Transcript Pneumococcal Vaccination Rates

Prevention in the 21st Century:
Using Advanced Technology and Care Models to Move from
the Hospital and Clinic to the Community and Caring
Building the Prevention Workforce:
1st Annual VA Preventive Medicine Training
Conference
Albuquerque, NM – August 11, 2003
Jonathan B. Perlin, MD, PhD, MSHA, FACP
Deputy Under Secretary for Health
Veterans Health Administration
Department of Veterans Affairs
1
Where Are We Now ?
Safety: Only the Tip of the Iceberg
 Patients don’t seek care just to be safe
 Come for help maintaining & improving health,
managing disease & distress
To Err is Human:
98,000 Patients
 Goal: To Close to Chasm . . .
 The Gap between optimal (best evidence
based care) & usual performance
 Evidence-based medicine: Uses rigorous, criteriadriven review of literature to identify practices
that achieve consistently better outcomes
 Closing Preventive Health is”gap” essential
 Is closing the gap enough?
J. Perlin - Veterans Health Administration: August, 2003
The Quality Chasm:
Every Patient
“Crossing the Quality Chasm” 2001: IOM
From Health Care Delivery
To Patient-Centered Care
 Safety:
 Avoid Getting it Wrong
 Quality:
 Get it Right . . . Consistently
 Patient-Centered Care:
 Support patients with safe, high-quality care, in health
and disease, at the time & place, and in the manner
patient desires
 Care extends from hospital & clinic to home &
community
J. Perlin - Veterans Health Administration: August, 2003
Veterans Health Administration :
Systematic Approaches to Preventive Health

Overview:
1. Framework for Successful (Preventive) Health Delivery

Preventive Health Priorities
2. Quality & Safety



Variation in Health Care
Quality (Safety) & Value as defining Strategies
Measurement & Accountability for Quality (Safety)
3. Information Technology & Health Care Quality

Patients, Providers and Community Perspective
4. Moving toward safer, more effective, more efficient,
and more patient-centered health care

