Implementation Research: Lessons Learned in OKPRN

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Implementation Research Lessons Learned in OKPRN

• James W. Mold, M.D., M.P.H.
• Department of Family and Preventive Medicine
• University of Oklahoma Health Sciences Center
• Oklahoma City

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Objectives

• Define quality improvement research
• Describe OKPRN
• Review what we have learned
• Discuss unanswered questions
• Speculate about next steps

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Oklahoma Physicians Resource/Research Network

• Established in 1994 (HRSA Grant)
• Emphasis on both resources and research
• (More like RD)
• Emphasis on information technologies
• Now a 501c3 non-profit organization but closely
  aligned with the OU DFPM
• 110 practices 235 clinician members
• Members care for 10 of the states pop.

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OKPRN Practices
?
OKC
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Cells
Diseases
People
Practices
Will it work? Is it worth it?
Whats possible?
Can it work?
Meta-analysis Guidelines
Cost-effectiveness
Best Practices
Phase III Trials
Re-engineering
Cells/Tissues
Exp. Animals
Implementation Dissemination
Training
Facilitation
Biochemistry
Phase I Trials
Phase II Trials
Phase IV Trials
Basic Research
Human Research
Practice- and Community- Based Research
Practice and Community
T1
T2
T3QI
Diffusion
Not ready for humans
Not ready for patients
Not ready for practice
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Cells
Diseases
People
Practices
Dissemination Research
Guidelines Development
Research Pipeline
Practice- and Community- Based Research
Basic Research
Human Research
Practice and Community
T3QI
T1
T2
Meta-analyses Systematic Reviews
Implementation Research
TTranslation
Not ready for humans
Not ready for patients
Not ready for practice
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OKPRN Practice-Based Research Studies

• Patient access to computers and e-mail
• 1997 and 2007
• Brown recluse spider bites
• Epidemiology and management
• Night sweats
• Epidemiology, associations, and consequences
• Peripheral neuropathy in older patients
• Epidemiology and consequences
• Why older patients change doctors
• Diagnosing influenza
• Exemplar studies (discussed later)

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The Challenge

• It has been estimated to take an average of 17
  years before 14 of biomedical innovations make
  it into generalized practice.
• Primary care must convert to a model or models of
  care better suited to the current and emerging
  health needs of the population
• Innovations are happening at an increasing rate

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Implementation Research Projects

• Pneumococcal immunization
• Before - After
• Diabetes care
• Prospective, uncontrolled
• Cluster RCT
• Smoking during pregnancy
• Before - After

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Implementation Research Projects

• Mammography RCT
• Cluster RCT
• Preventive Services Delivery
• Cluster RCT
• Prescription for Health (Unhealthy Behaviors)
• Phased/staggered Intervention in Practice
  Clusters

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How the Process Works

• For researchers and funders Studies of specific
  QI strategies development of products (software,
  guidebooks)
• For practices, these projects look like QI
• Clinician education (education, training, CME)
• Practice receives tangible support (e.g.
  facilitator, )
• Funding sources Agency for Healthcare Research
  and Quality, Oklahoma Foundation for Medical
  Quality, Robert Wood Johnson Foundation, QIO,
  Medicaid

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Which Practices Are Successful

• The QI initiative is a high priority for the
  practice
• The practice is able to change
• The practice is able to implement the critical
  components of the new process
• Solberg LI. Improving medical practiceA
  conceptual framework. Annals Fam. Med. 2007
  5(3) 251-256.

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Priority

• Administration is behind it
• Clinicians are behind it
• Staff are behind it
• Competing priorities are less important than the
  desired change and wont interfere with it.

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Change Capacity

• Shared quality of care mission
• Collaborative, cohesive environment
• Well-organized, non-chaotic
• Clear lines of authority/decision-making
• Well-developed QI process
• Regular QI meetings
• Stable workforce and administration
• Stable finances/financial management
• Effective policies and procedures

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Change Process Content

• Care management capabilities
• Patient self-management support
• Capable staff
• Patient tracking and registry functions
• EHR functionality
• Decision support options
• Test and referral tracking
• Task management systems
• Performance Tracking/Reporting

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Time

• The time that it takes to implement an innovation
  in committed practices depends upon
• The complexity of the intervention
• The magnitude of the changes required
• The number of people in the practice who must
  change their methods
• It generally takes about 6 months.

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Implementation Strategies Tested

• Feedback
• Benchmarking
• Identification of exemplars/exemplar methods
• Academic Detailing
• Literature review
• Exemplary practices (positive deviants)
• Practice facilitation
• HIT support
• Local Learning Collaboratives

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Feedback and Benchmarking

• Must be accurate and believable (trusted)
• Measures must be relevant/agreed upon
• Must be repeated at least monthly during
  implementation

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Exemplars and Exemplar Practices

• Okarche, Oklahoma 1998
• It doesnt help when the QIO comes in, audits
  my charts, and tells me what a lousy job I am
  doing. If they would tell me who is doing a good
  job, maybe I could talk with them and find out
  how to do it better.
• Mark Gregory,
  M.D.

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What Mark Didnt Say

• If they would just tell me
• What the literature says I should do.
• What the specialists say I should do.
• What the guidelines say I should do.
• What my academic colleagues say I should do.
• What CME resources are available.

