1 Using Advanced Technologies to be Both Safe and Effective Advancing Patient Safety and Quality : Using Advanced Technologies to be Both Safe and Effective

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  • 1 Using Advanced Technologies to be Both Safe and Effective Advancing Patient Safety and Quality : Using Advanced Technologies to be Both Safe and Effective Jonathan B. Perlin, MD, PhD, MSHA, FACP Deputy Under Secretary for Health Veterans Health Administration Department of Veterans Affairs Virginians Improving Patient Care & Safety Richmond, Virginia May 15, 2003
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  • J. Perlin - Veterans Health Administration: May, 2003 VHA: Systematic Approaches to Quality & Safety Overview: Relationship of Quality & Safety & the Patient Variation in Health Care Quality (Safety) as a Strategy Measurement of Quality (Safety) Measurement & Accountability Information Technology & Health Care Quality Patients, Providers and Community Perspective Strategies for Patient-Centered, High-Performance Health Care
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  • J. Perlin - Veterans Health Administration: May, 2003 Patients dont seek care just to be safe Come for help maintaining & improving health, managing disease & distress Goal: To Close to Chasm... The Gap between optimal (based on best evidence) & usual performance Evidence-based medicine: Uses processes that rigorous, criteria-driven review of literature demonstrate achieve consistently better outcomes VA Approach: Outcomes Can & Should Be Specified... a priori ! Measure to define where well be... Not to record where we were! To Err is Human: 98,000 Patients The Quality Chasm: Every Patient Crossing the Quality Chasm 2001: IOM Measurement & Performance Safety: Only the Tip of the Iceberg
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  • J. Perlin - Veterans Health Administration: May, 2003 Beneath: Gap Between Best & Actual Practice If, simplistically, To Err is Human identifies things that should never happen, Crossing the Quality Chasm identifies things that should always happen Certainly, as important as the question of how we prevent adverse events is the question: How do we consistently ensure the maximum known benefit of health care?
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  • J. Perlin - Veterans Health Administration: May, 2003 From Health Care Delivery To Patient-Centered Care Safety: Avoid Getting it Wrong Quality: Get it Right... Consistently Patient-Centered Care Support patients with safe, high-quality care, in health and disease, at the time & place, and in the manner patient desires Care extends from hospital & clinic to home & community
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  • J. Perlin - Veterans Health Administration: May, 2003 Quality & Safety To Err Is Human Safety is tip of iceberg Goal: Avoid Getting It Wrong Ex A: Penicillin in known PCN-allergic patient Adverse Event = All Risk = Adversity with no benefit
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  • J. Perlin - Veterans Health Administration: May, 2003 Quality & Safety Quality Chasm Virtually every patient experiences gap between optimal & actual care Ex B: Non PCN-type Rx for pneumonia in PCN allergic pt; pt not vaccinated Getting it Partially Right Evidence: Pneumonia Vaccination reduces hospitalization & death
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  • J. Perlin - Veterans Health Administration: May, 2003 Quality & Safety Quality Chasm Implementing Best Evidence Ex C: No need for RX, as no pneumonia. Prior pneumococcal vaccine Evidence: Pneumonia Vaccination reduces hospitalization & death
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  • J. Perlin - Veterans Health Administration: May, 2003 Vaccine Cuts Pneumonia Risk in High-Risk Patients Archives of Internal Medicine 1999;159:2437-2442 Dr. Kristin Nichol, VAMC / Minneapolis 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. 1996-1998: VA study of 1,900 elderly patients with chronic lung disease ; 2/3 vaccinated against pneumonia. Pneumococcal vaccination: 43% RR reduction in hospitalizations for pneumonia and influenza 29% RR reduction in the risk of death. Pneumonia and Influenza vaccination: 72% RR reduction in hospitalizations for these two diseases 82% RR reduction in deaths from all causes. Pneumococcal vaccination saved $294 per patient
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  • J. Perlin - Veterans Health Administration: May, 2003 Pneumococcal Vaccination Rates Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz HHS: National Health Interview Survey, >64 --BRFSS-- --BRFSS 90th--
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  • J. Perlin - Veterans Health Administration: May, 2003
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  • Pneumonia: Acute Inpatient DRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01) 9,500 fewer bed days 8,000 fewer discharges Effective, Efficient
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  • J. Perlin - Veterans Health Administration: May, 2003
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  • Pneumococcal Vaccination Rates * Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz Knowledge that Pneumococcal Vaccination Indicated in Elderly / Chronic Disease... Why so underutilized???