Expanded definition & role for preventive health
J. Perlin - Veterans Health Administration: August, 2003
Wagner Model of Chronic Care
( Applicable to Prevention ? )
Community
Self-management
Support
Informed,
Activated
Patient
Health System
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
Wagner Model of Chronic Care:
Extended
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
Quality & Safety
 To Err Is Human
 Safety is “tip of iceberg”
5
4
 Goal: “Avoid Getting It
Wrong”
3
 Ex A: Penicillin in known
PCN-allergic patient
1
 Adverse Event = All Risk =
Adversity with no benefit
Benefit
2
0
Risk
A
B
J. Perlin - Veterans Health Administration: August, 2003
Quality & Safety
 Quality Chasm
 Virtually every patient
experiences gap between
optimal & actual care
 Ex B: Non PCN-type Rx
for pneumonia in PCN
allergic pt; pt not
vaccinated
 Getting it Partially Right
 Evidence: Pneumonia
Vaccination reduces
hospitalization & death
5
4
3
Benefit
2
Risk
1
0
A
B
J. Perlin - Veterans Health Administration: August, 2003
C
Quality & Safety
 Quality Chasm
 Implementing “Best
Evidence”
 Ex C: No need for RX, as
no pneumonia. Prior
pneumococcal vaccine
5
4
3
Benefit
2
Risk
1
 Evidence: Pneumonia
Vaccination reduces
hospitalization & death
0
A
B
J. Perlin - Veterans Health Administration: August, 2003
C
Vaccine Cuts Pneumonia Risk in High-Risk Patients
Archives of Internal Medicine 1999;159:2437-2442
Dr. Kristin Nichol, VAMC / Minneapolis
 50% of elderly Americans / high-risk individuals have not
received the pneumococcal vaccine.
 1996-1998: VA study of 1,900 elderly patients with chronic lung
disease; 2/3 vaccinated against pneumonia.
 Pneumococcal vaccination:
 43% RR reduction in hospitalizations for pneumonia and influenza
 29% RR reduction in the risk of death.
 Pneumonia and Influenza vaccination:
 72% RR reduction in hospitalizations for these two diseases
 82% RR reduction in deaths from all causes.
 Pneumococcal vaccination saved $294 per patient
J. Perlin - Veterans Health Administration: August, 2003
Pneumococcal Vaccination
Rates
Percent Vaccinated
100
80
--BRFSS 90th--
60
--BRFSS--
40
20
0
FY 95
4th Qtr
97
VHA
4th Qtr
98
FY 99
FY 00
Healthy People 2000
CHG
Iowa 99*
FY01*
FY02
NHIS
•Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz
•HHS: National Health Interview Survey, >64
J. Perlin - Veterans Health Administration: August, 2003
Extrapolating from Dr. Nichol’s study:
Between 1996 and 1998, Increased Rates of
Pneumococcal Vaccination Averted 3914
Excess Deaths Nationally in VA Patients
with Chronic Lung Disease . . .
J. Perlin - Veterans Health Administration: August, 2003
Pneumonia: Acute Inpatient
104.0
16.0
9,500 fewer
bed days
100.5
15.5
8,000 fewer
discharges
FY1999
Acute Days
FY2000
94.5
15.2
106
104
102
100
98
96
94
92
90
88
Total Days (bedsection)
16.2
16
15.8
15.6
15.4
15.2
15
14.8
14.6
Thousands
Thousands
Total Discharges (bedsection)
DRG89-90; Unadjusted for Pt. Population (up 20%, FY99-01)
FY2001
Discharges
• Effective, Efficient
J. Perlin - Veterans Health Administration: August, 2003
Pneumococcal Vaccination
Rates
Percent Vaccinated
100
Knowledge that Pneumococcal
Vaccination Indicated in Elderly /
Chronic Disease . . .
80
60
Why so underutilized???
40
20
0
FY 95
4th Qtr 97
VHA
4th Qtr 98
Cum 99
Healthy People 2000
Cum 00
Iowa 99*
* Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz
J. Perlin - Veterans Health Administration: August, 2003
Why Doesn’t the Evidence of
Research Become the SOP?
Research => Knowledge => Operationalization
Optimal
Practice
Patient
Need
Variation
(Bataldan: Omission, Commission, Irrational, Discretionary, Supply)
J. Perlin - Veterans Health Administration: August, 2003
“Small Area Variation”
(Variation in Pneumonia Vaccination Among Medicare Beneficiaries)
Wennberg,
Dartmouth Health Atlas
J. Perlin - Veterans Health Administration: August, 2003
What’s Wrong With
Variation?
 Not All Variation is Positive




Inconsistent
Inconsistent
Inconsistent
Inconsistent
Quality & Safety
Cost (Efficiency)
Access
Satisfaction
 Inconsistent Processes Result in Inconsistent Outcomes
 Sub-optimal Processes Result in Sub-optimal Outcomes
 Patients don’t reliably experience the optimal
processes or outcomes
– c.f. IOM, 2001: The Quality Chasm
 How do we systematically reduce the negative variation and
drive the most effective, efficient, safe, equitable, timely, ptcentered practice ?
J. Perlin - Veterans Health Administration: August, 2003
What’s Wrong With
Variation?
#1: Ethical Responsibility for Consistently
Good Patient Care
Wanna Be Around ? ? ?



Mission (Viability) Assumes Reliability (Quality)


If Not Reliable, Not Justifiable, Poor (Value)


