Primary Health Care Quality Improvement Commendable Results

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Primary Health Care Quality ImprovementCommendabl
e Results

• BCHIMPS Spring Education Session
• Dr Art Macgregor and Rosemary Gray
• March 31, 2006

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Agenda

• Context, Collaboration Themes Chronology
  Rosemary
• Collaboratives Clinical Practice Implications
  Art
• So. Whats next?
  Rosemary
• Key Messages
  Art

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Context, Collaboration Themes Chronology
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The burden of chronic diseases in Canada
In Canada, for 2005 there were 231,000 total
deaths
500 million in loss of national income
89

80 of premature heart disease, stroke and type 2
diabetes could be prevented
Chronic diseases accounted for 89 of the deaths!
Source Preventing Chronic Disease A vital
investment WHO Global Report. World Health
Organization 2005.
5
Chronic diseases affect many people in BC,
especially seniors
Number of BC people with specific chronic disease
2004/05
A profile of Seniors in British Columbia,
Ministry of Health, Population Health and
Wellness, 2004 Source for chronic disease
prevalence MoH, Knowledge Management and
Technology
6
The burden of chronic diseases such as diabetes
is growing
7
The population is growing and aging which will
add to the system burden
Source P.E.O.P.L.E. 30
8
Seniors Health Compressing Morbidity
1980s
1990s
2000s
60 70 80
90
Age
Source Dr. Janet McElhaney
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Everyone has to die of something

• Most chronic diseases do not result in sudden
  death. Rather they are likely to cause people to
  become progressively ill and debilitated,
  especially if their illness is not managed
  correctly. Death is inevitable, but a life of
  protracted ill-heath is not.
• Source Preventing Chronic Disease a vital
  investment WHO Global Report. World Health
  Organization 2005.

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Increasing the emphasis on prevention and
proactive management
Clinical Transformation
Hospital days
Hospital days
1
2
3
Proactive management complication
prevention
Episodic reactive care
Prevention
Prevent Diabetes
Develop Diabetes Irreversibly changes
a persons life
Community Support
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But small changes can have a big impact

Hospital days

2
3
Proactive management complication
prevention
Episodic reactive care
4
People with Diabetes
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Collaboration Themes for QI in PHC

• Handling the increasing burden of chronic disease
• Health Authorities and Physicians are responsible
  for care delivery ??the Ministry just pays for
  services
• Central law of improvement every system is
  perfectly designed to achieve the results it
  achieves (Don Berwick)
• The VIHA CDM/P Collaborative its use of IT for
  measurement
• Chronic Disease Management (CDM) Toolkit
• Ongoing, mutually supportive communication among
• Government
• Health Authorities
• Physicians and their office staff
• Informatics industry (private and public)

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How did this lead to IT Collaboration for CDM?
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How did this lead to IT Collaboration for CDM?
(contd)
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So, what is the Chronic Disease Management (CDM)
Toolkit anyway?

• Its not an EMR.
• Its an interim, web-based system to support
  clinical quality improvement
• Its functionality will be integrated with (and
  replaced by) BC EMR standards
• It supports doctors and health care teams to use
  best practices in caring for patients with
  chronic conditions
• Diabetes, CHF, Depression, Chronic Kidney
  Disease, Chronic Disease Prevention for ages
  50-70
• New guidelines coming soon Hypertension,
  asthma, COPD, osteoarthritis, ...
• Supports longitudinal, guideline-based care for
  patients, among all members of the patients care
  team
• Provides a means to measure change for individual
  patients as well as patient populations
• For Providers
• Clinical process measurement are my patients
  receiving guideline-directed care?
• Health outcomes measurement how much is the
  care Im providing improving my patients health
• For Planners
• Aggregate process and outcome measures for health
  system planning
• Provides a foot in the door to adopting
  technology in primary care practice

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Toolkit Development Objectives

• Require no/low technology investment by users,
  and make the technology easy to use for
  paper-based AND EMR-enabled practices
• Permit health care providers to efficiently and
  effectively organize and share chronic care
  patient data and track quality improvement
• Provide tools for health system planners and
  policy makers to
• Support providers engaged in quality improvement
  activities
• Develop Provider and Population-level reporting
  capacity for policy-related decision support

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Benefits of the CDM Toolkit

• Improved patient health outcomes and patient
  safety through
• Increased decision support capacity for
  clinicians and administrators
• Incremental transition to technology assisted
  practice

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CDM Toolkit Benefits Decision Support and
Guideline Directed Care