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Performance Distributions

• Virtually always present
• Wider than you would expect
• Within practices and between practices
• High performers are often not the usual
  suspects
• Highest performers in one area arent necessarily
  the highest performers in other areas
• Some true exemplars (quest for excellence)

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Whats the best way to

• Manage laboratory test results?
• Deliver preventive services?
• Improve my care for patients with diabetes?
• Handle prescription refills?
• Help patients remember to bring their medications
  with them to appointments?
• Help overweight patients lose weight and keep it
  off?

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What Do Exemplars Know?

• Principles
• Techniques
• Scripts

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From a High School Math Quiz
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Academic Detailing

• Respectful sharing of information
• Discussion of current methods
• Discussion of how the principles and techniques
  might apply within that practice
• Plan for improvement

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Practice Facilitation

• One-half day per week for about 6 months
• Relationship with clinicians and staff is key
  takes several months
• Key functions include assessment and feedback,
  coaching, team-building, technical and hands-on,
  assistance, training, coordination of PDSA
  cycles, and cross-pollination

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OKPRN Board of Directors
NE OK
NW OK
Dept. of Family and Preventive Medicine
PEA
SW OK
SE OK
PEA Practice Enhancement Assistant
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HIT Support

• Generation of reports
• Template development
• Database development
• Implementation of registries
• Clinical decision support systems
• Communication systems

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Local Learning Collaboratives

• One-hour lunch meetings every 1 2 months
• Review performance data from all practices
• Share successes and failures
• Share anecdotes
• Share effective methods

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Effective Implementation of Innovations in
Primary Care
Literature and Exemplar Methods
Academic Detailing
Performance Feedback
Facilitation
Practice Enhancement Assistant
IT Support
Local Learning Collaboratives
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Proposed effects of the QI Interventions on
Change Elements
Priority
Change Capacity
Change Process Content
Performance Feedback
Academic Detailing
Practice Facilitation
HIT Support
Local Learning Collaboratives
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Disseminating the Implementation Process

• Longitudinal relationships
• Knowledge of local factors
• Travel time/cost
• Cross-practice collaboration

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It Takes a Village

• Primary care can no longer be practiced in
  relative isolation from public health, mental
  health, social services, and community
  organizations
• Obesity, lack of exercise, smoking, and abuse of
  alcohol account for 37 of all premature deaths.

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County Health Extension

• Key functions
• Performance monitoring/reporting
• Practice facilitation
• Local learning collaboratives
• HIT support
• PCMH capacities shared across practices

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County Health Extension

• Closing gaps
• Public health
• Mental Health
• Social Services and Community Resources

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Cooperative Extension

• 1889 Dept of Agriculture began issuing Farmers
  Bulletins and the Yearbook of Agriculture
  experimental farms issued research bulletins and
  popular bulletins publications reached small
  proportion of farmers, many of whom distrusted
  book farming
• 1880 -1911 Widespread establishment of farmers
  institutes and even mobile institutes to reach
  more farmers
• 1906 S. A. Knapp hired the first county
  extension agent to develop a personal
  relationship with every farm family in the county
  and help them implement innovations

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Cooperative Extension

• 1889 Dept of Agriculture began issuing Farmers
  Bulletins and the Yearbook of Agriculture
  experimental farms issued research bulletins and
  popular bulletins publications reached small
  proportion of farmers, many of whom distrusted
  book farming
• 1880 -1911 Widespread establishment of farmers
  institutes and even mobile institutes to reach
  more farmers
• 1906 S. A. Knapp hired the first county
  extension agent to develop a personal
  relationship with every farm family in the county
  and help them implement innovations

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Cooperative Extension

• Funding sources 30 federal, 70 state and
  local
• Headquartered in the land-grant university
• Staffing 1 federal, 32 university, 67 local
  in nearly all of the 3,150 counties in the U.S.
  plus more than 2 million volunteers
• Goal is to maintain meaningful bi-directional
  communication between the university and the
  farmers and provide on-site training and
  assistance to farmers and farm families so they
  can stay abreast of advances in science
• Taking the University to the People by Wayne D.
  Rasmussen Iowa State University Press, 1989

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• The insurance companies alone (including Medicare
  and Medicaid) are spending (mostly wasting) more
  than 5 billion a year on QI
• Now add in the money spent by AHRQ, the NIH, the
  CDC, private foundations, advocacy organizations,
  professional associations, etc.
• Pandemic influenza preparedness
• NHLBI asthma guidelines

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Community Care of NC

• Regional 501c3 organizations owned and run by
  primary care clinicians supported by Medicaid
  care management funds (3 PMPM) charged with
  improving quality of care for Medicaid patients.
• ROI 2 for every 1 invested
• Saved the state 60 million in Medicaid costs in
  2003 and 120 million in 2004

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Canadian County, Oklahoma

• Juvenile Justice System and community groups
  anteed up 10,000
• Matched through the Medicaid federal match to pay
  for a ½ time care manager for children
• Linked to a matching contract with the OU DFPM
  for 120,000 to improve well child care
• Drew the attention of a developmental
  pediatrician, who obtain a grant from a
  foundation for 100,000 to improve developmental
  screening
• Now approved by Medicaid as a HAN. Will receive
  5 PMPM (340,000 per year)

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The University of New Mexico HEROs Program

• Health Extension Rural Offices (HEROs)
• Mission
• Generate better health at lower cost
• Increase community capacity to address local
  problems in order to reduce health disparities
• Activities
• Tele-health projects
• Training
• Workforce development
• County health report cards

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University of Wisconsin
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Questions??????