Technical Quality, Safety Access, Satisfaction, Efficiency
Society will seek, even demand, alternatives
Periods of Economic Uncertainty (Now)
1. Call the Question of Value and
2. Offer Unique Opportunities and Propel Change
J. Perlin - Veterans Health Administration: August, 2003
2003: Who is “VA”
Veterans Health Administration
 VHA is Agency of the Department of Veterans Affairs
 Three Administrations, including VHA. Also:
 Veterans Benefits Admin (VBA)
 National Cemetery Admin (NCA)
 4.9 million patients, ~ 6.9 million enrollees
 Increased from 2.5 million patients / enrollees in 1995
 ~ 1,300 Sites-of-Care, including 162 medical centers or hospitals,
700 clinics, long-term care, domiciliaries, home-care programs
 To ’02: ~ $22 Billion budget (flat at ~ $19B from 1995 - 1999)
>
 Budget increase ’03: approximately $25B
 ~184,000 Employees (~15,000 MD , 50,000 Nurses, 33,000 AHP)
 21,000 fewer employees than 1995
 Affiliations with 107 Academic Health Systems
 Additional 25,000 affiliated MD’s
 60% (70% MDs) US health professionals have some training in VA
J. Perlin - Veterans Health Administration: August, 2003
Who Are Our Patients ?
 Older (and Aging)
 49 % over age 65
 Sicker
 Compared to Age-Matched Americans
 3 Additional Non-Mental Health Diagnoses
 1 Additional Mental Health Diagnosis
 Poorer
 ~ 70% with annual incomes < $26,000
 ~ 40% with annual incomes < 16,000
 Changing Demographics
 4.5% female overall
 Females: 22.5% of outpatients less than 50 years of age
J. Perlin - Veterans Health Administration: August, 2003
Veteran Population:
Age Trends: 2000 – 2020
The total veteran population will decrease by 32% between 2000 and 2020;
however, the number of veterans age 65 or over will peak in 2014;
veterans over age 85 will increase threefold from 380,000 to ~ 1.2 Million by 2010
28
26
24
22
20
18
Millions
16
14
12
10
8
6
4
2
0
9
FY
6
9
FY
7
9
FY
8
9
FY
9
0
FY
0
0
FY
Veteran Population
1
0
FY
2
0
FY
3
0
FY
4
0
FY
5
0
FY
6
0
FY
Live EOY Enrollment
7
0
FY
8
0
FY
9
1
FY
0
1
FY
1
1
FY
2
85 & Over, Number in 1,000’s
Unique Patients
J. Perlin - Veterans Health Administration: August, 2003
Changing Health Care
Delivery Patterns
Trended VA Produced Workload
900,000
809,717
Ambulatory Visits
Discharges
700,000
671,087
43,683,885
VA Hospital Discharges
604,946
