Disease Management in a Multi-Specialty Group Practice Terrigal Burn, MD

Palo Alto Medical Foundation: Palo Alto Division  Education Division  Research Institute  Health Care Division: 2002 Year End Data  227 FTE Physicians  999 Staff  868,943 patient visits  Surgecenter 6,718 surgeries  Main Campus in Palo Alto with satellite offices in Fremont, Los Altos, Portola Valley, and Redwood Shores

Palo Alto Medical Foundation: Palo Alto Division Locations Connected Through Epic

What is Disease Management? Interventions designed for groups of patients: populations Interventions designed for groups of patients: populations Interventions to supplement or even replace the 1 to 1 face to face encounter in the exam room Interventions to supplement or even replace the 1 to 1 face to face encounter in the exam room

Evidence Based Medicine-- Haven’t we always done that? Role of mentors Role of mentors Training emphasizes self reliance Training emphasizes self reliance Every patient is unique Every patient is unique

Keeping up with the Science Pharyngitis (sore throat) Pharyngitis (sore throat) 5240 articles in MedLine 5240 articles in MedLine 2345 articles in last 2 years 2345 articles in last 2 years 20 articles per day, 365 days per year 20 articles per day, 365 days per year

Applying EBM How to search the medical literature How to search the medical literature Understand hierarchies of evidence Understand hierarchies of evidence When is there good data, when not? When is there good data, when not? How to apply the evidence to the particular clinical situation How to apply the evidence to the particular clinical situation Use evidence to develop best practices Use evidence to develop best practices Monitor how well we do this Monitor how well we do this

Medication BPAs: Alternative Medications

Harnessing the Power of the Electronic Medical Record Case of an elderly patient taking a Non-Steroidal Anti-Inflammatory Drug (NSAID) who developed kidney failure was referred to Care Review Case of an elderly patient taking a Non-Steroidal Anti-Inflammatory Drug (NSAID) who developed kidney failure was referred to Care Review Variation existed in monitoring kidney function of patients receiving high-risk medications Variation existed in monitoring kidney function of patients receiving high-risk medications A Best Practice Alert was developed A Best Practice Alert was developed Measurable, durable improvement in monitoring of kidney function was the result Measurable, durable improvement in monitoring of kidney function was the result

Clinical Decision Support (CDS): Current Best Practice Alerts  Health Maintenance Alerts  Influenza and Pneumococcal Vaccine  Diabetes  Pap Smear  Well child  Medication Alerts  Allergies  Drug Interactions  Food/Alcohol Reactions  Alternative medication for formulary restrictions

Guidelines Epidural steroid injections in back pain Epidural steroid injections in back pain Shock wave treatment of plantar fasciitis Shock wave treatment of plantar fasciitis How to evaluate rectal bleeding in younger individuals How to evaluate rectal bleeding in younger individuals

Disease Management Congestive Heart Failure Congestive Heart Failure Diabetes Diabetes Antibiotic use in upper respiratory infection Antibiotic use in upper respiratory infection Preventive Health Care Preventive Health Care Seniors at Home Seniors at Home Shared Medical Appointments Shared Medical Appointments

A Suite of Tools Rosters Rosters Best Practice Alerts Best Practice Alerts Technology assessment Technology assessment Guidelines Guidelines Group visits Group visits Disease Management Disease Management Education about Evidence Based Medicine Education about Evidence Based Medicine Financial incentives Financial incentives