utah partnership for value quarterly...
TRANSCRIPT
Utah Partnership for Value Quarterly Meeting
December 19th, 2013 HealthInsight Boardroom
Shared Decision-Making
Daniel Chipping, MBA, MHA Project Coordinator
HealthInsight
What Is Shared Decision-Making?
• Shared decision-making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences. – Informed Medical Decisions Foundation
Decision-Making Levels Level Description
Basic Discussion of patient’s role in decision-making Explanation of clinical conditions Assessment of patient preference
Intermediate Discussion of risks and benefits Discussion of alternatives Assessment of patient understanding
Complex Discussion of uncertainty about decision
Today’s Speakers
• Dr. David Arterburn, Group Health Research Institute
• Catherine Hamilton, Intermountain Healthcare
• Robin Betts, Choosing Wisely Advisory Board
Success in Washington State: A Look at Group Health's Shared Decision Making Program David Arterburn MD, MPH Group Health Research Institute
Financial disclosure
• I have received research funding and salary support from the
Informed Medical Decisions Foundation
• I serve as a Medical Editor for the Informed Medical Decisions
Foundation in the area of bariatric surgery
What is Group Health?
• Group Health is a consumer-governed, non-profit
health system that integrates care and coverage for
over 600,000 residents of Washington state and
Northern Idaho (1 in 10 Washington residents)
• Two-thirds of our members get most of their care
within our Integrated Group Practice from salaried
Group Health providers
Outline
1. What was Group Health’s pathway to large-scale implementation
of Shared Decision Making?
2. What infrastructure elements did Group Health put in place to
support Shared Decision Making?
3. What did Group Health leadership do to create a culture of
expectation around Shared Decision Making and begin to build
competencies among providers?
4. What outcomes have we observed?
5. What steps are we taking now to optimize Shared Decision
Making at Group Health?
Group Health’s pathway to
shared decision making
Group Health rates of surgical procedures rising
Shared decision making – the highest legal standard in Washington state
• 2007 Washington state legislation: – Recognized the use of shared decision making
along with high-quality patient decision aids as the highest standard of informed consent
– Mandated, but did not fund, the state Health Care
Authority (HCA) to implement shared decision making demonstration projects
• 2012 Washington state legislation:
– Authorized the WA state HCA to certify high-quality
decision aids
Infrastructure elements to
support shared decision
making
Twelve preference-sensitive conditions
• Orthopedic Surgery – Hip Osteoarthritis – Knee Osteoarthritis
• Cardiology
– Coronary Artery Disease
• Urology – Benign Prostatic Hyperplasia – Prostate Cancer
• Women’s Health – Uterine Fibroids – Abnormal Uterine Bleeding
• Breast Cancer – General Surgery – Early Stage Breast Cancer – Breast Reconstruction – Ductal Carcinoma In Situ
• Neurosurgery – Spinal Stenosis – Herniated Disc
Epic ordering of patient decision aids
Appropriate staffing for implementation and ongoing process improvement
20
Project managers with experience implementing practice changes at Group Health were hired to carry out this work
Creating a culture of expectation
and building competencies for
providers
But I already DO shared decision-making with my patients…
Of course it is totally up to you, but if it was me, I’d choose to have the surgery.
Setting the tone for competency in shared decision making
“Nice to do if you have the time and inclination.”
“No patient should undergo a preference sensitive procedure without documented evidence that they got all the information they needed and then had a conversation with their provider in which their preferences were documented before they made their decision.”
Cultural spectrum
GH leaders want to push providers right
over here!
