SYSTEMS CHANGE TO REDUCE TOBACCO USE IN IN CLIN INICAL SETTINGS - - PowerPoint PPT Presentation

SYSTEMS CHANGE TO REDUCE TOBACCO USE IN IN CLIN INICAL SETTINGS

THE NUTS AND BOLTS

• DONNA WARNER, MA, MBA
• INDEPENDENT CONSULTANT

FORMER MANAGING PARTNER, MULTI-STATE COLLABORATIVE FOR HEALTH SYSTEMS CHANGE AND CESSATION DIRECTOR, MASSACHUSETTS TOBACCO CESSATION AND PREVENTION PROGRAM

TOPICS

Why are clinical systems to address

tobacco use important?

What do we mean by ‘systems change’

in the clinical setting?

Show me a good ‘system’! How do we know it works? Forces be with us

2/3/2016

PRESENTATION BASED ON TW TWO HEALTH SYSTEMS AND PUBLISHED RESULTS:

• Atrius Health, Massachusetts
• Thad Schilling MD, formerly with Atrius Health, currently with Reliant Medical Group,

Worcester MA

• LSU Public Hospitals, Louisiana
• Sarah Moody-Thomas PhD, Charles L. Brown, Jr., MD Professor of Health Promotion

Director, Tobacco Control Initiative, LSU Health New Orleans, School of Public Health

• Lead Researcher
• Thomas Land PhD, Director, Office of Data Management

and Outcomes Assessment, Commissioner’s Office, MA Department of Public Health

• AND, experience of many colleagues around the country working to improve

systems in healthcare to reduce tobacco use

WHY CLINICAL SYSTEMS?

• Unparalleled Reach
• 70% Tobacco Users
• including hard-to-reach and specific populations
• Feasible to Implement
• Powerful Incentives
• Benefits to Patients and Population Health
• Cost Savings to Healthcare Facilities

WHAT IS IS A SYSTEM?

Multiple Components

• CEO, CFO, Clinical Leadership
• Integrated clinical and EHR workflow
• Defined staff or team roles and

training: It’s your job!

• Feedback reports by team and site
• Performance measurement reported

to the “corporation”

• Not an individual clinician

burden

• Focus on reaching

sustained high levels of identification and brief intervention

• Electronic referrals for

more intensive treatment

SHOW ME A GOOD ‘SYSTEM’!

• A good system is one that, when implemented fully,

is easier to do than not do. WHAT IS IS A GOOD SYSTEM?

Trying harder to make the existing system work better may not be enough

THE A ATRIUS HEALTH SYSTEM

• HVMA serves 350,000 Patients in

17 Clinical Sites

• Uses EPIC
• Known as a “high performance”

system

• Operating under alternative

quality payment contracts

• An MD project leader assigned to

implement the Tobacco Intervention Project

• Tobacco Intervention System was

later expanded to 5 additional healthcare organizations ATRIUS umbrella, serving 770,000 patients.

BEFORE QI: “IN SHORT, WE HAD NO SYSTEM-WIDE INTERVENTION”

• Attempted to mine existing EPIC data to

establish a QI goal

• Data showed 84% - ask?
• Didn’t know what workflow produced these

results

• No record of the assessments or interventions
• No record of cessation prescriptions
• Only knew for sure the ½ of 1% referred to

quitline; only loose affiliation with state quitline

• No academic detailing, no supports to assist

clinicians “Our Chie

ief Medical l Officer id identifie ied sm smokin ing ce cessation as as an an im important in initia itiative to

• im

improve th the

• verall

ll heal alth of

• f ou
• ur

pop

• pula

lation.”

The intervention must:

• Be evidence-based, iterative, and

consistent through the system

• Integrated into daily practice.
• Support clinician intervention at point-
• f-care.
• Involve all members of the clinical team.
• Leverage community resources (like the

QuitWorks— the state’s quitline referral program).

Atrius Health

AFTER: WORKFLOW IM IMPLEMENTED IN IN 12 OF 17 CLINICS

Changes in 4 areas:

• clinical pharmacy
• information

technology

• patient health

education and marketing

• team training

New relationship with Quitline

• fully electronic

referrals

• customized feedback

report on patients referred

Teaming Approach with Decision Support Integrated into EHREHR

HOW THE WORK WAS ORGANIZED

• Clinical workflow features a teaming approach
• Roles defined for medical assistants, visit clinicians (usually an MD), and

advanced practice clinicians.

