©2005 David F. Lobach Showing Health Information Value in a Community Network David F. Lobach, MD, PhD, MS Division of Clinical Informatics Department

©2005 David F. Lobach©2005 David F. Lobach

Showing Showing Health Information Value in Health Information Value in

a Community Networka Community Network

David F. Lobach, MD, PhD, MSDavid F. Lobach, MD, PhD, MS

Division of Clinical Informatics Division of Clinical Informatics Department of Community and Family MedicineDepartment of Community and Family MedicineDuke University Medical Center, Durham, North Duke University Medical Center, Durham, North

CarolinaCarolina

Contact Information: [email protected] Information: [email protected]


AHRQ Health Information Technology ConferenceAHRQ Health Information Technology Conference June 9, 2005June 9, 2005AHRQ Health Information Technology ConferenceAHRQ Health Information Technology Conference June 9, 2005June 9, 2005


Presentation OverviewPresentation Overview

Project DescriptionProject Description Community Network (COACH)Community Network (COACH) Decision Support Tool (SEBASTIAN)Decision Support Tool (SEBASTIAN) Data-Driven InterventionsData-Driven Interventions

Selection of Evaluation MetricsSelection of Evaluation Metrics Study DesignStudy Design Obtaining and Using DataObtaining and Using Data Project ChallengesProject Challenges Practical IssuesPractical Issues


Community Information Community Information NetworkNetwork

Need for Information InfrastructureNeed for Information Infrastructure CCommunity-ommunity-OOriented riented AApproach to pproach to

CCoordinated oordinated HHealthcareealthcare Goal: Supporting the information needs Goal: Supporting the information needs

of the network of providers serving of the network of providers serving Medicaid beneficiariesMedicaid beneficiaries


Network PartnersNetwork Partners

1 Care Management Team1 Care Management Team 7 Primary Care Clinics7 Primary Care Clinics

(1 FM, 3 Peds, 1 IM, 1 Ob-Gyn, 1 (1 FM, 3 Peds, 1 IM, 1 Ob-Gyn, 1 FQHC)FQHC)

3 Urgent Care Facilities 3 Urgent Care Facilities 2 Emergency Departments2 Emergency Departments 2 Hospitals2 Hospitals 2 Government Agencies (HD, DSS)2 Government Agencies (HD, DSS)

A system designed for and used by line workers at A system designed for and used by line workers at partner sitespartner sites


COACH Information COACH Information SystemSystem


Current Status of Current Status of COACH ISCOACH IS

16,964 Active Patients16,964 Active Patients 69,786 Total Patients 69,786 Total Patients 193,146 Encounters (Internal + 193,146 Encounters (Internal +

External)External) 124 User Accounts124 User Accounts 49 Active Users49 Active Users


SebastiaSebastiann

SSystem for ystem for EEvidence-vidence-BBased ased AAdvice by dvice by SSimultaneous imultaneous

TTransmission or an ransmission or an IIntelligent ntelligent AAgent across a gent across a

NNetworketwork



Project GoalsProject Goals

Population Management - Population Management - Asynchronous recommendations Asynchronous recommendations generated though a rule-based generated though a rule-based intelligent agent running on a intelligent agent running on a clinical data repositoryclinical data repository

Patient Management - Interactive, Patient Management - Interactive, evidence-based recommendations evidence-based recommendations delivered to the point of caredelivered to the point of care


Alert in EmailAlert in Email


Alert MessageAlert Message


Encounters for Alert Encounters for Alert PatientPatient


Showing HIT ValueShowing HIT Value

Collaborators and PartnersCollaborators and Partners Specific Aims and ObjectivesSpecific Aims and Objectives Intervention OverviewIntervention Overview Study MeasuresStudy Measures Study DesignStudy Design Data SourcesData Sources

This work was funded in part by a grant fromThis work was funded in part by a grant from


Partner OrganizationsPartner Organizations

Organization Type Partner Organization

Hospitals Duke University Hospital (DUH)Durham Regional Hospital (DRH)

Clinics Duke Primary Care ClinicsDuke Affiliated Primary Care PracticesPrivate Primary Care ClinicsLincoln Community Health Center (LCHC)Duke Specialty Care Clinics

Urgent Care Facilities Duke Urgent CareLincoln Community Health Center (LCHC)

Government Agencies Durham County Health Department (DCHD)Durham County Department of Social Services (DSS)NC Medicaid

Community Organizations Durham Community Health Network (DCHN)


Specific AimsSpecific Aims

To evaluate the clinical, To evaluate the clinical, organizational and financial value of organizational and financial value of HIT in a community network from a HIT in a community network from a societal perspective. societal perspective.