Key culture change steps
• Required all providers to watch the relevant decision aids
• ½-day CME with outside experts trained 90% of our specialty providers
and surgeons
• Monthly feedback to leaders and providers
– Volume of decision aids ordered
– Volume of surgical procedures and total costs of surgical procedures
– Number and percent of surgical patients in each specialty who had
surgery without receiving a decision aid
• Patient satisfaction data related to decision aid use
Outcomes
Since January 2009,
we have delivered over 40,000
decision aids
Process measure – “defect measure” shows fewer missed opportunities for DA delivery
5%15%25%35%45%55%65%75%85%95%
Per
cent
Month
Percentage of Procedures Performed where Patient did not receive the video. (Hips, Back, Knee and Hysterectomy & Benign Prostatectomy)
% Did not receive videoTarget
29%
Other health conditions
• Clinically Localized Prostate Cancer: significantly lower rates of
intervention, but no difference in costs
• Medically treated BPH: significantly lower rates of intervention, but
no difference in costs
• Non-medically treated BPH: no difference in rates of intervention
or costs
• Abnormal Uterine Bleeding and Uterine Fibroids: non-significant
trend towards lower rates of surgery, but no difference in costs
Our next steps optimize
Shared Decision Making
Next steps
• Adding new decision aids:
– Acute & Chronic Low Back Pain, Weight Loss Surgery, End of
Life Care, End Stage Renal Disease, Maternity Suite
(Suspected Macrosomia, Elective Induction, and Vaginal Birth
After Cesearian)
• Piloting provider online training
• Implementing electronic knowledge and preference assessment
questionnaires
Conclusions
Shared decision making with decision aids
Acknowledgements • Funding • Informed Medical Decisions
Foundation • The Commonwealth Fund • Health Dialog • Group Health Foundation
• GH Physician Leadership • Michael Soman Marc Mora • Paul Sherman Chris Cable • Dave McCulloch Matt Handley • Charlie Jung Nate Green • Jane Dimer Mark Lowe • JC Leveque Gerald Kent • Paul Fletcher Tom Schaff • Rick Shepard
• Public Policy • Karen Merrikin
• GH Implementation • Tiffany Nelson Stan Wanezek • Charity McCollum Jan Collins • Andrea Lloyd Scott Birkhead • Colby Voorhees
• GH Research Institute • Emily Westbrook • Rob Wellman Carolyn Rutter • Tyler Ross Darren Malais • Clarissa Hsu Sylvia Hoffmeyer • David Liss Jane Anau
• External Advisors • Jack Wennberg Michael Barry • Doug Conrad Cindy Watts • David Veroff Richard Wexler • Kate Clay Leah Hole-Curry
Questions?
We want your ideas!
• Relevance to the community • Current • Topical:
– Transparency – Health System Improvement – Using HIT/Data to achieve the above
Utah Partnership for Value-Driven Health Care (UPV)
Engaging Patients: Shared Decision Making
Catherine Hamilton BSN, MS, MBA December, 2013
Shared Decision Making: What is it?
• Invitation to participate in decision making • Presentation of options • Provision of information on benefits and risks • Exploration of patient values and preferences • Facilitation, deliberation and decision making • Assistance with implementing the decision
Shared Decision Making at Intermountain Healthcare
• Board and senior leadership support • Web-based decision tools • Patients access tools as often as
they want • Patients have better understanding
of preferences • Patients have specific questions for
our doctors and clinicians
Expected Benefits
• Better inform patients of their treatment options • Improve the patient and clinician experience • Improve efficiency by increasing patient knowledge prior to
the clinical visit • Reduce cancellations • Achieve appropriate utilization
Progress in 2013
• Early stage breast cancer treatment options
• Prostate cancer treatment options • Low back pain • Osteoarthritis of the hip and knee • Bariatric surgery decisions
Emmi Solutions – Decision Aids
High Value Healthcare Collaborative
• Dartmouth awarded the CMS Innovation contract on behalf of HVHC
• Using Health Dialog web-based decision tools
• Goal is to demonstrate triple aim outcomes for high cost conditions (diabetes, heart failure) and treatments (hip and knee arthroplasty, spine surgery)
• Currently used in specialty and primary care clinics in the Utah southwest region
Archimedes IndiGO
• Simulation model of human physiology, clinical events, and health behaviors
• Accurately calculates changes in outcomes for several interventions
• Priority: chronic disease management (cardiovascular, diabetes, hypertension, depression)
• Appears in the EMR for use during the patient encounter
• Gives the patient a visual representation of factors under their control
• Helps patients learn how to affect risk of heart attack, stroke, or diabetes complications
Archimedes IndiGO
Copyright 2010 Archimedes
Copyright 2010 Archimedes
Copyright 2010 Archimedes
Copyright 2010 Archimedes
Copyright 2010 Archimedes
Copyright 2010 Archimedes
Copyright 2010 Archimedes
Questions and Comments
Questions
• For which kinds of decisions is shared decision-making most useful?
• What are the current barriers to broader implementation of shared decision-making?