• Easy identification of CDM or other high risk
  patients
• Developing a patient register is Step 1 toward
  improving quality of care
• Improved capacity for evidence-based care
• Access to current Guidelines and Protocols
• Support for proactive followup and planned care
• Standardized clinical and quality improvement
  (QI) reporting for providers and health system
  planners
• Self-monitoring for providers - Peer-to-peer and
  individual-to-group comparisons
• Monitoring changes in care processes and patient
  outcomes over time
• Apples to Apples comparisons of data across
  patient and provider populations, and over time
• Patient-level Point of care and
  Population-level Point of Reflection decision
  support

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CDM Toolkit Benefits Data Quality and Workflow

• Supports multiple comorbidities without data
  duplication
• Supports shared care (GP ?? Specialist) AND among
  multidisciplinary care teams
• Supports existing clinical and administrative
  workflow within a primary care practice
• New and revised flowsheets/guidelines
  automatically deployed to all users

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CDM Toolkit Benefits IT Integration Office
Automation

• Requires minimal IT automation for non-EMR GP
  offices
• Internet access and web browser minimum
• Integrates with office EMR software
• 1-way (current) XML data import to Toolkit
• 2-way (in development) upgrading to implement the
  WHIC CDM Infostructure message standards
• Can be replaced as BC EMR standards are
  implemented

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Decision support At the point of care for
health system planning
Clinical Transformation
Lab Data
Other Data
Evidence based care guidelines
Drug Data
EMR
Data
Network of Providers
Productive Interactions
Improved outcomes
Patients
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Critical Success FactorsLessons Learned from the
BC Experience

• Key Risk Management considerations
• Stakeholder engagement
• Through all project phases and ongoing operations
  
• listen and be responsive
• Change Management support
• Implementation and ongoing operational support
  and training
• Demonstrate value
• Fill a need thats perceivable by the end user
  add clinical and business value not just IT
  infrastructure
• Data stewardship and custodianship issues ???
• Legislation varies across jurisdictions. For BC
  this is not wholly resolved

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Collaboratives Clinical Practice Implications
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A business case

• What is the business of primary medical care?
• One-half is CDM
• This is a complex business it cannot be
  conducted without IT/IM

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A typical medical practice

• 1200 patients
• Depending on the location, age distribution
• About 50 people with diabetes
• 60 depression
• 100 hypertension
• 75 chronic kidney
  disease
• 100 arthritis
• Etc. etc. about half the 1200 patients.

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Every doctor has a population health problem

• How could one deliver good care for 600 people
  with complex problems?
• Some have 4 or 5 chronic conditions
• Each may require monitoring of from 3-10 issues
• And we have some people who dont come in
  regularly what if they dont? How would we know?

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The point of all this

• An information system has to help us care for
  individuals
• But we also need to know about our whole practice
  of CDM patients why would we simply select the
  individuals who came in regularly? Society
  wants us to look after the publics health all
  of them.

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Expanded Chronic Care Model
The ECCM is BCs model for collaborative Quality
Improvement in PHC
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Where were we in 2003 (before the Federal PHCTF)

• We had little organized information
• We thought things were not too good
• Absence of real data, absence of will, absence of
  real incentives to improve care had led to a
  general state of dissatisfaction, and the
  unraveling of the primary medical care system.

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The PHCTF sparked change

• It was a transition fund
• To produce change which then might be sustainable
  by co-incident or progressive change in primary
  care
• It fostered experiments in change management
• The most successful of which have been the BC CDM
  Collaboratives CHF, diabetes, depression have
  been the model diseases

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But we couldnt really start work on CDM in 2002

• We had four big worries when planning our various
  Collaboratives starting with CHF in March/03
  and then VIHA CDM in June/03
• We called them show stoppers
• NO INFORMATION SYSTEM
• Concern about physician recruitment
• shared and I-D care and
• about patient consent.

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Necessity is the mother of invention

• Sylvia Robinson (VIHA Project Manager) called
  Rosemary and George Fettes
• .. and they called Number 41 Media and IBM
• And they involved physician working groups
• And an interim information system was created
  in a few months and the rest is history.

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And

• The Ministry of Health and the BCMA had formed
  the GPAC (Guidelines and Protocols Advisory
  Committee) and together they produced evidence
  based guidelines, and flow sheets to guide
  daily work and these were put into the Toolkit
• Use of the Toolkit was the first experience many
  FPs had with ANY medical information system (MOAs
  did the billing)
• It opened their eyes to possibilities.

