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Dartmouth Experience: Proudly Accepting PGHD

Carolyn L Kerrigan MD MHCDS Professor of Surgery

Conflict of Interest Carolyn Kerrigan MD, MHCDS Has no real or apparent conflicts of interest to report.

© HIMSS 2015

Learning Objectives Learning Objective 1: Asses practical approaches to integrate PGHD into your organizations while minimizing workflow disruption.

Learning Objective 2: Recognize the key liability concerns posed by accepting PGHD and how to overcome these challenges.

Learning Objective 3: Describe techniques for measuring the return on investment when accepting PGHD.

Learning Objective 4: Demonstrate how the right tools can maximize patient uptake and provider usability to influence clinical decisions, shared decision making and achieve patient/care team goals.

The Big Idea

4

The Challenge

Health conditions could be more effectively co- or self-managed with information and data provided by patients themselves.

The Gap

If we are to improve value to consumers of health care it is critical that we enable them with tools to capture, use and share data pertinent to their health condition.

Key Question

Can we integrate the patients voice into “usual” care processes in a way that informs individual treatment decisions and quantifies outcomes?

Envision seamless integration of PROs in practice

Voice Changes Choice

Typical surgical patient has a score in the 50+ range preoperatively and improves to the 30 range

postoperatively

Typical surgical patient has a score in the 50+ range preoperatively and improves to

the 30 range postoperatively

10 16

24 32

26

0

25

50

75

100 Oswestry Disability Index

Our PGHD journey has taken us across several IT platforms

In 1997 opened the Spine Center with electronic capture of PRMs

1997-2004 piloted electronic capture in several other clinical programs and on 2 different IT platforms

2005-2010 partnered with Dynamic Clinical Systems to capture PGHD across 18 clinical conditions

Apr ‘11 Dec ‘12

Ver

GO-LIVE

2009 2010 2014

Nov ‘14

Many programs see value in using PGHD Department Health Condition/Program Psychiatry Sleep Disorders/Depression/Anxiety Ortho Hip/Knee/Shoulder/Hand Primary Care Annual Physical/Annual Wellness Spine Clinic Spine Diagnoses Pain Clinic Pain Surgery/Anesth Pre-Admission Testing Neurology Epilepsy/Multiple Sclerosis/Parkinson’s Vascular Aneurysm, Carotid Disease, Varicose Veins OB/GYN UroGyn/Post Partum Depression/Sub abuse screening Plastics Hand/Breast Hem/Onc Breast/Head & Neck/Neuro Onc/Prostate Transplant Transplant surgery Pediatrics Pedi Screening Rehab Functional Restoration Program Pulmonary Asthma/COPD Dermatology Patch Testing Endocrinology Diabetes/Health coaching Cardiology Heart Failure

Psychiatry

Ortho

Primary Care

Spine Clinic

Pain Clinic

Surgery/Anesth

Neurology

Top programs are highly engaged

• SET STRATEGY & STANDARDS • PRIORITIZE WORK • COLLABORATIVE LEARNING

STEERING COMMITTEE

• BUILD ITEM BANK • CUSTOMIZE SURVEY SETS • DESIGN DOCUMENTATION TOOLS &

REPORTS

IT

• WORKFLOW • TRAINING • CUSTOMER SUPPORT

OPERATIONS

Care Team workflows are redesigned BEFORE VISIT:

– SCHEDULER Auto queue questionnaires based on visit type – SCHEDULER Pitch portal sign up for new and existing

patients – NURSE Assign nurse pool to monitor questionnaire in basket – TEAM Huddle to check upcoming appts and questionnaire

status DURING VISIT:

– ALL Monitor questionnaire status in schedule view – PROVIDER Review results in navigator – PROVIDER Use documentation short cuts to bring select

results into encounter note – PROVIDER Discuss results with patients, use for care

management and/or shared decision making

Patient’s have a new workflow too!

• Respond to email alert re appointment pre-work • Complete Q on patient portal • Complete Q on tablet in clinic waiting area • Complete Q by interview from workstation in

exam room • Answer phone call and respond to interviewer

questions (no IVR yet!)

If answers are concerning, patient gets immediate message

1 Pt

All patients in half day session

Patients for more providers

Meet weekly to review completion rates and

workflow issues

Debrief and improve

Debrief and improve

Debrief and improve

Debrief and improve

New site implementation requires a structured process and at elbow support

Questionnaire in Visit Navigator

Care team is taught where to view results

Care team is shown how documentation can be done more efficiently

Care team shares results with patients during the visit (eg urogyn)

surgery

Care team shares results with patients during the visit (eg psych)

Decision for medication

Decision for counseling

Patients can review their responses, but not yet their scores

What other tools have we developed for frontline care teams?

