10/22/2013. The Dartmouth Spine Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH

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1 0/22/203 October 3, 203 International Society for Quality in Health Care Patient Reported Outcomes: Hospitals and Clinicians Perspective. There is a growing interest in the development of new outcome measures that would allow for a better assessment of patient-centered healthcare value across the continuum of care. 2. Within patient-centered outcome measures, patient reported outcomes will need to play a central role as we redesign health care systems around patients. Eyal Zimlichman MD, MSc Center for Patient Safety Research and Practice, Brigham and Women s Hospital Quality, Safety & Value Group, Partners Healthcare System Harvard Medical School 3. There is very limited experience with implementing and using patient reported outcomes for quality and value improvement. 2. What should we be asking patients? Generic vs. disease specific 2. What conditions would best fit PROMS? Surgical procedures vs. chronic conditions 3. How/when do we collect the data? Paper vs. electronic / home vs. on-site 4. How do we get patients to play along? Unlike patient satisfaction data 5. How do we ensure value for patients? What s in it for me PROMs support health care value comprehensively through the following stakeholders Patients Informed decision making and activation in care Will receive care that is patient-centered outcome driven Providers Better assessment of patient s global condition Ability to drive care towards patient centered outcomes with real-time feedback Comparative effectiveness and efficiency analysis Clinical/Quality Managers Support Care Redesign by using outcomes that matter to patients 4 Getting patients to report Getting clinicians buy-in so that they use the data Successfully bringing about an organizational PROMs paradigm shift The Dartmouth Spine Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH Our approach: Providing PROs data across the continuum Feed Forward Feed Back Real time automated reports Discussion with clinicians PRO dashboards on Patient Gateway James N. Weinstein, DO, MS William Abdu, M.D. M.S. Eugene Nelson, DSc, MPH 5 6

2 0/22/203 The Dartmouth Spine Center Case The Spine Center Summary Report Generated from Patient-reported Data for Use in Making and Monitoring the Care Plan. Nelson EC et al. Proceedings from British Columbia Ministry of Health Services Symposium on Measures of Health Outcomes to Improve Performance, Value and Productivity. Victoria, B.C., December 9, 200. Eyal Zimlichman Testimony by James Weinstein, DO, MS for the Office of the National Coordinator for Health Information Technology Policy Committee Testimony by James Weinstein, DO, MS for the Office of the National Coordinator for Health Information Technology Policy Committee Memorial Sloan-Kettering Cancer Center: The Urology Clinic Experience Andrew Vickers, PhD 2 2

3 0/22/203 Constitutes a pioneering attempt by a healthcare system to implement an operational PRO system, including- Collecting PRO data through a multi-modal approach Reporting PRO measures to providers and patients Using PRO data as quality metrics on a physician, clinic, hospital and system level Launched in early 202 with two conditions: CABG(a surgical procedure, many times symptoms driven) Diabetes(chronic, primary care focus) Expanding now to more conditions: stroke, urology, joint replacement 6 CABG PARTNERS PATIENT REPORTED OUTCOME TOOL TEMPLATE Providers (EHRs) Reporting Patients Managers (PHRs) (dashboards) CATEGORY PRE-PROCEDURE POST-PROCEDURE Partners Healthcare FUNCTIONAL STATUS (PROMIS-0) 0 0 SYMPTOMS LEVEL 6 6 Patient context maintained Quality Data Management, Inc. PERCEIVED HEALTH BENEFITS - 4 HEALTH UTILITY TOTAL: 7 2 Data Collection Modes IVR + phone operators Tablets Patient Gateway 7 8 3

