1. AHRQ 2008 Promoting Quality … Partnering for Change Bethesda, MD Sep 8, 2008 Designing for ACCORD with Patients Henry C. Chueh, MD, MS Massachusetts General Hospital Boston, MA

2. MGH Laboratory of Computer ScienceInnovative Designs for Informatics MGH PCP Network – Adult and FPs Only MDs = 178 FTEs = 101 Practices = 15 Patients = 155,590 At MGH IMA WHA BMG MWI Near MGH MGH Downtown MGH Beacon Hill MGMG Senior Health MGH Back Bay NECHC Charlestown Everett Chelsea 2 sites Waltham MGH Primary Care Network Revere 2 sites

3. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Quality Chasm

4. MGH Laboratory of Computer ScienceInnovative Designs for Informatics 24 hours in the life of a PCP “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care,” a report from the American College of Physicians, 2006 Yarnall KS, et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635 Ostbye T, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005; 3:209

5. MGH Laboratory of Computer ScienceInnovative Designs for Informatics “Computerized clinical information systems will help physicians close this quality gap by performing many of the repetitive, protocol-driven tasks.” -- Clement McDonald, 1976 The Promise of Information Technology

6. MGH Laboratory of Computer ScienceInnovative Designs for Informatics MGH Quality Measures By Linkage Status

7. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Our Challenge How do we design, build and implement the health information technology (HIT) tools to support and encourage busy practitioners and patients to “do the right thing?” …and that they’ll use.

8. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Preliminary work Patient-provider linkage is important Inter-visit workflow acceptable Providers will use well-designed tools Diversity of care processes can impact outcomes

9. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Focus on Follow-up Consumes time inappropriately Failure can result in poor outcomes 1 Fastest growing area of claims 2 Patients have interest 3 1 Earnest 2004 2 Shaefer 2000, Boohaker et al 1996, Murff HJ et al 2003 3 IOM 2001, WSJ Poll 2006

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11. MGH Laboratory of Computer ScienceInnovative Designs for Informatics A Fragile Loop Awareness of Issue Risk assessment Plan for care Follow-up Complete care ?

12. MGH Laboratory of Computer ScienceInnovative Designs for Informatics What about Clinical Decision Support Systems? Tend to be physician-oriented and visit- based Minimal effect for interventions that cannot be completed at the point of care Patient-centered approaches rare Often lack the ability to “close the loop”

13. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Redesign for Systems to Support Clinical Decisions Zapka et al 2003, 2004 “Ecologic Framework”

14. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Doctor and Patient Clarity Adjusted for age and insurance status 2 factors associated with appropriate follow-up care: –MD documentation of follow-up plan –Patient understanding of need for follow-up Poon, Haas, Puopolo 2004

15. MGH Laboratory of Computer ScienceInnovative Designs for Informatics ACCORD Ambulatory Care Compact to Organize Risk and Decision Making AHRQ Ambulatory Safety and QualityProgram: Health IT

16. MGH Laboratory of Computer ScienceInnovative Designs for Informatics “Make Clear Decisions Together”

17. MGH Laboratory of Computer ScienceInnovative Designs for Informatics

18. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Characteristics Patient-provider centered, informed decisions Preference and choice Self-documenting Explicit agreements with high visibility Fail-safe monitoring

19. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Focus Groups Patients Providers Patients with Providers Assess concept and initial design directions Identify incentives and barriers

20. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Focus Group Lessons Doctors worried about workflow intrusion Patients worried about doctors Patients concerned about potential barriers to access to their doctor Should enhance/increase face time with patients Flexibility needed for ACCORD creation

21. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Specific Aims Design models for Partnership Develop systems for Tracking Evaluate impact on Patient experience, quality

22. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Create

23. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Elements of an ACCORD Option Action Observation Time

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25. MGH Laboratory of Computer ScienceInnovative Designs for Informatics

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27. MGH Laboratory of Computer ScienceInnovative Designs for Informatics

28. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Propose

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30. MGH Laboratory of Computer ScienceInnovative Designs for Informatics

31. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Review

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33. MGH Laboratory of Computer ScienceInnovative Designs for Informatics

34. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Study Design

35. MGH Laboratory of Computer ScienceInnovative Designs for Informatics Systems to Support the Clinical Decision.

36. MGH Laboratory of Computer ScienceInnovative Designs for Informatics ACCORD Team Steven Atlas, MD, MPH Jeanhee Chung, MD, MS Richard Grant, MD, MPH Susan Edgman-Levitan, PA Robin Weinick, PhD Yu Chiao Chang, PhD Greg Estey David Berkowicz, MD Michael Yebba Mark Wylie Jeff Ashburner Alicia Wong