1 Using Advanced Technology and Care Models to Move from the Hospital and Clinic to the Community and Caring Prevention in the 21 st Century : Using Advanced Technology and Care Models to Move from the Hospital and Clinic to the Community and Caring Jonathan B. Perlin, MD, PhD, MSHA, FACP Deputy Under Secretary for Health Veterans Health Administration Department of Veterans Affairs Building the Prevention Workforce: 1 st Annual VA Preventive Medicine Training Conference Albuquerque, NM – August 11, 2003

J. Perlin - Veterans Health Administration: August, 2003  Patients don’t seek care just to be safe  Come for help maintaining & improving health, managing disease & distress  Goal: To Close to Chasm...  The Gap between optimal (best evidence based care) & usual performance  Evidence-based medicine: Uses rigorous, criteria- driven review of literature to identify practices that achieve consistently better outcomes  Closing Preventive Health is”gap” essential  Is closing the gap enough? To Err is Human: 98,000 Patients The Quality Chasm: Every Patient “Crossing the Quality Chasm” 2001: IOM Where Are We Now ? Safety: Only the Tip of the Iceberg

J. Perlin - Veterans Health Administration: August, 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: August, 2003 Veterans Health Administration : Systematic Approaches to Preventive Health  Overview: 1.Framework for Successful (Preventive) Health Delivery  Preventive Health Priorities 2.Quality & Safety  Variation in Health Care  Quality (Safety) & Value as defining Strategies  Measurement & Accountability for Quality (Safety) 3.Information Technology & Health Care Quality  Patients, Providers and Community Perspective 4.Moving toward safer, more effective, more efficient, and more patient-centered health care  Expanded definition & role for preventive health

J. Perlin - Veterans Health Administration: August, 2003 Wagner Model of Chronic Care ( Applicable to Prevention ? ) 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: August, 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: August, 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: August, 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: August, 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: August, 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: August, 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: August, 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: August, 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: August, 2003 Vaccine Cuts Pneumonia Risk in High-Risk Patients Archives of Internal Medicine 1999;159: Dr. Kristin Nichol, VAMC / Minneapolis  50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine.  : 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: August, 2003 Pneumococcal Vaccination Rates Iowa: Petersen, Med Care 1999;37: >65/ch dz HHS: National Health Interview Survey, >64 --BRFSS-- --BRFSS 90th--

J. Perlin - Veterans Health Administration: August, 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

J. Perlin - Veterans Health Administration: August, 2003 Pneumococcal Vaccination Rates * Iowa: Petersen, Med Care 1999;37: >65/ch dz Knowledge that Pneumococcal Vaccination Indicated in Elderly / Chronic Disease... Why so underutilized???

J. Perlin - Veterans Health Administration: August, 2003 Why Doesn’t 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: August, 2003 “Small Area Variation” (Variation in Pneumonia Vaccination Among Medicare Beneficiaries) Wennberg, Dartmouth Health Atlas

J. Perlin - Veterans Health Administration: August, 2003 What’s 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 don’t 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: August, 2003 What’s Wrong With Variation?  #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: August, : 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)  4.9 million patients, ~ 6.9 million enrollees  Increased from 2.5 million patients / enrollees in 1995  ~ 1,300 Sites-of-Care, including 162 medical centers or hospitals, > 700 clinics, long-term care, domiciliaries, home-care programs  To ’02: ~ $22 Billion budget (flat at ~ $19B from )  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 MD’s  60% (70% MDs) US health professionals have some training in VA

J. Perlin - Veterans Health Administration: August, 2003 Who Are Our Patients ?  Older (and Aging)  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: August, 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 over age 85 will increase threefold from 380,000 to ~ 1.2 Million by 2010 Veteran Population: Age Trends: 2000 – & Over, Number in 1,000’s

J. Perlin - Veterans Health Administration: August, 2003 Changing Health Care Delivery Patterns Health care moved from hospital to clinic, in the past decade. In this decade, health care will move from clinic to community..

