# Presentation: 940554

## New model research for PBRNs?

- a report from CaReNet

- Douglas Fernald, Anne Kinney, Elizabeth Staton, Bennett Parnes, Wilson Pace, Debbi Main

- Grant #R21 HS14871-01

## The Call for Practice Redesign

- Institute of Medicine
- Chronic Care Model
- American Academy of Family  Physicians
- American Academy of Pediatrics
- American College of Physicians
- American Osteopathic Association

**Notes:**
Crossing the quality chasm
Future of Family Medicine
Joint Principles on Medical Home

## New Model Practice Elements

- Patient-centered
- Shared information
- Continuous relationship of care
- Focus on quality improvement
- Advanced information systems
- Work with the community
- Proactive

**Notes:**
Crossing the quality chasm
Future of Family Medicine
Joint Principles on Medical Home

## How can PBRNs help practices ... ?

- Be patient-centered
- Share  information
- Build continuous relationship of care
- Use advanced information systems
- Focus on quality improvement
- Work with the community
- Be proactive

## Why PBRNs?

- Relationships with practices
- Resources...
- Analytical expertise
- Methodological expertise
- Funding
- Shared learning
- Community links (maybe)

## Why not PBRNs?

- Research “overhead”
- Short-term research focus
- IRB or HIPAA concerns/burden
- Mismatched interests
- Intermittent funding streams
- Different timetables

## One attempt...	

- A DIABETES REGISTRY QI PROJECT that is...
- Bi-directional
- Patient-centered
- Automated
- Persistent
- Scalable

## One attempt...	

- A DIABETES REGISTRY RESEARCH PROJECT that is...
- Inconspicuous
- Practical
- Congruent with QI objectives
- Robust in evaluation
- RE-AIM
- Aligned with new model principles

## Why registries?	

- Widely recommended...
- but not widely implemented
- In a recent study, 53% of primary care practices had any disease registry
- Of these, half had the ability to query and sort subpopulations by clinical priorities

**Notes:**
Graham Center policy statement – in press.

## CaReNet Registry Design Principles

- Patient-centered
- All patients with diabetes are “enrolled” in the registry
- Provides feedback to patients
- Provides feedback to clinicians
- Information sharing for building continuous care relationship
- Clinicians get patient self-management data
- Patients get clinical data 1 week before a visit
- (we get research data )

**Notes:**
when I talk to people about this project, many often use  traditional research terms such as 'enrolled' and 'eligible'-  
it's sometimes difficult to tell people that ALL people are INCLUDED if they have a icd9, etc. etc.- 

kinneya	5/7/2007
add in the heading for building continuous relationships of care-  patients get clinical data-  note that patients get their summary the week before each scheduled visit-  their doc gets one, too!

## Registry Design Principles

- Advanced information systems
- Automated population of registry (no manual data entry for clinic staff)
- One database; multiple data sources
- Focus on QI
- Help practices understand care of their diabetes patients
- Improve outcomes of patients?

**Notes:**
kinneya	5/7/2007
I'm sure the hope is that patient outcomes are improved, but that will probably be difficult to see in just a year, although there are probbaly several ways to look at that, but anyway-  off the top of my head, I've heard things from cilnics and patients such as, 'yes, the yellow paper (pt. profile)- I brought it in to my doctor, and he/she looked at it, and it reminded them to do _____(foot exam, get a test for microalbumin).' 

## INFORMATION FLOW MODEL

## Slide 13

## Slide 14

## Results to date

- Data from 3 primary care clinics
- Identified 673 patients with Type II diabetes
- 217 (32.2%) responded to invitation to participate in self-report portion
- 82 (33.6%) have completed baseline surveys
- 68 have completed at least 1 follow-up survey

**Notes:**
Anne’s notes:
Went from 695 to 673-  we took out those 3 minors from the denominator, and took out a group of people who only had 1 250.xx code, after I reviewed the charts to make sure they didn’t have type II.  (you can delete that note, just letting you know why I’m decreasing that #).

## Results to date

- About half choose paper to complete the survey
- 20% chose web, about 10% choose IVR- a little over 20% decline
- Paper users have the best response rate within their group- 60.4% return the survey (33.3% web, 14.3% IVR)

**Notes:**
I added this slide (Anne)
All patients (with valid addresses- I can get you this # if you really want it) have received at least one patient profile in the mail- 
we’ve sent 343 patients (as of 4/3/07) profiles based on their next appointment- most have had only 1 appointment
People w/o appointments get a call if no appnt w/n the past 120 days (58 people as of 3/15/07)
Other recv’d a profile in the mail as non-responders

#visits	n	%	
1		124	36.2%	
2		92	26.8%	
3		48	14.0%	
4		32	9.3%	
5+		47	13.7%	

## Successes

- High enthusiasm among clinicians and staff
- Refinement of processes with practice input
- Refinement of algorithms to ID patients and cleaning of registry
- Business Associate Agreement
- HIPAA and consent waived
- Patients have brought in reports (triggered action)

**Notes:**
how we modified with input from practices:
Helped us decide which visits to keep based on the ‘type of visit’-  i.e. we don’t give a woman going in for a OB appointment a diabetes fax or mail her a report.
patient profiles/yellow paper/Personal Diabetes Summary- 
weekly faxes to clinicians-  helped with design/told US what they needed to see/told us when to send them over
they really do look at them- one clinic has noticed their a1c’s are pretty good, so they must be ‘doing pretty well’
One clinic noticed we weren’t ‘getting it right- about 50% of all dm patients had a fax’- we figured out (in a team meeting, with most of the staff present + me) that it was because of same day or open access scheduling-  we were only checking appointments for the next week one time per week- we now check for appointments 3 times a week, and check back to the previous week, the current week, and for the week ahead-  clinics report the faxes are now ‘going well’

## Challenges

- Open access scheduling
- Fitting paper into electronic record
- Bringing new practices on line
- Patient participation in self-management
- Sustaining funding for IT

**Notes:**
Some of the success depends on the practice itself-  (plans to compare TRIP2 with TRIP1 data??)
i.e. #1: seniors doesn’t do a lot of open access scheduling-  they get the faxes the week before, the pcp’s see them in the charts
Westminster does almost all open access scheduling-  they don’t get many faxes the week before, so the doc’s never see them
i.e. #2:  park meadows is getting rid of the paper chart, and they are ‘going all electronic’-  the weekly faxes (clinician summaries) are scanned into the medical record and placed into some random category- something like misc. for that visit-  the doc doesn’t know to look for it ahead of time-  
Seniors can file they paper into the chart and when the doc opens the chart, the paper is there
practices report that yes, some people bring in the yellow sheet- but not an overwhelming amount of people-
When patients do bring them in, it is useful to see them-  the patient report and then fax reminds the clinician (when they see it) of what they should be doing for dm care (sometimes)

## Concluding thoughts

- A PBRN research effort can help practices deliver new model care while investigating questions about practice redesign and improved patient care for chronic illnesses such as diabetes.