Connected Primary Care

Preventive care and chronic disease management at Mayo Clinic

Rajeev Chaudhry MBBS MPHConsultant Primary Care Internal Medicine

Leader, Health Information Management Systems

Leader, Mayo Clinic Connection Platform, Center for Innovation

Employee and Community Health( Mayo Clinic’s Primary Care )

• 105 Physicians

• 154 Nurses ( 12 new case managers)

• 182 Allied Health employees

• 6 Practice locations

• 2 Divisions, 1 Department ( Internal Medicine, Family Medicine and Pediatrics)

Mayo’s Primary care’s Connected Care needs

• Systems must be designed to enable longitudinal care compared to “usual” episodic care :

• Know who our patients are• Know what our patients need in a proactive manner• Alert patients and provide them “coordinated”

access• We must “care for” the patient at all times, not just

when they request our care for a symptom related illness

• When we see them we need to provide all the care they need

Who we need to provide “connected” care for…

• All preventive services for 140,000 patients ( cancer screenings, immunizations, metabolic screenings and wellness counseling)

• Chronic disease management • 20,000 Hypertension patients• 10,000 Depression patients • 8,000 Diabetes patients• 7,000 Asthma patients• 7,000 Coronary Artery Disease patients• 3,000 Congestive Heart Failure patients• And many other chronic conditions

• Acute Illness management for all 140,000 patients

So what we needed…

• Information systems to know needs of all of our patients needs for care

• Utilizing our allied health staff to offload responsibilities from MD’s both at population level and for patients being physically seen ( GDMS-Vitalhealth Software) for preventive care and care for chronic conditions so that our MD’s can spend their valuable time caring for patients and not spending their time searching for the information

Health Information Management Systems at Mayo

• Point of care –Generic Disease Management System ( GDMS, 2007)

• Population Management and Quality Reporting (Microsoft Amalga, 2009)

• Cost and utilization Reporting

( Currently physician portal)

GDMS Application StructureMayo ClinicEMR Data

Mayo ClinicEMR Data

Web Services

Web Services

Labs, VitalsPreventive services

Problem listImmunizations

Allergies

Labs, VitalsPreventive services

Problem listImmunizations

Allergies

Vital HealthGDMS

Vital HealthGDMS

DemographicsDemographics

ColonoscopyFlex Sig

ColonoscopyFlex Sig

Tobacco useTobacco use

Web interfaceWeb interface

GDMSapplication

GDMSapplication

GDMSdatabase

MICSCl. Notes

CRD

GI

PPICP1309217-13

GDMS ECH User Satisfaction SurveyApril 2008, All staff n=122

Time saved per patient for preventive services, diabetes and CAD care

• 3.9 minutes per patient for MD's

• 2.7 minutes per patient for LPN's

• 2.17 minutes per patient for CA's/ appointment coordinators

Time saved per patient for preventive services, diabetes and CAD care

• 3.9 minutes per patient for MD's

• 2.7 minutes per patient for LPN's

• 2.17 minutes per patient for CA's/ appointment coordinators

CP1309217-8

GDMS ECH Zoster Vaccine Volumes

CP1309217-4

0

100

200

300

400

500

600

Jan

Feb Mar Apr

May Ju

nJu

lAug

Sept

Oct

NovDec Ja

nFeb

PCIMPCIM

FMFM

2008200820072007

376%increase

ECHECH

Percent of People that Received AAA Screening after their Appointment and had not Received the Screening in the past 5 years in 2007and 2008

0.00% 0.00%

20.00%

21.84%

15.75%

4.05%3.80% 3.22%

25.29%

18.24%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Mayo Family ClinicNorthwest

Mayo Family ClinicNortheast

Family Medicine-Baldwin

Primary Care InternalMedicine

Total

Mayo Locations

Per

cen

tag

es 2007

2008

Response Frequency %Strongly agree 24 62.3Somewhat agree 12 31.6Neither agree nor disagree 2 5.3Somewhat disagree 0 0.0Strongly disagree 0 0.0

Response Frequency %Strongly agree 24 62.3Somewhat agree 12 31.6Neither agree nor disagree 2 5.3Somewhat disagree 0 0.0Strongly disagree 0 0.0

Response Frequency %Strongly agree 24 64.9Somewhat agree 11 29.7Neither agree nor disagree 2 5.4Somewhat disagree 0 0.0Strongly disagree 0 0.0

