Designing for ACCORD with Patients

Slides

Slide 1

Designing for ACCORD with Patients

Henry C. Chueh, MD, MS
Massachusetts General Hospital (MGH)
Boston, MA
AHRQ 2008: Promoting Quality...Partnering for Change
Bethesda, MD, Sept. 8, 2008

Slide 2

MGH Primary Care Network

The map shows a portion of Massachusetts with Waltham, Everett, Charlestown, Revere-2 sites, and Chelsea-2 sites noted. Two arrows point to Boston.

• At MGH:
  • IMA [Internal Medicine Associates ]
  • WHA [Women's Health Associates ]
  • BMG [Bulfinch Medical Group ]
  • MWI [Medical Walk-In Unit ]
• Near MGH:
  • MGH Downtown
  • MGH Beacon Hill
  • MGMG [Massachusetts General Medical Group]
  • Senior Health
  • MGH Back Bay
  • NECHC [North End Community Health Center]
• Noted: MDs=178; full-time-equivalents (FTE)=101; Practices=15; and Patients=155,590

Slide 3

Quality Chasm

• Guidelines:
  • Preventive care
  • Medication safety
  • Patient centered care
  • Chronic disease mgmt
• Practice

Slide 4

24 hours in the life of a Primary Care Physician (PCP)

The pie chart shows Preventive Care-7.4 hrs, Chronic Care-10.6 hrs, and Leftover-6 hrs.

• Note: "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care," a report from the American College of Physicians, 2006
• Note: Yarnall KS, et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635
• Note: Ostbye T, et al. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 2005; 3:209

Slide 5

The Promise of Information Technology

"Computerized clinical information systems will help physicians close this quality gap by performing many of the repetitive, protocol-driven tasks."

—Clement McDonald, 1976

Slide 6

MGH Quality Measures By Linkage Status

The bar graph shows:

• Mammography (n=35,865):
  • PCP Linked: approximately, 80%
  • Practice Linked: approximately, 60%
• Pap Test (n=65,860):
  • PCP Linked: approximately, 85%
  • Practice Linked: approximately, 75%
• CRC Screening (n=37,605):
  • PCP Linked: approximately, 65%
  • Practice Linked: approximately, 50%

Slide 7

Our Challenge

How do we design, build and implement the health information technology (Health IT) tools to support and encourage busy practitioners and patients to "do the right thing?"

...and that they'll use.

Slide 8

Preliminary work

• Patient-provider linkage is important.
• Inter-visit workflow acceptable.
• Providers will use well-designed tools.
• Diversity of care processes can impact outcomes.

Slide 9

Focus on Follow-up

• Consumes time inappropriately.
• Failure can result in poor outcomes.¹
• Fastest growing area of claims.²
• Patients have interest.³

Note:
¹ Earnest 2004.
² Shaefer 2000, Boohaker et al 1996, Murff HJ et al 2003.
³ Institute of Medicine (IOM) 2001, Wall Street Journal (WSJ) Poll 2006.

Slide 10

The graph shows the percentage of "Follow-ups Completed" for Squamous and Glandular cases, during a twelve month period.

Slide 11

A Fragile Loop

The diagram shows two circles. The inner circle shows a question mark. The outer circle flows in a clockwise formation and reads: Awareness of Issue, Risk assessment, Plan for care, Complete care, and Follow-up.

Slide 12

What about Clinical Decision Support Systems?

• Tend to be physician-oriented and visit-based.
• Minimal effect for interventions that cannot be completed at the point of care.
• Patient-centered approaches rare.
• Often lack the ability to "close the loop."

Slide 13

Redesign for Systems to Support Clinical Decisions

"Ecologic Framework."

• Productive Interactions come from:
  • Prepared, Proactive Med Team:
    • Leadership at Multiple Levels—MGH Primary Care Practice-Based Research Network (PBRN).
    • Delivery System Design-Patient—Centered Model (SA 1).
    • Clinical Information Systems—The ACCORD System (SA 2).
  • Informed, Active Patients.
    • Patient Self-Management Support—Patient-Centered Model (SA 1).
    • Clinical Decision Support—The ACCORD System (SA 2).

Note: Zapka et al. 2003, 2004.

Slide 14

Doctor and Patient Clarity

• Adjusted for age and insurance status.
• 2 factors associated with appropriate follow-up care:
  • MD documentation of follow-up plan.
  • Patient understanding of need for follow-up.

