1. Collaborative care for chronic illness and information technology Introduction AcademyHealth 2005 David A. Dorr, MD MS OHSU

2. Objectives State of collaborative and chronic physical and mental illness care Framework for collaborative care and Information Technology (IT) use Successes and challenges

3. Chronic illness care: problems Underuse Effective treatments for chronic illness care only given 54% of the time. Misuse Preventable, injurious outpatient AEs occur in 1- 9% of patients. Overuse Up to 30% of treatments provided for some illnesses (low back pain) are inappropriate. Terms from Chassin MR. JAMA. 1998; Sources: EA McGlynn, NEJM; Rothman, Annals; Wennberg; Forster, 2003; Dorr 2004.

4. Chronic illness care: VA transformation Jha 2003.

5. Root causes of problems with chronic illness care Culture / History “Tyranny of the urgent” Art and craft of medicine Complexity Individual versus population focused Financial

6. Root causes: information based Information/knowledge needed is Enormous Challenging to find Lacking In the wrong form Difficult to communicate

7. Information system: definition Any system to store / retrieve / display / aggregate / or otherwise touch information Not just computers or charts in broad sense Our focus is primarily on computer-supported information systems

8. Information System domains (IOM) Health information / data Results management Order entry Decision support Communication and connectivity Patient support Administrative process Reporting and population health

9. More successes Results management Patient worksheet Order entry Corollary orders and order sets improve safety, can reduce cost, and improve outcomes. Savings of up to $44 billion dollars per year. Pertinent labs Preventive care summary Medications Chronic conditions Pertinent exams Passive reminders Organized by illness Wilcox 2005; CITL report 2003.

10. Individual categories: successes Decision support 30-66% improvement in adherence to preventive care and acute care guidelines. But … chronic illness has mixed results. Patient support Congestive heart failure

11. IT and domains: hierarchy Access Best Practices Communication Health information / data Results management Order entry Decision support Communication and connectivity Patient support Administrative process Reporting and population health

12. Care management packages to Improve Quality of Care: Information System focus Chronic Care Model Hartford / Intermountain Health Care generalist care management Disease management Veterans’ Administration transformation QUERI (reTIDES, EQUIP, PAS, CHIACC)

13. Improving Care for Chronic Illness Community Health System Resources and Policies ------ Organization of Health Care Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patients & Caregivers Prepared, Proactive Practice Team Collaborative Care Functional and Clinical Outcomes From: E.H. Wagner & RWJF Improving Chronic Illness Care Initiative

14. Generalist care management system Improvement in diabetes, depression, and congestive heart failure outcomes. Dorr et al, HSR, in press; Dorr et al, Disease management, in press.

15. Disease management Companies external to health workers provide Technology (e.g. monitoring devices) System (e.g. 24 hour nursing support) To reduce utilization and cost.

16. Final thoughts IS use can help solve chronic illness performance issues. Advanced information system use only 15- 25% in US, and still difficult to know what will work. Financial, implementation, and workflow barriers significant.

17. Thanks! Amy Cohen, PhD Adam Wilcox, PhD Laurie Burns Paul D. Clayton, PhD Larry Casalino, MD PhD