Safety is Not Enough: Moving to Effectiveness and Caring through New Care Models and New Technologie

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Safety is Not EnoughMoving to Effectiveness and
Caring through New Care Models and
New Technologies
Innovations In Patient Safety AcademyHealth and
Agency for Healthcare Research Quality San
Diego, CA June 6, 2004

• Jonathan B. Perlin, MD, PhD, MSHA, FACP
• Acting Under Secretary for Health
• Veterans Health Administration
• Department of Veterans Affairs

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Safety is Not Enough

• Patients dont seek care just to be safe, Safety
  is Fundamental
• Goal Avoid Getting It Wrong
• Safety Effectiveness, To Close to Chasm
• Expect effectiveness in maintaining improving
  health, managing disease distress
• Goal Getting It Right . . . Consistently
• Patient-Centered, Coordinated Care
• Patient is locus of control
• Seamless across environments
• Integrates disease-specific, general health and
  social needs
• Anticipates health trajectory and modifies risks,
  even before traditional risk factors
  manifest
• Goal Care that is safe, effective predictive
  and delivered in the
  time, place manner that the patient prefers
• Information Technologies Care Coordination
  in Supporting
  These Goals

To Err is Human 98,000 Patients
The Quality Chasm Every Patient Crossing the
Quality Chasm 2001 IOM
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• . . . Given the huge increase in
  personal computer and Internet use, as well as
  the dramatic changes in other industries, most
  consumers assume that healthcare is highly
  electronic and computerized. The reality,
  however, is that 90 percent of the business of
  healthcare remains paper-based. Why?

Rx 2000 Institute http//www.rx2000.org/KnowledgeC
enter/hipaa/elearning/QC_govt.htm
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Why is IT a Strategy ?Shortcomings of a Cottage
IndustryDual Challenges

• Information
• 1 in 7 hospital admissions occurs because care
  providers do not have access to previous medical
  records.
• 12 of physician orders are not executed as
  written
• 20 of laboratory tests are requested because
  previous studies are not accessible.
• 1 in 6.5 hospitalizations complicated by drug
  error
• 1 in 20 outpatient prescriptions

• Effectiveness
• 98,000 Americans die each year from medical
  errors
• Virtually every patient experiences a gap in
  care from best evidence
• Health care inflation accelerating without
  commensurate value
• ? Uninsured pharm uninsured
• ? Administrative costs
• American health care is reactive
• Safety net after catastrophe
• Marginal Prevention
• Unable to systematically anticipate needs that
  will predictably arise
• Patient / Payors / Providers increasingly
  dissatisfied

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Except in VA !
Every VA Medical Center has Electronic Health
Records !
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2004 Who is VAVeterans Health Administration

• VHA is Agency of the Department of Veterans
  Affairs
• Three Administrations, including VHA. Also
• Veterans Benefits Admin (VBA)
• National Cemetery Admin (NCA)
• 5.1 million patients, 7.5 million enrollees
• Increased from 2.5 million patients / enrollees
  in 1995 (104)
• 1,300 Sites-of-Care, including 162 medical
  centers or hospitals, 850 clinics,
  long-term care, domiciliaries, home-care programs
• 27.4 Billion budget
• (flat at 19B from 1995 - 1999) 42 increase
  since in 1995
• 193,000 Employees (15,000 MD , 56,000 Nurses,
  33,000 AHP)
• 13,000 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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Who Are Our 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 lt 26,000
• 40 with annual incomes lt 16,000
• Changing Demographics
• 4.5 female overall
• Females 22.5 of outpatients less than 50 years
  of age

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Vaccine Cuts Pneumonia Risk in High-Risk
PatientsArchives of Internal Medicine
19991592437-2442Dr. Kristin Nichol, VAMC /
Minneapolis

• 50 of elderly Americans / high-risk individuals
  have not received the pneumococcal vaccine.
• VAMC study of 1,900 elderly patients with chronic
  lung disease 2/3 vaccinated against pneumonia.
• Pneumococcal vaccination
• 43 reduction in hospitalizations for pneumonia
  and influenza, and a 29 reduction in the risk of
  death.
• Pneumonia and Influenza vaccination
• 72 reduction in hospitalizations for these two
  diseases and an 82 reduction in deaths from
  all causes.
• Pneumococcal vaccination saved an average of 294
  per vaccine recipient over the 2-year period.