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  • J. Perlin - Veterans Health Administration: May, 2003 Why Doesnt the Evidence of Research Become the SOP? Research => Knowledge => Operationalization Optimal Practice Variation (Bataldan: Omission, Commission, Irrational, Discretionary, Supply) Patient Need
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  • J. Perlin - Veterans Health Administration: May, 2003 Small Area Variation (Variation in Pneumonia Vaccination Among Medicare Beneficiaries) Wennberg, Dartmouth Health Atlas
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  • J. Perlin - Veterans Health Administration: May, 2003 Whats Wrong With Variation? Not All Variation is Positive Inconsistent Quality & Safety Inconsistent Cost (Efficiency) Inconsistent Access Inconsistent Satisfaction Inconsistent Processes Result in Inconsistent Outcomes Sub-optimal Processes Result in Sub-optimal Outcomes Patients dont reliably experience the optimal processes or outcomes c.f. IOM, 2001: The Quality Chasm How do we systematically reduce the negative variation and drive the most effective, efficient, safe, equitable, timely, pt- centered practice ?
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  • J. Perlin - Veterans Health Administration: May, 2003 Variation Also Occurs at the Facility, Clinic & Practitioner Level after DA Burnett, UHC, 1995 Positive Variation Negative Variation
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  • J. Perlin - Veterans Health Administration: May, 2003 after DA Burnett, UHC, 1995 Reasonable Expectation Certainly, what youd want! Unfortunate Experience - What you would not want Should it matter where (in VA) you get your care, or from which clinician? Variation Also Occurs at the Facility, Clinic & Practitioner Level
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  • J. Perlin - Veterans Health Administration: May, 2003 after DA Burnett, UHC, 1995 How do we capture and systematize best practices ? How do we drive these practices to be more like those above? How do we know throughout VA how were doing? Variation Also Occurs at the Facility, Clinic & Practitioner Level
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  • J. Perlin - Veterans Health Administration: May, 2003 Why Should A Health System Bother With Quality? #1: Ethical Responsibility for Consistently Good Patient Care Wanna Be Around ? ? ? Mission (Viability) Assumes Reliability (Quality) Technical Quality, Safety Access, Satisfaction, Efficiency If Not Reliable, Not Justifiable, Poor (Value) Society will seek, even demand, alternatives Periods of Economic Uncertainty (Now) 1.Call the Question of Value and 2.Offer Unique Opportunities and Propel Change
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  • J. Perlin - Veterans Health Administration: May, 2003 after DA Burnett, UHC, 1995 Evidence-based, Safe Justifiable Unjustifiable Variation Also Occurs at the Facility, Clinic & Practitioner Level
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  • J. Perlin - Veterans Health Administration: May, 2003 2003: Who is VA Veterans Health Administration VHA is Agency of the Department of Veterans Affairs Three Administrations, including VHA. Also: Veterans Benefits Admin (VBA) National Cemetery Admin (NCA) 4.7 million patients, ~ 6.9 million enrollees Increased from 2.5 million patients / enrollees in 1995 ~ 1,300 Sites-of-Care, including > 170 medical centers or hospitals, > 700 clinics, long-term care, domiciliaries, home-care programs To 02: ~ $22 Billion budget (flat at ~ $19B from 1995 - 1999) Budget increase 03: approximately $25B ~184,000 Employees (~15,000 MD, 50,000 Nurses, 33,000 AHP) 21,000 fewer employees than 1995 Affiliations with 107 Academic Health Systems Additional 25,000 affiliated MDs 60% (70% MDs) US health professionals have some training in VA
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  • J. Perlin - Veterans Health Administration: May, 2003 Who Are VAs 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 4.5% female overall Females: 22.5% of outpatients less than 50 years of age
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  • J. Perlin - Veterans Health Administration: May, 2003 The total veteran population will decrease by 32% between 2000 and 2020; however, the number of veterans age 65 or over will peak in 2014; veterans age 85 or over will increase by 173% between 2000 and 2020. Veteran Population: Age Trends: 2000 2020 85 & Over, Number in 1,000s
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  • J. Perlin - Veterans Health Administration: May, 2003 Reducing Variation: From Evidence to Practice Patient W