4 0/22/203 Individual Patient Report: Description of score category Time trends Current score Decision aids 2 Conceived and designed by Neil Wagle, MD 22 Patient, Henry PROMIS-0!? EQ-5 Health Utility LOCATION RESULT REF RANGE FLAG DATE TIME Off site Mental 3-82 ABNORMAL 03/02/ Health: 0 Patient, Henry MRN: Patient Reported Outcome Snapshot, Patient Gateway PROMIS-0 Global Physical Score: 53 (ref 5-78) PROMIS-0 Global Mental Score: 7 (ref 3-82) Flagged responses: Global02: In general, how would you rate your mental health, including your ability to think? Response: Poor" Global0: In the past 7 days, how often have you been bothered by emotional problems such as Hospital Condition Completed Partial Total Attempted Offered Cardiac Pre-Op % 7.62% % Cardiac Post-Op % 5 4.3% % 363 site % % % Total 586 Cardiac % % % Pre-Op Cardiac Post-Op % % % 35 site % % % Total 987 Cardiac % % 4.76% Pre-Op 34 3 Cardiac Post-Op % % % 3 Total site % % % % % % 893 Total Pre-Op Total Post-Op % % % 745 Total Cardiac Surgery, % % %,638 4

5 0/22/203 Data Reporting Hospital 2 3 Physical function Mental status Health utility Shortness of breath Chest pain Condition Average% low Average % low Average % low Average % low Average% low Pre-Op % % % % % Post-Op % % % % % Pre-Op % % % % % Post-Op % % % % % Pre-Op % % % 0.00% % Post-Op NA NA NA NA NA NA NA NA NA NA Total Cardiac Pre-Op % % % % % Surgery Post-Op % % % % % Partners HealthCare Data: The Effect of Cardiac Surgery on Chest Pain Pre-Op Post-Op Follow-Up Chest Pain at Rest Chest Pain with Exercise Unpublished Data 27 The patient experience: Patients say their doctors should be asking these questions Patients comment that the tablets are fun to use and very user-friendly Patients are willing to answer these questions at home The staff experience: Practice Administrators have created unique workflow plans for their clinics to best incorporate PROMs Medical assistants and nurses generally understand the importance and provide guidance to the patients through the process The physician experience: Variable response from champions to critics Most agree there is value in measuring and using PROMs but see different aspects of PROMs (long term follow-up, screening, population health, individual patient care, research) Buy-in from local leadership Local physician leader to lead the change (i.e. Champion) Dissemination of rationale and importance to clinical staff Successfully navigation clinic work flow issues Gradually building physician buy-in and penetration 5

6 0/22/203 Careful attention to each clinic s unique workflow and organizational culture Develop data collection and reporting workflow on a clinic-by-clinic basis Tailor workflow by taking into consideration care redesign in play (e.g., new clinical care pathways, new staffing models, team based care, PCMH etc.) Design of PROMs data collection and reporting tools requires early and frequent dialogue with clinics, clinicians and patients! MAYO Clinic Clinical Pathways in response to PRO Problems or Concerns with physical health Pain Fatigue Vision problems Sleep problems Difficulty walking Possible Actions Assess where, when, severity, duration, associated with New onset vs recurrent Therapy and effect Patients assessment of why they have pain Impact of pain on daily life Administer brief pain inventory for more details Consider pain clinic referral Assess intensity of fatigue New onset vs chronic issue Patient assessment of why they are fatigued Discuss sleeping patterns and habits Consider administering brief fatigue inventory for more details Look for common causes of fatigue: depression, blood sugar elevated or low, medications causing fatigue, stress Consider an evaluation for anemia with appropriate interventions such as exercise program counseling or iron supplements Assess pattern and new or sudden onset Associated symptoms such as pain or watering Consider referral for eye exam---if pain may need to be emergent Assess risk of elevated blood sugar Discuss sleeping patterns Identify barriers to getting enough sleep and strategies for overcoming barriers Consider depression screen Consider referral to sleep therapist Consider prescription for a sleeping aid Assess why: dyspnea, pain, weakness, gait issues, etc Consider referral to physical therapy Discuss getting more exercise Discuss if patient needs help with/has assistance getting everyday tasks done Development phase Pilot phase Roll-out phase Resolve clinic specific work flows Clinical decision pathways Population health Identify clinical leadership Condition specific tool design Involve staff in development Identify champions Alert thresholds and mechanism Wide spread use Patient activation/ Shared decisions IT implementation Case studies PRO measures 0 How to use as quality metrics? What level of risk-adjustment is needed? The exact metrics need to be defined Create ability to benchmark outside. For this to happen:. Agreement on instruments (PROMIS) 2.Agreement on methods and metrics. National policy 2. Collaborative Eyal Zimlichman, MD, MSc ezimlichman@partners.org