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

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

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

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

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?

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

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

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

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

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

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--

J. Perlin - Veterans Health Administration: May, 2003

Pneumonia: Acute Inpatient DRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01) 9,500 fewer bed days 8,000 fewer discharges Effective, Efficient

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???

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

J. Perlin - Veterans Health Administration: May, 2003 Small Area Variation (Variation in Pneumonia Vaccination Among Medicare Beneficiaries) Wennberg, Dartmouth Health Atlas

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 ?

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

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

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

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

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

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

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

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

J. Perlin - Veterans Health Administration: May, 2003 Reducing Variation: From Evidence to Practice Patient With Need Patient Need Met Possess Knowledge Operationalize Knowledge Pneumococcal Vaccination Indications Computerized Health Information System + Measurement => Accountability => System Changes

J. Perlin - Veterans Health Administration: May, 2003 Value = QUALITY (SAFE) Cost Challenge: Create Value For Veterans and America Value = OUTCOMES Cost

J. Perlin - Veterans Health Administration: May, 2003 VHA Strategy: Measuring Quality & Value VHA Strategic Objective Areas Quality Access Community Health Satisfaction Functional Status Cost-Effectiveness zProvide consistently reliable, accessible, satisfying, high-quality care which maximizes functional status, is cost-effective and fosters healthy communities... Challenge: To Create & Communicate VALUE Value = Access + Technical + Functional + Satisfaction + Community Health Cost

J. Perlin - Veterans Health Administration: May, 2003 Quality: Influenza Vaccination Rates --BRFSS-- --BRFSS90*-- * Sampling more stringent; vaccine shortage

Immunizations +/- Mental Health Diagnosis (FY 2001) Effective Equitable Efficient

Quality: Gender / Age Approp Care Breast CA & Cervical CA Screen --HCUP--

Tobacco Non-use VA: Tobacco Use Counseling 3X / yr FY200049% FY200163% FY2002 69% HEDIS (NCQA) Patient counseled once most recent visit? 66% CY2000 825,000 Veterans Received Counseling 3X / yr 1,136,000 Counseled once VHA 4% decrease in tobacco users represents approximately 184,000 veterans US Population Non-Use Rate Increasing 0.5% / yr for past two years

J. Perlin - Veterans Health Administration: May, 2003 Public Accountability to Veterans & USA OMB Accountabilities (GPRA) Congressional Accountabilities VA Mission & Goals VHA Mission => Strategic Goal Areas (Q, A, S, FS, CE, CH) Measure Alignment, Vetting, Priority Reconciliation Creation of Directors Performance Contract Performance Mgmt Work Group USH / Policy / Planning => VISION Internally Identified Opportunities & Priorities Past Performance Performance Analysis, Measurement and Reporting Office of Quality & Performance Performance Measure Development Office of Quality & Performance (OQP) Clinical Recommendations & Support Tools: Office of Quality & Perf National Clinical Practice Guideline Council National Clinical Program Offices Under Secretary for Healths Performance Accountability Contract Executed by Office of Under Secretary for Health with VAs Clinicians & Managers VAs Performance Contract Formally Executed between Under Secretary for Health and Senior Leadership Involves Clinicians & Managers Supports Strategic Plan Measures Grounded in evidence-based medicine (and management) Explicit accountability for performance Supported by Information & Advanced Technologies |----------------Plan Development Cycle---------------|

J. Perlin - Veterans Health Administration: May, 2003 Quality: Prevention Index, 1996 2002 * Sampling methodology more stringent

J. Perlin - Veterans Health Administration: May, 2003 Survival after MI Soumerai SB "Adverse Outcomes of Underuse of Beta Blockers in Elderly Survivors of Acute Myocardial Infarction," JAMA 1997; 277(2):115-21 Elderly patients who receive beta blockers following a heart attack are 43 percent less likely to die in the first 2 years following the attack than patients who do not receive this drug, according to a new study funded by the Agency for Health Care Policy and Research (AHCPR), published in the January 8 issue of The Journal of the American Medical Association (JAMA). The study found that patients who receive beta blockers are rehospitalized for heart ailments 22 percent less often than those who do not get beta blockers, (and avoid almost $20,000 in excess health care costs). However, only 21 percent of eligible patients receive beta blocker therapy. Researchers found that these patients were almost three times as likely to receive a new prescription for a calcium channel blocker than for a beta blocker after their AMI. Eligible patients receiving calcium channel blockers instead of beta blockers doubled their risk of death.

