Enabling Chronic Disease Care through Health IT (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

By Dean Schillinger, MD

On September 9, 2008, Dean Schillinger made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (7.2 MB).

Slide 1

Enabling Chronic Disease Care through Health Information Technology (Health IT)

Dean Schillinger, MD
University of California San Francisco (UCSF) Professor of Medicine
Director, UCSF Center for Vulnerable Populations,
San Francisco General Hospital
Chief, Diabetes Prevention and Control; CA Dept. of Public Health

Slide 2

Current Team (partial list)

Margaret Handley, M.P.H., Ph.D.
Olin Lau, NP
Alison Lum, Pharm.D.
Urmimala Sarkar, M.P.H., MD
Dean Schillinger, MD
Catalina Soria
Stanley Tan

Slide 3

The photograph shows a man sitting at a table with a bottle of alcohol in one hand and a giant glass full of alcohol in the other.

My Doctor said, "Only 1 glass of alcohol a day." I can live with that.

Slide 4

IDEALL Project: Improving Diabetes Efforts Across Language and Literacy

• Community Health Network of San Francisco Department of Public Health (SF/DPH).
• Agency for Healthcare Research and Quality (AHRQ).
• The Commonwealth Fund (CMWF), The California Endowment (TCE), California HealthCare Foundation (CHCF).

Slide 5

Automated Telephone Diabetes Self-Management (ATSM)

The diagram shows the patient's first step is interacting with either their Primary Care Physician or ATSM: Weekly Monitoring and Health Education. The next step involves the Nurse Diabetes Care Manager who can then interact directly with the patient.

• Interactive health technology, touch tone response.
• Weekly surveillance & health education (39 weeks = 9 months).
• In patients' preferred language (English, Spanish, or Cantonese).
• Generates weekly reports of out of range responses.
• Live phone follow-up through a bilingual nurse -> behavioral action plans.

Slide 6

Key Findings of IDEALL Program Estimating Public Health "Reach" of Programs

Composite reach product:

• Overall:
  • ATSM:  22.1
  • Group medical visits (GMV):  4.8
• English:
  • ATSM:  20.0
  • GMV:  6.4
• Chinese:
  • ATSM:  22.0
  • GMV:  2.7
• Spanish:
  • ATSM:  24.3
  • GMV:  4.0
• Adequate Literacy:
  • ATSM:  15.6
  • GMV:  7.6
• Limited Literacy:
  • ATSM:  28.0
  • GMV:  3.6

Slide 7

Results: Structure and Process Measures

Four bar graphs show the measures of structure and process for "pre" and "post" UC, ATSM, and GMV when looking at PACIC, Self-Efficacy, Communication, and Self-Management Behavior.

Slide 8

Results: Functional Outcomes

Four bar graphs show the measure of functional outcomes for "pre" and "post" UC, ATSM, and GMV when looking at Bed Days, Diabetes Interference, SF12-Mental Health, and SF12-Physical Health.

Slide 9

Results: Physiologic Outcomes

Four bar graphs show the measure of physiologic outcomes for "pre" and "post" UC, ATSM, and GMV when looking at systolic blood pressure (SBP), diastolic blood pressure (DBP), HbA1c, and body mass index (BMI).

Slide 10

ATSM as Surveillance Tool?

• ATSM Data.
  • Automated Completed Calls.
  • Patient-Nurse Encounters.
• Consensus.
  • Adverse Event (AE).
  • Potential AE (PotAE).
  • No event.
• Medical Record.
  • Classification.
    • Preventability.
    • Primary Provider Awareness.

  Slide 11

  Automated Telephony Provides Safety Surveillance Function

  The bar graph measures the number of events that were preventable, ameliorable, unable to be determined, and non-preventable when looking at Incident AE, Prevalent AE, Incident PotAE, and Prevalent PotAE. Looking at the results for all four categories, preventable events rated high for three out of the four categories.

  • 111 participants, 54% inadequate health literacy.
  • 264 events among 93 participants (86%).
  • 111 AE's and 153 PotAE's.

  Sarkar, Schillinger, et al. JGIM 2008.