To evaluate the value of HIT in a To evaluate the value of HIT in a community network from the community network from the perspective of specific stakeholder perspective of specific stakeholder groups, including patients, providers, groups, including patients, providers, hospitals, payers, and purchasers. hospitals, payers, and purchasers.


Intervention OverviewIntervention Overview

SEBASTIANCDSS

COACHClinical

Database

FeedbackReports

COACHQuery

Database

Data from CommunityPartners

Patient Entered Data via eHealth KioskSystem

EmailAlerts

PatientReminders

Patients

CareProviders

ClinicManagers

Interventions


Email Alerts to Email Alerts to ProvidersProviders


Sample Feedback Sample Feedback ReportReport


Sample Patient LetterSample Patient Letter


Sample EventsSample EventsFocus Care Issue

Clinical Outcomes Three ED encounters within 90 daysLow severity ED encounter ED encounter for asthmaED encounter for diabetesHospitalization for asthmaHospitalization for diabetes

Care Quality No mammogram in 2 yearsNo Pap smear in 3 yearsNo Chlamydia screening in 1 yearNo post-partum visit after delivery in 21 to 56 daysNo glycated hemoglobin test in 1 yearNo lipid panel in 1 yearNo urine protein/albumin test in 1 yearNo dilated eye examination in 1 yearOne or fewer well child visits in 1 yearNo well child visits in 1 year

Care Coordination Two missed appointments in 60 daysNo Follow-up appointment after ear infection in 2 wks


Sample Events Sample Events (Pending)(Pending)

Focus Care Issue

Clinical Outcomes Medication incompatibility

Care Quality No staging of asthmaNo asthma action plan in 2 yearsPatient-reported health risk: new onset pregnancyPatient-reported health risk: missed >10 days of school/yearPatient-reported health risk: no blood test for lead poisoning in past yearPatient-reported health risk: no blood test for lead poisoning everPatient-reported health risk: signs or symptoms of vision problemsPatient-reported health risk: signs or symptoms of hearing problemsPatient-reported health risk: high risk of TB exposurePatient-reported health risk: concern about weightPatient-reported health risk: recreational drug usePatient-reported health risk: alcohol abusePatient-reported care barrier: need assistance to get care servicesPatient-reported barrier: need assistance to get medical equipmentPatient-reported care barrier: need assistance to get medications

Care Coordination Pending appointment and h/o missed appointments in last 60 days


Frequency of Frequency of InterventionsInterventions

ALERTS FEEDBACK REMINDERS

Care Issue Frequency Target Group Frequency Frequency

ED encounter for asthma / diabetes / low severity / 3rd in 90 days daily CHW, CLM, PCP monthly weekly

Hospitalization for asthma / diabetes daily CHW, CLM, PCP monthly weekly

No follow-up appointment after ear infection daily CHW, CLM, PCP monthly weekly

Two missed appointments in 60 days daily CHW, CLM, PCP monthly weekly

One or fewer well child visits for 1-2 yo /no well child visits for 3-6 yo monthly CHW, CLM monthly quarterly

No mammogram / Pap smear / Chlamydia testing monthly CHW, CLM monthly quarterly

No post-partum visit after delivery weekly CHW, CLM, PCP monthly biweekly

No HgbA1c / lipid panel / urine microalbumin / dilated eye exam monthly CHW, CLM monthly quarterly

Pending appt. and h/o missed appt. in last 60 days n/a n/a n/a daily

No staging of asthma / no asthma action plan monthly CHW, CLM monthly quarterly

Reported health risk: new onset pregnancy weekly CHW, CLM monthly n/a

Reported health risk: missed >10 days of school/year monthly CHW, CLM monthly n/a

Reported health risk: no blood test for lead poisoning monthly CHW, CLM monthly quarterly

Reported health risk: signs or symptoms of vision or hearing problems / weight concerns / recreational drug use / alcohol abuse

monthly CHW, CLM monthly n/a

Reported health risk: high risk of TB exposure daily CHW, CLM, PCP monthly daily

Reported barrier: assistance to get care services / assistance to get medical equipment / assistance to get medications

weekly CHW, CLM monthly n/a

Medication incompatibility daily CHW, CLM, PCP monthly daily


Choosing Study Choosing Study MeasuresMeasures

Optimal Measures:Optimal Measures: Solid clinical outcomes of Solid clinical outcomes of significance to health care (e.g. mortality)significance to health care (e.g. mortality)

Will any true clinical outcomes be impacted Will any true clinical outcomes be impacted by the intervention that can be detected by the intervention that can be detected during the study period?during the study period?

