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