Transcript Using Decision Support Effectively: Lessons from the Field Indian Health Service

Indian Health Service
Using Decision Support
Effectively:
Lessons from the Field
Lisa Dolan-Branton, RN
Indian Health Service
Office of Information Technology/Chronic Care Initiative
AHRQ 2007 Annual Meeting
•Indian Health System Setting
•IHS Resource and Patient Management
System
•Clinical Decision Support in RPMS
•Key Elements of a responsive HIS
(so clinicians use it with every patient)
Presentation Overview
Mission: to raise the physical, mental, social, and
spiritual health of American Indians and Alaska
natives to the highest level.
Goal: to assure that comprehensive, culturally
acceptable personal and public health services are
available and accessible to American Indian and
Alaska Native people.
Mission and Goal
IHS
33 Hospitals
49 Health Centers
46 Health Stations
Tribal
15 Hospitals
198 Health Centers
121 Health Stations
180 Alaska Village Clinics
34 Urban health care services and resource centers
1.8 million users (Federally Recognized Tribes)
56% AIAN rely primarily on IHS funded care (2000 census)
$3.1 billion from FY 2006 Appropriations
$628 million from Third-Party collections (2004)
The Indian Health System
IHS APPROPRIATIONS PER CAPITA
COMPARED TO OTHER FEDERAL HEALTH
EXPENDITURE BENCHMARKS
6,168
Forecast
to 2004
$6,000
$5,000
5,454
5,184
1999
2001
2004
3,965
3,832
3,753
$4,000
IHS
2003
1999
1999
$3,000
2,101
Year of
Last
Published
Data
$2,000
2004
Medical
Care
$1,000
500
Nonmedical
$M edicare
Expenditures per
Enrollee
M edical Care for
Veterans
Administration
Users
US Per Capita
Expenditures for
Personal M edical
Services
M edical Care for
Federal Prison
Inmates
M edical Care for FEHB M edical Care IHS Appropriations
M edicaid Enrollees Benchmark per IHS & Collections Per
User
User
* Census 2000, One race (AI/AN) alone
WA
NH
VT
MT
ND
ME
MN
OR
ID
SD
WI
NY
MI
WY
CA
NV
IA
NE
PA
IL
UT
IN
NJ
OH
WV
CO
KS
MO
DE
VA
KY
MD
NC
AZ
TN
NM
OK
AR
SC
AL
TX
AI/AN Population
by State, 2000
GA
MS
100,00 to 333,400
LA
FL
AK
50,000 to 99,999
10,000 to 49,999
1,713 to 9,999
HI
American Indian and Alaska Native
Population By State
COMMUNITY ORIENTED
PRIMARY CARE
Cultural & Spiritual
Behavioral & Social
Medical Care
Public Health
Water & Sanitation
The Indian health care system is built on a broad spectrum approach to health. It
starts with a base of fundamental public health and sanitation infrastructure. It
provides inpatient and ambulatory medical services. It also integrates
community-oriented programs promoting healthy behaviors and lifestyles.
COMMUNITY ORIENTED PRIMARY CARE
HAS REDUCED AI/AN MORTALITY
25
12.8
Suicide
American Indians
& Alaska Natives
25.9
Pneumonia & Influenza
20
27.2
Alcohol-Related
31.2
Cerebrovascular
15
US All Races
54.3
Homicide
56.4
Accidental
10
64.0
Maternal Deaths
US White
66.0
Infant Deaths
5
76.0
% Decrease in Mortality
Rates since 1973
02
20
93
91
89
87
85
100
83
80
81
60
79
40
77
20
19
0
0
75
80.8
Tuberculosis
73
Cervical Cancer
Infant Mortality Rates
1973 – 2002
(25.0 to 8.5/1,000)
66% Reduction
Resource Patient Management System
(RPMS)
Indian Health System
Spectrum of CIS Use
•
•
•
•
•
No RPMS
RPMS PCC with paper charts and
centralized data entry
PCC+ with centralized data entry
Partial use of EHR or other Electronic
Medical Records
Fully implemented EHR
•Order Checks
•Med orders are checked for drug-drug
interactions and allergies
•All orders are checked for duplicate
orders
•Prescribing Restrictions / Guidance
•Prescribing guidelines in pharmacy
package accessible to prescribers (see
screenshot)
Decision Support in EHR
Oral Contraceptive Help
•Info Button
•Customizable links to web pages from POV
(diagnosis) and Patient Ed components
•Can be configured to insert selected text into web
site’s search function
•Reminders
•National or locally created
•Health maintenance or condition-driven
•Reminder Dialogs enable simultaneous resolution
of reminders (orders, education, etc.) and
documentation
Decision Support in EHR
(cont’d)
Supports Web Link Information button on POV
and Education components
EHR v1.1
Immunizations due
Weight, Height, BMI
Blood pressure
Allergies
Current medications
Patient Wellness Handout
Patient Wellness Handout
26 IHS health centers implementing EHR between
June 2003 and December 2005
69% federally operated, 31% tribal health centers
Mountain – 58%
Pacific – 19%
West south central – 12%
South atlantic – 8%
West north central – 4%
Median number of physicians per clinic: 5.0 (IQR 2-19)
Median number of NP/PA per clinic: 2.0 (IQR 1-6)
EHR Physician Study Setting
Agreed (%)*
EHR helps to improve quality of care
35
EHR helps to improve patient safety
36
EHR decreases quality of physician-patient
interaction
39
60
EHR creates less time to talk with patients in
the office
Impact of EHR on Quality
* At least 4 on a 5 point Likert scale
Use of Key EHR Functionality
iCare: Population Management GUI
iCare - Pre-Planning
iCare - Patient Panels
iCare - Flags
iCare - Panel Outcomes
•Documentation of individual and group encounters
•DSM IV-TR Axis I – V Diagnostic Coding
•Treatment Plans
•Case Management Information
•Suicide data collection
•Ability to document non-direct patient care activities
such as community education, Performance
Improvement, clinical supervision, training, etc.
•Robust reports module: workload, case management,
condition-specific
RPMS Behavioral Health
Applications Functions
Future Clinical Decision Support
Key Elements of Responsive CDS
•
•
•
HIT solution can drive improvement at each patient visit
Vision of a HIT system that provides you with the ability to
manage patients, communities and populations within your
mission context
Value of requirements development with Clinicians
•
•
•
Clear and specific requirements that put the clinical and
public health needs at the center of the specification and
programming process
Rapid cycle development
Like a good community organizer—becomes background
noise
•
It’s not about IT
QUESTIONS?
•
QUESTIONS?
Lisa Dolan-Branton, RN
[email protected]