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A major Collaborative success

• The development of, use of, and importance of the
  Toolkit
• Aided by collaborative efforts between BCMA and
  Ministry and Health Authorities to roll out the
  technology which carries with it the evidence and
  the daily instructions in how to use it
• For many BC doctors it is still the main game in
  town
• It needs to be nurtured, and any information
  system for physicians offices needs to learn
  from the Toolkit

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Event Reduction Based on Steno-2 Study (1/3 of
Type 2 DM popln 40 of them at targets)
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What comes first in CDM?

• The patient registry
• Who are they? What particular chronic conditions
  do they have?
• How are they doing? Have their blood sugar,blood
  pressure, blood cholesterol actually been
  measured?
• Are these things under control? Why not? How
  could you find out?
• Can you get them to come in? Do you or the nurse
  need to go out to them?

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What happens when people get good data

• Oh my Gawd
• The universal reaction of those who care
• I had no idea about the numbers of people with
  diabetes, etc. etc.
• I had no idea what a poor job Im doing
• Now Ill start to measure things.

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The second law of quality improvement

• The act of measurement itself improves
  performance.

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CDM Accomplishments - Patients are getting better
care
The evidence shows that BCs CDM initiatives are
making a huge difference
Source Provincial CHF Collaborative Results CDM
Toolkit data
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System change strategy and learning model CHF
Collaborative
What was achieved in the CHF Collaborative?
100
Closing congress
Start of collaborative
75

Percentage
50
25
24
21
22
15
4
Had specific self-management goals for diuretics
Patients who
Had documented ejection fraction
Established self-management goals
Were on ACE-I / ARB
Were on B-Blockers
Making BIG changes video may be viewed at
http//www.heartbc.ca/pro/collaboratives/chf/bigch
anges.htm
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IHI suggestions for IT in CDM

• Information is available to all providers
• The system generates reminders and offers
  evidence based recommendations for care
• Users are able to generate reports on outcomes
  for a population of patients.

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Reliability science in CDM

• Prevent failure by following g-ls (which must be
  at hand on a moment to moment basis)
• Identify failures and mitigate harm by prompts,
  reminders, and summary reports
• Redesign the process based on failure analysis
  by reviewing outcomes on the whole population and
  recalling failures in order to deliver g-l
  quality care.

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Lessons learned

• We need each other
• Government and HAs are not all bad
• Dont talk to me about changing unless you
  provide me with some of the tools to do so
• What needs changing right now? Its the freeze on
  Toolkit improvements it is slowing our work and
  preventing new initiatives
• All of this work is promoting major system
  change
• helping to align incentives with desired outcomes
  see new BCMA contract
• Collaboration is the new way of doing business

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Doctors Stories pre Toolkit (contd)
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Doctors Stories post Toolkit

• I can manage my time better
• I feel Im doing a better job - Toolkit data
  proves it
• My MOA is invaluable
• I started on my own, but my office partner has
  now joined a Collaborative

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So. Whats next?
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Physician care according to guidelines is
increasing
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There is still lots of work to do
58 X
42 ?
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System change strategy and learning model
Knowing how to improve patient and population
outcomes is not enough. In order to obtain the
improved outcomes, a system change strategy and a
learning model to spread the change are required
A) Coordinate patient journey
B) Improve patient and care experience
E) Manage demand and capacity

• Teams with a Clear Aim
• Change Principles
• Small scale testing of changes PDSA
• Measuring impact
• Sharing and Collaboration

C) Optimize care delivery
D) People as part of the same system
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FSFP Support Framework Approach
2
3
Integrated Support Team
2
4
4
3
Physician/Practice Team
Provincial design of a Menu of support
services, that physician teams (practices) can
select from the three domains clinical, practice
management and technology.
Physicians can go it alone, or request support
from a regional Integrated Support Team. If
required, the Support Team will work with the
practice to help assess its needs, and provide
relevant support across the three domains.
The model supports small, locally relevant,
incremental, iterative changes for continuous
quality improvement (PDSAs). Physicians can try
different supports over time.
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Working together to achieve a shared vision
Ministry
CDM/QI Task Force
Health Authorities
MSD
CDM PHC
Provincial Steering Committees
INDIVIDUALS WITH CHRONIC DISEASES
Strategic Alliances
PHC Steering Committee
Other Stakeholders
BCMA
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Primary Health Care Transformation Bringing it
all together
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Key Messages

• We have made a transition
• from stalemate/anxiety to hope
• We have made a huge amount of progress through a
  QI framework that supports incremental change
• There is an ongoing expectation of progress to
  continue to move the change agenda forward
• The gains weve made are still fragile they
  rely on sustained support
• Everyone in this room can help