Comparing Lessons from Two Health Systems and Two Projects
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Kate Bukowski ProCare Health Limited (Friday, 3.00, Innovation in Practice 3) Explores two domains which, on the surface, may seem very different – the US policy directing metrics to measure HIT adoption across the nation and the implementation and utilisation of a practice management system auditing tool (Dr Info) within a region of New Zealand’s general practices. Yet, when looked at under a different view, there are similarities which drive the use of HIT to improve results that engage patients in self-management of their health and clinicians in population health management. Both can improve the delivery of healthcare and provide value for money but both also need support and systems that foster innovation at a patient and practice level. This will continue to be an issue as the health workforce ages and becomes smaller. It is therefore crucially important how we utilise and train our workforce, that they have HIT systems that support their work with the approach that through showing results and improving results, clinicians will engage and want to use the technology to improve their practice. At the same time patients will need support to self-manage their conditions through the utilisation of patient portals and other innovative HIT initiatives.
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Comparing Lessons from Two Health Systems and Two Projects
- 1. Comparing Lessons from Two Health Systems and Two Projects
- 2. Presented by • Kate Bukowski • Project Manager, Health Promotion and Workforce & Strategy • ProCare Health Ltd. • Email: kateb@procare.co.nz • Phone: +64 21 984 070 • LinkedIn: http://nz.linkedin.com/in/katebukowski Liz Schoff Director, Business Intelligence Orion Health Email: liz.schoff@orionhealth.com Phone: +64 21 496 801 LinkedIn: http://nz.linkedin.com/in/city4liz
- 3. and
- 4. Differences New Zealand United States
- 5. Commonalities Wal Footrot Homer Simpson
- 6. Innovation If ever a field needed a makeover, it's medicine. Chaotic, expensive, inefficient, and often ineffective, health care is dying for innovation.’ 1. Gardner Morse, Harvard Business Review; 2011
- 8. Clinical Problem • Change management and health IT • Secondary healthcare implements change through large management structure • Primary care less resourced to support change • Patients also need to adapt to new health IT • Electronic records • New recall methods • Patient portals
- 9. Population Health in Primary Care POPULATION HEALTH MANAGEMENT IN PRIMARY CARE
- 10. Population Health • ‘… making use of demographic and health needs data to plan clinical programmes • … also involves promoting health above and beyond diagnosing and treating illness’ Winnard, Crampton, Cumming, Sheridan, Neuwelt, Arroll, Dowell, Matheson & Head (2008).
- 11. Barriers for Clinicians Barrier 2010 (N=226) Insufficient time 79.1% (n=167) Limited access to a computer with ‘Dr Info’ to 30.3% (n=64) audit PMS for follow-up or recall Computer skills insufficient to use an IT system 31.8% (n=67) to monitor population Too few nurses to provide healthcare in clinics 55% (n=116)
- 12. DrInfo 2010 rollout User friendly Quick updates Identify and target hard to reach populations
- 13. GeoCoded Maps
- 14. Population Health Management with ‘Meaningful Use’
- 15. Metrics US ‘Meaningful Use’ Approx 50 metrics Change Management Adoption Best Practice Patient Engagement Personalised Education Resources, Reminders, Electronic copies Timely online access to records
- 16. Adoption 42,000 registered to obtain funding (June 2011) 100,000 primary care physicians have signed up with Regional Extension Center to get assistance for implementing EHRs (30%) 2011-2012 2013 2015 • Data • Advance • Improved capture & clinical Outcomes sharing processes
- 17. Lessons Shared & Future Directions SHARING LESSONS
- 18. Shared Lessons • Better population heath • Identifying and recalling management patients • Meaningful use of data • Access and time for HIT • Use then improve, then • Workforce capacity measure outcomes building Clinicians’ meaningful use of health IT Patients’ understanding of and accessing to health IT
- 19. Future Directions Development of health workforce IT skills Using health metrics to improve population health Improved health outcomes through patient health literacy and self management using IT
Notes de l'éditeur
- Thank you for coming to our presentation today.Today we are going to talk about two health system – the US and NZLooking at examples from how to measure meaningful use of dataAnd the rollout of DrInfo a patient management system auditing tool for general practice.