J. Perlin - Veterans Health Administration: May, 2003 AHCPR: Soumerai et al. JAMA 1997;277(2):115-21 Non-Govt: Krumholz HM et al. Ann Int Med 1999;131(9):648-54 --HCUP-- AMI Care Improvement: Performance Measurement Works Unmeasured Performance Measurement Measurement + Accountability

J. Perlin - Veterans Health Administration: May, 2003 Reducing Variation: From Evidence to Practice Patient With Need Patient Need Met Possess Knowledge Operationalize Knowledge Beta-Blocker Indications Measurement Framework + Supporting Technologies Computerized Health Information System + Accountability System Changes

J. Perlin - Veterans Health Administration: May, 2003 Evolving VA Technology for Patient-Centered Care Information Model for High-Performance Health Care Provider Perspective Patient Perspective My Health eVet Patient / Community Perspective Care Coordination

J. Perlin - Veterans Health Administration: May, 2003 Wagner Model of Chronic Care Community Informed, Activated Patient Productive Interaction Optimal Patient Outcomes Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design

J. Perlin - Veterans Health Administration: May, 2003 Wagner Model of Chronic Care: Extended Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Optimal Patient Outcomes

J. Perlin - Veterans Health Administration: May, 2003 Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes

J. Perlin - Veterans Health Administration: May, 2003 Computerized Patient Record System... Every VA medical center has the Computerized Patient Record System... Every VA medical center has the Computerized Patient Record System...

J. Perlin - Veterans Health Administration: May, 2003 Better Provider Support: Multimedia Patient Record 65% Medical Centers have filmless images immediately available for doctor & patient...

Health Care is a Team Sport ! Health Care is a Team Sport !

J. Perlin - Veterans Health Administration: May, 2003 Reminders help us do the right thing consistently well...

J. Perlin - Veterans Health Administration: May, 2003 Clinical Reminders Standardizing Best Practices Reduces Negative Variation Create Standardized Data Acquisition of health data beyond care delivered in VA

J. Perlin - Veterans Health Administration: May, 2003 Quality: Diabetes Measures Sawin CT, Walder DJ, Bross DS, Pogach LM, Diabetes process and outcome measures in the VHA, Diabetes Care, 1999 Age-Standardized Amputation Rates Decreasing

J. Perlin - Veterans Health Administration: May, 2003 Better Provider Support: The New Guidelines... Bullets: Recommendation & EvidenceAlgorithm Evidence Table Expanded Discussion Primary References CAUTION!!! Task Support VS Task Interference

J. Perlin - Veterans Health Administration: May, 2003 Performance Measures for Lipid Screening & Mgmt in Patients with Diabetes

The Human Cost of Poor Penmanship... In 1999, a Texas jury awarded a woman $450,000 after her husband died when his pharmacist misread "Plendil" (a medication for high blood pressure), for "Isordil", a medication for heart pain. The jury concluded that his physicians poor handwriting was responsible for the error. One is 7 hospitalizations & one in 20 outpatient encounters in the United States is complicated by avoidable adverse medication events. Prescribing, preparing, and dispensing of medication each account for about one-third of the errors....

J. Perlin - Veterans Health Administration: May, 2003 The Human Cost of Poor Penmanship... In 1999, a Texas jury awarded a woman $450,000 after her husband died when his pharmacist misread "Plendil" (a medication for high blood pressure), for "Isordil", a medication for heart pain. The jury concluded that his physicians poor handwriting was responsible for the error.

J. Perlin - Veterans Health Administration: May, 2003 z Computerized Provider Order Entry (CPOE), one of the Leapfrog Groups Top 3 Safety Strategies zOutside of VA, CPOE < 8% nationally, < 30% among Academic Medical Centers zNationally, 91% of all VA Rxs Now CPOE zUp from 79%, one year ago zCorporate Performance Measure zUltimate Goal: 100% zVA is the Benchmark for CPOE

J. Perlin - Veterans Health Administration: May, 2003 CMOPs: Technology at Work Consolidated Mail Outpatient Pharmacy ~200 Million 30-Day Equivalent Prescriptions / Year (40K per shift per CMOP) zMedication Deficiencies: 5.8 sigma zWrong Medication: 0.0009% zLabeling problem: 0.0001% zDamage in Mails: 0.0014% zDelays in Delivery: 0.0178% zPatient Satisfaction Rating: 90% VG/E

J. Perlin - Veterans Health Administration: May, 2003 IV Room Label Printer (Similar process for p.o. Rxs)

Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes

J. Perlin - Veterans Health Administration: May, 2003 My Health e Vet Internet-based, secure Personal Health Space. Provides veterans with copies of key parts of their VA health information (from VistA) Veterans can retain, view, and update their personal health data (BP, Blood Sugar, Wt, etc.) Comprehensive, Personalized Health Education Information Personalized Health Assessments Activate & Empower partnership with health care providers in achieving optimal health, through the sharing of health information

Hey, Doc, I have Diabetes, Shouldnt I be on an ACE Inhibitor ?

Patient begins to tie together diet & weight with nutrition information & blood sugar & Understanding of disease from health education & Begins to take control of health Process changes from Transactional (making appointments) TO Transformational (Changing Health Behaviors & Health)

J. Perlin - Veterans Health Administration: May, 2003 Community Informed, Activated Patient Productive Interaction Health System Prepared, Proactive Practice Team Self-management Support Clinical Information System Decision Support Delivery System Design Model for Care Coordination Optimal Patient Outcomes Optimal Population Outcomes Operational Definition...

