Integrated Care Coordination Information System: Primary Care Redesign
Integrated Care Coordination Information System: Primary Care Redesign through Care Coordination and Population Management
David A Dorr, MD MS
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.
- Care Management Plus: International Conference on Cybernetics, Informatics and Systemics (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.
Image: A diagram shows the interaction between specialists, the primary care team, the caregiver, and the patient.
Image of a flowchart.
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.
- Goal setting and follow up.
- 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 information technology (IT).
Additional Care Management elements requested from 7 teams with EHRs:
- Care Planning
- Follow Up
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.
Image: Screen shot of the Care Manager Encounter Tickler List.
Quality measure dashboard
Image: Screen shot of the Quality measure dashboard is shown.
Dashboard can be run by clinic, team, or individual PCP.
ICCIS Interactive Quality Reports
Image: Screen shot of a ICCIS Interactive Quality Report is shown.
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.
Image: Screen shot of a Patient Worksheet is shown.
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.
It worked! (see our poster)
Table 1. Care coordination activities
|Arm 1||Arm 2|
Figure 3: Absolute adherence change for Arms and Clinics Arms reimbursed Table 1. Care coordination activities
Unintended consequences: Errors / fixes
- 278 fixes of systemic errors in first 6 months of study.
- Data (multiple EHRs, minimal standards).
- Understanding/naming to reduce confusion.
Sustainability—'Free, take one'—dissemination to 208 teams
Image: A map of the United States shows the locations of the 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
CM+: care management plus
- 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 Widmeir.
- Mary Carpenter.
- Bryan Gardner.
- Ann Larson.
- Advisory Board:
- K. John McConnel.
- Tom Bodenheimer.
- Eric Coleman.
- Cheryl Schraeder.
- Heather young.
- Steven Counsel.
- Larry Caslino.
Thank you & Main lessons
|Workflow||Tickler as CDSS and single workflow||Needs assessment and requirements; usability|
|Patient-centered Care||Patient Worksheet||Accuracy, usefulness from clinical staff|
|Unintended consequences||Error tracking with clinical consequences||Fixes needed|
|Sustainability||"Free, take one" v.|
|Need has to be clearly assessed and targeted|
|Data in many different EHRs||EHRs have different data structures||Extracted data from 4 different EHRs|
|Functions in HIT systems siloed||Many functions are in separate EHR settings||Create universal workflows in separate application|
|EHRs have variable standard implementations||Although a standard vocabulary is available, it isn’t used||NOT EASY—manual mappings, many errors until it is solved|
|Population management is an analytic, not transactional issue||Reports take a long time to run and are static||Create interactive views of the reports (e.g., quality measure performance) with associated tables|
Image: Flow chart shows the following steps:
Log metrics: click throughs (<5 seconds on page): 62% ; loops/ repeated actions
Interviews: Use / workflow / challenges / errors