Center for Information Therapy

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Pre-Visit Information Therapy
Center for Information Therapy IxInsights January
17, 2006 3-4 pm ET
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Todays Agenda

• Introductions
• IxCenter and IxAction Alliance highlights
• Fred Brodsky, MD and Megan Montgomery, Group
  Health Cooperative-Madison
• Elizabeth Kaplan, MPH, John D. Stoeckle Center
  for Primary Care Innovation, Massachusetts
  General Hospital
• Q A
• Closing

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New Members

• Ix Solutions Partner
• Enhanced Medical Decisions, Inc
• www.enhancedmd.com

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IxAction Alliance Insight Webinars

• February 21 Selecting Ix tools and interventions
  for Disease Management American Healthways and
  Health Hero Network
• March 21 Open for volunteers/suggestions

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Designing Real World Workflows Around New
Technologies

• Enhancing the Annual Physical Using a Web Based
  Patient Portal

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GHCs MyChart Team
Fred Brodsky, MD Director, Clinical
Information Services Group Health Cooperative,
Madison, WI fred_brodsky_at_ghc-hmo.com
Megan Montgomery Senior Clinical
Analyst Group Health Cooperative, Madison,
WI megan_montgomery_at_ghc-hmo.com
Holly Jones Senior Clinical Analyst Group
Health Cooperative, Madison, WI holly_jones_at_ghc-
hmo.com
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Group Health Cooperative of South Central
Wisconsin

• Staff Model HMO insuring and providing care for
  50,000 members in Madison, Wisconsin
• Employ 40 physicians
• Family Medicine
• Internal Medicine
• Pediatrics
• Dermatology
• Ancillary Clinical Departments
• PT
• Mental Health
• Optometry
• Complementary Medicine and Chiropractic

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GHCs MyChart Deployment

• Implementation Timeline
• Statistical Overview
• Enrollment growth
• Demographics of MyChart Users
• Usage
• Messaging
• Scheduling
• Healthwise
• GHC Enroll

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GHCs MyChart Functionality

• Lab and Radiology Results Viewing
• Secure Messaging
• Direct Appointment Scheduling
• Healthwise Clinical Content
• Patient Entered Data
• Insurance Information
• On-line Insurance Enrollment

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Information Therapy and MyChart

• Striving for Relevance Using the Annual Physical
  Exam

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Goals

• Use Ix to meet NCQA/HEDIS/CAHPS goals
• Improve operating efficiency of the clinic
• Patients will arrive to clinic informed and
  prepared.
• Wrap up process will cement issues covered at
  visit.

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Why the Annual Physical?

• Archetypical office visit for an outpatient
  facility
• Repetitive process that may be amenable to mass
  customization.
• Less time pressure than other visit types
• Visit agenda reasonably predictable

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Target Groups

• Identify patients
• MyChart users who are overdue for physicals
• Use our scheduling system to produce reports
• Nursing still needs to use some judgment
• MyChart users who have already scheduled
  physicals
• At this point, requires a manual scan of future
  appointments
• Two very different groups of patients

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• Demonstration of Workflow

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Example of actual email correspondence through
GHCMyChart

• Example Maria
• Proactive scheduling
• Advance labwork for physical exam
• Patient Education

1) Nurse to Patient
----- Message ----- From Joanie Blankenship Cma
531 To PATIENT,MARIA Sent 7/21/05 320 PM
Subject overdue for annual physical exam Hi
Maria, My name is Joanie and I work with Dr.
Brodsky at Sauk Trails Clinic. According to our
records, it looks like you might be overdue for
your annual physical exam. You can use GHCMyChart
to schedule your physical with Dr. Brodsky by
clicking on the appointment scheduling link
above. After you have scheduled the
appointment, please reply to this message to let
us know if there are any health issues that you
would like to discuss with the doctor. In
addition, after you have scheduled your
appointment, I will work with you to arrange any
testing that you might need prior to your visit.
I look forward to hearing back from you.
Sincerely, Joanie B
Contd
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Example, continued
2) Doctor to Patient

• ----- Message -----
• From Fred Brodsky 10106 To PATIENT,MARIA
  Sent 8/3/05 921 AM
• Subject Upcoming physical
• Hi Maria,
• It looks like you have a physical coming up in
  the near future. I have put orders in the system
  for you to come in and have fasting labwork done
  a few days prior to the visit. You should fast
  for 12 hours prior to the test. Water is OK. You
  can go to any of our clinic sites on a weekday to
  have this done and they open up at 730AM.
• I am looking forward to seeing you!
• Dr. B
• Follow these Healthwise links for important
  preventive health information
• Healthy Exercise Fitness
• Healthy Diet Healthy Eating
• Breast Self Examination Breast Self-Examination
• Mammograms Mammogram
• Osteoporosis Information Osteoperosis
• Colon Cancer Prevention Colorectal cancer
  screening recommendations

