1. Clinical Care Overview: My Journey Mike Davies, MD FACP Mark Murray and Associates

2. Question How does a practice assure that all patients, including those with chronic diseases (diabetes, depression, & ischemic heart disease) and preventable diseases (cancer screening) receive the absolute best possible care?

3. Vaccine Cuts Pneumonia Risk in High-Risk Patients Archives of Internal Medicine 1999;159:2437-2442 2-year retrospective study involving ~1,900 elderly patients with chronic lung disease. ~2/3 had been vaccinated against pneumonia or influenza. Pneumococcal vaccination was associated with 43% reduction in hospitalization for pneumonia or influenza and 29% reduction in overall risk of death. Patients receiving both vaccines had a 72% reduction in hospitalizations and an 82% reduction in death. Pneumococcal vaccination was associated with an average cost savings of $294 per vaccine recipient over the 2-year period.

4. BUT---patients still don't get the vaccine Petersen, RL, et al. Influenza and Pneumococcal Vaccine Receipt in Older Persons With Chronic Disease: A Population-Based Study. Medical Care. 37(5):502- 509, May 1999. 787 urban and rural Iowa adults age 65 years and older with one or more self-reported target medical conditions were surveyed. Only 68% reported influenza vaccination in the last year, and 51% reported ever receiving the pneumococcal vaccine. Receipt of the vaccines was unrelated to geographic location in a rural area. Despite their proven safety and efficacy, many persons with at least two indications to receive either vaccine remain unvaccinated.

5. Regional Variation in Practice: Angiography

6. Regional Variation in Practice: Prostatectomy

7. Variation in Practice: Practitioner Level Efforts to improve compliance with the National Cholesterol Education Program guidelines. Results of a randomized controlled trial. Headrick et al; Arch Intern Med 1992 152:2490-6. The Lake Wobegone phenomenon. Most practitioners believe they are more efficient; have sicker patients, and have better outcomes than than their peers in the same practice. Physicians were offered either a lecture alone, lecture plus generic chart reminders, or lecture and patient-specific feedback and explicit recommendations for further action. Significant within-group improvements in compliance were noted for groups 2 and 3 (7.6% and 10.6%, respectively), but not for group 1 (4.5%). Physicians markedly overestimated their personal compliance with guidelines.

8. Perspective “No physician can read all of the current literature in his specialty and retain his reason.” [Davidson, 1942] “Over 10,000 RCT’s published every year.” [1990’s) “Development (in medicine) has been limited by the rate of discovery, but now is limited by the rate of implementation.” [Br. Med. J.] “Doctors are most likely to react to new information …delivered by another physician in a position of clinical leadership; …concerning quality as well as cost; and when there was frequent feedback.” [Eisenberg]

9. What is a Clinical Guideline? Compendium of recommendations for management of a given disease or condition Typically formulated by an expert panel –Consist of many different steps or sets of recommendations –Recommendations are often graded (A,B,C for confidence about the strength of the recommendation) –Intended to apply to populations and may or may not apply to individuals –Separate steps may form the basis of performance measures

10. What is a Clinical Guideline (continued)? Often quite lengthy. –Diabetes mellitus: 14 modules, each with sub- parts and 5-20 pages of annotations –Ischemic Heart Disease: 190 pages –Major Depressive Disorders: 100+ pages depending on format Difficult to disseminate the entire guideline except as an on-line document.

11. VHA Clinical Guideline for Management of DM

15. What is a Clinical Pathway? A set of defined steps for management of a patient or group of patients through a specific intervention or during delivery of care for a disease entity. Typically defined by time-limited stages. Usually individualized by clinic. May be based on and often overlap with clinical guidelines, but usually more concerned with the steps and time frame of a care delivery process. –GI Surgery –Acute MI –CABG

18. What is a Performance Measure? A specific goal to be achieved. –Ideally corresponds to a management step in a clinical guideline and can be used as a surrogate for overall guideline implementation*. –Best defined by grade "A" recommendations (e.g. widely accepted). –Usually requires narrowing of a data definition to assure applicability to the target population, or lowering of the goal to allow for "outliers".

20. Timeline of Key Events – Performance Measures “Implement” 5 “self determined” guidelines 1996 “Adapt” 12 nationally developed guidelines: measure and implement locally (in the network) 19971998 “Implement” 5 nationally developed guidelines 2006 Performance Measurement System National National Clinical Practice Guidelines Council 51 Clinical Interventions Measured

21. Guideline Implementation Challenges Access to critical part of the CPG at point of clinical decision or need Guideline distribution Communication directly with providers Guideline concordant CME “Activated” patient/patient education for care specific to their needs

22. Approach to Implementation of CPG’s Assess provider opinions Facilitate computer tool development –Web Site –Clinical Reminders Provide a national forum for education and planning Provide practical implementation tools

23. 7. My preference for the BEST FORM of VA CPG for me to use is:

24. 8. Copies of VA Clinical Guidelines should be AVAILABLE in:

25. 13. A FACILITY or NETWORK champion, mentor, or expert for each guideline would be helpful as a resource to me. Agree Disagree Neutral Agree

26. 14. EDUCATION about the content of CPG’s would be most helpful in the form of: (Slide 1)

27. 14. EDUCATION about the content of CPG’s would be most helpful in the form of: (Slide 2)

28. 16. The most important areas I need HELP UNDERSTANDING are:

29. 21. Who besides providers NEED TRAINING in clinical practice guidelines?