600,000
581,226
36,375,335
500,000
31,009,211
400,000
300,000
200,000
100,000
50,000,000
50,000,000
37,786,271
564,013
40,505,531
566,318
40,000,000
563,209
551,082
33,417,287
30,000,000
28,371,349
Health care moved from hospital to clinic,
in the past decade. In this decade, health
care will move from clinic to community . .
0
20,000,000
10,000,000
0
EOFY 96
EOFY 97
EOFY 98
EOFY 99
EOFY 00
EOFY 01
EOFY 02
J. Perlin - Veterans Health Administration: August, 2003
VA Hospital Discharges
VA Outpatient Visits
EOFY 03
(projected)
VA Outpatient Visits
800,000
60,000,000
Preventive Health Challenges
U.S.
Deaths*
Heart Disease (1)
710,760
Malignant Neoplasm
553,091
Cerebrovascular Dz
167,661
COPD, Pulm Dz
122,009
Accidents
97,900
Diabetes (2)
69,301
Influenza & Pneumonia 65,313
Alzheimer’s
49,558
Kidney Diseases
37,251
Sepsis
31,224
*
1
2
%
Deaths
29.6
23.0
7.0
5.1
4.1
2.9
2.7
2.1
1.5
1.3
Behavioral /
Environmental
FHx /
++
++
++
+
+
+
++
+
++
++
+
+
Death Rates, CDC, 2000
Lifetime Risk after 40 years: 49% males; 32% Females
Prevalence: U.S. 7.3%; VA 19.8%
J. Perlin - Veterans Health Administration: August, 2003
Genetic
+
Should We Consider Safety & Quality Preventive Health Opportunities ?
U.S.
Deaths*
Heart Disease (1)
710,760
Malignant Neoplasm
553,091
Cerebrovascular Dz
167,661
COPD, Pulm Dz
122,009
Medical Adverse Events ? 98,000
Accidents
97,900
Diabetes (2)
69,301
Influenza & Pneumonia 65,313
Alzheimer’s
49,558
Kidney Diseases
37,251
Sepsis
31,224
%
Deaths
29.6
23.0
7.0
5.1
Behavioral /
Environmental
FHx /
++
++
++
+
+
+
++
+
Genetic
Provider
4.1
++
2.9
++
2.7
+
+
2.1
1.5
1.3
c.f. To Err is Human, IOM, 1998
J. Perlin - Veterans Health Administration: August, 2003
+
Factors in Early Mortality:
Intervention Opportunities
Environmental
Factors
20%
Behavioral Factors
50%
Genetic Factors
Inadequate Access
20%
to Medical Care
10%
Public Health Service, 1993
J. Perlin - Veterans Health Administration: August, 2003
Obesity: Percent of U.S. Population
By BMI, CDC, 2002
J. Perlin - Veterans Health Administration: August, 2003
Tobacco:
(U.S. Smoking Rate 1990 – 2001)
CDC, 2002
J. Perlin - Veterans Health Administration: August, 2003
(Preventable) Causes of
Premature Mortality
Estimate Deaths Proportion of
in U.S.
Total
Behavioral /
Environmental
Tobacco
400,000
38%

