Jonathan B. Perlin, MD, PhD, MSHA, FACP Deputy Under Secretary for Health

1. Jonathan B. Perlin, MD, PhD, MSHA, FACP Deputy Under Secretary for Health Veterans Health Administration Department of Veterans Affairs No One Grows Old Saying, “Gee, I Hope I End Up in a Nursing Home !”New Strategies for Using Advanced Technology and Care Models for Safer, More Effective, More Humane Health Services SPRY Foundation Conference “Computer-Based Technology & Caregiving for Older Adults” Washington, DC – October 2, 2003

2. Safety: Only the Tip of the Iceberg • Patients don’t seek care just to be safe • Expect effectiveness in maintaining & improving health, managing disease & distress • Goal: Safety & Effectiveness, To Close to Chasm • Gap between care scientific evidence defines as best and the care most Americans receive • Goal: To provide Patient-Centered, Coordinated Care • Patient is locus of control • Seamless across environments • Integrates disease-specific and general health and social needs To Err is Human: 98,000 Patients The Quality Chasm: Every Patient “Crossing the Quality Chasm” 2001: IOM

3. From Health Care Delivery To Patient-Centered Care • Safety: Avoid Getting it Wrong • Quality: Get it Right . . . Consistently • Patient-Centered Care • Support patients with safe, high-quality care, in health and disease, at the time & place, and in the manner patient desires • Care extends from hospital & clinic to home & community • Using Information Technologies for Creating Effective Relationships between Patients, Caregivers and the Health System

4. 2003: Who is “VA”Veterans Health Administration • VHA is agency of the Department of Veterans Affairs • 3 Administrations: Veterans Health, Veterans Benefits, National Cemetery • 4.9 million patients, ~ 6.9 million enrollees • Increased from 2.5 million patients / enrollees in 1995 (+96% / 7 yrs) • ~ 1,300 Sites-of-Care, including 162 medical centers or hospitals, > 700 clinics, long-term care, domiciliaries, home-care programs • 51 million Ambulatory Care visits, 600,000 hospitalizations • ~ $25 Budget: • ~ $19B from 1995 – 1999 (+ 32% / 7 yrs) • ~185,000 Employees (~15,000 MD , 50,000 Nurses, 33,000 AHP) • 21,000 fewer employees than 1995 • Affiliations with 107 Academic Health Systems • Additional 25,000 affiliated MD’s; 100,000 trainees / year • 60% (70% MDs) US health professionals have some training in VA

5. Who Are Our Patients ? • Older • 49 % over age 65 • Sicker • Compared to Age-Matched Americans • 3 Additional Non-Mental Health Diagnoses • 1 Additional Mental Health Diagnosis • Poorer • ~ 70% with annual incomes < $26,000 • ~ 40% with annual incomes < 16,000 • Changing Demographics • 4.5% female overall • Females: 22.5% of outpatients less than 50 years of age

6. Veterans 85 & Over, Number in 1,000’s No one grows older saying, “Gee, I hope I end up in a nursing home !” • Between today and 2010, VA’s Veterans aged 85 and over will increase from 380,000 to ~ 1.2 million

7. Long-Term Care Costs as Percent of per capita GDP

8. Wagner Model of Chronic Care Community Health System Self-management Support Decision Support Delivery System Design Clinical Information System Informed, Activated Patient Prepared, Proactive Practice Team Productive Interaction Optimal Patient Outcomes

9. Wagner Model of Chronic Care:Extended Community Health System Self-management Support Decision Support Delivery System Design Clinical Information System Informed, Activated Patient Prepared, Proactive Practice Team Productive Interaction Optimal Patient Outcomes

10. Model for Care Coordination Optimal Population Outcomes Community Health System Self-management Support Decision Support Delivery System Design Clinical Information System Informed, Activated Patient Prepared, Proactive Practice Team Productive Interaction Optimal Patient Outcomes

11. Model for Care Coordination Optimal Population Outcomes Community Health System Self-management Support Decision Support Delivery System Design Clinical Information System Informed, Activated Patient Prepared, Proactive Practice Team Productive Interaction Optimal Patient Outcomes

12. VA’s Computerized Patient Record System . . . Every VA Medical Center has Electronic Health Records !

14. Health Care is a Team Sport !

15. Vaccine Cuts Pneumonia Risk in High-Risk PatientsArchives of Internal Medicine 1999;159:2437-2442Dr. Kristin Nichol, VAMC / Minneapolis • 50% of elderly Americans / high-risk individuals have not received the pneumococcal vaccine. • VAMC study of 1,900 elderly patients with chronic lung disease; 2/3vaccinated against pneumonia. • Pneumococcal vaccination: • 43% reduction in hospitalizations for pneumonia and influenza, and a 29% reduction in the risk of death. • Pneumonia and Influenza vaccination: • 72% reduction in hospitalizations for these two diseases and an 82% reduction in deaths from all causes. • Pneumococcal vaccinationsaved an average of $294 per vaccine recipient over the 2-year period.

