AcademyHealth 2004 Annual Research Meeting HIT: Where Are We? How Can We Get Where We Must Go? Sunset Room, Town & Country Resort, San Diego, California Sunday, 6 June 2004 -- 3:00p - 4:30p
Managing Complexity through Information Flow
Brent C. James, M.D., M.Stat. Executive Director, Institute for Health Care Delivery Research Intermountain Health Care Salt Lake City, Utah, USA
HbA1c testing
100 100
90 83 91 90.5 National 90th
% diabetic patients tested appropriately
%tile (2002)
80
78.5
80
60
60
40
40
20
20
0
19 98 19 99 20 01 20 00 20 02
0
(Commercial products)
Poor HbA1c control
100 100
% diabetic patients not tested or > 9.5
80
80
60
60
40
34.6
40
32.4 24.3
20
19.7
National 90th 21.4 %tile (2002)
20
0
19 98 19 99 20 01 20 00 20 02
0
(Commercial products)
Average HbA1c
10
8
8.1
7.9
7.7
7.5
7.3
Average HbA1c (%)
6
4
2
0
20 01 20 00 20 02 19 98 19 99
(Commercial products)
Biannual LDL testing rates
% diabetic patients w/ LDL at least q 2 years
100
91.7 85.2 87.8
100
National 90th %tile (2002)
80
73.7 65.9
80
60
60
40
40
20
20
0
19 98 19 99 20 01 20 00 20 02
0
(Commercial products)
Excellent lipid control
100 100
% diabetic patients w/ LDL < 130
80
69.8 65.5 61.3
80
National 90th %tile (2002)
60
49.6 39.9
60
40
40
20
20
0
19 98 19 99 20 01 20 00 20 02
0
(Commercial products)
Retinal examination rates
% diabetic patients w/ annual retinal exam
100 100
80
80
National 90th %tile (2002)
64
62
60
52 47.9
56
60
40
40
20
20
0
19 98 19 99 20 01 20 00 20 02
0
(Commercial products)
Diabetes MD report
HgbA1c Testing Among Employed MDs
90 patients 100% All employed FPs 4,190 patients All employed MDs 14,495 patients 100%
Testing rates
80%
Test results
80%
60%
60%
40%
26%
35% 37%
40%
31% 27% 27% 16% 16% 22% 20% 31%
20%
8% 3% 9% 11% 4% 12% 7%
20%
0% Not tested Result unavailable <=7 >7 and <=8 >8 and <=9 >9
0%
Hemoglobin A1c Testing -- Summary of Last Test
Data source: IDX -- 1 Jan 98 thru 31 Dec 98
Diabetes outlier patient list
15 Mar 99 1
Clinical Workstation Diabetes Action List
Physician Name: XXXXXX, XXXXXX X (Internal Medicine) Examinations Presently Due Lipid Panel Urine Protein Retinal Exam Sensory Exam 13FEB1998 13FEB1998 9MAR1998 11MAR1998 11MAR1998 08MAR1998 24FEB1998 4DEC1997 14MAR1998 11MAR1998 08MAR1998 24FEB1998 4DEC1997 3MAR1998 11MAR1998 11MAR1998 11MAR1998 9MAR1998 22DEC1997
Pt. Name XXXXX, XXXXXX X XXX, XXXXXX X XXXXXX, XXXXX XXXX, XXXXXXXX X XXXXXXXX, XXXXXX XXXXXXXXX, XXXXX XXXXX, XXXXXXXXX XXXXXXXXX, XXXXX XXXXX, XXXXXX X XXXX, XXXXX X XXXXX, XXXXX X
IDX-MRN
A1c
XXXXXXX 15DEC1998 XXXXXXX XXXXXXX 12SEP1998 XXXXXXX 9AUG1998 XXXXXXX 11MAR1998 XXXXXXX XXXXXXX XXXXXXX 4DEC1997 XXXXXXX 29NOV1998 XXXXXXX 14AUG1998 XXXXXXX 12AUG1998
4DEC1997
Diabetes worksheet
15 Mar 99 ID# 12345
Clinical Workstation Diabetes Worksheet
PATIENT NAME SEX DOB
DOE, JOHN Q.
Active Medications
M
05/21/1933
- Diabetes Mellitus [250]
1. - Glucophage (metformin hcl), 500mg, tablet, 1 tablet bid
HgbA1c (<=7.0)
02/10/1999 11/29/1998 10/11/1998 6.6% 6.9% 7.5% 02/10/1999
LDL (<100)
113 mg/dl
TriG (<200)
211 mg/dl
BP (<135/85)
02/10/1999 11/29/1998 10/11/1998
o
136/84 mmHg 130/80 mmHg 130/78 mmHg
UA Protein
10/11/1998 Negative
uAlb/Cr (<30)
10/29/1998 9.55
24 Urine Albumin (<30)
Dilated retinal exam
10/11/1998 Robert Christiansen, MD
Pedal sensory exam
10/11/1998 Normal
The caring professions are changing
From craft-based practice
individual physicians, working alone (housestaff ::= apprentices) handcraft a customized solution for each patient based on a core ethical commitment to the patient and vast personal knowledge gained from training and experience
To profession-based practice
groups of peers, treating similar patients in a shared setting plan coordinated care delivery processes (e.g., standing order sets) which individual clinicians adapt to specific patient needs
early experience shows
less expensive (facility can staff, train, supply an organize to a single core process) less complex (which means fewer mistakes and dropped handoffs, less conflict) better patient outcomes
Protocols can improve care
A multidisciplinary team of health professionals 1. Select a high priority care process 2. Generate an evidence-based "best practice" guideline 3. Blend the guideline into the flow of clinical work staffing training supplies physical layout measurement / information flow educational materials 4. Use the guideline as a shared baseline, with clinicians
free to vary based on individual patient needs
5. Measure, learn from, and (over time) eliminate
variation arising from professionals; retain variation arising from patients ("mass customization")
Why "profession-based" practice?
1. It produces better outcomes for our patients 2. It eliminates waste, reduces costs, and
increases available resources for patient care
3. It puts the caring professions back in control of
care delivery
4. It is the foundation for useful shared electronic
data -- an important next step in care delivery improvement
Core principle:
You can't destroy clinical productivity!!!
(issue: system response times and screen formats)
Think in terms of a series of reasonable, incremental steps, each of which
(1) (2)
pays its own way; and lays the foundation for the next step
Levels of data automation
1. Automation of billing scheduling
encoded patient demographics
2. Automation of lab - (encoded) clin path - microbiology - surgical path pharmacy - 3 national services, standard (encoded) formats message logs imaging - HL-7 formatted text (active research --> encoding) InfoButton
Results Review lab management
- digital image storage consultation reports - HL-7 formatted text
3. The 'electronic file cabinet' - all electronic record (don't care about encoding)
efficient data entry - dictation/transcription --> 'hot text,' voice recognition efficient storage and retrieval across many care sites practice operations support - telephone call support, lab results management
4. Level 1 encoding (assumes encoded patient demographics, pharmacy, and lab)
encoded problem list - automatic 'registries' for common chronic diseases encoded medication list - first easy step in computerized order entry encoded allergy list
5. Level 2 encoding - focused condition-specific encoding 6. Level 3 encoding - fully encoded EMR, with text comments to customize