# Presentation: 316459

## Showing Health Information Value in a Community Network

***Showing ******Health Information Value in a Community Network***

- David F. Lobach, MD, PhD, MS
- Division of Clinical Informatics
- Department of Community and Family Medicine
- Duke University Medical Center, Durham, North Carolina
- Contact Information: david.lobach@duke.edu

- ©2005 David F. Lobach

- AHRQ Health Information Technology Conference	June 9, 2005

## Presentation Overview

- Project Description
- Community Network (COACH)
- Decision Support Tool (SEBASTIAN)
- Data-Driven Interventions
- Selection of Evaluation Metrics
- Study Design
- Obtaining and Using Data
- Project Challenges
- Practical Issues

## Community Information Network

***Community Information Network***

- Need for Information Infrastructure
- Community-Oriented Approach to Coordinated  Healthcare
- Goal: Supporting the information needs of the network of providers serving Medicaid beneficiaries

## Network Partners

- 1 Care Management Team
- 7 Primary Care Clinics
- 		 (1 FM, 3 Peds, 1 IM, 1 Ob-Gyn, 1 FQHC)
- 3 Urgent Care Facilities
- 2 Emergency Departments
- 2 Hospitals
- 2 Government Agencies (HD, DSS)
- A system designed for and used by line workers at partner sites

## COACH Information System

## Current Status of COACH IS

- 16,964 Active Patients
- 69,786 Total Patients
- 193,146 Encounters (Internal + External)
- 124 User Accounts
- 49 Active Users

## Sebastian

**Sebastian**

**S****ystem for ****E****vidence-****B****ased ****A****dvice by ****S****imultaneous ****T****ransmission or an ****I****ntelligent ****A****gent across a ****N****etwork**

- ©2003 David F. Lobach

## Project Goals

- Population Management - Asynchronous recommendations generated though a rule-based intelligent agent running on a clinical data repository
- Patient Management - Interactive, evidence-based recommendations delivered to the point of care

## Alert in Email

## Alert Message

## Encounters for Alert Patient

## Showing HIT Value

- Collaborators and Partners
- Specific Aims and Objectives
- Intervention Overview
- Study Measures
- Study Design
- Data Sources

- This work was funded in part by a grant from

## Partner Organizations

| Organization Type | Partner Organization |
| --- | --- |
| Hospitals | Duke University Hospital (DUH)
Durham Regional Hospital (DRH) |
| Clinics | Duke Primary Care Clinics
Duke Affiliated Primary Care Practices
Private Primary Care Clinics
Lincoln Community Health Center (LCHC)
Duke Specialty Care Clinics  |
| Urgent Care Facilities | Duke Urgent Care
Lincoln Community Health Center (LCHC) |
| Government Agencies | Durham County Health Department (DCHD)
Durham County Department of Social Services (DSS)
NC Medicaid |
| Community Organizations | Durham Community Health Network (DCHN) |

## Specific Aims

- To evaluate the clinical, organizational and financial value of HIT in a community network from a societal perspective.
- To evaluate the value of HIT in a community network from the perspective of specific stakeholder groups, including patients, providers, hospitals, payers, and purchasers.

## Intervention Overview

## Email Alerts to Providers

## Sample Feedback Report

## Sample Patient Letter

## Sample Events

| Focus | Care Issue |
| --- | --- |
| Clinical Outcomes | Three ED encounters within 90 days
Low severity ED encounter 
ED encounter for asthma
ED encounter for diabetes
Hospitalization for asthma
Hospitalization for diabetes |
| Care Quality | No mammogram in 2 years
No Pap smear in 3 years
No Chlamydia screening in 1 year
No post-partum visit after delivery in 21 to 56 days
No glycated hemoglobin test in 1 year
No lipid panel in 1 year
No urine protein/albumin test in 1 year
No dilated eye examination in 1 year
One or fewer well child visits in 1 year
No well child visits in 1 year |
| Care Coordination | Two missed appointments in 60 days
No Follow-up appointment after ear infection in 2 wks |

## Sample Events (Pending)

| Focus | Care Issue |
| --- | --- |
| Clinical Outcomes | Medication incompatibility |
| Care Quality | No staging of asthma
No asthma action plan in 2 years
Patient-reported health risk: new onset pregnancy
Patient-reported health risk: missed >10 days of school/year
Patient-reported health risk: no blood test for lead poisoning in past year
Patient-reported health risk: no blood test for lead poisoning ever
Patient-reported health risk: signs or symptoms of vision problems
Patient-reported health risk: signs or symptoms of hearing problems
Patient-reported health risk: high risk of TB exposure
Patient-reported health risk: concern about weight
Patient-reported health risk: recreational drug use
Patient-reported health risk: alcohol abuse
Patient-reported care barrier: need assistance to get care services
Patient-reported barrier: need assistance to get medical equipment
Patient-reported care barrier: need assistance to get medications |
| Care Coordination | Pending appointment and h/o missed appointments in last 60 days |