30. 22. List the BIGGEST BARRIERS you experience in following CPG recommendations in your clinic setting.  TIME - to see patients  ACCESS - to guidelines  AVAILABILITY - of guidelines  WORKLOAD  STAFFING  PATIENT COMORBIDITIES  PATIENT NON-COMPLIANCE

31. 4. How important do you feel it is to provide FEEDBACK to you on your compliance with clinical guideline elements?

32. Feedback EPRP – External Peer Review Program –Nationwide –Review individual charts against criteria –Outside contractors so as to insure no bias –Required “perfect” measurement criteria –Measures used to reward/punish leaders –Took ½ hour + to abstract 1 chart

33. Diabetes Measures 50% Successful +/- 2 Standard Errors 51 49 53 47 41 59 29 71 n=18,700n=850 in each n=131 in each n=22 in each

34. Effect of Sample Size on Variability of Estimate Bars Represent +/- 2 SE 18 82

35. Effect of Sample Size on Variability of Estimate Bars Represent +/- 2 SE

36. VISNs VAMCs Providers VHA (n=22) (n=143) (n~858) MDD Screen Hypertension Diabetes COPD MDD GAF Schizophren. AMI CHF 43,800 34,600 18,700 15,500 7,800 5,300 4,000 3,000 1,991 1,573 850 705 355 241 182 136 306 242 131 108 55 37 28 21 51 40 22 18 9 6 5 3 FY99 EPRP Data

37. Insight: Feedback needed at patient and provider level Huge debate about how to do feedback Multiple strategies considered Goals –Something that would be easy –Something useful in the course of patient care –Something electronic – in the record –Something that could find “mistakes”

38. Linking Clinical Care Protocols with Feedback – the 3 options Clinical record documentation (paper or electronic) Registry Electronic record smart systems (clinical reminders)

39. Insight: Feedback needed at patient and provider level Huge debate about how to do feedback Multiple strategies considered Goals –Something that would be easy –Something useful in the course of patient care –Something electronic – in the record –Something that could find “mistakes”

40. The Clinical Reminders “Story” National CPG Council initiative July of 1998 brought Clinical, Information, and National Leaders together Reviewed existing technology Proposed improving current clinical reminder functionality by linking them to progress notes and encounter forms. Idea was for the computer to “do work” for the provider. “Make the right way the easy way” Create reports

47. # Patients with Reminder Applicable Due ---------- --- Hep C Risk Factor Screen 172 16 Hep C Test for Risk 30 7 Hep C Diagnosis Missed 0 0 Hep C Diagnosis 36 36 Hep C- Dz & Trans Ed 36 27 Hep C - Eval for Rx 36 15 Chr Hep - Hep A Titer 45 3 Hepatitis A Vaccine 19 4 Chr Hepatitis - AFP 12 4 Chr Hepatitis - U/S 13 6 HepB sAg pos - no DX/sAb 1 1 Report run on 175 patients.

48. Clinical Reminders Logic very flexible & under local control –A few national reminders are being developed Can be “assigned” to professions –Nurse Reminders –Physician Reminders Allow almost “perfect” information on key measures Require computer “expert” to interface between clinical and computer services

51. Next Learning: What beyond feedback of data is important?

52. Top 8 Most Frequently Planned CPG Implementation Strategies Improve provider or team feedback Establish steering committee Implement or standardize clinical reminders Broaden implementation team Develop clinical champions Improve dissemination and education Improve patient education Implement or improve electronic medical record

53. Create an Oversight Team(s)! Clinical champion(s) -physician, nursing and others as appropriate Data Manager Performance Improvement Consultant/Coordinator Clinical Application Coordinator

54. Create a structure for reporting CGL performance Through services or service lines Clinic-specific performance (focus on the process) Provider-specific performance showing de- identified comparisons to peers.

55. Toolkits: Patient, System and Provider Aids in Implementation of CPG’s

56. Contents of Implementation Toolkits Guideline Provider Tools –Pocket cards (multiple copies) –Guideline “lites” (multiple copies) –Videotape (from satellite)

57. Toolkit Contents Cont…. Patient Tools –Self-management (multiple copies) –Patient education videotape System-Tools –Documentation forms –Information about automated reminders –Implementation manual –Facilitator’s guide

58. http://www.qmo.amedd.army.mil/pguide.ht mhttp://www.qmo.amedd.army.mil/pguide.ht m http://www.oqp.med.va.gov/cpg/cpg.htm

59. “Guidelines” Today Large documents – “complete” guidelines –Very useful for researchers –Very useful for providers who know how to access and use them to answer ?’s –Overall not as useful Tools (pocket cards, pt. ed materials, etc) –Most commonly employed education method –Compliment the measures Measures –Where “all” the action is.