Diet / Activity
300,000
28%

Alcohol
100,000
10%

Infectious
90,000
8%
Immunization
Toxic
60,000
6%

Firearms
35,000
4%

Sexual Behavior
30,000
2%

MVA
25,000
2%

Illicit Drugs
20,000
1%

McGinnis, Foege, JAMA. 1993;270(18):2207-12
J. Perlin - Veterans Health Administration: August, 2003
Reducing Variation:
From Evidence to Practice…
Reduce Quality Chasm
Possess Operationalize
Knowledge Patient
Patient Knowledge
Need
With
Measurement
Pneumococcal
Met
Need
Framework /
Pneumonia
Vaccination
Indications
Accountability
+
Technologies
(Computerized
Health Information)
+
New Delivery Models

System Changes
J. Perlin - Veterans Health Administration: August, 2003
Challenge: Create Value
For Veterans and America
Value
Value
=
QUALITY
Cost
=
OUTCOMES
Cost
J. Perlin - Veterans Health Administration: August, 2003
VHA: A Defining Strategy
Producing & Measuring Quality & Value
 VHA “Values”
 Quality
 Access
 Community Health
 Satisfaction
 Functional Status
 Cost-Effectiveness
Challenge: To Create & Communicate VALUE
Value =
Access + Technical + Functional + Satisfaction + Community Health
Cost
 Provide consistently reliable, accessible, satisfying,
high-quality care which maximizes functional status,
is cost-effective and fosters healthy communities . . .
J. Perlin - Veterans Health Administration: August, 2003
Quality: Prevention Index,
1996 – 2002
100
Prevention Index:
Immunization:
 Influenza Immunization
 Pnuemococcal Vaccination
Cancer Screening:
 Breast Cancer Screening
 Cervical Cancer Screening
 Colorectal Cancer Screening
 Prostate Cancer Screening
Substance Use:
 Alcohol Use
 Tobacco Use
 Smoking Cessation Counseling
80
60
40
20
0
B
e
s
a
lin
e
9
6
1
99
7
1
99
8
1
99
9
2
00
0
2
00
1
*
2
00
2
* Sampling methodology more stringent
J. Perlin - Veterans Health Administration: August, 2003
Annual Influenza Vaccine
Quality:
Influenza Vaccination Rates
100
80
--BRFSS90*---BRFSS--
60
40
20
0
FY 95 4th Qtr 4th Qtr FY 99
97
98
VHA
FY 00
Healthy People 2000
CHG FY 01* FY 02
Iowa 99
BRFSS
* Sampling more stringent; vaccine shortage
J. Perlin - Veterans Health Administration: August, 2003
Immunizations
+/- Mental Health Diagnosis
100
80
67
68
77
81
60
40
20
0
Influenza
With MH dx
Pneumoccocal
Without MH Dx
J. Perlin - Veterans Health Administration: August, 2003
(FY 2001)
Quality: Gender / Age Approp Care
Breast CA
& Cervical CA Screen
100
100
80
80
60
60
--HCUP--
40
40
20
20
0
0
FY 95 4th Qtr 97 4th Qtr 98 FY 99
VHA
NCQA
FY 00
CHG
Healthy People 2000
FY 01*
FY 95 4th Qtr 97 4th Qtr 98 FY 99
VHA
J. Perlin - Veterans Health Administration: August, 2003
NCQA
FY 00
CHG
Healthy People 2000
FY 01*
Tobacco Non-use
 Almost
 FY2000
 FY2001
 FY2002
49%
63%
69%
 HEDIS
(NCQA) Patient
counseled once most
recent visit? 66% CY2000
100
Percent Not smoking (HP)
Not using tobacco (VHA)
100% Screened
 97% Counseled 1x / yr
 VA: Tobacco Use
Counseling 3X / yr
76
70
77
77
73
74
FY2001
FY2002
50
FY2000
VHA (EPRP)


