Measuring the Quality of Health Across a Population: The Indian Health Experience

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Theresa Cullen, made this presentation at the 2008 Annual Conference. Select to access the slide presentation (PDF File, 3.6 MB).

Slide 1

Measuring the Quality of Health Across a Population: The Indian Health Experience

• Theresa Cullen, MD, MS.
• Indian Health Service (IHS)
  Chief Information Officer.

Slide 2

Population Health in the IHS

• IHS Health Care.
• What Works.
• What Doesn't.
• The Future.

Slide 3

Indian Health Service User Population by Area

• The slide includes a map of the United States with regional areas highlighted.
• Total IHS user population for Fiscal Year (FY) 2006: 1,448,249.

Slide 4

The Indian Population We Serve

• The slide includes a bar graph showing population growth during the years of 2000—2008.
• IHS Service Population Growth.
• Average population growth since 2000 is 1.8% per year.
• 71% high school graduates (80% U.S.) and 10% college graduates (24% U.S.)
• 29% of American Indians/Alaska Natives (AI/AN) fall below poverty standards.
• Unemployment is 4.0 times the U.S. rate for males and females.
• Less than 22% with self reported access to the internet.

Slide 5

Partnership with Tribal Governments

• The Indian Self-Determination Act of 1975 includes an opportunity for Tribes to assume the responsibility of providing health care for their members, without lessening any Federal treaty obligation.
• Slide includes a visual breakdown of the number of IHS, Tribal, and Urban health care sites.

Slide 6

Indian Health Service: Facilitates a Broader Picture of Health

• Slide includes an image of the overlap of Demographics, Conditions, Population Statistics, and Environmental Community.
• Personal Health.
• Family Health.
• Community Health.
• Public Health.
• Population Health.
• Transparency of Data.
  • New Quality of Care Web site.
  • Patient needs based on demographics, environment and community, population data, and conditions.

Slide 7

IHS Health Information Technology (HIT) Solution (Resource and Patient Management System - RPMS)

• A decentralized automated information system comprised of over 60 integrated software applications.
• Over 25 years old with a GUI placed 'on the top' in 2003.
• 4 major categories of software:
  • Infrastructure applications.
  • Practice Management applications.
  • Clinical applications.
    • Electronic recognition of 'candidates for disease DX'.
  • Population and Public Health.
    • Reminders at point of contact (POC).
    • Electronic clinical quality reporting.
      • Using structured data retrieval.
      • Allows for refusals and exceptions.
  • Population data delivered at the POC.
  • Early sentinel event recognition at POC.
  • Integrated case management application.
    • Diabetes, asthma, cardiovascular disease (CVD), HIV, etc.

Slide 8

RPMS Integrates Multiple Clinical Systems

• Slide includes a flow chart with arrows going back and forth between PCC Patient Database and the following elements:
• RCIS.
• PCC data entry.
• Behavioral Health System.
• Dental.
• Women's Health.
• Immunization.
• Radiology.
• CHR.
• Appointment System.
• Pharmacy.
• Public Health Nursing.
• Emergency Room.
• Laboratory.
• Patient Registration.
• Elder Care.
• Surgery.
• Case Management.
• An element, marked EHR [Electronic Health Record] has an arrow that goes back and forth between it and Surgery/Case Management.

Slide 9

• Slide includes a flow chart that includes Data Entry Tools, RPMS Database, and Data Mining and Reporting Tools, sandwiched between Electronic Health Record and iCARE (population management); arrows are pointing back and forth between the sandwiched items and the outside elements.
• An arrow marked Inputs points at the center of the entire flow chart.

Slide 10

Improvement Tools

• Standardized reports (include...)
  • Management/clinical reports.
  • Population health reports.
• Clinical system:
  • iCARE.
  • Clinical quality (Health Plan Employer Data Set [HEDIS], Elder, Patient Education, Government Performance Results Act [GPRA]).
  • Bundled measures/exceptions monitored/denominator only reduced by MOGE criteria.
• Audit Data:
  • Immunization, diabetes, HIV, CVD, etc.
• On the fly audit with on the fly denominator and numerator defined by end user.
• Patient Wellness Handout.
• Quality of Care Web Site:
  • Includes site specific information.
  • Includes patient screening tools and 'questions to ask'—not just information.
  • Consistent with patient wellness handout.

Slide 11

iCARE

• Functionality:
  • Comprehensive knowledge management couplers.
  • Community health data.
    • Fluoride levels in wells.
    • Early suicide alerts based on community and other demographic factors.
    • Centers for Disease Control and Prevention (CDC) reportable cases ( limited definitions).
  • Population health data
    • Comparative health status.
    • Access to care.
    • Clinical quality for any denominator, as well as defined denominator.
    • Expanded structured 'candidate' list for sentinel events.

Slide 12

Disease Diagnostic Tags

• Asthma.
• Chronic Obstructive Pulmonary Disease (COPD).
• CVD At Risk.
• CVD Significant Risk.
• CVD Highest Risk.
• CVD Known.
• Diabetes.
• HIV/AIDS.
• Hypertension.
• Obese.
• Pre-Diabetes Mellitus (DM) Metabolic Syndrome.
• Tobacco Users.

Slide 13

Create Patient Panels

• Slide includes a screen shot of IHS iCARE with the following text next to it:
• By provider.
• By appointment.
• By register.
• By search.
• By visit date.
• By diagnosis.
• By community.
• By age or gender.

Slide 14

See How Your Panel Meets Outcomes

• Slide includes a screen shot of IHS iCARE.

Slide 15

See How Well Individual Patients Meet Outcomes

• Slide includes a screen shot of IHS iCARE.

