Collaborative care for
chronic illness and
information
technology
Introduction
AcademyHealth 2005
David A. Dorr, MD MS
OHSU
Objectives



State of collaborative and chronic physical
and mental illness care
Framework for collaborative care and
Information Technology (IT) use
Successes and challenges
Chronic illness care: problems

Underuse


Misuse


Effective treatments for chronic illness care only
given 54% of the time.
Preventable, injurious outpatient AEs occur in 19% of patients.
Overuse

Up to 30% of treatments provided for some
illnesses (low back pain) are inappropriate.
Terms from Chassin MR. JAMA. 1998; Sources: EA McGlynn,
NEJM; Rothman, Annals; Wennberg; Forster, 2003; Dorr 2004.
Chronic illness care: VA
transformation
Chronic disease
100
% adherent
VA
Medicare
75
50
25
0
Diabetes testing Diabetes control
Jha 2003.
Hypertension
control
Root causes of problems with chronic
illness care

Culture / History





“Tyranny of the urgent”
Art and craft of medicine
Complexity
Individual versus
population focused
Financial
Root causes: information based
12000
12000
first RCT published: 1952 (Daniels and Hill in the British Medical Journal,
comparing treatments for tuberculosis)


Enormous
Challenging to find
first five years (66-70): 1% of all RCTs published from 1966-1995
last five years (91-95): 49% of all RCTs published from 1966-1995
10000
(Medline search as of 1 June 98)
8000
6000
6000
4000
4000
2000
2000
0
0
Year
Chassin, Mark R. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4)

Lacking

In the wrong form

Difficult to communicate
10000
8000
19
6
19 6
6
19 7
6
19 8
6
19 9
7
19 0
7
19 1
7
19 2
73
19
7
19 4
7
19 5
7
19 6
7
19 7
7
19 8
7
19 9
8
19 0
8
19 1
8
19 2
83
19
8
19 4
8
19 5
8
19 6
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
93
19
9
19 4
95
Information/knowledge
needed is
Number of RCTs

Information system: definition

Any system to store / retrieve / display /
aggregate / or otherwise touch information

Not just computers or charts in broad sense

Our focus is primarily on computer-supported
information systems
Information System domains (IOM)

Health information /
data

Communication and
connectivity

Results management

Patient support

Order entry

Administrative process

Decision support

Reporting and
population health
More successes

Results management

Chronic conditions
Medications
Preventive care summary
Patient worksheet
Pertinent labs

Order entry


Corollary orders and
order sets improve
safety, can reduce cost,
and improve outcomes.
Savings of up to $44
billion dollars per year.
Wilcox 2005; CITL report 2003.
Pertinent exams
Passive reminders
Organized by illness
Individual categories: successes

Decision support

30-66% improvement in adherence to preventive
care and acute care guidelines.


But … chronic illness has mixed results.
Patient support

Congestive heart failure
IT and domains: hierarchy

Access




Best Practices



Communication



Health information / data
Results management
Order entry
Decision support
Communication and
connectivity
Patient support
Administrative process
Reporting and population
health
Care management packages to Improve
Quality of Care: Information System focus

Chronic Care Model

Hartford / Intermountain Health Care generalist
care management

Disease management

Veterans’ Administration transformation
QUERI (reTIDES, EQUIP, PAS, CHIACC)
Improving Care for Chronic Illness
Community
Health System
Resources and Policies ------ Organization of Health Care
SelfManagement
Support
Informed,
Activated
Patients &
Caregivers
Delivery
System
Design
Decision
Support
Collaborative
Care
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
From: E.H. Wagner & RWJF Improving Chronic Illness Care Initiative
Generalist care management system
Care management
Referral
- For any condition or need
- Focus on certain
conditions

Care manager
- Assess & plan
- Catalyze
- Enact
Technology
- Access
- Best Practices
- Communication
Evaluation
- Ongoing with feedback
- Based on key process
and outcome measures
Improvement in diabetes, depression, and
congestive heart failure outcomes.
Dorr et al, HSR, in press; Dorr et al, Disease management, in press.
Disease management


Companies external to health workers
provide

Technology (e.g. monitoring devices)

System (e.g. 24 hour nursing support)
To reduce utilization and cost.
Final thoughts

IS use can help solve chronic illness
performance issues.

Advanced information system use only 1525% in US, and still difficult to know what will
work.

Financial, implementation, and workflow
barriers significant.
Thanks!





Amy Cohen, PhD
Adam Wilcox, PhD
Laurie Burns
Paul D. Clayton, PhD
Larry Casalino, MD PhD