General Population
VHA 4% decrease in tobacco users represents
approximately 184,000 veterans
US Population Non-Use Rate Increasing 0.5% /
yr for past two years
 825,000
Veterans Received
Counseling 3X / yr
 1,136,000 Counseled once
J. Perlin - Veterans Health Administration: August, 2003
Survival after MI
Soumerai SB "Adverse Outcomes of Underuse of Beta Blockers in Elderly
Survivors of Acute Myocardial Infarction," JAMA 1997; 277(2):115-21
Elderly patients who receive beta blockers following a heart attack are
43 percent less likely to die in the first 2 years following the attack than
patients who do not receive this drug, according to a new study funded by
the Agency for Health Care Policy and Research (AHCPR), published in the
January 8 issue of The Journal of the American Medical Association
(JAMA).
The study found that patients who receive beta blockers are rehospitalized
for heart ailments 22 percent less often than those who do not get beta
blockers, (and avoid almost $20,000 in excess health care costs). However,
only 21 percent of eligible patients receive beta blocker therapy.
Researchers found that these patients were almost three times as likely to
receive a new prescription for a calcium channel blocker than for a beta
blocker after their AMI. Eligible patients receiving calcium channel blockers
instead of beta blockers doubled their risk of death.
J. Perlin - Veterans Health Administration: August, 2003
AMI Care Improvement:
Performance Measurement Works
Percent Eligible Pations
Measurement + Accountability
100
80
Measurement
--HCUP--
60
40
Unmeasured
Performance
20
0
FY 95
4th Qtr 4th Qtr
97
98
VHA
NCQA
FY 99
FY 00
AHCPR (NJ)
FY 01
Non-Govt
AHCPR: Soumerai et al. JAMA 1997;277(2):115-21
Non-Govt: Krumholz HM et al. Ann Int Med 1999;131(9):648-54
J. Perlin - Veterans Health Administration: August, 2003
FY02
Impact: QALY’s Saved
J. Perlin - Veterans Health Administration:
August,AB
2003et
Coffield
al. AJPM 2001;21(1):1-9,, 2002
Impact: $ Saved per QALY
J. Perlin - Veterans Health Administration:
August,AB
2003et
Coffield
al. AJPM 2001;21(1):1-9,, 2002
So Many Opportunities,
So Little Time . . .
 Prioritization & Specific Opportunities:
 Clinically Preventable Burden (CPB)
 QALY’s – Cost-Effectiveness (CE)
Coffield AB et al. AJPM 2001;21(1):1-9,, 2002
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
Evolving VA Technology for PatientCentered Care
 Information Model for High-Performance
Health Care
 Provider Perspective
 Patient Perspective
 My Health eVet
 Patient / Community Perspective
 Care Coordination
J. Perlin - Veterans Health Administration: August, 2003
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
VA’s Computerized Patient
Record System . . .
J. Perlin - Veterans Health Administration: August, 2003
Hypertension Control in US
Percent Patient's BP < 140/90
60
50
40
30
20
10
0
VA
Best US
US Avg
J. Perlin - Veterans Health Administration: August, 2003
Health Care is a
Team Sport !
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Reminders
Contemporary Expression of CPG’s:
• Reduces Negative Variation
• Create Standardized Data
• Acquisition of health data
beyond care delivered in VA
J. Perlin - Veterans Health Administration: August, 2003
Quality:
Diabetes Measures
90
A1c
75
A1c < 9.5
60
Ft Exam
Ft Sens
45
Age-Standardized
Amputation Rates
Decreasing
30
15
Nutrition
Smoking
Ret Exam
0
1995
1997
1998
1999
2000
Sawin CT, Walder DJ, Bross DS, Pogach LM, “Diabetes process and outcome measures in the VHA,” Diabetes Care, 1999
J. Perlin - Veterans Health Administration: August, 2003
Better Provider Support:
The New Guidelines . . .
Primary References
Expanded Discussion
Evidence Table
Bullets: Recommendation & Evidence
Algorithm
CAUTION!!!
Task Support VS Task Interference
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
Performance Measures for
Lipid Screening & Mgmt
in Patients with Diabetes
100
80
LDL<130
LDL<120
60
LDL<100
40
Ann Screen
QO Year
20
0
1997
1998
1999
2000
2001 Q2 02
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
 Computerized Provider Order Entry
(CPOE), one of the Leapfrog Group’s
“Top 3 Safety Strategies”
 Outside of VA, CPOE < 8% nationally,
< 30% among Academic Medical Centers
 Nationally, 91% of all VA Rx’s Now CPOE
 Up from 79%, one year ago
 Corporate Performance Measure
 Ultimate Goal: 100%
 VA is the Benchmark for CPOE
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
CMOPs:
Technology at Work