Process measures are fed back to programs and used for improvement

Mental health clinicians can use PGHD to manage a population of patients

• Successful integration of PGHD “scoring” questionnaires into an EPIC environment:

– Patient Reported Outcomes – Patient Reported Risk scores – Patient reported decision quality (after delivery

of decision aid) • Successful design of workflows to “order”, “result” and “use” data at the point of care across 30+ health conditions (for individuals and populations)

• Tracking and improving completion rates: 68% (range 97% - 6% depending on the specific clinic)

To summarize our successes:

• Patient experience with Q use by care team • Patient facing reports • Triggering best practice advisories from PGHD

Working on …

Don’t

• Overburden patients • Assume all work will land on providers • Underestimate complexity of integration into daily workflows and culture change

• Underestimate complexity of IT build and integration into EMR

• Use proprietary instruments (or at least minimize their use)

Do

• Identify early adopter Provider Champions • Make sure Senior Leaders resource initiative with IT and operational support

• Be clear about WIIFM for frontline team • Train clinicians and flow staff on use of PROs in care processes

• Optimize patient portal for collection of PRO data • Thank patients and use their information during encounters

Questions • carolyn.l.kerrigan@hitchcock.org

Kaiser Permanente Experience: Proudly Accepting PGHD

April 15, 2015 Mark Groshek, MD, Kaiser Permanente Medical Director, Digital Services Group

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Mark Groshek, MD Has no real or apparent conflicts of interest to report.

© HIMSS 2015

Learning Objectives Learning Objective 1: Asses practical approaches to integrate PGHD into your organizations while minimizing workflow disruption. Learning Objective 2: Recognize the key liability concerns posed by accepting PGHD and how to overcome these challenges. Learning Objective 3: Describe techniques for measuring the return on investment when accepting PGHD. Learning Objective 4: Demonstrate how the right tools can maximize patient uptake and provider usability to influence clinical decisions, shared decision making and achieve patient/care team goals.

The Big Idea

32

The Challenge

Health conditions could be more effectively co- or self-managed with information and data provided by patients themselves.

The Gap

If we are to improve value to consumers of health care it is critical that we enable them with tools to capture, use and share data pertinent to their health condition.

Key Question

Can we seamlessly integrate patient information into care processes in a way that enables individual treatment decisions and improved outcomes, regardless of where the patient is?

What is Patient (Member) Generated Data?

1 Office of the National Coordinator (ONC) for HIT, Consumer Empowerment Workgroup. July 2013

Member role in data generation Applicability to patient health

Qualifies as MGD?

Collected data

Member-generated

Non-member generated

Health related

Non-transactional health data is considered MGD: • Health history, symptoms, biometric data,

treatment history, lifestyle choices, and other information that is – Created, recorded, gathered, or inferred by or

from patients or their designees – To help address a health concern1

Clinical transaction data is not MGD: • Data entered as part of a care encounter • Data entered into secure emails with

clinicians as free text

Not health-related

• MGD does not include: – Health plan data, data entered into forms – Member registration information

• Data generated prior to enrollment by non-members is not MGD

How is the data generated? • Active

– when the member (or their designee) reports it themselves

• Passive – captured by a remote device (e.g. blood pressure

recording, fitness device, etc…) – indirectly captured (e.g. usage patterns or affiliations on

social networks)

Proactive Assessment of Total Health & Wellness to Add Active Years (PATHWAAY): A comprehensive care delivery strategy for seniors receiving primary care

Components: – Total Health Assessment (THA) – KP.org/Clarity + Health Trac results

processing and scoring – PATHWAAY MA/RN team outreach

calls for identified risks, prior to Annual Wellness Visit

– Personalized Prevention Plan (PPP) – Patient-centered office visit

A new workflow integrated into existing office workflows

35

PATHWAAY Workflow

In Clinic

Staff in clinic see message on schedule to “print PPP” and any other pre-visit needs (Orthostatic BP, PVR, Adv Directive book, etc.)

In Clinic

Provider reviews PPP letter and Support Team note, acts on the information and/or encourages follow-up with appropriate health care staff

Prior to office visit

Initiate THA collection via KP.org or IVR when the visit is scheduled

Prior to Office Visit

THA responses scored, PPP letter created in Health Connect, and positive triggers referred to support team

Collaboration:

Provider hands member the printed PPP

Patient-centered Care

Region-wide Implementation Nov 2012

• 51,700 Annual Wellness Visits completed

• 43,000 THAs completed • 23,500 RN outreach calls

have been made to patients with risk responses on the THA

37 .