## Frequency of Interventions

|  | ALERTS |  | FEEDBACK | REMINDERS |
| --- | --- | --- | --- | --- |
| Care Issue | Frequency | Target Group | Frequency | Frequency |
| ED encounter for asthma / diabetes / low severity / 3rd in 90 days | daily | CHW, CLM, PCP | monthly | weekly |
| Hospitalization for asthma / diabetes | daily | CHW, CLM, PCP | monthly | weekly |
| No follow-up appointment after ear infection | daily | CHW, CLM, PCP | monthly | weekly |
| Two missed appointments in 60 days | daily | CHW, CLM, PCP | monthly | weekly |
| One or fewer well child visits for 1-2 yo /no well child visits for 3-6 yo | monthly | CHW, CLM | monthly | quarterly |
| No mammogram / Pap smear / Chlamydia testing  | monthly | CHW, CLM | monthly | quarterly |
| No post-partum visit after delivery | weekly | CHW, CLM, PCP | monthly | biweekly |
| No HgbA1c / lipid panel / urine microalbumin / dilated eye exam | monthly | CHW, CLM | monthly | quarterly |
| Pending appt. and h/o missed appt. in last 60 days | n/a | n/a | n/a | daily |
| No staging of asthma / no asthma action plan | monthly | CHW, CLM | monthly | quarterly |
| Reported health risk: new onset pregnancy | weekly | CHW, CLM | monthly | n/a |
| Reported health risk: missed >10 days of school/year | monthly | CHW, CLM | monthly | n/a |
| Reported health risk: no blood test for lead poisoning | monthly | CHW, CLM | monthly | quarterly |
| Reported health risk: signs or symptoms of vision or hearing problems / weight concerns / recreational drug use / alcohol abuse | monthly | CHW, CLM | monthly | n/a |
| Reported health risk: high risk of TB exposure | daily | CHW, CLM, PCP | monthly | daily |
| Reported barrier: assistance to get care services / assistance to get medical equipment / assistance to get medications | weekly | CHW, CLM | monthly | n/a |
| Medication incompatibility | daily | CHW, CLM, PCP | monthly | daily |

## Choosing Study Measures

- _Optimal Measures:_ Solid clinical outcomes of significance to health care (e.g. mortality)
- Will any true clinical outcomes be impacted by the intervention that can be detected during the study period?
- Can a change in surrogate clinical measures be detected during the study period?
- Will any process measures be impacted by the intervention?
- What are the cost implications of the intervention?
- Will any descriptive/qualitative measures be effected by the study intervention?

## Selecting & Defining Measures

- How will you know that your intervention is a success?
- Fewer ED visits for ambulatory care sensitive conditions
- Higher quality care
- Better coordination of care services
- Lower costs
- Patients will be more satisfied with the care they receive

## Selecting & Defining Measures

- How can that endpoint be measured*?
- Relative number of ED visits
- HEDIS quality metrics
- Rates of follow-up appointments
- Costs of care provided
- Satisfaction surveys
- *Consider what has been measured in similar studies.  Don’t re-invent the wheel!

## Selecting & Defining Measures

- What data are needed to assess these measures?
- # of ED visits, billing diagnoses for visit, severity level of visit
- Claims data with ICD9 and CPT Codes, plan enrollment history
- # of appointments kept and missed
- Estimates of care costs
- Satisfaction survey data

## Selecting & Defining Measures

- How can one obtain these data?
- State Medicaid claims data
- Chart audits (electronic or manual)
- Clinic encounter records
- Claims data and Medicare reimbursement rates
- Satisfaction surveys

## Selecting & Defining Measures

- What type of comparison needs to be made between control and intervention groups to detect a significant difference?
- 1.-5.  Compare differences between groups – Wilcoxon rank sum statistic

## Outcome Measures

| Measurement Focus | Measures |
| --- | --- |
| Clinical Outcomes.  
ED Encounters
Hospitalizations | ED encounters per 1000 pt years
Hospitalizations per 1000 pt years
Primary care encounters per 1000 pt years
HgbA1c levels |
| Care Quality.
Preventive Services
Chronic Disease Management for Asthma & Diabetes | HEDIS scores for mammograms, Pap smears, Chlamydia screening
HEDIS scores for asthma staging, recording action plans, prescribing inhaled corticosteroids 
HEDIS scores for performing glycated hemoglobin, microalbumin, lipid panel, dilate eye exam
HEDIS scores for well child visits
AHRQ PQI for asthma
AHRQ PQI for uncontrolled diabetes, short- & long-term complications  |
| Care Coordination. 
Missed Appointments
F/U Appointments | Missed appointments per 1000 patient years
Rate of f/u after ear infection per 1000 patient years |
| Costs/Revenues. 
ED costs
Hospitalization Costs | Costs of HIT interventions including personnel/hardware/software costs
Co-pay costs
Professional fees
Technical fees
Pharmaceutical reimbursement 
ED costs
Hospitalization costs |
| Satisfaction.
Patient Satisfaction
Patient Quality of Life
Provider Opinions | Patient satisfaction survey
EuroQoL
Provider opinion surveys |

