Transforming Health Care

1. Crossroads
Transforming Health Care Delivery with
Informatics: A perspective from the
Massachusetts General Hospital (MGH)
Henry C. Chueh, MD, MS

2. Coming up...
Introduce the problem
Suggest a theme to solutions to the problem
Provide a brief description of MGH
Describe our path through stories about tools
Revisit the theme

3. One Day in the Life of a PCP
Hours needed to manage 2,500 patients...
6.0
10.6
7.4
Chronic disease (10 Dx) Prevention Free
Yarnall KS, et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635
Ostbye T, et al. Is there time for management of patients with chronic diseases
in primary care? Ann Fam Med 2005; 3:209

4. “Computerized clinical information systems
will help physicians close this quality gap
by performing many of the repetitive,
protocol-driven tasks.” (McDonald, conveyed by the
"the burden of harm 1976)
collective impact of all of our health
care quality problems is
“The current care staggering" (Chassen et al., 1998)
systems cannot do the
job...trying harder will not work...changing
care systems will.” (IOM, 2001)
"Our recovery plan will invest in electronic
health records and new technology that will
reduce errors, bring down costs, ensure
privacy, and save lives." (Obama, Feb 2009)

6. supply
Lack of time Flawed process
demand

8. CDSS

10. MGH Primary Care
(at MGH)
IMA
WHA
Everett Revere (2) BMG
MGH West
MWI
Charlestown
Chelsea (2)
(near MGH)
Downtown
Beacon Hill
MGMG
Senior Health
Back Bay
NECHC
MDs = 178 • FTEs = 101 • Practices = 15 • Patients = 155,590

11. IT infrastructure at MGH
Online registration and scheduling
Outpatient electronic health records and e-prescribing
Clinical data repository for results and reports
Inpatient provider order entry
Patient portal

13. Information “push”
Decision support in diabetes
Visit
(A1C, SBP, LDL)
patient
1 info
primary care provider
nd
me
om
rec
2 info
nurse care manager
Modest improvements in process outcomes only

14. Patients don’t always come in for clinic visits.
Clinic visits are busy.
Providers are good at deciding, but bad at doing.

15. Getting there from here
Loyalty cohort: Connectedness
FastTrack: Enhanced CDSS/SSCD outside visits
ACCORD: Involving patients

16. Who are my patients?
Visit to registered PCP
Repeated visits to a specific practice
Age and home address as variables

17. Connection Status
PCP connected Practice connected Not connected
6%
34%
59%
n = 155,590

18. MGH Preventive Metrics
PCP Linked Practice Linked
85
P<0.0001 P<0.0001 P<0.0001
68
Percentage (%)
51
34
17
0
Mammography Pap Test CRC Screening
(n=35,865) (n=65,860) (n=37,605)

19. MGH Disease Metrics
PCP Linked Practice Linked
90
P<0.0001 P<0.0001 P<0.0001
72
Percentage (%)
54
36
18
0
Diabetes A1C Diabetes LDL CAD LDL
(n=9,632) (n=9,632) (n=6,612)

21. A patient-tailored information letter
A hard copy Rx, to be signed
Automatic electronic documentation
A 6-week reminder timer

22. Results

23. Breast cancer screening
PCP/screened Practice/screened
Practice/overdue PCP/overdue
11%
9%
15%
64%

24. Mammography FastTrack
Decision support in breast
cancer prevention
population info
patients primary care physician
Outside the Visit
action
care delegate

25. Mammography FastTrack:
6-month results
Intervention Control
30.0
P = 0.01
Completion rate (%)
P = 0.01
22.5
P = 0.02
15.0
7.5
0
All Patients MD-Linked Practice-Linked

27. A Fragile Loop
Awareness of Issue
Risk assessment
Follow-up
?
Plan for care
Complete care

28. Follow-up
1/3 have no system, <1/3 satisfied with system
Patients want communication
Lack of documentation
Lack of patient understanding

29. ACCORD
Ambulatory Care Compact to Organize Risk and Decision-making

33. ACCORD characteristics
Patient-Provider preferences
Explicit agreement with documentation
Fail-safe monitoring
High visibility

34. CDSS
SSCD

35. challenges. tools.
Continuous, not visit-based
Population-based
Patient-provider preferences