care reminders

8 8 Why a common CDR? Better ~ access to technology and tools Software for risk-adjustment, registries, etc. Web-based platform Comparison benchmarking Richer ~ simplifies data collection Faster ~ shorter build time than separate efforts Cheaper ~ economies of scale Technology and development far more expensive for medical groups to build/buy individually

9 Health Plan Eligibility and paid claims data ( facility, POS, mental health and vision claims) Health plan/PBM Pharmacy data Medical group Physician claims/encounter data Laboratory Claims and results data Hospital Claims data CAPG Clinical Data Repository Inputs

10 CAPG Clinical Data Repository Patient action lists Disease registries Web based ad hoc reports Personal Health Records Data extracts Clinical Data Repository Outputs Benchmark reports

11 11 How Will the Data Be Used? Care management/disease management Population reports and comparison statistics Exception lists to physician offices Point-of-care reminders Care management opportunities and coordination Utilization management Prescribing and referral patterns Physician feedback Ultimately a Personal Health Record Patient self-management Sharing information with physician for remote care

12 12

13 13 Registries Identify, stratify and track populations Find patients falling through the cracks Provide point-of-care support Generate comparison reports Interconnect members of the care team

14 14

15 15 Types of Products Public domain, Access-based Commercial Locally installed Web based Home grown

16 16 Challenges Automating the data feeds Algorithms to ID and stratify patients Integrating into patient care

17 17 Electronic Health Records Acquire and assemble data – lab, radiology, etc. Connect to colleagues – consults, team care Introduce decision support in dx and rx Identify patients overdue for routine care – prompts Drug-drug; drug-dx; drug-lab; dose checking Tagged literature to support decision-making Support clearer and fuller documentation

18 18

19 19 Benefits for Chronic Care Supports every encounter for any condition Clinical nuance beyond registries May be able to interconnect with other systemspharmacy, lab ordering, etc. When used efficiently adds time to day

20 20 Challenges for Chronic Care Few products have good population views Can distract from the few key care issues If no decision support, does not guide care decisions Can automate office dysfunction

21 21 Personal Health Records Same data as EHR, different format Great for motivating and providing self- management support for some patients Can dramatically improve office efficiency

22 22

23 23 Member ID: Cherie Jones-Montgomery Member Name:Richard MontgomeryElena Montgomery Current Plan:Health Plus Primary Physician:Alice Trice Months Enrolled:33 Member InformationDependents Drug Summary Ordering Last DrugPurposePhysicianDoseScriptsFilled LipitorCholesterol LoweringDr. Alice Trice10 mg186/12/04 PrilosecStomach Acid Red.Dr. Alice Trice20 mg346/12/04 VancerilTreats AsthmaDr. Alice Trice.042 mg96/12/04 Cardizem CDHigh Blood PressureDr. Susan Giltrist180 mg69/15/03 Preventive Care Financial Summary Prostate Specific Antigen Test 3/2/04Coronary Artery Disease Office Visit Established Patient 3/2/04Asthma Dental Visit 1/15/03COPD Clinical Conditions Gaps in Care Medical Detail Physician Link Drug Detail Personal Data Health Library Print My History HelpSetup My Medstat Personal Health Record Last Updated 7/10/04

24 24 Member ID: Male Member Name:Richard Montgomery51 Years of Age Managing Your Disease Primary Preventive Services: Staying Well Financial Summary Last ServiceFrequencyServiceStatus Prostate Specific Antigen TestOnce per year3/2/04Up-to-date Cholesterol ScreeningOnce per year~Missing Colon Cancer ScreeningOnce per year~Missing Primary Care VisitOnce per year3/2/04Up-to-date Dental VisitOnce per year1/15/03Overdue Gaps in Care Medical Detail Physician Link Drug Detail Personal Data Health Library Print My History HelpSetup My Medstat Personal Health Record Last Updated 7/10/04 Last ConditionServiceFrequencyServiceStatus AsthmaRx-Inhaled Steroid Ongoing6/12/04Up-to-date AsthmaSpirometry Every 1 – 2 yrs~Missing Heart DiseaseLipid TestOnce per year4/9/03Overdue Heart DiseaseRx-Beta BlockerOngoing6/12/04Up-to-date


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