Page 1 Using a Patient Registry to Improve Outcomes for Adult Diabetic Patients. Conference on Practice Improvement: Constructing the Medical Home November 5-8, 2009 John Anderson MD, MPH Duke Primary Care Duke University Health System

Objectives Role of a patient registry in implementing The Chronic Care Model. Understand the impact on process improvement and delivery of care by developing appropriate reports and displaying data. Role of population management and The Chronic Care Model in constructing a Medical Home. Page 2

Goals for today Who we are What has been our journey Why undertake this work How have we implemented this tool What have we accomplished What are the lessons learned Page 3

Primary Care Network: Who We Are 27 primary care practices 22 building sites 7 counties in the Triangle area average practice size = 6 providers Family Medicine, Internal Medicine, Geriatrics, Pediatrics and Urgent Care Services Top Diagnoses: Preventive Services (Adult and Child), Hypertension, Diabetes, Hyperlipidemia, Pharyngitis, Bronchitis, URI, Sinusitis, Otitis Media Encounters: Fiscal Year 2009 Actual = 404,000 Fiscal Year 2010 Budget = 480,000 Staffing for Fiscal Year 2010: Physician FTEs 109 Non-Physician Provider FTE’s 25 Staff FTEs 520( staff to provider ratio = 3.9 staff per provider )

Page 5 Learning a New Approach IHI Annual Forum: Chronic Care Workshop Diabetes Learning Collaborative: NCPCA and NC Diabetes Prevention and Control Internal spread at Triangle Family Practice Adoption of BridgingCare Planner (DocSite) disease registry – DUAP Diabetes Collaborative –

Page 6 Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Planned Care Model Wagner EH. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4

Page 7 Disease Registry Visit planning Outreach Reporting Level of Control & point of care action Proactive Medicine, Compliance Profiling, Impact of Therapy, Outcomes

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Page 11 Data Issues CVDEMS registry to new Docsite Registry Delays in reports Denominator difficult to follow Difficult to track Improvement Population management difficult to define based on 15 month data

Page 12 Aim Statement – Diabetes Collaborative Improve the health and delivery of care to our diabetic patients Apply consistent and reliable processes of care Achieve near normal glycemic, blood pressure and lipid control Improve provider and staff job satisfaction Develop processes that are “person” specific, not “disease” specific

Page 13 Mission: To improve the care delivered to our diabetic patients through the application of consistent and reliable processes of chronic illness care that will allow us to significantly improve the health of our patients with diabetes. While our initial focus is on diabetes, it is our intent is to expand this approach so that it can be applied to other chronic conditions and to health maintenance care. Effective Network Leadership Effective Practice QI and Technical Support Aligned Motivators and Incentives Shared data and performance measurement Engaged consumers DUAP Improvement Network Key Driver Diagram Improved Outcomes, Experience, Value > 40% with A1c <7 at last reading > 92% with A1C > 35% with BP <130/80 > 42.5% with LDL <100 > 90% with 2 A1Cs > 15% meet “perfect care” goal (A1C < 7, BP < 130/80, LDL < 100, tobacco counseling and aspirin use) > 80% with foot exam > 90% with influenza vaccine > 66% with documented dilated eye exam > 90% of diabetic patients listed in Registry > 90% continuity 3rd available <5 days Shared vision and expectations Leaders recognize successes Leaders take responsibility for results Link with community resources Active efforts to create performance incentives Alignment with CME, MOC, P4P Effective QI Coaching Guidelines, change ideas and tools Care management Promote peer-to-peer communication Incorporate improvement into ongoing network activities Routine measurement of changes and outcomes IT system enables learning from variation Practices use data for improvement Public disclosure Consumer education OutcomesKey Drivers Interventions

Page 14 DUAP Improvement Practice Key Driver Diagram:

15 S EBASTIAN System for Evidence-Based Advice through Simultaneous Transaction with an Intelligent Agent across a Network ©2009 David F. Lobach

16 Clinical Decision Support (CDS) The act of providing clinicians, patients and other health care stakeholders with pertinent knowledge and/or person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care (Osheroff et al., 2006).

17 Success Factors for CDS* v Provide decision support automatically, as part of clinician workflow v Deliver decision support at the time and location of decision making v Generate decision support using a computer v Provide recommendations rather than just assessments => Common Theme: minimize the effort required to receive & act on CDS recommendations ©2008 Kensaku Kawamoto * K Kawamoto, CA Houlihan, EA Balas, DF Lobach. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330:

18 Duke eBrowser -- Electronic Record Viewer © 2007 David F. Lobach

19 Duke eBrowser – Disease Management Module © 2007 David F. Lobach

20 Duke Health Disease Management System – Diabetes © 2009 David F. Lobach

21 Duke Health Disease Management System – Diabetes Knowledge © 2007 David F. Lobach

22 Duke Health Disease Management System – Diabetes © 2009 David F. Lobach

23 Duke eBrowser – Disease Management Data Entry Screen © 2007 David F. Lobach

24 Duke Health Disease Management System – Health Maintenance © 2009 David F. Lobach

25 Duke Health Disease Management System – Hypertension © 2007 David F. Lobach

Chronic Disease Management Reporting Data manually entered or automatically populated into summary tab in eBrowser Weekly “snapshot” taken of data in browser and copied into a data repository Reports generated from data using Cognos Performance ReportsPopulation Management Reports

Patient Detail Reporting

SAMPLE OUTLIER REPORT

Diabetes: Perfect Care (A1C<7, LDL<100, Aspirin Therapy, Non-Smoker, BP<130/80) DPC Perfect Care: 15%

Metrics Process – 90% –A1C done –LDL done –ASA –Flu shot –Monofilament –Urine Microalbumin –* Eye exam-66% Int. Outcomes –A1C < 7 –A1C >9 –BP < 130/80 –LDL < 100 –“Perfect Care” (BP <13/80, A1C <7, LDL <100, ASA, Non-smoking status) 39

Chronic Disease Management: Diabetes June 08 – June 09 n =10,915 * Not consistently entering BP and BMI in eBrowser

42 Community-Oriented Approach to Coordinated Healthcare -- Health Information Exchange ©2009 David F. Lobach

43 Population Health Management SEBASTIAN CDSS COACH HIE Community Network Clinical Database Feedback Reports Query Database Data from Community Partners Patient Entered Data via Kiosk System Alerts Patients Care Providers Clinic Managers Interventions Patient Reminders

44 COACH HIE Context Enables Population Health Management model of care Supports care management activities (documentation, communication, referrals, care plans, etc.) Receives and displays external billing/claims/clinical data from 5 hospitals, 8 clinics and NC State Medicaid 6 Counties => 40,000 Medicaid Beneficiaries Centralized data repository

Lessons Learned Registry should be a “tool” that is part of a larger, redesign initiative. Design Reliable processes and protocols. Must be a team effort – staff and providers. “Data hygiene” is critical. Regular reporting at the provider level. Use data sets that are actionable. Page 45

References Wagner EH. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2-4 K Kawamoto, CA Houlihan, EA Balas, DF Lobach. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330: Kawamoto K, Lobach DF. Design, implementation, use, and preliminary evaluation of SEBASTIAN, a standards-based web service for clinical decision support. Proceedings / AMIA Annual Symposium. 2005: Page 46