Slide 16

Clinical Reporting System

• Clinical Reporting System (CRS)—since 2000.
• Automated tracking of clinical performance.
• Eliminates the need for manual chart audits.
• Used at over 95% of I/T/U facilities (data on 1.5 M).
• All patients served by IHS direct sites and over 80% of tribally operated health facility users report data into the national data set.

Slide 17

Clinical Reporting System

• Reporting tool used by:
  • Local site and local community.
  • Reports to tribal health departments/facility boards/etc.
  • Department of Health and Human Services (HHS).
  • Congress.
• Used to improve clinical performance.
• Supports IHS' commitment to a culture of quality.

Slide 18

Types of Reports

• Slide includes a screen shot of the Visual CRS.

Slide 19

Summary Reports

• Slide includes a screen shot of a report.

Slide 20

2007 National Dashboard

• Slide includes a table comparing various diabetes, dental, immunizations, and prevention rates for 2005-2007.

Slide 21

Facility #1—Assessment

• Slide includes a bar graph for 2004-2007 with Blood Pressure assessed and low-density lipoprotein (LDL) assessed plotted.

Slide 22

Facility #1—Control

• Slide includes a bar graph for 2004-2007 with Blood Pressure controlled and LDL controlled plotted.

Slide 23

Facility #1—Immunizations

• Slide includes a bar graph for 2004-2007 with pneumovax and flu shots plotted.

Slide 24

Facility #1—Screening

• Slide includes a bar graph for 2004-2007 with tobacco, intimate partner violence (IPV), and ETOH [alcohol] plotted.

Slide 25

Facility #1—Women's Health

• Slide includes a bar graph for 2004-2007 with PAP smear rate and mammogram rate plotted.

Slide 26

Chronic Care Initiative: Colorectal Cancer Screening

• Slide includes a graph comparing the average denominator vs the weighted average rate of colorectal cancer screening.

Slide 27

Chronic Care Initiative: Breast Cancer Screening

• Slide includes a graph comparing the average denominator vs the weighted average rate of breast cancer screening.

Slide 28

Patient Wellness Handout

• Information provided to the patient.
  • Pre-screening information.
  • Promotes Healthcare communications.
  • Tool for medical record reconciliation.
    • Immunizations Due.
    • Weight, Height, Body mass index (BMI).
    • Blood Pressure.
    • Allergies.
    • Medications.

Slide 29

Patient Wellness Handout

• Slide includes a copy of a report with the following text next to it:
• Data extracted from RPMS.
• Logic used to provide information about results.
• Reviewed with patient by clinician, nurse, educator or pharmacist.

Slide 30

Clinical Information System Optimization

• Day-to-day Function.
• Proactive Planned Care.
• Optimization of the care team.
  • Decision Support:
    • Use a Healthcare Event Report (HER).
    • Reminders: Align and use HER and Health Maintenance Reminders and quality reports.
    • iCare/CRS/traditional registry applications.
  • Self Management:
    • Use self-management goal setting.
    • Maximize use of patient wellness handout.
    • Access for patient and family to their own data.
    • Handouts and other educational materials readily available.
  • Care Plan:
    • Maximize use of problems lists.
    • Collaboratively develop a plan of care for each individual that summarizes all pertinent patient info in one place.
    • Optimize care team data utilization and management.
    • Use patient specific goals and standards (e.g. frequency of colonoscopy).
  • System Redesign:
    • Utilize RPMS to plan for visits (iCare and reminders).
    • Manage the population proactively -finding groups I need of specific types of care and then delivering that care to them.
    • Designated provider function to manage panels of patients and organize care teams.
    • Develop a multidisciplinary team that optimizes the role of each team member.
    • Response to reminders.
    • Integration of the care team -enhance sharing of info.
    • Case management by nurses.
  • Clinical Information System:
    • Flow of information to and from systems outside of IHS.
    • Improved documentation and input EHR.

Slide 31

Facilitate Improvement: Create an ongoing Learning community

• Reporting:
  • Web site for reporting on measures for improvement on monthly basis.
• Sharing/interconnectivity:
  • WebEx infrastructure—maximize use of WebEx.
  • Enhance training strategies (recorded sessions, user manuals).
  • Sharing of lessons learned.
• Knowledge Management:
  • A system where knowledge is continuously organized and utilized to increase knowledge levels throughout the organization.
  • User manual for functions for planned care.
  • A central location/system for knowledge sharing and accumulation.
• Measurements for implement:
  • Define quality goals.
  • Align improvement measures with quality goals.
  • Instruction manuals for measures and measure reporting.

Slide 32

The IHS HIT Vision

• A health care IT system that incorporates family, population, public and community health as a cornerstone of personal health care delivery ( not just an afterthought) at the point of care.
• Data standards that address the non traditional determinants of health status.
• Inclusion of non traditional data information into the traditional patient, provider, family and community perspective.
• The elimination of health inequities, using HIT as a major enabler.

Slide 33

Indian Health Service

• Slide includes a photo montage of various people in celebration.
• http://www.ihs.gov

Slide 34

Dine' Prayer

• In beauty may I walk.
  All day long may I walk.
  Through the returning seasons may I walk.
  On the trail marked with pollen may I walk.
  With grasshoppers about my feet may I walk.
  With beauty may I walk.
  With beauty before me may I walk.
  With beauty behind me may I walk.
  With beauty above me may I walk.
  With beauty all around me may I walk.
  In old age wandering on a trail of beauty, lively, may I walk.
  In old age wandering on a trail of beauty, living again, may I walk.
  If it finished in beauty,
  It is finished in beauty.
• Dine' Prayer