The Language of Quality

Transcription

1 Conference on Quality in Health Care Manila October 2007 Four Axes of Health Improvement Improving Access to health services Ensuring Equity in providing health services Increasing Cost-Efficiency Is there a link?? Improving Quality of Care Dennis J. Streveler, Ph.D. University of Hawai`i What is Quality? You will know it when you see it! The Language of Quality Inputs Outputs A QUALITY Burger! Outcomes BK QUAD STACKER: 1,000 Calories 620 Calories from Fat 68g Fat 30g Saturated Fat 3 g Trans Fat 240 mg Cholesterol 1,800 mg Sodium Clinical Quality (health indicators) Perceived Quality ( patient satisfaction ) 1 g Fiber Global Trends in Infant Mortality, 1999 Measuring Quality: A Brief History Nosocomial Infection Rates 120 [USA] NCQA HEDIS Measures (from claims data) Report cards Patient Safety measures (after the IOM report) [USA] AHRQ Quality Indicators (QIs) Pay-for-Performance infant mortality rate Cancer Survival Rates WHO Health Indicators (e.g. IMR, MMR ) Sierra Leone 160 Angola Guinea 100 Gabon 80 Ghana Namibia China 60 Botswana Latvia Philippines [34, $1200] (2004) Sri Lanka Slovak Rep per capita GDP, US$ Courtesy of The World Bank 1

2 Selected HEDIS measures [USA]: Antidepressant Medication Management Beta Blocker Treatment Breast Cancer Screening Cervical Cancer Screening Cholesterol Management After Acute Cardiovascular Events Childhood Immunization Status Comprehensive Diabetes Care Follow-up After Hospitalization For Mental Illness Prenatal and Postpartum Care THE STRATEGIC APPROACH: INTEGRATION Five Characteristics Determine the Value of Good Health Information Relevance of the information to the needs of the health system decision-making Coverage, both geographical and by program/service component Completeness of the information Accuracy of the information Timeliness of the information Strategy Set standards for data The systems we build must work together in order to enjoy their full value. Principles Health information should flow directly from health delivery operations. There must be a feedback loop of information to those providing the data. An HMIS system is only as good as its users! To be sustainable, an Information System requires maintenance, and a support center. Interventions Build Clinic Information, Hospital Information, and ultimately an Electronic Health Record Create a bottom-up as well as a top-down data reporting structure Build a Computer Literacy Center and Computer Training Center Build a Support Center collection Collect the most valuable data (not too much, not too little) Create a center which focuses on the analysis of these data ( data warehouse ) Act on the results! Intervention Health Data Dictionary Data Inventory Health Data Warehouse Information for Action! Components HARD COMPONENTS: Hardware Software Telecommunications Equipment Supplies SOFT COMPONENTS: Health care delivery process re-design Introduction of an information culture Computer-ready buildings Budgeting for sustainability Training and retraining Updates and support 2

3 Iran s Vital horoscope Primary Health Clinic, near Isfahan, Iran, 2002 Cairo, Egypt: Jeseniče, Slovenia: Clinic Information System with physician access, 1999 Online Insurance Kiosk with Smart Card access, 2001 Shanghai, China: Electronic Patient Record, Ruijin Digital Hospital, 2004 Nuku`alofa, Kingdom of Tonga,

4 Quality, some final remarks We will improve quality only if we demand an improvement in quality! Dennis Streveler, University of Hawai`i We will improve quality only if we invest in improvements to quality! We will improve quality only if we are committed to aggressively using the health data which we collect! PROMIS 1970 Larry Weed, VT MIS, El Camino Hospital, Mountain View CA, first 1972 Clinic, Katowice, Poland, 2006 Steps to Information Nirvana Define National Priorities Identify Data Sources Calculate the Cost/Benefit of collecting the data Define how each Data Source WILL be used Build /modify the HMIS Create the Datawarehouse Build capacity to analyze the Data Evaluate the Impact Define Quality VISUALIZE the data Choose Health Indicators Make the data available to decision-makers along with recommended actions Modify the strategy as necessary Iterate bar-coding 4