Note: Poon, Haas, Puopolo 2004.

Slide 15

ACCORD: Ambulatory Care Compact to Organize Risk and Decision Making

• AHRQ Ambulatory Safety and QualityProgram: Health IT.

Slide 16

"Make Clear Decisions Together"

The diagram shows two circles, one for the Patient and the other for the Provider. They intersect with an image of two hands shaking in a diamond.

• Patient.
  • Abnormal Findings, Preventative Screening, Medication Monitoring.
  • Care Plan and Notifications.
  • "On Demand" access to ACCORD.
    • Web-based Personal Health Application.
    • Patient Letters.
    • Patient and Family Learning Center/Patient Educational Resources.
• Provider/Practice.
  • Abnormal Findings, Preventative Screening, Medication Monitoring.
  • Care Plan and Notifications.
  • "On Demand" access to ACCORD.
    • Electronic Health Record.
    • Population Management Applications.
• Fail Safe Monitoring.

Slide 17

The diagram shows the breakdown of ACCORD.

Slide 18

Characteristics

• Patient-provider centered, informed decisions.
• Preference and choice.
• Self-documenting.
• Explicit agreements with high visibility.
• Fail-safe monitoring.

Slide 19

Focus Groups

• Patients.
• Providers.
• Patients with Providers.
• Assess concept and initial design directions.
• Identify incentives and barriers.

Slide 20

Focus Group Lessons

• Doctors worried about workflow intrusion.
• Patients worried about doctors.
• Patients concerned about potential barriers to access to their doctor.
• Should enhance/increase face time with patients.
• Flexibility needed for ACCORD creation.

Slide 21

Specific Aims

• Design models for Partnership.
• Develop systems for Tracking.
• Evaluate impact on Patient experience, quality.

Slide 22

Create

Note: QuickTime and a decompressor are needed to see this picture.

Slide 23

Elements of an ACCORD

• Option
• Action
• Observation
• Time

Slide 24

A screen shot of SAAT-Simple Accord Authoring Tool with the tab for "Author Templates and Options" opened and "Colon cancer screening and surveillance" highlighted.

Slide 25

A screen shot of SAAT-Simple Accord Authoring Tool with the tab for "Author Templates and Options" opened and the sub screen for "Colon cancer screening and surveillance" showing.

Slide 26

A screen shot of SAAT-Simple Accord Authoring Tool with the tab for "Author Templates and Options" opened and the sub screen for "Routine screening by colonoscopy" showing.

Slide 27

A screen shot of SAAT-Simple Accord Authoring Tool with the tab for "Author Templates and Options" opened and the sub screen for "Colonoscopy" showing.

Slide 28

Propose

Note: QuickTime™ and a decompressor are needed to see this picture.

Slide 29

A screen shot of APT-ACCORD Proposal Tool with "Preventive Health", "Colon cancer screening", and various types of routine screenings all highlighted.

Slide 30

A screen shot of APT-ACCORD Proposal Tool with "Preventive Health", "Colon cancer screening", and "Surveillance colonoscopy for significant polyps" highlighted.

Slide 31

Review

Slide 32

The screen shot shows iHealthSpace's Web site with a sub screen open to "My Accords."

Slide 33

The screen shot shows iHealthSpace's Web site with a sub screen open to "My Accords" with "Surveillance colonoscopy for significant polyps" and "Your Doctors Recommendation" highlighted.

Slide 34

Study Design

• 12 Primary Care Practices in the MGPC-PBRN.
• Stratified Randomization
• 8 Practices: Implementation and Training in the ACCORD System vs. 4 Practices: Standard electronic medical record (EMR) and Usual Care.
  • Patient Measure: CAHPS® [Consumer Assessment of Healthcare Providers and Systems].
  • Preventive Screening: Technical Quality.
• 4 Practices: ACCORD plus SDM Orientation vs. 4 Practices: ACCORD only.
  • Patient Measure: PAM-13.

Slide 35

Systems to Support the Clinical Decision

Slide 36

ACCORD Team

• Steven Atlas, MD, MPH.
• Jeanhee Chung, MD, MS.
• Richard Grant, MD, MPH.
• Susan Edgman-Levitan, PA.
• Robin Weinick, PhD.
• Yu Chiao Chang, PhD.
• Greg Estey.
• David Berkowicz, MD.
• Michael Yebba.
• Mark Wylie.
• Jeff Ashburner.
• Alicia Wong.