- This presentation will look at two case studies in the US and New Zealand.It will compare and contrast and discuss lessons learnt.
- Liz:It might be easy to think about the differences between New Zealand and the US.Obvious is SIZE NZ fewer than 4.5Million; US has seventy times this number – 300,000 million. NZ around 200 hospitals, 26,000 beds, 6.2 per thousand; US has about 30 times as many slightly fewer than 6000 hospitals – and nearly 1 million hospital beds (950,000) 3.6 per thousandDifferent health systemsNZ – has public health system – substantially funded through the government; US has private or payer health system (CMS funds 30% of health care expenditure)My partner, is Kiwi was living in the US traveled to NZ – hurt his foot, covered by ACC as a NZ citizen.I, as a US citizen living in NZ, buy medical insurance when I return home for visitsNZ – regulatory environment for HIT is different than in the US, where products like Orion Health Rhapsody are now registered as a ‘medical device data system’ or EHRs are ‘certified’ (David B)NZ – National registries for immunisations, breast screening programs, National Health ID – US is a federated country – health care traditionally managed at a state or even regional level*** COULD look at these differences and use them to DIVIDE and SEPARATE us, nothing is relevant, but we could put on another pair of glasses, and observe our commonalities within the context of our differences …What do we have in common, well – we both have character – or more specifically – characters -
- KateThough nations such as New Zealand, United Kingdom, Canada, and US have fundamental differences in their health systems, their national health plans increasingly focus on a consistent set of common needs – -improving patient safety caring for an ageing population Agrowing incidence of chronic conditions. As well as an aging workforce rapidly changing technology that clinicians need to adapt to and adopt.providing more services with fewer resources, doing less with moreThese common issues are evident in the similar use of health information technology to address these problems. For example, the use of a clinical portal to share a patient’s longitudinal record is an innovation which has been adopted by all of these nations. Meaningful use in primary healthcare may mean general practice using coding systems (such as READ) to record things like smoking status of patients and audit patient management systems to see which patients need to be engaged in screening activities in a systematic way that improves clinical quality.
- LizWhy is this innovation in practice in a health care context ?Health informatics is not just about technology – Also about understanding, use or sharing of information to promote healthThe Latin root for innovation means ‘to renew’ or ‘to change’. Looking to renew or change health care systems – ask ourselves – how can we do this by having a greater understanding, use or sharing information in a health care context?This isn’t about commercial partnership of our employers, working collaboratively on the same project, primary care or secondary care sector – it’s about two people who are passionate about health informatics sharing our respective experiences and seeing what we can learn from each other – Of course there are differences, but also, what are the commonalities? What can we learn?
- KateWe are now going to have a look at 2 issues in 2 different setting.This has been a conversation between Liz and I for the last few months because of our interest in comparative health systems, quality, and change management and ofcourse health IT.We will first discuss the NZ case study –from primary care And then the US case study – from secondary care
- KATEEven within health care systems, innovation implementation has some level of uniqueness and customisation to fit a local need. Both primary and secondary health care providers have implemented electronic health records However:Secondary healthcare can implement change through large management structures, and invest in training that will support HIT utilisationPrimary care depends on small businesses adopting, implementing and utilising new HIT systems in time poor environments that can be seen to detract from clinician time with patients.Patient also have things that they need to adapt to eg a clinician using more health IT in the clinical session. We know that this can be done well, in a way that can engage the patient, and poorly, that detracts from the clinical alliance. But there are HIT tools that are being used in primary care that can engage patients for egmental health screens, heart forecast tools (uses BP and cholesterol, and family hx to calculate the risk of a patient getting heart disease) And tools like GP’s Patient dashboards can be filled out with the patient to engage patients in conversation about their health (BMI, smoking status, alcohol consumption etc)- And being recalled by text messaged, email etc and patient portals. To navigate healthcare, patients need a high level of health literacy to be able to convey what they think they want and need, often in time poor environments.LIZEmphasize the need for bringing patients into our problem domainHow can we solve health system problems without heavily leveraging our largest stakeholder group?PCEHR in Australia is using one approachIn US, Blumenthal mentioned the MU metrics which include information to improve patient health awareness and literacyAs a health IT software vendor, we are seeing more and more of our customers asking us about our patient portal capabilities** With this as the clinical portal domain – what are our experiences?