• Workflow includes scripts and prompts for each step in the intervention

built into the EHR.

• Real-time data entry in the EHR is required: the identification of smokers

and interventions has to be recorded as they occur during the patient visit.

• Measurement and feedback monthly to clinical teams

BY FEEDBACK, WE MEAN AN R REVIEW PROCESS

Monitor performance data monthly by clinic, by team, and by team member on

the “ask,” “assess,” and “assist” steps.

• Provide monthly feedback reports
• Review performance with each department, clinician and medical assistant
• n each measure
• Review patient cases with missing assessments
• Identify staff for coaching to improve assessment and identification rates.
• For staff with lower scores, conduct periodic refreshers on the EHR screens

that contain the smoking assessment and intervention prompts

ACTIVE

It is this active review process with each team, not simply providing reports, that is critical to performance improvement.

HOW DO WE KNOW IT IT WORKS?

WHAT WAS DONE? HOW DID PATIENTS FARE? OBTAIN AND ANALYZE ENCOUNTER RECORDS—MILLIONS OF THEM!

Helping Patients Quit: New Research on Clinical Tobacco Interventions August 9, 2012

WHAT WAS DONE? GROUPING 17 SIT ITES BY ROLL-OUT DATE

Identification Rates by Site

Jan 2008 - Oct 2010 0.25 0.5 0.75 1

J an- 08 Jul- 08 J an- 09 Jul- 09 J an- 10 Jul- 10 % of Visits with Tobacco Use Identification BOS BTR BUR CAM CHE CND COP FAU KEN LMA MFD PBY QCY SOM WEL WRX WR

Measure: Total number

• f identifications in

proportion to the total number of visits

Data Source: 17 sites Population: 310,577 adult

patients

Green Sites: Identification

rate over 80% in Jan 2008

Orange Sites: Identification

rate increased significantly between January 2008 and October 2010

Blue Sites: Identification

rate did not change significantly between January 2008 and October 2010

HOW DID ID PATIENTS FARE?

FEWER SELF-REPORTED SMOKERS

Population: 75,129 adults who were screened prior to 7/1/2008 Data Sources: 15 Sites (not including BTR and CHE) Tobacco use status for population determined by most recent status prior to the beginning of each quarter.

Total Current Smokers at Most Recent Screening

(n = 75,129, 1st screening <7/1/2008)

10000 10500 11000 11500 Oct-08 Dec-08 Feb-09 Apr-09 Jun-09 Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-10 # Current Smokers

TO SU SUM IT IT UP

• Decreases in smoking prevalence were 40% greater at sites that

achieved systems change (13.6% vs. 9.7%, p<.01).

• Likelihood of quitting increased by 2.6% per occurrence of brief
• intervention. (p<0.05, 95% CI: 0.1%–4.6%)
• For patients with a recent history of current smoking, the

likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis in sites where systems change occurred (p<0.05, 95% CI: 0.5%–8.1%).

It’s the System Itself That Works

IS IS TH THIS A ONE-TRICK PONY? NOT!

“

LS LSU TOBACCO CONTROL IN INITIATIVE (2 (2000 TO 2012)

• Louisiana State University (LSU) 10-

hospital public safety-net system--one

• f our country’s largest
• With a diverse, low-income, primary

care population: Mean age 49 years; 71%

female; 53% AA; 66% uninsured

Effect of systems change in Louisiana similar to Atrius Health

“The [Tobacco Control Initiative} data collection allowed us, for the first time, to understand the prevalence of tobacco use among our primary care patients, while analyses of EHR data showed improved rates

• f intervention and quit rate”. -- S. Moody-

Thomas

Sarah Moody-Thomas PhD

Professor LSU School of Public Health, New Orleans Director, Tobacco Control Initiative,

LS LSU CLINICAL AND EHR WORKFLOW

WANT TO KNOW MORE?

The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking- Related Primary Care Office Visits.

