David A. Dorr, MD, MS Associate Professor

Integrated Care Coordination Information System: primary care redesign through care coordination and population management David A. Dorr, MD, MS Associate Professor Department of Medical Informatics & Clinical Epidemiology General Internal Medicine & Geriatrics OHSU Funding for this research from The John A. Hartford Foundation, AHRQ, Intermountain Healthcare, and the National Library of Medicine More information at caremanagementplus.org

Overview • Care Management Plus: ICCIS need and trial • Prioritized functions • Unintended consequences • Sustainability: Free take one vs. thoughtful partnership A.k.a – How to build a better system of care for your most at-risk primary care patients

Becomes

Needs assessment / Build system (1 year + ) Train clinics and care managers Randomly assigned goals for IT use Arm 1: Coordination of Care -Complete assessment/care plan -Education -Goal setting and follow up -Communication -Motivation/coaching -Completing CM services Arm 2: Quality -choose 5 of 20 quality measures: prevention, diabetes, vulnerable elderly, asthma, congestive hearth failure Data from ICCIS, Payers Evaluation (Aim 4): Outcomes (health/satisfaction) and their relationship to implementation and use of IT

Needs assessment Behkami, Proc AMIA, 2009

ICCIS Care Coordination Workflow A centralized reminder list of tasks and communications that were proactively planned but incomplete allows population-based tasks to be merged with individual encounter tasks.

Quality measure dashboard Dashboard can be run by clinic, team, or individual PCP

ICCIS Interactive Quality Reports The abilities to document exclusions at multiple levels and generate targeted population-based review cycles avoid the problems caused by static quality reports and allow providers to efficiently focus outreach efforts on high risk populations.

Patient Worksheet When working with persons with multiple illnesses or complex illness, a clinical summary that captures a core set of information improves patient outcomes (1). Care coordination and behavioral modification (goal setting) elements often require special effort and the quality summary requires more advanced monitoring and implementation than most standard EHRs provide. (1)Wilcox, Proc of AMIA Symp, 2005

It worked! (see our poster) Figure 3: Absolute adherence change for Arms and Clinics Table 1. Care coordination activities • Arms reimbursed

Unintended consequences: Errors / fixes • 278 fixes of systemic errors in first 6 months of study • Sources : • data (multiple EHRs, minimal standards); • workflow/usability; • Understanding/naming to reduce confusion

Sustainability - ‘Free, take one’ – dissemination to 208 teams OHSU (9 teams) PeaceHealth (20 teams) Intermountain (16 teams) SFDPH (12 sites) Colorado Access (16 teams) HealthCare Partners (2 sites) Daughters of Charity (5 teams)

Sustainability: Thoughtful partnership • Readiness assessment : define benefit up front • E.g., Medical Home care coordination; ACO reduction in hospitalizations and shared savings • Partner on achievement of goals • Share savings or benefit together • Example: intensive care management demonstrations; SNP plans

Oregon Health & Science University David Dorr, PI Kelli Radican Susan Butterworth Nima Behkami Marsha Pierre-Jacques Williams Gwenivere Olsen Molly King Kristin Dahlgren Columbia University Adam Wilcox Intermountain Healthcare Cherie Brunker, Co-PI (UU) Liza Widmier Mary Carpenter Bryan Gardner Ann Larsen Advisory Board K. John McConnell Tom Bodenheimer Eric Coleman Cheryl Schraeder Heather Young Steven Counsell Larry Casalino

Thank you & Main lessons dorrd@ohsu.edu http://www.caremanagementplus.org

Thank you! • dorrd@ohsu.edu • http://www.caremanagementplus.org

Sticky problems

Usability Log metrics: click throughs (<5 seconds on page): 62% ; loops/ repeated actions Interviews: Use / workflow / challenges / errors

David A. Dorr, MD, MS Associate Professor