60. Pneumococcal Vaccination Rates VHA Healthy People 2000 Iowa99* * Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz

61. Beta Blocker following AMI in VHA Medical Centers VHA NCQA Non-Govt AHCPR (NJ)

62. Dr. Roswell’s Statement to Congress VA’s performance now surpasses many government targets for health care quality as well as measured private sector performance. For 16 of 18 clinical performance indicators, critical to the care of veterans, and directly comparable externally, VA is now the benchmark. This includes use of beta-blockers after a heart attack, breast and cervical cancer screening, cholesterol screening, immunizations, tobacco screening and counseling, and multiple aspects of diabetes care.

63. Mental Health Measures Clinics - In FY 2006, clinics serving more than 1500 unique patients will provide Mental Health specialty services for encounters in at least 10% of patient visits. Homeless patients who have receive MH or SUD specialty care within sixty days of intake assessment. Homeless patients who receive MH or SUD specialty care within sixty days of entry to a homeless program. Homeless patients who receive Primary Care within sixty days of entry to a homeless program. Homeless veterans who receive MH or SUD specialty care within sixty days of discharge from a homeless program.

64. Cancer Screening a. Cancer Screening - Breast b. Cancer Screening - Cervical c. Cancer Screening - Colorectal (52 - 80 yrs)

65. Cardiovascular 1. Inpt EKG Timely 2. Inpatient refersusion as appropriate STEMI 3. Inpatient Reperfusion PCI in 120 mins STEMI 4. Inpatient Reperfusion Thrombolytic Therapy in 30 mins STEMI 5. Inpatient Risk Hihg/Moderate with Cardiology Involvement in 24 hrs of acute arrival 6. Inpatient Risk High/Moderate with diagnostic catheterization prior to discharge 7. Inpatient Troponin returned within 60 minutes of order time

66. Cardiovascular: CHF 1. EF < 40 on ACEI/ARB prior to inpatient admission 2. Inpatient Discharge complete instruction (Diet/Weight/Meds/Activity/Symptions/Follow-Up) 3. Inpatient Weight instruction prior to admission

67. Cardiovascular: HTN and Lipids 1. Outpatient Dx HTN and BP < or = 140/90 2. Outpatient Dx HTN BP > or = 160/100 or not recorded (lower is better) 1. Outpt LDL=c< 100 on most recent rest AND having a full lipid profile in the past 2 years 2. Outpt LDL-c> or = 120 (lower is better)

68. Diabetes Percent of patients with Diabetes Mellitus in the Nexus Clinics and SCI & D Cohorts and: a. BP less than or equal to 140/90 (Nexus Clinics) b. BP less than or equal to 140/90 (SCI&D Clinics) c. BP greater than or equal to 160/100 - lower is better (Nexus Clinics) d. BP less than or equal to 160/100 - lower is better (SCI&D)

69. Diabetes Continued… e. Glycemic control - HBA1c>9 or not done (lower number is better) [Nexus] f. Glycemic control - HBA1c>9 or not done (lower number is better) [SCI&D] g. LDL-C 120 mg/dl (Most recent test in past 2 years AND having a full lipid profile in the prior two years) [Nexus] h. LDL-C 120 mg/dl (Most recent test in past 2 years AND having a full lipid profile in the prior two years) [SCI&D] i. Retinal examination at the appropriate interval (Nexus) j. Retinal examination at the appropriate interval (SCI&D)

70. VA Clinical Practice Guidelines www.opq.med.va.gov/cpg/cpg.htm

71. Thoughts to Consider in Chinook

72. High Reliability Systems Reliability: Right Care AT Right Time Every Time FOR Every One

73. Organizational Characteristics Low Focus on success (breeds dangerous confidence) Failures are thought of as localized isolated incidents Expensive time-requiring learning and problem solving not routine High Focus on measurement Improvement is constantly pursued System redesign constant Done in context of team

74. System Design Characteristics Traditional CME Work harder to prevent errors Be vigilant Personal check list High reliability system Mindset Information plan Bundles –Desired action is default –Leverage habits/patterns Redundancy Standardization

75. Safety…..to…..Reliability Guidelines/protocols/pathways/sytems Words matter Safety more in-pt. oriented (mistakes) Reliability has more traction in out-pt (system design) Orientation different

76. Pearls Bundles take out complexity “If you can’t do it on paper, you can’t do it on vapor” What are the few things that really matter? Leaders drive standardization Standardization requires infrastructure

77. Thoughts about Chinook How does a practice assure that all patients, including those with chronic diseases (diabetes, depression, & ischemic heart disease) and preventable diseases (cancer screening) receive the absolute best possible care?

78. Thoughts about Chinook

79. Pick small number of key interventions (goal) Measure baseline performance Implement changes Remeasure

80. Thoughts about CHC’s Provide tools Provide training to all Make it topic of regular team meetings Pick complete guideline reference Align incentives

81. Thoughts about CHC’s….changes Standardize protocols Do it on paper first Do it by panel Compare panel performance Assign responsibility to nurses