Collaborative care for chronic illness and information technology

1
Collaborative care for chronic illness and
information technology

• Introduction
• AcademyHealth 2005
• David A. Dorr, MD MS
• OHSU

2
Objectives

• State of collaborative and chronic physical and
  mental illness care
• Framework for collaborative care and Information
  Technology (IT) use
• Successes and challenges

3
Chronic illness care problems

• Underuse
• Effective treatments for chronic illness care
  only given 54 of the time.
• Misuse
• Preventable, injurious outpatient AEs occur in
  1-9 of patients.
• Overuse
• Up to 30 of treatments provided for some
  illnesses (low back pain) are inappropriate.

Terms from Chassin MR. JAMA. 1998 Sources EA
McGlynn, NEJM Rothman, Annals Wennberg
Forster, 2003 Dorr 2004.
4
Chronic illness care VA transformation
Jha 2003.
5
Root causes of problems with chronic illness care

• Culture / History
• Tyranny of the urgent
• Art and craft of medicine
• Complexity
• Individual versus population focused
• Financial

6
Root causes information based

• Information/knowledge needed is
• Enormous
• Challenging to find
• Lacking
• In the wrong form
• Difficult to communicate

7
Information system definition

• Any system to store / retrieve / display /
  aggregate / or otherwise touch information
• Not just computers or charts in broad sense
• Our focus is primarily on computer-supported
  information systems

8
Information System domains (IOM)

• Health information / data
• Results management
• Order entry
• Decision support

• Communication and connectivity
• Patient support
• Administrative process
• Reporting and population health

9
More successes
Chronic conditions
Medications

• Results management
• Patient worksheet
• Order entry
• Corollary orders and order sets improve safety,
  can reduce cost, and improve outcomes.
• Savings of up to 44 billion dollars per year.

Preventive care summary
Pertinent labs
Pertinent exams
Passive reminders Organized by illness
Wilcox 2005 CITL report 2003.
10
Individual categories successes

• Decision support
• 30-66 improvement in adherence to preventive
  care and acute care guidelines.
• But chronic illness has mixed results.
• Patient support
• Congestive heart failure

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IT and domains hierarchy

• Access
• Best Practices
• Communication

• Health information / data
• Results management
• Order entry
• Decision support
• Communication and connectivity
• Patient support
• Administrative process
• Reporting and population health

12
Care management packages to Improve Quality of
Care Information System focus

• Chronic Care Model
• Hartford / Intermountain Health Care generalist
  care management
• Disease management
• Veterans Administration transformation QUERI
  (reTIDES, EQUIP, PAS, CHIACC)

13
Improving Care for Chronic Illness
Collaborative Care
Functional and Clinical Outcomes
From E.H. Wagner RWJF Improving Chronic
Illness Care Initiative
14
Generalist care management system

• Improvement in diabetes, depression, and
  congestive heart failure outcomes.

Dorr et al, HSR, in press Dorr et al, Disease
management, in press.
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Disease management

• Companies external to health workers provide
• Technology (e.g. monitoring devices)
• System (e.g. 24 hour nursing support)
• To reduce utilization and cost.

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Final thoughts

• IS use can help solve chronic illness performance
  issues.
• Advanced information system use only 15-25 in
  US, and still difficult to know what will work.
• Financial, implementation, and workflow barriers
  significant.

17
Thanks!

• Amy Cohen, PhD
• Adam Wilcox, PhD
• Laurie Burns
• Paul D. Clayton, PhD
• Larry Casalino, MD PhD