Consolidated Mail Outpatient Pharmacy
 ~200 Million “30-Day Equivalent” Prescriptions /
Year (40K per shift per CMOP)
 Medication Deficiencies: 5.8 sigma
 Wrong Medication: 0.0009%
 Labeling problem: 0.0001%
 Damage in Mails: 0.0014%
 Delays in Delivery: 0.0178%
 Patient
Satisfaction
Rating:
90% VG/E
J. Perlin - Veterans
Health Administration: August,
2003
HealtheVet Desktop &
Care Management
 Care Management:
 New application that displays in the Desktop
 Provides views across patients
 “Electronic Index Cards!”
 Desktop serves as “Dashboard” for scanning
patient results, tasks, notes, events
 Search utility – query for items across patients
 Multiple signature – sign documents across patients
 Additional Options can be added
 Access to BCMA, VistA Imaging, other VistA applications,
commercial applications
J. Perlin - Veterans Health Administration: August, 2003
Patient Display
 Clinician Dashboard:
 Has 4 columns for each patient
 Display of results
 Tasks due
 Admission/discharge events
 Signatures required
 Can Also Create Tasks
J. Perlin - Veterans Health Administration: August, 2003
Care Management: Clinician Dashboard, Results
Abnormal Results
Red Square
Results, Tasks, Events, Signatures
Normal Result
Blue Circle
Acknowledged All
Gray
Acknowledge
Result
Expand or
Collapse
Results
Link Task
Will support “looking” at a panel of patients and
determining status of certain preventive services.
J. Perlin - Veterans Health Administration: August, 2003
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
My Health eVet
 Internet-based, secure Personal Health Space.
 Provides veterans with copies of key parts of their
VA health information (from VistA)
 Veterans can retain, view, and update their
personal health data (BP, Blood Sugar, Wt, etc.)
 Comprehensive, Personalized Health Education
Information
 Personalized Health Assessment
 Activate & Empower partnership with health
care providers in achieving optimal health,
through the sharing of health information
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
“Hey, Doc,
I have Diabetes,
Shouldn’t I be on an ACE
Inhibitor ?”
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
Patient begins to tie together diet
& weight with nutrition
information & blood sugar
&
Understanding of disease from
health education
&
Begins to take control of health
Process changes from
Transactional (making
appointments)
TO
Transformational
(Changing Health Behaviors
& Health)
J. Perlin - Veterans Health Administration: August, 2003
Model for Care Coordination
Optimal Population Outcomes
Community
Health System
Self-management
Support
Informed,
Activated
Patient
Decision
Support
Delivery
System
Design
Productive
Interaction
Prepared,
Proactive
Practice Team
Optimal Patient Outcomes
J. Perlin - Veterans Health Administration: August, 2003
Clinical
Information
System
From Health Care Delivery
To Patient-Centered Care
 Patient-Centered Care Coordination
 Support patients with safe, high-quality care,
in health and disease, at the time & place,
and in the manner patient desires
 Care extends from hospital & clinic to home &
community
 Imperative to Care for an Aging Population
J. Perlin - Veterans Health Administration: August, 2003
CARE COORDINATION
The Clinic (Care Coordinator)
Becomes Aware that the
High-Risk Patient
Is Beginning to
“Get Into Trouble,”
Proactively, The Patient
Is Called To Come Into Clinic
...
Or Visited at Home!
Before S/He “Crashes”
J. Perlin - Veterans Health Administration: August, 2003
VISN 8 Community Care Coordination
Service Program Sites
Lake City
Gainesville
Bay Pines
Ft. Myers
•
Orlando
•
West Palm Beach
•
Miami
•
Patient (not provider) centric
Designed to fill gaps in “system”
Collaboration with providers.
Expands patient and provider
relationship into the home (hometelehealth technologies)
• Successful in Doms and State
Nursing Homes
• Positive med/psyc/soc Outcomes
• Expandable & Reproducible
San Juan
J. Perlin - Veterans Health Administration: August, 2003
Long-Term Care Costs as
Percent of per capita GDP
J. Perlin - Veterans Health Administration: August, 2003
Home-Telehealth Technologies
Flexible Sensor Connectivity
Camera
Thermometer
ECG
Blood pressure
30
9
Pulse O22
Digital Scale
Blood sugar
Stethoscope
The Health Buddy:
Demonstrated Uses
 Single Dialogues
 HTN, COPD, DM, CHF, Cancer
Care, Depression, Chronic pain,
HIV, Hep C, Anticoagulation,
Bi-polar Disorder
 Dual Dialogues