“The PPP provokes conversations that might not happen - like falls, depression, incontinence - because the patients don't normally bring these up on their own.” KPCO Internal Medicine Physician

38 | © Kaiser Permanente 2010-2011. All Rights Reserved. April 9, 2015

VALUE of AWV – Increased Identification & Addressing of Risk Factors Nearly everyone who triggered positive for a particular condition reported discussing the health

condition with the PCP during the AWV. Many members (one-third to one-half) reported discussing these conditions with the PCP,

even when the member did not “trigger” positive, inferring a preventative approach in identifying and addressing possible risk factors.

N = 74

N = 89

39 | © Kaiser Permanente 2010-2011. All Rights Reserved. April 9, 2015

Personalized Prevention Plan (PPP)

52%

Valu

able

% “Yes”

BOTTOMLINE Most members recall receiving a PPP and found it easy to understand. Members, in general, keep their PPP and half had referred to it after their AWV. Members, in general, believe the PPP is valuable.

N = 79

N = 119

78%

14% Ext Val

Impact of PATHWAAY Experience on Awareness & Confidence

40 | © Kaiser Permanente 2010-2011. All Rights Reserved. April 9, 2015

Participating in the PATHWAAY program resulted in an increased awareness of the actions to take to improve health.

Participants also reported high confidence in their ability to make changes that would improve their health.

N = 254

Impact of PATHWAAY on Self-Reported Action to Improve Health

41 | © Kaiser Permanente 2010-2011. All Rights Reserved. April 9, 2015

Still Working On . . .

•Better integration with the HER • Improved tools to automate production of the Personal Prevention Plan based on patient answers

Remote Monitoring enabled by Interchange: Diabetes Management tool-kit

Each member is assigned a glucometer device.

A CD to install the My Link desktop application

A patient dashboard for member access

A provider dashboard for the physicians

The member uses the glucometer device to take his/her blood glucose readings.

The patient installs this My Link desktop application on hi/her personal computer. The patient needs to connect his glucometer to the USB of his PC to be able to automatically send all his readings to the Kaiser physician.

The patient logs into the patient portal to view all readings sent to Kaiser. He/she views graphical representation of the readings along with many great features to help them track their diabetes.

The physician views all patients in the pilot. They can also view the individual reading of the patients thus using that information to help out the patients in a timely and efficient manner.

Glucometer Portal for patients Portal for Providers Desktop

Application – My Link

The Nurse and the patient connect every week to go over the readings and the graphs

44 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only. April 9, 2015

The Nurse at her Desk at a Kaiser facility The Member at his/her home

The patient logs in with member id and password and observes his readings. He no longer needs to spend hours narrating the readings to the nurse. He also observes the various graphical representations of his progress that highlight his progress and encourage him to keep on track.

The nurse is able to view the readings of her patients on the web directly. She does not need to manually record the readings anymore. Her readings are updated immediately upon the patient uploading their data She can cut and paste the patients readings directly into Health Connect

0

5

10

15

20

PrePost

Figure 1: Graph View

Self-Tracking Affects Outcomes: A1C Pre Vs. Post of Engaged Members (1.6 avg decrease)

We tracked A1C of the 14 most engaged patients over the course of the pilot.

Figure 1 (Graph View) shows that A1C of all the patients came down after 3 months as compared to when they started the pilot.

Table (figure 2: List View) shows that the average A1c for the 10 patients reduced from 9.8 to 8.2 over the duration of the pilot.

Remote Monitoring Improves Efficiencies: Average Call Time – Pre v/s Post

31.7% decrease in call time

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10

20

30

40

50

Patient1

Patient2

Patient3

Patient4

Patient5

Patient6

Patient7

Patient8

Patient9

Patient10

PrePost

Note – A few users had call time similar to the pre pilot phase, as they now spent more time getting tutored from the providers.

The notifications go a long way in letting the diabetic patient know about what is “not right”.

Alerts/Data Visualization Changes Behavior: No of Critical and Non-Critical Notifications during pilot

0

20

40

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80

100

120

140

160

180Total Red Alerts

Total YellowAlerts

Legal Issues • What is the expectation of the care team to

respond to results that are out of range? – Data upload frequency varied from daily to just

before scheduled call—alerts triggered when data is uploaded, so not available in real time

– Patients have been educated about how to respond to out of range values

• Terms and conditions specified that patients are responsible to contact Diabetes Care Manager when they receive an alert. If not already contacted, DCM did contact patient when they received an alert

Legal Issues •Data that is used to make or change a medical decision should be part of the electronic medical record

•For now, this means copying and pasting data and/or curves from the Diabetes Care System into care notes in the EHR

Still working on . . .

• Need an enterprise platform for receiving device generated data, compatible with multiple devices, or with data aggregators

• Integration into EHR

Questions Mark Groshek, MD Medical Director, Digital Services Group Kaiser Permanente mark.r.groshek@kp.org