J. Perlin - Veterans Health Administration: August, 2003 U.S. Deaths* % Deaths Behavioral / Environmental FHx / Genetic Heart Disease (1)710, Malignant Neoplasm553, Cerebrovascular Dz167, COPD, Pulm Dz122, Accidents97, Diabetes (2)69, Influenza & Pneumonia65, Alzheimer’s49, Kidney Diseases37, Sepsis31, * Death Rates, CDC, Lifetime Risk after 40 years: 49% males; 32% Females 2Prevalence: U.S. 7.3%; VA 19.8% Preventive Health Challenges

J. Perlin - Veterans Health Administration: August, 2003 U.S. Deaths* % Deaths Behavioral / Environmental FHx / Genetic Heart Disease (1)710, Malignant Neoplasm553, Cerebrovascular Dz167, COPD, Pulm Dz122, Medical Adverse Events? 98,000Provider Accidents97, Diabetes (2)69, Influenza & Pneumonia65, Alzheimer’s49, Kidney Diseases37, Sepsis31, c.f. To Err is Human, IOM, 1998 Should We Consider Safety & Quality Preventive Health Opportunities ?

J. Perlin - Veterans Health Administration: August, 2003 Factors in Early Mortality: Intervention Opportunities Public Health Service, 1993

J. Perlin - Veterans Health Administration: August, 2003 Obesity: Percent of U.S. Population By BMI, CDC, 2002

J. Perlin - Veterans Health Administration: August, 2003 Tobacco: (U.S. Smoking Rate 1990 – 2001) CDC, 2002

J. Perlin - Veterans Health Administration: August, 2003 (Preventable) Causes of Premature Mortality Estimate Deaths in U.S. Proportion of Total Behavioral / Environmental Tobacco400,00038%  Diet / Activity300,00028%  Alcohol100,00010%  Infectious90,0008%Immunization Toxic60,0006%  Firearms35,0004%  Sexual Behavior30,0002%  MVA25,0002%  Illicit Drugs20,0001%  McGinnis, Foege, JAMA. 1993;270(18):

J. Perlin - Veterans Health Administration: August, 2003 Reducing Variation: From Evidence to Practice… Patient With Need Patient Need Met Possess Knowledge Operationalize Knowledge Pneumococcal Pneumonia Vaccination Indications Measurement Framework / Accountability + Technologies (Computerized Health Information) + New Delivery Models  System Changes Reduce Quality Chasm

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

J. Perlin - Veterans Health Administration: August, 2003 VHA: A Defining Strategy Producing & Measuring Quality & Value  VHA “Values”  Quality  Access  Community Health  Satisfaction  Functional Status  Cost-Effectiveness  Provide 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: August, 2003 Quality: Prevention Index, 1996 – 2002 * Sampling methodology more stringent

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

J. Perlin - Veterans Health Administration: August, 2003 Immunizations +/- Mental Health Diagnosis (FY 2001)

J. Perlin - Veterans Health Administration: August, 2003 Quality: Gender / Age Approp Care Breast CA & Cervical CA Screen --HCUP--

J. Perlin - Veterans Health Administration: August, 2003 Tobacco Non-use  Almost 100% Screened  97% Counseled 1x / yr  VA: Tobacco Use Counseling 3X / yr  FY200049%  FY200163%  FY %  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: August, 2003 Survival after MI Soumerai SB "Adverse Outcomes of Underuse of Beta Blockers in Elderly Survivors of Acute Myocardial Infarction," JAMA 1997; 277(2): 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: August, 2003 AHCPR: Soumerai et al. JAMA 1997;277(2): Non-Govt: Krumholz HM et al. Ann Int Med 1999;131(9): HCUP-- AMI Care Improvement: Performance Measurement Works Unmeasured Performance Measurement Measurement + Accountability

J. Perlin - Veterans Health Administration: August, 2003 Impact: QALY’s Saved Coffield AB et al. AJPM 2001;21(1):1-9,, 2002

J. Perlin - Veterans Health Administration: August, 2003 Impact: $ Saved per QALY Coffield AB et al. AJPM 2001;21(1):1-9,, 2002

J. Perlin - Veterans Health Administration: August, 2003 So Many Opportunities, So Little Time...  Prioritization & Specific Opportunities:  Clinically Preventable Burden (CPB)  QALY’s – Cost-Effectiveness (CE) Coffield AB et al. AJPM 2001;21(1):1-9,, 2002

J. Perlin - Veterans Health Administration: August, 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: August, 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: August, 2003 VA’s Computerized Patient Record System...