• What can the UPV group do to improve the use of shared decision-making in Utah?
Resources
• Dartmouth Institute: http://med.dartmouth-hitchcock.org/csdm_toolkits.html
• Informed Medical Decisions Foundation: http://www.informedmedicaldecisions.org/what-is-shared-decision-making/
Choosing Wisely Utah UPV Project Update
December 19, 2013 HealthInsight Board Room
What is Choosing Wisely? • Initiative of the ABIM Foundation, Choosing Wisely
– Encourages physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.
• Leading specialty societies have created lists of “Things Physicians and Patients Should Question” — evidence-based
• Consumer Reports is developing and disseminating materials
• More than 50 specialty societies participating
Project Intended Outcomes
• Educate providers – Including our own physician office
colleagues
• Develop partnerships • Create meaningful dialogue • Educate community • Raise awareness • Facilitate shared decision making
Choosing Wisely Utah’s Top 5 • Antibiotics should not be used for apparent viral
respiratory illnesses in children • Don't do imaging for uncomplicated headaches • Don’t routinely prescribe antibiotics or x-ray in mild
or moderate sinusitis • Don’t do imaging test for back pain in first six
weeks • Computed tomography (CT) scans are not necessary
in the immediate evaluation of minor head injuries in children
Anticipate Patient
Dialogue
Activities Update
Radio PSAs • Developed with technical assistance from
ABIM, PR firm in DC • Focuses on CW concepts and one
recommendation: antibiotics for head colds in kids.
• Coming to your car soon: to air January and February across Wasatch Front on 45+ stations
Community Dialogues
• SLC event: March 27th, 2014, UofU • Provo event TBD: 1 month later • Local media host • National and local panelists • Promote discussion on overuse and shared
decision-making • Looking for co-sponsors! • Invite-only reception for UPV members
Choosing Wisely Utah Website
healthinsight.org/choose
Choosing Wisely Advisory Board Members
Alan Ormsby – AARP Brian Jackson – ARUP Chet Loftis – PEHP David Clark – Zion’s Bank Deanna Welch – Intermountain Gregory Kratz – ARUP Jennifer Dailey – UAFP
Katie Martin – U of U Kirsten Stoesser – U of U Michelle McOmber – UMA Peter Taillac – UDOH Robin Betts – Intermountain Saskia Spiess – U of U Toan Lam – PEHP
Ways you can help/get involved
• Come to the March 27th Town Hall • Distribute Choosing Wisely materials • Link to the HealthInsight Choosing Wisely
Website • Provide feedback from the community • We invite your engagement!!
Questions?
Thank you
Check your email and VOTE!
The Utah Medical Home
Proposed Standards and Measures
Created by UPV Medical Home Standards and Measures Work Group
Utah Partnership for Value-driven Health Care (UPV)
December 19,2013
UPV Standards and Measures Workgroup Participants
• Karen Coats, UDOH • Jenifer Lloyd, AUCH • John Neal, Consultant • Gail Rapp, Medicaid, UDOH • Arlen Jarret, M.D., Iasis • Deanne Pranke, formerly of AUCH • Libbey Chuy, AUCH • Marc Babitz, M.D., UDOH • John Berneike, M.D., St Marks Fam. Med. • Annie Mervis, University of Utah • Alan Pruhs, AUCH • Sarah Woolsey, M.D., HealthInsight
• Jason Cooke, Utah Health Policy Project
• Matt Hoffman, M.D., UHIN • Joyce Kim, Health Choice Utah • Jeff Black, HealthInsight • Wayne Cannon, Intermountain • Janet Tennison, HealthInsight • Julie Day, M.D., University of Utah • Teresa Rivera, UHIN • Doug Smith, M.D., Arches Health Plan • Kim Dunn, HealthInsight • Daniel Chipping, HealtInsight
Purpose
• Educate that the Patient Centered Medical Home (PCMH) model is a value proposition – lower cost, better outcomes, satisfied patients
• Develop baseline standards for a Utah Medical Home – Acknowledge national PCMH certifications may be
challenging for some – Allow participation of all interested Utah primary care
providers – Set standards for new reimbursement arrangements – Allow for local input