## Choosing a Study Design

- _Optimal Design:_ Double-blinded Randomized Control Trial
- Can a simultaneous control group be established?
- Can individuals be randomly assigned to a group?
- Is a placebo available?
- Can the use of the intervention be hidden from the study subjects?
- Can the use of the intervention be hidden from the study team?

## Design & Randomization Plan

| Care 
Group |  | Run-in | CYCLE 1 | CYCLE 2 | CYCLE 3 | CYCLE 4 | CYCLE 5 |
| --- | --- | --- | --- | --- | --- | --- | --- |
|  |  | Months 
0-3 | Months 
4-9 | Months 
10-15 | Months 
16-21 | Months 
22-27 | Months 
28-33 |
| High
Level |    1 |  | Alerts | Alerts
Feedback | Alerts
Feedback
Pt Reminders | Alerts
Feedback
Pt Reminders | Alerts
Feedback
Pt Reminders |
|  | 2 |  | Feedback | Feedback
Pt Reminders | Feedback
Pt Reminders 
Alerts | Feedback
Pt Reminders 
Alerts | Feedback
Pt Reminders 
Alerts |
|  | 3 |  | Pt Reminders | Pt Reminders
Alerts | Pt Reminders 
Alerts
Feedback | Pt Reminders
Alerts
Feedback | Pt Reminders 
Alerts
Feedback |
| Low
Level | 4 |  |  |  |  | Alerts | Alerts
Feedback |
|  | 5 |  |  |  |  | Feedback | Feedback
Pt Reminders |
|  | 6 |  |  |  |  | Pt Reminders | Pt Reminders 
Alerts |

## Data Analysis Intervals

|  | Month
0-3 | Months 
4-9 | Months 
10-15 | Months 
16-21 | Months 
22-27 | Months 
28-33 |
| --- | --- | --- | --- | --- | --- | --- |
| Overall
Comparison | Comparisons of the six clinical/organizational and three economic endpoints.  Strategies 1-3 are compared with strategies 4-6. |  |  |  |  |  |
| Comparisons
Among HIT
Treatments | Comparisons of the six clinical/organizational and three economic endpoints.  Indicator variables are used to denote the three highlighted strategies: provider alerts, feedback reports, and patient reminders. |  |  |  |  |  |
| 
Dose
Response
Comparisons |  | ONE
Intervent.
vs. no
Added
Intervent. | TWO
interventions
vs. no
Added
intervention | THREE
interventions vs.
no interventions | THREE
Intervent.
vs. ONE
Intervent. | THREE
Intervent.
vs. TWO
Intervent |

## Choosing Data Sources

- _Optimal Data:_ Coded clinical data entered electronically by the data generating source
- What coded data is available?
- What clinical data is available?
- What claims data is available?
- Is there a data dictionary for interpreting the data?
- What is required to make the data available?
- Will chart audits be required?

## Project Challenges

- Controlling Expectations
- Avoiding “Scope Creep”
- Start up Funding
- Operational Funding
- Obtaining Data from Partners
- HIPAA Implications

## Practical Issues	

- How to work with community partners
- Challenges working in the community setting
- How to navigate the academic institution

## Open House @ Duke University

- Learn more about the AHRQ-funded Duke HIT Value Project at Duke University Medical Center
- Friday, August 12, 2005
- 9:00 AM to 4:00 PM
- Detailed project presentations
- Onsite demonstrations
- Cost: ~$25 for lunch, snacks and local transportation
- For more information and registration:
- Call 919.684.6421
- Email _[sherri.gerringer@duke.edu](mailto:sherri.gerringer@duke.edu)_
- Visit: http://dmi-www.mc.duke.edu/

## Acknowledgments

- DCI
- Jennifer M. Macri, MS
- Garry Silvey
- Allen Mayers
- Kensaku Kawamoto
- Jan Willis, MS
- DCH
- Susan Yaggy, MPA
- Fred Johnson, MBA
- Jessica Simo
- Pam Phillips

- Other Duke Groups
- Eric Eisenstein, DBA
- Kevin Anstrom, PhD
- Vic Hasselblad, PhD
- David Crosslin, MS
- Bob Rezzarday
- Outside Collaborators
- Richard Low (Topsail Technologies)

**Notes:**
In closing, I want to acknowledge the contribution of ...

- Questions?
- Contact Information: david.lobach@duke.edu