5 THE HEALTH INSURANCE ENVIRONMENT The Role of the Payer Claims processor - the bank the intermediary Risk aggregator 1. Payer 3. Interface and Communication 2. Provider Educator beneficiary, provider Monitor The Incentivizer Case manager Active intervention Cause célèbre? Our biggest problem: Our biggest problems: Insurance coverage/affordability Continuity of care Referrals to higher levels of care Returns to lower levels of care Follow-ups, compliance Dumping Lucrative patient grabs WHO Rankings: Tobacco control initiative: smokers droop 1. France 2. Italy 3. San Marino 4. Andorra 5. Malta 6. Singapore 7. Spain 8. Oman 9. Austria 10. Japan 31. Finland 32. Australia 33. Chile 34. Denmark 35. Dominica 36. Costa Rica 37. United States of America 38. Slovenia 39. Cuba 40. Brunei 5

6 THE UH CAMPUS IS 84% SMOKE FREE! Distressed Beach near Gaza City, 2004 Tajikistan: Porud Health Center, 2003 Uvurkhangai aimag, central Mongolia, 2003 Ministry of Finance, Manama, Kingdom of Bahrain, 2001 Shahrud, Iran: The Digital Hospital Radiology Digital Archiving,

7 Telecardiology at Hospital #3 Heart Center, Ulaan Baatar, Mongolia November 2003 Telemedicine Center, MOPH, Nonthaburi, Thailand, Feb 2001 Interview results: Is Home-based Telemedicine years ago! ICS 614 Project Presentation December 4, 2004 Lisa Yoda Remember My Health Record Consumer-oriented, longitudinal health record Technology often gives us back Emergency information Clipboard Replacement CONSUMERS Immunization Tracker Hospitals Consumer Health Record Event manager & health reminders & trackers what Labs Health Plan Consumer-defined access rights PHYSICIANS Pharma technology had taken away! The Harvard Conference on American Health Care, Nov 3,

8 Transaction example: THE HEALTH INSURANCE ENVIRONMENT THE HEALTH INSURANCE ENVIRONMENT REQUEST FOR PAYMENT (CLAIM) 1. Payer 3. Interface and Communication 2. Provider 1. Payer PROVIDER PAYMENT 2. Provider Transaction example: THE HEALTH INSURANCE ENVIRONMENT ENROLLMENT 1. Payer ELIGIBILITY 2. Provider Provider System Provider System Functionality FUNCTIONALITY TODAY: Patient registration and rostering Eligibility checking Claims / encounter creation Claims / encounter submission Appointment scheduling Payment processing Contract monitoring Business unit-level management information Central budgetary control Inventory management Clinical functionality FUTURE POTENTIAL FUNCTIONALITY: Virtual longitudinal lifelong electronic patient records Support for clinical practice guidelines Telemedicine and teleconsultation Video teleconferencing Medical research resources Payer System Payer System Functionality Registration and Eligibility Premium Collection Contracting and Contract Management Claims Adjudication Provider Payments Utilization Management Quality Management Financial Management and Analysis, Accounting, Financial and Actuarial Projections 8

9 Virtual re-integration EMR A Referral system ( code share ) RHIOs/Shared visit index (e.g. Holomua Project) Shared clinical summary Electronic medical record (EMR) Personal health record (PHR) First EMR attempt? Morris Cullen, MD Kaiser-Permanente, Hayward Clinic, Northern California, years ago! Holomua : AHRQ Awards Over $22.3 Million in Health Information... The Holomua project in Hawaii will implement a health IT system to improve the flow of information among patients, community health centers and hospitals k Political, and economic, reality NEW YORK TIMES July 10, 2007 A State Finds No Easy Fixes on Health Care By KEVIN SACK Gov. Edward G. Rendell of Pennsylvania, who campaigned as a health care reformer, is learning that to contain costs is to pluck dollars from someone s pocket. Obstacles: Lack of data Cost of data input Lack of data standards HIPAA constraints Defensive medicine Lack of a focus on quality Lack of a culture of quality Lack of political will! 9

10 COSTS: The Iceberg Challenge Recognized Costs Remember The EMR is no panacea! What data are available? How can the data be shared? Data entry is not free! Hidden Costs Source: Binseg Wang Dennis J. Streveler, Ph.D. University of Hawaii 10