Elements • Appropriate Access • Population Management • Care Management/ Care Coordination • Ongoing and Continuous Quality Improvement • Patient Empowerment and Activation • Electronic Health Record Utilization Note: all align with Nationally Recognized Standards
Timeline
• December 2012-UPV workgroups formed • Monthly meetings January-December 2013 • December 2013 Standards Document
complete • January to March 2014-spread and solicit
support • April 2014-reassess progress and next steps
with UPV
Requested Actions
Feedback and Spread • Content • Distribution • Raise Awareness • Alignment with State
Innovation Model
Direct Outreach -Next 3 months
• Patients/ families • Primary care providers • Hospitals • Coordinating Care Providers • Behavioral Health Providers • Payers • Policy Makers
Questions/Discussion
UPV HIE for Care Coordination Workgroup Participants
• Wain Allen, MD, Coalville Health Center • John Berneike, MD, St Mark’s Family
Medicine • D’Arcy Cassaday, Harmony Home Health • Daniel Chipping, HealthInsight • Phillip Davis, University of Utah,
Inception • Michele Gentz, HealthInsight • Marti Kullen, Avalon Healthcare • Brenna Long, VA • Jaime Montuoro, Smiths Pharmacy
• Chuck Norlin, MD, University of Utah, Dept. of Pediatrics
• Wyatt Packer, HealthInsight • Stephen Prather, MD, Wellness Policy
Network • Merri Rock, UHIN • Jan Root, UHIN • David Smith, HealthInsight • Iona Thraen, UDOH • Peter Weir, ARUP • Sarah Woolsey, MD, HealthInsight
UPV HIE Workgroup
• Vision: Find effective ways our community can tap into the HIE to coordinate patients across care settings and payer types in support of the Medical Home model - Timely, relevant data that prevents bad things from happening to patients; timely information that prompts the primary care home to act and prevent readmissions, ER use, etc.
Pilot Use Cases
1) VA Provider-to-Provider: VA to Harmony Home Health through DIRECT. Result: Successful
2) Provider-to-Provider: SL Regional SBAR to Avalon Healthcare through DIRECT. Result: Incomplete due to vendor delay of functionality
3) Provider-to-Provider: St Marks Radiology reports to Dr. Wain Allen’s SpringCharts EHR through cHIE. Result: Incomplete due to delay of cHIE connectivity with EHR
4) Provider-to-Payer: U Health Plans to CNS through DIRECT. Result: Successful
UPV Structure 2014
Steering Committee Attendance (non-HI, June 2011- Dec. 2013)
0
5
10
15
20
25
30
35
40
Jun-
11Ju
l-11
Aug
-11
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11O
ct-1
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1Ja
n-12
Feb-
12M
ar-1
2A
pr-1
2M
ay-1
2Ju
n-12
Jul-1
2A
ug-1
2Se
p-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13Fe
b-13
Mar
-13
Apr
-13
May
-13
Jun-
13Ju
l-13
Aug
-13
Sep-
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3
Attendees
Linear (Attendees)
Year in Review; Looking Ahead
• Increasing attendance (rotating) • Focused on “topics of interest” and
discussion that sometimes spins off into concrete work
• 3 NEW workgroups in 2013 with 65 active members
• Advisory board function missing
UPV Steering Committee • ~100 members • Meets Quarterly
• Goal: Start conversations, align efforts, spread good ideas • “Come when you can.”
Delivery Optimization: Medical Home
Standards (monthly) 2012-2013
Delivery Optimization: Medical Home
HIE/Care Coordination
(monthly) 2012-2013
Transparency: Transparency Action Group
(monthly-quarterly)
2008-present
Waste/Over-use: Choosing Wisely
Utah (quarterly) 2013-2015
For more information: http://healthinsight.org/upv
Advisory Board 10-12 members
Monthly or bimonthly Guide UPV Work and Progress towards Goals
? ?
Advisory Board
• ~12 members representing the 4Ps: • Payors • Providers • Purchasers • Public
• Guide UPV agenda, activities, action-focused work
• Meeting frequency TBD • Guided by principles of “Collective Impact” • Contact: [email protected] if interested
Next Steps
• Contact Sarah if you can help spread the Medical Home white paper
• Next meeting UPV meeting will be the Choosing Wisely event: March 27th 4-5 pm
• First UPV advisory board meeting will be in February
• AB will take topic poll from today and plan for 2014 quarterly meetings.
• Happy holidays!