Decision Support: More Than Guidelines

1. Decision Support: More Than Guidelines Winston F. Wong, M.D., M.S. The Care Management Institute Kaiser Permanente CAPH CCLC November 2, 2004 ICIC Website: http://www.improvingchroniccare.org/

2. Chronic Care Model Community Health System Resources and Policies Health Care Organization Self-Management Support DeliverySystem Design ClinicalInformationSystems Decision Support Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

3. Decision Support Systems • A process for incorporating guidelines, education, expert advice and practice aids into routine clinical practice NCQA

4. Decision Support • Embed evidence-based guidelines which describe stepped-care into daily clinical practice. • Integrate specialist expertise and primary care. • Use proven provider education methods. • Share evidence-based guidelines and information with patients to encourage their participation.

5. Knowledge Management…One Approach

6. What Works & What Doesn’t? • Meta-analysis of 99 trials, 160 interventions designed to change physician behavior – • Effective change strategies • Provider reminders • Patient-mediated interventions • Outreach visits (academic detailing) • Opinion leaders • Multifaceted interventions • Less Effective • Audit with feedback and educational materials • Not Effective • Formal CME conferences or activities, without enabling or practice-reinforcing strategies. • Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700-5.

7. What is evidence-based medicine? Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. -David Sacket, BMJ 13 Jan 1996

8. What is evidence-based medicine? • Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence. • The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments. McMaster University

9. What is evidence-based practice? • Efforts made to base clinical & other healthcare decisions on the best available evidence • Evidence is critically appraised & synthesized • The evidence synthesis is adapted to assist providers & patients in making decisions about specific clinical conditions.

10. Embed evidence-based guidelines into daily practice

13. Clinical Practice Guidelines • Clinical guidelines are systematically developed statements to assist practitioners and patients in choosing appropriate healthcare for specific conditions. -The Institute of Medicine

14. Clinical Practice Guidelines Efforts to distill a large body of medical knowledge into a convenient, readily usable format. - Eddy. The challenge. JAMA 1990;263:287-290

15. The purpose of clinical practice guidelines GAP Health status Satisfaction Cost Utilization Current Practice Current outcomes Optimal Practice Optimal Outcomes

16. QUALITY A quality gap persists: “…on average, Americans receive about half of recommended medical care processes.” — McGlynn, et al, NEJM, 6/26/03 # of Indicators % Recommended Received IOM: “What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology…” Overall care 439 54.9% Preventive 38 54.9% Acute 153 53.5% Chronic 248 56.1% Screening 41 52.2% Diagnosis 178 55.7% Treatment 173 57.5% Follow-up 47 58.5% Type of Care Function NEJM 348:26, Rand study

17. Need for Information at the Point of Care Clinicians carry frequently used information resources with them Information systems goal: Empty the lab coat pocket

18. Evidence-based Practice • Begin with NIH Guidelines • all team members should be familiar • Identify thought/opinion leaders • within your organization and outside • systematic literature review • organized learning within organization Steve Simpson, MD Kansas University

19. Stickies were ubiquitous Labels with patient Information and pre-visit summaries are also used as reminders

20. Evidence-based practice, cont. • Customize guidelines to your setting • Embed in practice: able to influence real time decision-making Flow sheets with prompts Decision rules in EMR Share with patient Reminders in registry Standing orders • Have data to monitor care

21. Attributes of Good Guidelines • Clear definition of condition and population • Exceptions are described • Evidence summaries are available with links to key articles • Clinical actions for stepped-care are clearly stated • “Nice-to’s” that are not evidence-based are omitted • Regularly updated to incorporate new data

22. http://pkc.kp.org

23. Stepped Care • Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more) • First choice medication • Either increase dose or add second medication, and so on • Includes referral guideline

25. DM care path 2003

26. Intensive Case Management Moderate Case Management by Yes We Can Asthma team Basic Case Management by Yes We Can Asthma team Self-Management Support by Primary Care Yes We Can Stratification Model • LEVEL 4 • Intensive Case Management • Child with poor asthma control and • Family in need of self-management skills and • Highly complex and unstable social/psychosocial criteria • LEVEL 3 • Moderate Case Management • Child with poor asthma control and • Family in need of self-management skills and • Moderately complex and unstable social/psychosocial issues • LEVEL 2 • Basic Case Management • Child with poor asthma control • Family in need of self-management skills • Relatively stable social/psychosocial issues • LEVEL 1 • Self-Management Support • Child with relatively well controlled asthma • Family has self-management skills • Relatively stable social/psychosocial status

27. Integrating Specialist and Primary Care Expertise Clarifying roles and working together

28. Definitions • Referral: transfer of care • Consultation: one-time or limited time • Collaboration: on-going co-management

29. Effective specialty-primary care interactions • When to consult • trouble making a diagnosis • specialized treatment • goals of therapy not met Adapted from material by Steve Simpson, MD Kansas University

30. Using Consultants Effectively Make your consultants partners • 1st principle of partnership - communication • communication begins with you • ask a specific question • specify type of consult: ongoing (referral), one time only, duration of specific problem Steve Simpson, MD Kansas University

31. Communicating • Telephone or in person • Letter • Letter with supporting objective data • e-mail • e-mail must be encrypted Steve Simpson, MD Kansas University

32. Example of an agreement in place Primary Care 1. State that you are requesting a consultation 2. The reason for the consultation and/or question(s) you would like answered 3. List of any current or past pertinent medications 4. Any work-up and results that has been done so far 5. Your thought process in deciding to request a consult 6. What you would like the Specialist to do Source: HealthPartners, MN

33. The agreement in place Specialty Care 1. State that you are returning the patient to primary care for follow-up in response to their consult request 2. What you did for the patient and the results 3. Answers to Primary Care Physicians questions in their consult request 4. Your thought process in arriving at your answers 5. Recommendations for the Primary Care Physician and educational notes as appropriate 6. When or under what circumstances the Primary Care Physician should consider sending the patient back to you Source: HealthPartners, MN

34. Going beyond referral and consultation: integrating specialist expertise • Shared care agreements • Alternating primary-specialty visits • Joint visits • Roving expert teams • On-call specialist • Via nurse case manager

35. Use proven provider education methods Beyond CME…

36. Effective educational methods Interactive, sequential opportunities in small groups or individual training • Academic detailing • Problem-based learning • Modeling (joint visits)

37. Effective educational methods • Build knowledge over time • Include all clinic staff • Involve changing practice, not just acquiring knowledge Result: better diagnosis, continuing care and guideline based care in children with asthma Evans et al, Pediatrics 1997;99:157

38. Share evidence-based guidelines and information with patients to encourage their participation.

39. What is shared decision-making? • Patient and clinician share information with each other (clinician shares medical information, patient shares personal knowledge of illness and values) • Participate in a decision-making process • Agree on a course of action Sheridan et al Am Jrnl Prev Med 2004

40. Guidelines for patients • Expectations for care • Wallet cards • Web sites • Workbooks • Stoplight tools

45. Example of a successful strategy: Adults with asthma • Developed a skill-oriented self-help workbook • Health educator session for 1 hour • Support group • Telephone calls RCT: better inhaler skills and use, decreased symptoms, less ER use. Bailey et al Arch Inter Med 1990;150:1664

46. Stoplight tools: patient guidelines

47. Supporting the Patient Role

49. What Does Work? • Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med, 2002 May 7; 136(9):641-51. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG.

50. Important Web Addresses • PubMed • http://www4.ncbi.nlm.nih.gov/PubMed/ • Guidelines • http://www.guidelines.gov • NIH - http://www.nih.gov