Response Frequency %Strongly agree 24 64.9Somewhat agree 11 29.7Neither agree nor disagree 2 5.4Somewhat disagree 0 0.0Strongly disagree 0 0.0

Response Frequency %Strongly agree 26 70.3Somewhat agree 11 29.7Neither agree nor disagree 0 0.0Somewhat disagree 0 0.0Strongly disagree 0 0.0

Response Frequency %Strongly agree 26 70.3Somewhat agree 11 29.7Neither agree nor disagree 0 0.0Somewhat disagree 0 0.0Strongly disagree 0 0.0

ECH Satisfaction Survey for GDMS – April 2008Physicians n=38

CP1309895-1

4. The GDMS recommended action for patient age and sex-specific average risk preventive services help me with identifying the services that need to be scheduled

4. The GDMS recommended action for patient age and sex-specific average risk preventive services help me with identifying the services that need to be scheduled

0 20 40 60 80 100

5. The GDMS recommended action for patient tests needed for diabetes mellitus (DM) help me with identifying the tests that need to be scheduled

5. The GDMS recommended action for patient tests needed for diabetes mellitus (DM) help me with identifying the tests that need to be scheduled

0 20 40 60 80 100

6. GDMS supports my work flow and improves efficiency in providing average risk preventive services and testing for diabetes patients

6. GDMS supports my work flow and improves efficiency in providing average risk preventive services and testing for diabetes patients

0 20 40 60 80 100

Data BaseMSS/GPAS

MICS Lastword

Dept.Systems

ClinicalNotes

EOP SIRS

DSS

PPI

Patient AppointmentsProvider Panels

ImmunizationsAllergies

Problem List

Vitals

Preventive Services

Tobacco UseExternal Services

Medications MastectomyHysterectomy

Views/Queries/Reports

Rules/Applications

Patient VisitsCost

EMR Interfaces Overview for HIMS at Mayo

RegLabs

Amalga UIS Applications at Mayo

Parsing of data for application

Data from Clinical Systems

Systems for end users

Systems are designed to lead to Standardized care

Registry view to get “real time” information of all the Diabetic patients

List of all the Diabetic patients to be contacted in “next 30 days” with “real time” data

List of all the patients that “care manager” needs to contact in next 7 days for “optimal care”

Patient “detail view” enabling navigating from all the patients to one patient in “real time”

“Plan of care” module to record patient’s preferences and “goal setting”

Result to MD

Consumer

Past processes of care

Report received

Preventive Services

Call patient

MD to RN

Appointment Office takes message

Mammogram done

Message to RN

OK to RN

Call PatientRetrieve

Message

Mammogram ordered

Call MD Office for Mammogram

MD reviews message

RN to Appt. Office

Not Home

Call back appt. office

Clinic

Consumer

Population Management (Prevention and Diseases) New Process

MayoPopulation

Management

Pull data of all 140,000 patients

Clinic

ECH130,000 patients

Identify who is due (Evidence based)

Schedule services due( visit or non visit based) Communication to

patients

Services performed

Call PAC

Will population management help Primary Care

•Population-based systems to improved breast cancer screening by 33% in a randomized controlled trial for 12,000 patients.

•Only 0.5 FTE appointment secretary needed to manage the needs of all patients

Chaudhry R, Scheitel S, McMurtry E, et al. Web-Based Proactive System to Improve Breast Cancer Screening: A Randomized Controlled Trial. Arch Intern Med 2007; 167:606-

611.

Will population management help Primary Care-Contd.

• Diabetic patients managed with a single contact based on information systems had significant improvement in low-density lipoprotein control (35.4% vs 13.3%; P=.004). The intervention group also had a greater percentage of patients who also showed better control of hemoglobin A1c

• Chaudhry R, Tulledge-Scheitel SM, Thomas MR, Hunt VL, Liesinger JT, Rahman AS, Naessens JM, Davis LA, Stroebel RJ, Clinical Informatics to Improve Quality of Care: A Population-Based System for Patients With Diabetes Mellitus, Primary Care Informatics, 2009 ; 17: 95-102

33

Population informatics-based system to improve osteoporosis screening in women in a primary care

practice.

• 25% of the 689 patients responded to the letter and completed osteoporosis screening. Patients who had osteoporosis screening received appropriate treatment.

J Am Med Inform Assoc. 2010 Mar-Apr;17(2):212-6.

Kesman RL, Rahman AS, Lin EY, Barnitt EA, Chaudhry R.

Thanks !

Needs of Patients Come First— Dr. Mayo

Questions?