Contd
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Example, continued
3) Patient to Doctor

• ----- Message -----
• From PATIENT,MARIA To Fred Brodsky 10106 Sent
  8/11/05 928 AM
• Subject RE Upcoming physical
• Dr. Brodsky,
• I'm just seeing your message today, so I'll fast
  tonight and stop by Sauk Trails tomorrow (Aug.
  12) for the bloodwork. The physical is Monday, so
  maybe you won't have results by then. I should
  have checked e-mails sooner. I've put off my
  annual physical because I've been unsuccessful at
  my weight loss. I know it needs to be a priority
  for me. I have a few health concerns to discuss
  with you the main one is a constant gasey,
  queasy stomach. I take Prilosec -- its the first
  thing I grab in the morning, but I still often
  wake up in the night because of stomach problems.
  I've had symptoms of Acid Reflux in recent years,
  and maybe we should talk about whether or not
  getting an inside look at the condition of my
  esophagus would be good. I'm worried a bit about
  erosion. And, it's probably good we're having
  blood work done -- another concern I have is my
  kidney function and the effect of borderline high
  blood pressure over the years. Maybe my stomach
  problems tie with that. I'm on low dose diuretic,
  but maybe it should be increased. By the end of
  the day, My legs and ankles are very swollen, and
  I think I"m retaining a lot of fluid even with
  the pills I"m taking. All of my problems could be
  helped with weight loss so I need to get serious
  about that. If there's an x- ray or a simple test
  for arthritis, I'd be curious to see what stage
  and what type of arthritis I have. I'm extremely
  stiff, especially in the mornings. Joint pain in
  my right knee and right hip are pretty bad, too.
  WEll, that's enough for us to discuss. Despite
  these few health problems, I'm enjoying life and
  lead a busy, active life.
• I turn 51 next month and contribute most of my
  problems to accumulation of birthdays and being
  overweight. Smaller issues that are still around
  carpal tunnel, adult acne, a reoccuring small,
  red stye on the lining of my right eye. Other
  than that, I'm in perfect health. See you Monday.

Contd
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Example, continued
4) Patient to Nurse

• ----- Message -----
• From PATIENT,MARIA To Joanie Blankenship Cma
  531 Sent 8/11/05 934 AM
• Subject RE overdue for annual physical exam
• Thanks for your message. I'm just seeing it now.
  I have a physical set with Dr. Brodsky on Monday,
  and he sent me a message so I'll fast tomorrow
  and come in for blood work. I wrote him directly
  on his message about a few health concerns I
  have. I would repeat them to you, but it's
  probably not necessary. Had I seen your message
  first, I would have written you. I"m not always
  good about checking my emails. But you have a
  nice system here and I'll try to be better about
  using it. Have a nice day.
• --Maria

5) Doctor to Patient
----- Message ----- From Fred Brodsky MD To
MARIA PATIENT Sent 8/11/05 346 PM Subject RE
Upcoming physical Hi Maria, It sounds like we
will have plenty to discuss on Monday. It would
probably be best if you would identify the two or
three topics that are most important to you so we
make sure we cover those thoroughly. We might
need a follow up visit to get through everything.
Dr. B
Contd
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Example, continued
6) Doctor to Patient

• ----- Message -----
• From Fred Brodsky MD To MARIA PATIENT Sent
  8/22/05 156 PM
• Subject Info on your high blood pressure
• It was nice to see you at the time of your
  physical last week. I am including links that
  will allow you to learn a little more about your
  high blood pressure. We can discuss further at
  the time of your follow up visit.
• Follow this link from Healthwise to learn more
  about hypertension High Blood Pressure
  (Hypertension)
• Dr. B

7) Patient to Doctor
----- Message ----- From MARIA PATIENT To Fred
Brodsky MD Sent 8/23/05 1135 AM Subject RE
Info on your high blood pressure Thanks. There's
a lot of good information via these links you
provided me. I know high blood pressure is
serious business, and I'll try to be more
successful at some lifestyle changes. So far, the
new blood pressure medications are working out
okay. And, I'm eating a banana every day -- to
help my potassium levels. I'll do blood work this
Friday, and the followup appontment is next
Tuesday. Thanks again for this info.
end of example
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Challenges of On-Line Ix
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Workflow Issues

• Challenges of email communication
• Critical mass of patients required to sustain
  real workflows
• Writing skills of clinical staff and patients
• Privacy and security issues
• Uneven familiarity with on-line transactions
• Appropriateness of on-line communication

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Physician Adoption Ix vs. Rx

• Familiarity
• Indications
• Spectrum of activity
• Side effects

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Pre-visit Information TherapyTargeting the
50-year-old annual physical Elizabeth Kaplan,
MPH Stoeckle Center for Primary Care
InnovationJanuary 17, 2006
IxInsights Users Group Webinar
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Background Goals

• Overarching goal to improve
• Satisfaction clinician, patient/family, and
  practice staff
• Decision quality
• Role of patients values preferences in
  decision-making
• Efficiency of valuable face-to-face time of the
  office visit

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Background Why Before the Visit?