Land TG, Rigotti NA, Levy DE, Schilling T, Warner D, Li W (2012); PLoS ONE 7(7): e41649. doi:10.1371/journal.pone.0041649 Sarah Moody-Thomas, Laura Nasuti, Yong Yi, Michael

• D. Celestin, Jr, Ronald Horswell, and Thomas G.
• Land. American Journal of Public Health: April 2015,
• Vol. 105, No. S2, pp. e1-e7. doi:

10.2105/AJPH.2014.302274

Effect of Systems Change and use of Electronic Health Records on Quit Rates Among Tobacco Users in a Public Hospital System

LIMITATIONS AND PRACTICAL LESSONS LEARNED

LI LIMITATIONS

• Length of time to ramp-

up to steady state

• Leadership essential
• Measurement essential
• Access to large patient

encounter data sets

Timeline for LSU Public Hospitals Project

LESSONS LEARNED FROM ATRIUS HEALTH

Team-based intervention

• Physician involvement is critical but minimal
• Medical Assistants trained successfully to begin 5A’s

intervention

Operations

• Make the right thing to do the easy thing to do”

Performance feedback

• Real time, usable, public/transparent, operator level critical

Community partnerships

• Close collaboration with Massachusetts Quitline helped us

define our vision

25 50 75 100 125 150

October November December January February March

• No. of Referrals

Atrius Referrals 2009-2010 (Before Launch) Atrius Referrals 2010-2011 (After Launch)

Quitline Referrals Doubled After e-Referral Launch

LE LESSONS LE LEARNED FROM LS LSU

WIN IN-WIN-WIN APPROACH

A Win for the Tobacco Control Initiative (TCI)

• Opportunity: Integrated the TCI into existing processes of

care through the chronic disease program underway across all hospitals in the system

A Win for Patients

• Made evidence-based treatments (counseling, quitline,

medications) available as standard care for all patients at low

• r no cost

A Win for the Healthcare Organization

• Helped facilities meet accreditation and recognition from a

variety of organizations (e.g. Joint Commission, National Committee on Quality Assurance)

ADVICE FROM LSU’S DR. MOODY-THOMAS *

Be Practical

• Lots of interconnected parts
• Synchronicity not always possible
• Move what you can, when you can

Be Persistent

• Given ANY opportunity, momentum can be lost
• Use data to keep the pressure on

Be Patient

• Systems change is gradual and front-end loaded
• Reach the tipping point, change is rapid, rewards great

*Moody-Thomas, S., October 2010 Presentation, A Tobacco Control Initiative: A Systems Approach to Guideline

Implementation in a Public Hospital Network

EYE ON TH THE PRIZE: CRITICAL SU SUCCESS FACTORS

• Organization commitment AND sponsorship by upper level

management -Administration, clinical workflow, information technology and

quality improvement

• Integration of tobacco measures into internal QI processes-Aligned

with Meaningful Use, Joint Commission, or private payer quality measures

• A certified Electronic Health Record THAT:
• Has templates that adhere to clinical guidelines and provide decision support
• Can generate reminders, registries, and feedback reports easily
• Stores data for process reporting and longitudinal data for outcome reporting
• Integration with internal or community resources for tobacco

treatment -Such as the quitline, with bi-directional data exchange and reporting.

http://www.cdc.gov/tobacco/quit_smoking/cessation/index.htm

EASY READS

FAQs and Q/A Case St Studie ies CDC Office ice on Sm Smokin ing and Healt lth

Cess ssation Resources for Tob

• bacco Con
• ntrol

l Programs

THE FLIP SID IDE OF MEASUREMENT– TOO MUCH, TOO SOON?

“THE SECRET OF QUALITY IS LOVE”

• -Avedis Donabedian, 2000

As quoted in NY Times 01 17 2016, “How Measurement Fails Us”, Opinion, by Robert M. Wachter, author of The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age

“WE WILL LIKELY SEE RATES OF TOBACCO INTERVENTIONS INCREASE SIGNIFICANTLY IN THE COMING YEARS”*

• Large forces driving healthcare to adopt a systems approach
• Value in system-wide adoption of MU core tobacco measures
• Real opportunities to improve healthcare quality:
• tailored feedback systems to motivate clinicians
• new ways to identify and address health disparities
• payment systems that tie bonuses to reliable measures of improving population

health.

Ultimately, substantial savings from the decreased utilization of health care services related to tobacco use.

* The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking-Related Primary Care Office Visits. Land

TG, Rigotti NA, Levy DE, Schilling T, Warner D, Li W (2012) PLoS ONE 7(7): e41649. doi:10.1371/journal.pone.0041649

THANK YOU!

DONNADWARNER@GMAIL.COM