Indian Health Service Using Decision Support Effectively: Lessons from the Field

1. Indian Health ServiceUsing Decision Support Effectively: Lessons from the Field • Lisa Dolan-Branton, RN • Indian Health Service • Office of Information Technology/Chronic Care Initiative • AHRQ 2007 Annual Meeting

2. Indian Health System Setting • IHS Resource and Patient Management System • Clinical Decision Support in RPMS • Key Elements of a responsive HIS • (so clinicians use it with every patient) Presentation Overview

3. Mission: to raise the physical, mental, social, and spiritual health of American Indians and Alaska natives to the highest level. • Goal: to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people. Mission and Goal

4. IHS • 33 Hospitals • 49 Health Centers • 46 Health Stations • Tribal • 15 Hospitals • 198 Health Centers • 121 Health Stations • 180 Alaska Village Clinics • 34 Urban health care services and resource centers • 1.8 million users (Federally Recognized Tribes) • 56% AIAN rely primarily on IHS funded care (2000 census) • $3.1 billion from FY 2006 Appropriations • $628 million from Third-Party collections (2004) The Indian Health System

5. 6,168 5,454 Forecast to 2004 5,184 1999 2004 2001 3,965 3,832 3,753 IHS 2003 1999 1999 2,101 Year of Last Published Data 2004 Medical Care 500 Non-medical IHS APPROPRIATIONS PER CAPITA COMPARED TO OTHER FEDERAL HEALTH EXPENDITURE BENCHMARKS

6. * Census 2000, One race (AI/AN) alone WA NH VT ME MT ND MN OR ID SD WI NY MI WY CA IA PA NV NE NJ OH IL IN UT WV DE CO KS MO VA MD KY NC TN AZ NM OK AR SC AI/AN Population by State, 2000 AL GA TX MS 100,00 to 333,400 LA FL 50,000 to 99,999 AK 10,000 to 49,999 1,713 to 9,999 HI American Indian and Alaska Native Population By State

7. COMMUNITY ORIENTED PRIMARY CARE Cultural & Spiritual Behavioral & Social Medical Care Public Health Water & Sanitation The Indian health care system is built on a broad spectrum approach to health. It starts with a base of fundamental public health and sanitation infrastructure. It provides inpatient and ambulatory medical services. It also integrates community-oriented programs promoting healthy behaviors and lifestyles.

8. American Indians & Alaska Natives US All Races US White COMMUNITY ORIENTED PRIMARY CARE HAS REDUCED AI/AN MORTALITY Infant Mortality Rates 1973 – 2002 (25.0 to 8.5/1,000) 66% Reduction %Decrease in Mortality Rates since 1973

9. Resource Patient Management System (RPMS)

10. No RPMS RPMS PCC with paper charts and centralized data entry PCC+ with centralized data entry Partial use of EHR or other Electronic Medical Records Fully implemented EHR Indian Health System Spectrum of CIS Use

11. Order Checks • Med orders are checked for drug-drug interactions and allergies • All orders are checked for duplicate orders • Prescribing Restrictions / Guidance • Prescribing guidelines in pharmacy package accessible to prescribers (see screenshot) Decision Support in EHR

12. Oral Contraceptive Help

13. Info Button • Customizable links to web pages from POV (diagnosis) and Patient Ed components • Can be configured to insert selected text into web site’s search function • Reminders • National or locally created • Health maintenance or condition-driven • Reminder Dialogs enable simultaneous resolution of reminders (orders, education, etc.) and documentation Decision Support in EHR (cont’d)

14. Supports Web Link Information button on POV and Education components EHR v1.1

18. Patient Wellness Handout

19. Patient Wellness Handout

20. 26 IHS health centers implementing EHR between June 2003 and December 2005 • 69% federally operated, 31% tribal health centers • Mountain – 58%Pacific – 19%West south central – 12%South atlantic – 8%West north central – 4% • Median number of physicians per clinic: 5.0 (IQR 2-19)Median number of NP/PA per clinic: 2.0 (IQR 1-6) EHR Physician Study Setting

21. Impact of EHR on Quality * At least 4 on a 5 point Likert scale

22. Use of Key EHR Functionality

23. iCare: Population Management GUI

24. iCare - Pre-Planning

25. iCare - Patient Panels

26. iCare - Flags

27. iCare - Panel Outcomes

28. Documentation of individual and group encounters • DSM IV-TR Axis I – V Diagnostic Coding • Treatment Plans • Case Management Information • Suicide data collection • Ability to document non-direct patient care activities such as community education, Performance Improvement, clinical supervision, training, etc. • Robust reports module: workload, case management, condition-specific RPMS Behavioral Health Applications Functions

29. Future Clinical Decision Support

30. HIT solution can drive improvement at each patient visit • Vision of a HIT system that provides you with the ability to manage patients, communities and populations within your mission context • Value of requirements development with Clinicians • Clear and specific requirements that put the clinical and public health needs at the center of the specification and programming process • Rapid cycle development • Like a good community organizer—becomes background noise • It’s not about IT Key Elements of Responsive CDS

31. QUESTIONS? QUESTIONS? Lisa Dolan-Branton, RNlisa.dolan@ihs.gov