Can a change in surrogate clinical measures Can a change in surrogate clinical measures be detected during the study period?be detected during the study period?

Will any process measures be impacted by Will any process measures be impacted by the intervention?the intervention?

What are the cost implications of the What are the cost implications of the intervention?intervention?

Will any descriptive/qualitative measures be Will any descriptive/qualitative measures be effected by the study intervention?effected by the study intervention?


Selecting & Defining Selecting & Defining MeasuresMeasures

How will you know that your How will you know that your intervention is a success?intervention is a success?

1.1. Fewer ED visits for ambulatory Fewer ED visits for ambulatory care sensitive conditionscare sensitive conditions

2.2. Higher quality careHigher quality care

3.3. Better coordination of care Better coordination of care servicesservices

4.4. Lower costsLower costs

5.5. Patients will be more satisfied Patients will be more satisfied with the care they receivewith the care they receive



How can that endpoint be How can that endpoint be measured*?measured*?

1.1. Relative number of ED visitsRelative number of ED visits2.2. HEDIS quality metricsHEDIS quality metrics3.3. Rates of follow-up appointmentsRates of follow-up appointments4.4. Costs of care providedCosts of care provided5.5. Satisfaction surveysSatisfaction surveys

*Consider what has been measured in similar *Consider what has been measured in similar studies. Don’t re-invent the wheel!studies. Don’t re-invent the wheel!



What data are needed to assess What data are needed to assess these measures?these measures?

1.1. # of ED visits, billing diagnoses for # of ED visits, billing diagnoses for visit, severity level of visit visit, severity level of visit

2.2. Claims data with ICD9 and CPT Claims data with ICD9 and CPT Codes, plan enrollment historyCodes, plan enrollment history

3.3. # of appointments kept and missed# of appointments kept and missed

4.4. Estimates of care costs Estimates of care costs

5.5. Satisfaction survey dataSatisfaction survey data



How can one obtain these data?How can one obtain these data?1.1. State Medicaid claims dataState Medicaid claims data

2.2. Chart audits (electronic or manual)Chart audits (electronic or manual)

3.3. Clinic encounter recordsClinic encounter records

4.4. Claims data and Medicare Claims data and Medicare reimbursement ratesreimbursement rates

5.5. Satisfaction surveysSatisfaction surveys



What type of comparison needs to What type of comparison needs to be made between control and be made between control and intervention groups to detect a intervention groups to detect a significant difference?significant difference?1.-5.1.-5. Compare differences between Compare differences between

groups – Wilcoxon rank sum groups – Wilcoxon rank sum statisticstatistic


Outcome MeasuresOutcome MeasuresMeasurement Focus Measures

Clinical Outcomes. ED EncountersHospitalizations

ED encounters per 1000 pt yearsHospitalizations per 1000 pt yearsPrimary care encounters per 1000 pt yearsHgbA1c levels

Care Quality.Preventive ServicesChronic Disease

Management for Asthma & Diabetes

HEDIS scores for mammograms, Pap smears, Chlamydia screeningHEDIS scores for asthma staging, recording action plans, prescribing inhaled

corticosteroids HEDIS scores for performing glycated hemoglobin, microalbumin, lipid panel,

dilate eye examHEDIS scores for well child visitsAHRQ PQI for asthmaAHRQ PQI for uncontrolled diabetes, short- & long-term complications

Care Coordination. Missed AppointmentsF/U Appointments

Missed appointments per 1000 patient yearsRate of f/u after ear infection per 1000 patient years

Costs/Revenues. ED costsHospitalization Costs

Costs of HIT interventions including personnel/hardware/software costsCo-pay costsProfessional feesTechnical feesPharmaceutical reimbursement ED costsHospitalization costs

Satisfaction.Patient SatisfactionPatient Quality of LifeProvider Opinions

Patient satisfaction surveyEuroQoLProvider opinion surveys


Choosing a Study Choosing a Study DesignDesign

Optimal Design:Optimal Design: Double-blinded Double-blinded Randomized Control Trial Randomized Control Trial

Can a simultaneous control group be Can a simultaneous control group be established?established?

Can individuals be randomly assigned Can individuals be randomly assigned to a group?to a group?

Is a placebo available?Is a placebo available? Can the use of the intervention be Can the use of the intervention be

hidden from the study subjects?hidden from the study subjects? Can the use of the intervention be Can the use of the intervention be

hidden from the study team?hidden from the study team?