- KateGeneral practice has been tasked with taking a population health approach. This means targeting at risk group, linking general practices with their communities and service provider that can assist the patients and their practice are important ways in which general practice can improve population health. Taking a population health approach within a PHO means making use of demographic and health needs data to plan clinical programmes in partnership with the communities served. delivering services in a variety of community settings to improve access taking account of health inequalities and how these might best be reduced. It also involves promoting health above and beyond diagnosing and treating illness. This means engaging patients before they fall off practices registers, keeping up with routine screening and immunisation and doing more health promotion to support patients wider determinants of health.
- KateIn 2010 I managed a population health project as part of my role at ProCare Health Ltd. ProCare is a primary healthcare organisation which serves over 850,000 patients enrolled at approximately 200 general practices in the wider Auckland region.At the beginning of the project an online survey of practice staff was done to see what the barrier to taking a population health approach was:the biggest barrier to practices using new HIT systems were existing work volume patient management systems being see as time consuming and as taking clinicians away from face-to-face clinical work. Frequently, it appeared that the general practices who had adopted population health auditing systems such as Dr Info were also the employers of nurses who were motivated, and had undertaken postgraduate education or other focussed training. This group, perhaps because of the data they were using, appeared to have a better knowledge of their practice’s enrolled population.The barriers to delivering a population health approach were seen to be insufficient time (79.1%), too few nurses to provide healthcare in clinics (55.0%), computer skills insufficient to use an IT system to monitor population (31.8%), limited access to a computer with Dr Info to audit PMS for follow up and recalls (30.3%). It could be proposed that even when practice staff has access to population health auditing tools such as Dr Info, there are sometimes insufficient computer skills to use the tools to monitor and population health. This can be attributed to an aging workforce, clinicians not using HIT systems regularly in their workday and there not be enough time for clinicians to develop and maintain their HIT skills.
- A solution to this was seen to be DrInfo, a patient management system auditing tool that allows practices to go online and see which patients need recalling, who is about to fall off their register In July 2010, ProCare Health Ltd funded the rollout of DrInfomember practices.DrInfo was seen as an easy solution for practices in time poor environments A quick way of identify and target patients who needs recalling working towards their PHO performance health targets and improve quality
- Geocoded mapsOther health workers can use DrInfo to see which localities need interventionsWhere to but a breast screening busWhere to do CVD risk assessments in the community
- David Blumenthal gave some explanation to MU approach yesterday, show how metrics are being used to improve adoption, best practice and health literacyEvolutionary process, metrics are categorized in a way that any practioner eligible for funding should be able to find an applicable metric in any of these 6 categories.Many metrics focus on change management aspects. Adoption: Quite a bit of research showing use of Computerized Physician Order Entry systems reduce redundant orders, more likely to reduce medication errors and improve likelihood of receiving an alert. Some metrics ask ‘are you using it?’ Best Practice – Research and guidelines are available to recommend best practice, some metrics, such as regular use of eye or foot exams for diabetic patients ask the question, ‘are you following a guideline?’First stage of metrics puts the onus on the clinician to begin the patient education process – metrics that ask are you giving education, moving to – are you giving online access? Doesn’t require a patient portal, but facilitated by a patient portalMany of the Meaningful Use criteria establish benchmarks which encourage evidence-based, best practice guidelines. Metrics have financial incentive benchmarks, but also display in comparison to other individuals, organisations or geographical districts. How am I doing compared to….