J. Perlin - Veterans Health Administration: August, 2003

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

J. Perlin - Veterans Health Administration: August, 2003 Clinical Reminders Contemporary Expression of CPG’s: Reduces Negative Variation Create Standardized Data Acquisition of health data beyond care delivered in VA

J. Perlin - Veterans Health Administration: August, 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: August, 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: August, 2003

Performance Measures for Lipid Screening & Mgmt in Patients with Diabetes

J. Perlin - Veterans Health Administration: August, 2003

 Computerized Provider Order Entry (CPOE), one of the Leapfrog Group’s “Top 3 Safety Strategies”  Outside of VA, CPOE < 8% nationally, < 30% among Academic Medical Centers  Nationally, 91% of all VA Rx’s Now CPOE  Up from 79%, one year ago  Corporate Performance Measure  Ultimate Goal: 100%  VA is the Benchmark for CPOE

J. Perlin - Veterans Health Administration: August, 2003

CMOPs: Technology at Work Consolidated Mail Outpatient Pharmacy  ~200 Million “30-Day Equivalent” Prescriptions / Year (40K per shift per CMOP)  Medication Deficiencies: 5.8 sigma  Wrong Medication: %  Labeling problem: %  Damage in Mails: %  Delays in Delivery: %  Patient Satisfaction Rating: 90% VG/E

J. Perlin - Veterans Health Administration: August, 2003 HealtheVet Desktop & Care Management  Care Management:  New application that displays in the Desktop  Provides views across patients  “Electronic Index Cards!”  Desktop serves as “Dashboard” for scanning patient results, tasks, notes, events  Search utility – query for items across patients  Multiple signature – sign documents across patients  Additional Options can be added  Access to BCMA, VistA Imaging, other VistA applications, commercial applications

J. Perlin - Veterans Health Administration: August, 2003 Patient Display  Clinician Dashboard:  Has 4 columns for each patient  Display of results  Tasks due  Admission/discharge events  Signatures required  Can Also Create Tasks

J. Perlin - Veterans Health Administration: August, 2003 Care Management: Clinician Dashboard, Results Normal Result Blue Circle Abnormal Results Red Square Acknowledged All Gray Expand or Collapse Results Acknowledge Result Link Task Will support “looking” at a panel of patients and determining status of certain preventive services. Results, Tasks, Events, Signatures

J. Perlin - Veterans Health Administration: August, 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: August, 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 Assessment  Activate & Empower partnership with health care providers in achieving optimal health, through the sharing of health information

J. Perlin - Veterans Health Administration: August, 2003

“Hey, Doc, I have Diabetes, Shouldn’t I be on an ACE Inhibitor ?”

J. Perlin - Veterans Health Administration: August, 2003

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: August, 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: August, 2003 From Health Care Delivery To Patient-Centered Care  Patient-Centered Care Coordination  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  Imperative to Care for an Aging Population

J. Perlin - Veterans Health Administration: August, 2003 CARE COORDINATION The Clinic (Care Coordinator) Becomes Aware that the High-Risk 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: August, 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: August, 2003 Long-Term Care Costs as Percent of per capita GDP

Home-Telehealth Technologies

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

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

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

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

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

J. Perlin - Veterans Health Administration: August, 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

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

J. Perlin - Veterans Health Administration: August, 2003  2002: Leadership by Example recognizes VA’s:  Clinical Performance Improvement  Performance Measurement  Information Technologies  Health Services Research  Patient Safety Evidence, Measurement, Technology & Accountability Strategies for the Future...

J. Perlin - Veterans Health Administration: August, 2003 From “Just in Case” to “Just in Time”  Health care in the past decade moved from hospital to clinic  Health care in the current decade moves from clinic to community  New Model: From Preventive to Prospective Care

J. Perlin - Veterans Health Administration: August, 2003

98 For Health Care & For VA Need to think broadly about prevention:  Classically, to prevent avoidable disease, disability & early death  Expansively, to support function, functional independence, and success in negotiating challenges of chronic disease and aging  Goal for the 21 st century: Safe, Effective, and Patient-centered Health Care...