Design & Randomization Design & Randomization PlanPlan

Care Group

Run-in CYCLE 1 CYCLE 2 CYCLE 3 CYCLE 4 CYCLE 5

Months 0-3

Months 4-9

Months 10-15

Months 16-21

Months 22-27

Months 28-33

HighLevel

1 Alerts AlertsFeedback

AlertsFeedbackPt Reminders



2 Feedback FeedbackPt Reminders

FeedbackPt Reminders Alerts



3 Pt Reminders Pt RemindersAlerts

Pt Reminders AlertsFeedback

Pt RemindersAlertsFeedback

Pt Reminders AlertsFeedback

LowLevel

4 Alerts AlertsFeedback

5 Feedback FeedbackPt Reminders

6 Pt Reminders Pt Reminders Alerts


Data Analysis IntervalsData Analysis Intervals

Month0-3

Months 4-9

Months 10-15

Months 16-21

Months 22-27

Months 28-33

OverallComparison

Comparisons of the six clinical/organizational and three economic endpoints. Strategies 1-3 are compared with strategies 4-6.

ComparisonsAmong HITTreatments

Comparisons of the six clinical/organizational and three economic endpoints. Indicator variables are used to denote the three highlighted strategies: provider alerts, feedback reports, and patient reminders.

DoseResponse

Comparisons

ONEIntervent.vs. noAddedIntervent.

TWOinterventionsvs. noAddedintervention

THREEinterventions vs.no interventions

THREEIntervent.vs. ONEIntervent.

THREEIntervent.vs. TWOIntervent


Choosing Data SourcesChoosing Data Sources

Optimal Data:Optimal Data: Coded clinical data Coded clinical data entered electronically by the data entered electronically by the data generating sourcegenerating source

What coded data is available?What coded data is available? What clinical data is available?What clinical data is available? What claims data is available?What claims data is available? Is there a data dictionary for Is there a data dictionary for

interpreting the data?interpreting the data? What is required to make the data What is required to make the data

available?available? Will chart audits be required?Will chart audits be required?


Project ChallengesProject Challenges

Controlling ExpectationsControlling Expectations Avoiding “Scope Creep”Avoiding “Scope Creep” Start up FundingStart up Funding Operational FundingOperational Funding Obtaining Data from PartnersObtaining Data from Partners HIPAA ImplicationsHIPAA Implications


Practical IssuesPractical Issues

How to work with community How to work with community partnerspartners

Challenges working in the Challenges working in the community settingcommunity setting

How to navigate the academic How to navigate the academic institutioninstitution


Open House @ Duke Open House @ Duke UniversityUniversity

Learn more about the AHRQ-funded Duke HIT Learn more about the AHRQ-funded Duke HIT Value Project at Duke University Medical CenterValue Project at Duke University Medical Center

Friday, August 12, 2005Friday, August 12, 2005 9:00 AM to 4:00 PM9:00 AM to 4:00 PM Detailed project presentationsDetailed project presentations Onsite demonstrationsOnsite demonstrations Cost: ~$25 for lunch, snacks and local Cost: ~$25 for lunch, snacks and local

transportationtransportation For more information and registration:For more information and registration:

Call 919.684.6421Call 919.684.6421 Email Email [email protected]@duke.edu Visit: http://dmi-www.mc.duke.edu/Visit: http://dmi-www.mc.duke.edu/


AcknowledgmentsAcknowledgments

DCIDCI Jennifer M. Macri, MSJennifer M. Macri, MS Garry SilveyGarry Silvey Allen MayersAllen Mayers Kensaku KawamotoKensaku Kawamoto Jan Willis, MSJan Willis, MS

DCHDCH Susan Yaggy, MPASusan Yaggy, MPA Fred Johnson, MBAFred Johnson, MBA Jessica SimoJessica Simo Pam PhillipsPam Phillips

Other Duke GroupsOther Duke Groups Eric Eisenstein, DBAEric Eisenstein, DBA Kevin Anstrom, PhDKevin Anstrom, PhD Vic Hasselblad, PhD David Crosslin, MS Bob Rezzarday Bob Rezzarday

Outside Collaborators Richard Low (Topsail Richard Low (Topsail

Technologies)Technologies)


Questions?Questions?


Questions?Questions?


Documents

©2005 David F. Lobach Showing Health Information Value in a Community Network David F. Lobach, MD, PhD, MS Division of Clinical Informatics Department