  Slide 12

  Clinician Survey Findings

  • Responses from 87 of 113 (77%) physicians who cared for 245 of the 330 (74%) patients (mean, 2.8 per physician).
  • Compared to UC, patients exposed to ATSM were perceived as more likely to be activated to create and achieve goals for chronic care (standardized effect size, ATSM vs. UC, +0.41, p = 0.05).
  • Over half of physicians reported that ATSM helped overcome 4 of 5 common barriers to diabetes care.
  • Physicians rated quality of care as higher among patients exposed to ATSM compared to usual care (OR 3.6, p = 0.003), and compared to GMV (OR 2.2, p = 0.06).
  • The majority felt ATSM should be expanded to more patients with diabetes (88%).
  • A technology-facilitated SMS model was particularly effective for their patients and practice settings, suggesting that such programs should be disseminated and implemented more widely.

  Bhandari, Schillinger SGIM 2008.

  Slide 13

  Health System Findings: Cost-Effectiveness; Health Plans

  • Based on functional improvements, we estimated that the cost per quality-adjusted life year (QALY) for ATSM was:
    • >$65,000 for both set-up and ongoing costs.
    • >$32,000 for ongoing costs only
  • Cost effectiveness could be further improved with (a) scaling up; or (b) metabolic outcomes improved.
  • A large majority of CA Medicaid health plans reported an interest in employing ATSM-like technology.

  Slide 14

  Key Findings of IDEALL Program

  • Reach significant, especially for lower literacy, non-English speaking, Medi-Cal, uninsured.
  • Interactive health technology improves patient -centered care, health behaviors, functional status and promotes safety, due to:
    • Proactive nature.
    • Hierarchical logic.
    • Communication tailoring.
  • For physiologic effects to be achieved, need medication intensification.
  • Health plans and clinicians favorably inclined.
  • Probably too difficult for individual clinics to implement.

  Slide 15

  The cartoon shows a pack of wolves howling at the moon with one asking, "My question is: Are we making an impact?"

  Slide 16

  Current Project

  • Partner with a local Medicaid health plan: San Francisco Health Plan (SFHP.
    • SFHP care managers will make ATSM response calls.
  • Test effectiveness when implemented in 'real-world.'
  • Compare ATSM-ONLY with ATSM-PLUS (medication activation).
  • ATSM-PLUS involves merging pharmacy claims data with ATSM data to enable care manager counseling.

  Slide 17

  Design and Outcomes

  • Wait List Design, with randomization among exposed participants. Total N = 260.
  • Outcomes (wait-list vs. ATSM vs. ATSM-Plus):
    • Communication.
    • Behavior.
    • Functional status.
    • Metabolic indicators.
    • Patient safety (prevalence and root causes).

  Slide 18

  The diagram shows the current project structure.

  Slide 19

  SFHP Pre-Enrollment Post Card English

  The two SFHP document images show a cover promoting "An important message about your health," and a page informing the individual about how to get help with diabetes.

  Slide 20

  Spanish

  The same two SFHP document images, but geared and partially written in Spanish.

  Slide 21

  Cantonese

  The same two SFHP document images, but geared and partially written in Cantonese.

  Slide 22

  SFHP Wallet-Size Card English, Spanish and Cantonese

  Three images of wallet-sized cards from SFHP's Diabetes Program with important contact information written specifically for either English speakers, Spanish speakers, or Cantonese speakers.

  Slide 23

  Care Manager Field

  A screen shot of the ATSM page from the SFHP's Web site with the sub screen "Trigger/Mgr Act" opened.

  Slide 24

  Potential Safety Event

  A screen shot of the ATSM page from the SFHP's Web site with the sub screen "Safety Issues" opened.

  Slide 25

  Safety Event Assessment

  A screen shot of the ATSM page from the SFHP's Web site with the sub screen "Safety Protocol" opened.

  Slide 26

  Current Plans and Challenges

  • Delays in implementation, successes in IT.
  • Initiate outreach and enrollment 9/08.
  • Overcome Member inertia/barriers to enrollment.
  • Develop Memoranda of Understanding (MOUs) with clinics for enrollment and coordination of care.
  • Finalize protocols re medication intensification/adherence promotion.
  • Finalize/shorten pre- and post-questionnaires.