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Pneumococcal Vaccination Rates
--BRFSS 90th--
--BRFSS--

• Iowa Petersen, Med Care 199937502-9. gt65/ch dz
• HHS National Health Interview Survey, gt64

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Immunizations/- Mental Health Diagnosis (FY
2001)

• Effective
• Equitable
• Efficient

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Pneumonia Acute InpatientDRG89-90 Unadjusted
for Pt. Population (up 20, FY99-01)Improving
Efficiency by Reducing Excess Health Care
Utilization
9,500 fewer bed days
8,000 fewer discharges

• Effective, Efficient

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Clinical Reminders
Links Reminder

• Contemporary Expression of Practice Guidelines
• Time Context Sensitive
• Reduce Negative Variation
• Create Standard Data
• Acquire health data beyond care delivered in VA

With the Action
With Documentation
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Organizing Strategy Closing the Quality Chasm
Value QUALITY Cost
Value OUTCOMES Cost

• VHA Values
• Quality
• Access
• Community Health

• Satisfaction
• Functional Status
• Cost-Effectiveness

Value Access Technical Functional
Satisfaction Community Health Cost
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Reducing VariationFrom Evidence to Practice
Operationalize Knowledge
Possess Knowledge
Patient Need Met
Patient With Need
Pneumococcal Pneumonia Vaccination Indications
Performance Measurement Accountability Support
ing Technologies Computerized Health
Information System ? System Changes
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Performance MeasurementSetting the U.S.
Benchmark for 18 Comparable Indicators
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Improved Efficiency Enrollees, Patients
Resources/Patient 1996-2002 (2003 est)
Resources/Patient
Enrollees
Veteran Patients
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Myths VAs Different . . .

• VAs Command Control
• Truth Yes, 17,000 staff physicians, but 25,000
  affiliated faculty 35,000 housestaff through
  affiliations with 107 academic health systems
• VA has an appropriated budget
• True, but VA 1.5 of 25 B (FY03) was revenue
  from billing, increased from 300 M, 3 years
  prior
• VAs patients are former military, thus overall
  healthier follow instructions
• VA patients define adverse selection
• Think of VA as Living Laboratory

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Computerized Patient Record System . . .
Every medical center has the Computerized Patient
Record System . . .
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Multimedia Patient Record
154 / 158 Medical Centers have filmless images
immediately available for doctor patient . . .
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Health Care is a Team Sport !
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Electronic Health Records (EHR) Computerized
Provider Order Entry (CPOE)

• CPOE is one of the Leapfrog Groups Top 3
  Safety Strategies
• Outside of VA, CPOE lt 8 nationally
• lt 30 among Academic Medical Centers
• Nationally, 94 of all VA Rxs by CPOE
• Ultimate Goal 100
• VA is the Benchmark for CPOE

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Medication Bar Coding
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Bar-Coded Medication Administration (BCMA)
Virtually Eliminates Errors at the Point of
Administration
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Bar-Coded Laboratory Acquisition (BCLA)
Coming Soon ! ! !
Virtually Eliminates Errors During Acquisition
Processing
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CMOPs Technology at WorkConsolidated Mail
Outpatient Pharmacy

• 200 Million 30 Day Equivalents / Year
  (40K per shift per CMOP)
• Performance 5.7 Sigma
• Wrong Medication 0.0007
• Patient Satisfaction Rating 90 VG/E
• Helped hold per patient pharmacy costs virtually
  constant for 54 months, despite more Rxs per
  patient increased ingredient cost!

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Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management Support
Clinical Information System
Decision Support
Delivery System Design
Informed, Activated Anticipated Patient
Prepared, Proactive Practice Team
Productive Interaction
Optimal Patient Outcomes
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My Health e VetPatients Personal Health Record
Hey, Doc, I have Diabetes, Shouldnt I be on an
ACE Inhibitor ?
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Process changes from Transactional (making
appointments) TO Transformational (Changing
Health Behaviors Health)
PHR allows Care Team to be aware if patients
condition deteriorates Proactively, the
patient is called to come into clinic . . . or
visited at home!
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No one grows older saying, Gee, I hope I end up
in a nursing home !

• Between today and 2010, VAs Veterans aged 85 and
  over will increase from 380,000 to 1.2 million

Europe Annual Cost of Institutional Long-Term
Care Approximates Average Annual Earnings
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Home-Telehealth Technologies
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Low-Tech Hi Tech

• 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

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Improved Utilization
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Past Informs Present Future and Predictable
Future Informs Present
Predict
Prevent
Intervene
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Future Vision

• Building on Safety and Quality as System
  Properties, The Vision for VA Patients is
  High-Performance, High-Value, Patient-Centered
  Health Care . . .