16. Pneumococcal Vaccination Rates --BRFSS 90th-- --BRFSS-- • Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz • HHS: National Health Interview Survey, >64

18. Closing the Quality Chasm Reducing Variation:From Evidence to Practice… Operationalize Knowledge Possess Knowledge Patient Need Met Patient With Need Pneumococcal Pneumonia Vaccination Indications Performance Measurement + Accountability + Supporting Technologies Computerized Health Information System  System Changes

19. Clinical Reminders Links Reminder • Contemporary Expression of Practice Guidelines • Time & Context Sensitive • Reduce Negative Variation • Create Standard Data • Acquire health data beyond care delivered in VA With the Action With Documentation

20. Immunizations+/- Mental Health Diagnosis(FY 2001) • Effective • Equitable • Efficient

21. Pneumonia: Acute InpatientDRG89-90 VHA Data - Unadjusted 9,500 fewer bed days 8,000 fewer discharges

22. Quality: Prevention Index, 1996 – 2002 * Sampling methodology more stringent

23. Performance Measures for Lipid Screening & Mgmt in Patients with Diabetes

29. Computerized Provider Order Entry (CPOE), one of the Leapfrog Group’s “Top 3 Safety Strategies” • Outside of VA, CPOE < 8% nationally, < 30% among Academic Medical Centers • Nationally, 92% of all VA Rx’s Now CPOE • Ultimate Goal: 100% • VA is the Benchmark for CPOE

31. CMOPs: Technology at WorkConsolidated Mail Outpatient Pharmacy • ~200 Million “30-Day Equivalent” Prescriptions / Year (40K per shift per CMOP) • Medication Deficiencies: 5.8 sigma • Wrong Medication: 0.0009% • Labeling problem: 0.0001% • Damage in Mails: 0.0014% • Delays in Delivery: 0.0178% • Patient Satisfaction Rating: 90% VG/E

32. 2001 Satisfaction with Pharmacy ServicesPrescriptions by Mail vs. In-person Received Meds by Mail Waited In-person < 30 Minutes Waited In-person > 30 Minutes

33. Performance MeasurementClosing The Quality Chasm

34. Evidence, Measurement, Technology & Accountability • 2002: Leadership by Example recognizes VA’s: • Clinical Performance Improvement • Performance Measurement • Information Technologies • Health Services Research • Patient Safety

35. Model for Care Coordination Optimal Population Outcomes Community Health System Self-management Support Decision Support Delivery System Design Clinical Information System Informed, Activated Patient Prepared, Proactive Practice Team Productive Interaction Optimal Patient Outcomes

36. MyHealtheVet • Internet-based, secure Personal Health Record. • Provides veterans with copies of key parts of their VA health information • Veterans can view, retain, and update their personal health data (BP, Blood Sugar, Wt, etc.) • Comprehensive, Personalized Health Education Information • Personalized Health Assessments • Activate & Empower patients as partners with health care providers in achieving optimal health, through the sharing of health information

42. “Hey, Doc, I have Diabetes, Shouldn’t I be on an ACE Inhibitor ?”

44. Patient begins to tie together diet & weight with nutrition information & blood sugar & Understanding of disease from health education & Begins to take control of health Process changes from Transactional (making appointments) TO Transformational (Changing Health Behaviors & Health)

45. Model for Care Coordination Optimal Population Outcomes Community Health System Self-management Support Decision Support Delivery System Design Clinical Information System Informed, Activated Patient Prepared, Proactive Practice Team Productive Interaction Optimal Patient Outcomes

46. From Health Care Delivery To Patient-Centered Care • Patient-Centered Care Coordination • Support patients with safe, high-quality care, in health and disease, at the time & place, and in the manner patient desires • Patient is locus of control and care is seamless across diseases and locations • Care extends from hospital & clinic to home & community • Imperative to Care for an Aging Population

47. CARE COORDINATION The Clinic (Care Coordinator) Becomes Aware that the Patient Is Beginning to “Get Into Trouble,” Proactively, The Patient Is Called To Come Into Clinic . . . Or Visited at Home! Before S/He “Crashes”

48. VISN 8 Community Care Coordination Service Program Sites Lake City • Patient (not provider) centric • Designed to fill gaps in “system” • Collaboration with providers. • Expands patient and provider relationship into the home (home-telehealth technologies) • Successful in Doms and State Nursing Homes • Positive med/psyc/soc Outcomes • Expandable & Reproducible Gainesville Orlando West Palm Beach Bay Pines Miami Ft. Myers San Juan

49. Home-Telehealth Technologies

50. The Health Buddy:Demonstrated Uses • Single Dialogues • HTN, COPD, DM, CHF, Cancer Care, Depression, Chronic pain, HIV, Hep C, Anticoagulation, Bi-polar Disorder • Dual Dialogues • HTN/COPD • DM/CHF • DM/HTN • CAD/Angina • HTN/Hyperlipidemia (Spanish) • CHF/Hyperlipidemia (Spanish) • Trialogue • HTN/CHF/DM