• How can we make the office visit more efficient?
• Can we decrease the amount of work that must be
  done during the office visit?
• What can be taken out of the office visit?
• What can the patients do themselves?

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Background Goals

• Whats in it for the clinician?
• Do I trust the content of decision support aids?
• Does it save time?
• Does it improve productivity?
• Does it improve outcomes?
• Does it improve my relationship with the patient?
• Does it help with documentation, paper work?

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Background Guiding Principles

• The process must be
• user-friendly from the clinicians perspective
• add value for the clinician
• seamless from perspective of the practice staff
• deemed useful by the patient family

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Project Work To Date

• Identified target visit
• Developed packet material
• Tested material with patients
• Developed system to identify patients and pull
  data
• Developed processes, trained staff
• Current work Pilot and test process and
  effectiveness

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Packet Material

• 1. Appointment Reminder Letter
• 2. Educational Material
• Health review (changes in health, family history,
  health habits, vaccination updates)
• What to expect during the visit
• Cancer screening and additional health
  information
• 3. Preparation Form
• 4. Medication List

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What Patients Had to Say (testing phase)

• All patients read the material and filled out med
  list and preparation form.
• Reactions to receiving the packet
• Unbelievable this is exactly what Im going
  through now.
• Interesting and helpful. Im reasonably
  up-to-date on things relevant to me, but its
  good to have it all written down in one place.
• I was impressed and pleased that something like
  this was being done.
• I prefer to be prepared, so I always want more
  information before seeing the doc.

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What Patients Had to Say (testing phase)

• Reactions to material
• Yes. Definitely useful.
• It made me think about thingsgot me in the
  mindset to start thinking about the visit.
• Helped formulate areas and topics I wanted to be
  sure to discuss.
• Well laid out in segments so it was easy to read
  and follow.
• To the point. Well-developed and well-written.
• It wasnt overwhelming or too clinical, which is
  good for understanding.

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What Patients Had to Say (testing phase)

• Reactions to the preparation form
• This was great, very useful.
• Its easier to fill out at home than in the
  office.
• Really liked the top 3 health concerns question!

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What Patients Had to Say (testing phase)

• Reactions to the medication list
• Medication run-down was very helpful. Its good
  to make sure youre on the same page.
• Mine was very dated. I took the changes with me
  so now the record is correct. I wouldnt have
  known it was incorrect if I hadnt gotten the
  list, and I wouldnt have thought to tell the
  doc.
• Extremely helpful much easier to fill out at
  home.

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What Weve Seen in the Pilot

• Medication Lists 23 returned (6 office)
• Average of meds listed 5.0
• Range 0-15
• Average crossed off 2.6
• Range 0-9
• Average dose corrections 0.3
• Range 0-1
• Average meds added 3.0
• Range 0-9

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What Weve Seen in the Pilot

• 11 returned questionnaires
• All patients reviewed the information in the
  packet.
• All patients completed med list and prep form,
  and all but one said they brought them to the
  visit.
• All but two patients (one MD) reported that the
  doctor reviewed the information with them during
  the visit.

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What Weve Seen in the Pilot

• 11 returned questionnaires

1 Not at all 2 A little 3 Somewhat
4 Quite a bit 5 A great deal
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Next Steps

• Continue patient surveys
• Feedback from physicians and practice staff
• Medication list and Preparation form to all
  patients of current participating physicians
• Expand 50-year-old Previsit Packet to entire
  practice
• Other visit types to pilot

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Discussion

• Open time to discuss presentations
• Questions for Fred Brodsky or Megan Montgomery of
  GHC-Madison
• Questions for Elizabeth Kaplan of the Stoeckle
  Center

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Contact Us

• Center Staff
• Josh Seidman jseidman_at_IxCenter.org
• Dorothy Jeffress djeffress_at_IxCenter.org
• Kyle Silk-Eglit ksilk-eglit_at_IxCenter.org
• Presenters
• Fred Brodsky, MD Fred_Brodsky_at_ghc-hmo.com
• Megan Montgomery Megan_Montgomery_at_ghc-hmo.com
• Elizabeth Kaplan, MPH ekaplan_at_partners.org