J. Perlin - Veterans Health Administration: May, 2003 CARE COORDINATION The Clinic (Care Coordinator) Becomes Aware that the Patient Is Beginning to Get Into Trouble, Proactively, The Patient Is Called To Come Into Clinic... Or Visited at Home! Before S/He Crashes

J. Perlin - Veterans Health Administration: May, 2003 San Juan Gainesville Lake City West Palm Beach Miami Bay Pines Ft. Myers VISN 8 Community Care Coordination Service Program Sites Orlando Patient (not provider) centric Designed to fill gaps in system Collaboration with providers. Expands patient and provider relationship into the home (home- telehealth technologies) Successful in Doms and State Nursing Homes Positive med/psyc/soc Outcomes Expandable & Reproducible

J. Perlin - Veterans Health Administration: May, 2003 The Health Buddy: Demonstrated Uses Single Dialogues HTN, COPD, DM, CHF, Cancer Care, Depression, Chronic pain, HIV, Hep C, Anticoagulation, Bi-polar Disorder Dual Dialogues HTN/COPD DM/CHF DM/HTN CAD/Angina HTN/Hyperlipidemia (Spanish) CHF/Hyperlipidemia (Spanish) Trialogue HTN/CHF/DM

J. Perlin - Veterans Health Administration: May, 2003 iCare Desktop Software

J. Perlin - Veterans Health Administration: May, 2003 VISN8 Blood Pressure Medication Compliance In the past 24 hours, have you taken all of your blood pressure medicines as your doctor has ordered them?

J. Perlin - Veterans Health Administration: May, 2003 VISN8: Diabetes Care Have you checked your blood sugar in the last 24 hours?

J. Perlin - Veterans Health Administration: May, 2003 VISN8: Diabetes Care Have you taken your diabetes pill or insulin in the last 24 hours?

J. Perlin - Veterans Health Administration: May, 2003 Utilization Outcomes ServicesCare Coordination Usual care Clinic visits+30%+15% ER visits-36%+11% Admissions-46%+7% BDOC-61%+8% Ext Admissions-47%+65% BDOC-81%+68%

J. Perlin - Veterans Health Administration: May, 2003 SF 36 V: Chronic Disease N= 738

J. Perlin - Veterans Health Administration: May, 2003 SF 36 V Mental Health N=114

J. Perlin - Veterans Health Administration: May, 2003 Clinical Outcomes Compared to Usual Care, Care Coordination Resulted in... Blood Pressure Improvement: 62% greater reduction in systolic bp (p=0.015) 38% greater reduction in diastolic bp (p=0.050) Diabetes Care (HbA1c) Improvement: Regression analysis showed significantly greater decrease in HbA1c

Home-Telehealth Technologies

J. Perlin - Veterans Health Administration: May, 2003 Gaps: Evolving Framework - The Right Framework ? Health Promotion Preventive Care Primary Care Specialty Care Rehabilitation Tertiary Care Long Term Care Home Care Continuum of Care Access CostQualitySatisfaction Functional Status Community Health Strategic Objective Areas Population Segments Vulnerable Cohorts Patients Performance Measurement System Framework for Action

J. Perlin - Veterans Health Administration: May, 2003 Measuring the Iceberg: From Why to How & What... Principles: Underuse, Overuse, Misuse Information age: Local Standard of Practice anachronistic High Opportunity (Variability) High Prevalence (CAD, CHF, DM) High Risk (Transplant, Cardiac Surgery) High Vulnerability (Mental Illness, Poverty, Minority) High Leverage Relatively Easy to Implement (Known Best Practices) Efficiency (Economy of Measurement) Dove-tails with other goals (e.g CPRS implementation) Dove-tail with required measurement (e.g. HEDIS, ORYX) High Road Effectiveness of Mission Culture of excellence, desire to raise bar Commitment to Measuring: Measure to define where well be, not to record where we were ! Mechanics: Ideal: Electronic Medical Record Challenge: Non-standard data Solution: Health Data Repository Other Practical Approaches: Chart Review Patient Self-Report (Survey) VA Uses Hybrid

J. Perlin - Veterans Health Administration: May, 2003 Setting the Benchmark... Closing The Quality Chasm

J. Perlin - Veterans Health Administration: May, 2003 Rough Mapping of VA Domains to IOM Aims... VA DOMAINS Quality (Safe) Access Satisfaction Functional Status Cost-Effective Community Health IOM QUALITY CHASM AIMS Effective Safe Timeliness Patient-Centered Efficient Equitable

J. Perlin - Veterans Health Administration: May, 2003 2002: Leadership by Example recognizes VAs: Clinical Performance Improvement Performance Measurement Information Technologies Health Services Research Patient Safety Evidence, Measurement, Technology & Accountability

J. Perlin - Veterans Health Administration: May, 2003 Is It Safety ? Is It Quality ? Are all patients benefiting equally? Higher? Broader, Different? Is It Just Good Care ?

J. Perlin - Veterans Health Administration: May, 2003 Is It Quality or Safety ? ... The best measure of quality is not how well or how frequently a medical service is given, but how closely the result approaches the fundamental objectives of prolonging life, relieving distress, restoring function, and preventing disability. Lembcke, 1952

98 For Health Care & For VA Technology is a means, not an end, An enabler, not a goal The goal is high-performance, high- value, high-quality, safe, patient- centered health care...