HTN/COPD
DM/CHF
DM/HTN
CAD/Angina
HTN/Hyperlipidemia (Spanish)
CHF/Hyperlipidemia (Spanish)
 Trialogue
 HTN/CHF/DM
J. Perlin - Veterans Health Administration: August, 2003
iCare Desktop Software
J. Perlin - Veterans Health Administration: August, 2003
VISN8 Blood Pressure
Medication Compliance
“In the past 24 hours, have you taken all of your blood
pressure medicines as your doctor has ordered them?”
2%
Yes
98%
J. Perlin - Veterans Health Administration: August, 2003
No
VISN8: Diabetes Care
“Have you checked your blood sugar in the last
24 hours?”
11%
3%
86%
Yes
No
I don't check my
blood sugar
J. Perlin - Veterans Health Administration: August, 2003
VISN8: Diabetes Care
“Have you taken your diabetes pill or insulin in the
last 24 hours?”
0% 4%
Yes
96%
No
I don't take
medication for
diabetes
J. Perlin - Veterans Health Administration: August, 2003
Utilization Outcomes
Services
Care
Coordination
Usual care
Clinic visits
+30%
+15%
ER visits
-36%
+11%
Admissions
-46%
+7%
BDOC
-61%
+8%
Ext Admissions
-47%
+65%
BDOC
-81%
+68%
J. Perlin - Veterans Health Administration: August, 2003
SF 36 V: Chronic Disease
N= 738
SF-36V Quality of Life Measure
Chronic Disease
Sco r e R ang e ( 0 - 10 0 )
80
Baseline
6 Month
70
60
50
40
30
20
10
0
N =>
S ub- s c a le s
=>
744
736
740
735
742
744
727
740
Physical
Functioning
RolePhysical
Bodily Pain
General
Health
Vitality
Social
Functioning
RoleEmotional
Mental
Health
J. Perlin - Veterans Health Administration: August, 2003
SF 36 V Mental Health
N=114
SF-36V Quality of Life Measure
Mental Health
Score Range (0-100)
80
70
60
50
40
30
Baseline
6 Month
20
10
0
N =>
S ub- s c a le s
=>
108
106
109
107
107
107
106
108
Physical
Functioning
RolePhysical
Bodily Pain
General
Health
Vitality
Social
Functioning
RoleEmotional
Mental
Health
J. Perlin - Veterans Health Administration: August, 2003
Clinical Outcomes
Compared to Usual Care, Care Coordination Resulted in . . .
 Blood Pressure Improvement:
 62% greater reduction in systolic bp
(p=0.015)
 38% greater reduction in diastolic bp
(p=0.050)
 Diabetes Care (HbA1c) Improvement:
 Regression analysis showed significantly
greater decrease in HbA1c
J. Perlin - Veterans Health Administration: August, 2003
Rough Mapping of VA
Domains to IOM Aims . . .
 IOM “QUALITY CHASM” AIMS
 VA “DOMAINS”
 Quality (Safe)
 Effective
 Safe
 Access
 Timeliness
 Satisfaction
 Functional Status
 Patient-Centered
 Cost-Effective
 Efficient
 Community Health
 Equitable
J. Perlin - Veterans Health Administration: August, 2003
Setting the Benchmark . . .
Closing The Quality Chasm
Comparable Measure (% Pts):
Advise Smoking Cessation Annually
Beta Blocker, D/C post-MI
Breast CA Screening
Cervical CA Screening
Cholesterol Screening, All pts
Cholesterol Screening, post-MI
LDL Cholesterol < 130 post-MI
Colorectal CA Screening
Diabetes: Hgb A1c in past year
Diabetes: Poor Control (A1c>9.5)
Diabetes: LDL Measured
Diabetes: LDL Controlled <130
Diabetes: Eye (retinal) Exam
Diabetes: Kidney Function Assessed
Immunization: Influenza, > 65 yrs
Immunization: Pneumococcal, >65 yrs
Mental Health F/U < 30 days of inpt D/C
VA 01
93
94
80
89
88
89
71
60
93
20
91
68
66
72
73
79
84
VA 02
>95
97
80
89
91
NA
69
64
94
17
94
64
72
78
68
81
NA
MA/MC
NA
83/89
55/74
60/NA
44/71
NA
NA
NA
68/82
55/33
NA
NA
43/63
38/45
NA
NA
55/59
J. Perlin - Veterans Health Administration: August, 2003
Best Reported
66 (NCQA 2001)
94 (MMCP 2001)
75 (MMCP 2001)
80 (NCQA 2001)
73 (BRFSS 2001)
77 (NCQA 2001
59 (NCQA 2001)
59 (BRFSS 1999)
86 (MMCP 2001)
37 (NCQA 2001)
87 (MMCP 2001)
50 (NCQA 2001)
69 (MMCP 2001)
46 (NCQA 2001)
65 (BRFSS 2001)
60 (BRFSS 2001)
73 (NCQA 2001)
Evidence, Measurement,
Technology & Accountability
 2002: Leadership by
Example recognizes VA’s:
 Clinical Performance
Improvement
 Performance Measurement
 Information Technologies
 Health Services Research
 Patient Safety
Strategies for the Future . . .
J. Perlin - Veterans Health Administration: August, 2003
From “Just in Case” to
“Just in Time”
 Health care in the past
decade moved from
hospital to clinic
 Health care in the current
decade moves from clinic
to community
 New Model: From
Preventive to Prospective
Care
J. Perlin - Veterans Health Administration: August, 2003
J. Perlin - Veterans Health Administration: August, 2003
For Health Care & For VA
Need to think broadly about
prevention:
 Classically, to prevent avoidable disease, disability
& early death
 Expansively, to support function, functional
independence, and success in negotiating challenges
of chronic disease and aging
 Goal for the 21st century: Safe, Effective, and
Patient-centered Health Care . . .
98