- Adoption of electronic health records in the US – LIZIs it working?42,000 registered – intend to – only a few thousand have (need 90 days of meeting requirements) – expected push at end of year100K have gone to 62 REC for assistance – RECs are funded groups whose role is to sign up & assist with implementation (70% rural – Blumenthal50% are small practices:small private practices (38 percent) or small practice consortia (12 percent). anticipated outcomes, such as improved patient safety, better management of chronic conditions and increased engagement with patients, has yet to be shown. ** yesterday the question was asked – ‘is this just creating a checklist culture to tick a box?’ Start of this process.Studies have shown that it can take as long as two years or more to be able to measure the anticipated improved outcomes of HIT. (Spalding, 2009) While the US government has reported an increase in the adoption of HIT, studies providing evidence of the value from HIT continue to prove challenging in the short term.The Health and Human Services Department has announced that it intends to conduct surveys of patients and providers to better understand the perceptions around the use of EHRs. MU: Meaningful Use DefinedMeaningful use is using certified electronic health record (EHR) technology to:Improve quality, safety, efficiency, and reduce health disparitiesEngage patients and familyImprove care coordination, and population and public healthMaintain privacy and security of patient health informationUltimately, it is hoped that the meaningful use compliance will result in:Better clinical outcomesImproved population health outcomesIncreased transparency and efficiencyEmpowered individualsMore robust research data on health systems
- Liz and KateLizUS focus is on better population health patient management – particularly by encouraging the meaningful use of data – starting with a check list, but directionally headed towards measuring outcomesEvolutionary – start with just using it, then look at improving, then look at outcomes – early focus on clinicians, beginning to think about patients KateIn New Zealand, health workforce capacity is going to become an increasingly pressing issue. Based on feedback from the Dr. Info implementation for identifying and recalling patients there needs to beaccess to computers for general practice staff and training for clinicians to have the computer skills they need could be one way to support general practice to manage their population’s health. However time and resources are needed to enable this. What these implementations shared was supporting the clinicians in their meaningful use of HIT andEncouraging patient understanding & access of HIT
- KateThe health workforce also needs to be supported to adopt HIT and utilise it so that they can follow best practice guidelines and engage patients in education, reminders and information about their health. This may include additional computer training and availability to those already utilizing HIT or transforming models of care by extending further into the community for long-term condition management. Nurse clinics, that have HIT systems that support population health management, could be one potential way of addressing this issue. Nurse clinics could support patients with long-term conditions (such as diabetes, cardiovascular disease or HIV in some areas.) LizRegardless of the specific approaches used by health systems to improve population health metrics are a common tool used to gauge the effectiveness of HIT. Understanding how to tie metrics to outcomes – whether it is adoption, best practice adherence or patient engagement, is important.KateNew Zealand has low levels of health literacy even though there is a high level of literacy.The advantage of improving health literacy is that it can enable and empower patients to make the optimal health decisions for themselves. Health literacy can also decrease patient risk factors, increase self-confidence and self-efficacy.Patients are going to need to be supported to self-manage their long term condition and improve their health literacyuseonline patient portals and other HIT tools that can support their health
- Our paper provided review of two case studies from disparate health systems – and yet, they are both approaches to using metrics to meet health targets and improve quality. Kate and I didn’t work on the same project, we don’t work for the same company, but we found common ground to share our experience and observe what we could learn.We would like to offer a call to action for everyone attending this year’s conference to move past boundaries that are a reflection of differences, and put innovation into practice by looking for commonalities. If you haven’t already met three people at this conference whom you have learned from, we would encourage you to make the most of the afternoon tea and wrap up sessions to do a little speed networking.