Health Informatics University of Wollongong 2006 - Lecture week10
Content
GPs use of IT, Evidence based
healthcare, practice evaluation
• Function of GP IT
– Environment
– Business drivers
– Prerequisites for meaningful IM
– IT microenvironment
• Role of Government
– Regulatory requirements
Dr. Khin Than Win
Environment
• 22 000 GPs
• Reactive model of care
– financed by FFS
– trending to planned care financed by blended
payments
• Main issues include
– workforce inc part time GPs, old GPs
– red tape
• Trending to larger more sophisticated
practices
• Role of Divisions of General Practice
– Data collection and aggregation
Business Drivers
• Patient demand
– ageing population with chronic disease
• Greater demand on hospitals
– sicker patients in community
• Greatest financial rewards to GPs who can
see patients in the shortest time
• Commonwealth incentives
– add to workload rather than replace it
1
Prerequisites for population
based IM
Role of government
• Pay Medicare rebate for FFS activity
• 2001 incentives for GPs to computerise
• Encourage population-based approach to
health
“Mrs. Marshall, get on the
scale…”
•
•
•
•
Coding
Messaging standards
Unique IDs
System of capitation
Better, Cheaper
Care
HealthHero
Home-based Telemedicine for Uninsured, High-risk Diabetic Population
Inpatient Admissions
Emergency Room Encounters
Outpatient Visits
32%
34%
49%
(Diabetes Technology & Therapeutics Journal, 2002)
Vocera
Epocrates
Asthma Self-management for High-risk Pediatric Population*
Activity Limitation
High Peak Flow Readings
Urgent Calls to Hospital
(p = .03)
(p = .01)
(p = .05)
(Arch Pediatr Adolesc Med. 2002)
CHF Solutions
Alere
HealthHero
Visicu
Care Coordination: Hypertension, Heart Failure, COPD, and Diabetes*
Emergency Room Visits
Hospital Admissions
Hospital Bed Days of Care
Nursing Home Admissions
Nursing Home Bed Days of Care
40%
63%
60%
64%
88%
(Disease Management, 2002)
2
Remote Management of Chronic
Disease
• Highly cost-effective vs. standard care
– 32% reduction in hospitalizations
– 25% cost savings of approximately $1,800/patient
• Effective and efficient care management
– Leverages use of RNs
– Targets care to those who need it
Knowledge Gaps
between what is known and what is done
• What are the “gaps” between research and
practice?
• Why do such “gaps” exist?
• How can we close a specific gap?
• How can we close all gaps?
• Improvement in patient quality of life
– Fewer hospitalizations
– Increases patient education and contact with care
Remote Physiological Monitoring: Innovation
managers
in the Management of Heart Failure July 2004
www.nehi.net
– High patient satisfaction levels
Knowledge Gaps
The Epidemiology of Ignorance
in Health Care
• What “gaps” between research and practice
are you involved in?
• What do we know about what we know?
between what is known and what is done
– Prevalence & Incidence
– Aetiology/Causation
– Prognosis
– Treatment
3
Is bed rest ever helpful?
A systematic review of trials*
Many “Leaks” from research & practice
• 10 trials of bed rest after spinal puncture
– no change in headache with bed rest
– Increase in back pain
• Protocols in UK neurology units - 80% still
recommend bed rest after LP
Aware Accept Target Doable Recall Agree Done
Valid
Research
Serpell M, BMJ 1998;316:1709–10
If 80% achieved at each stage then
0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21
• …evidence of harm available for 17 years
preceding...
*Allen, Glasziou, Del Mar. Lancet, 1999
Knowledge Gaps
between what is known and what is done
• What “gaps” between research and practice
are you involved in?
• Why does the “gap” exist?
– (list several possibles causes)
Not
Organised
What do you think about “flight socks?”
0
Aware Accept Target Doable Recall Agree Done
1
2
3
4
5
6
7
4
JASPA*
Causes
(Journal associated score of personal angst)
1. Too much information
2. Too much information
3. Too much information
J: Are you ambivalent about renewing your JOURNAL
subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?
P: Are you surrounded by PILES of PERIODICALS?
A: Do you feel ANXIOUS when journals arrive?
YOUR SCORE? (0 TO 5)
* Modified from: BMJ 1995;311:1666-1668
Size of Medical Knowledge
Rule 31 – Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
• NLM MetaThesaurus
• Diagnosis Pro
1 per day for
25 years
– 9,200 diseases
– 20,000 abnormalities (symptoms, signs, lab, Xray,)
– 3,200 drugs (cf FDAs 18,283 products)
2500000
Medical Articles per Year
– 875,255 concepts
– 2.14 million concept names
5,000?
per day
2000000
1500000
1,500
per day
1000000
500000
55 per
day
0
Biomedical
MEDLINE
Trials
Diagnostic?
5
Organising I:
systematic reviews - 20% done for therapy
And the information we need
is widely scattered
!
"
Reviews and protocols for reviews on
The Cochrane Database of Systematic Reviews
Issue 1/2005
#$
New protocols
Existing protocols
New reviews
Updated reviews
Existing reviews, not incl updates
3800
3600
%&'
%%&
!
*
*
Alderson, 2005
4000
3400
3200
('
(&)
+
,
-..
/ 0(
3000
2800
2600
2400
2200
1
1"
#
2000
/
"
1800
"
"
1600
1400
1200
(&
1000
2 " 3
%45
800
600
400
200
between what is known and what is done
2004/2
2003/4
2004/1
2003/2
2003/3
2002/3
2002/4
2003/1
2001/4
2002/1
2002/2
2001/1
2001/2
2001/3
2000/3
2000/4
1999/4
2000/1
2000/2
1999/1
1999/2
1999/3
1998/3
1998/4
1997/4
1998/1
1998/2
1997/1
1997/2
1997/3
1996/1
1996/2
1996/3
1995/1
Knowledge Gaps
1995/2
0
The Prognosis of Ignorance is Poor
• What “gaps” between research and practice
are you involved in?
• Why does the “gap” exist?
• What would you do to “fix” the gap?
Not
Organised
0
Aware Accept Target Doable Recall Agree Done
1
2
3
4
5
6
7
6
Prevention & Treatment
Evidence-Based Medicine
•
Questioning
•
Skills in EBM
•
Evidence Resources
•
Time (substitution)
Myth, opinion,
poor research
Patient Choice
•
Decision Aids
•
Education
•
Compliance aids
Aware Accepted Applicable Able Acted on Agreed Adhered to
Where is your
main activity?
"
#$
%
Quality Improvement
•
Skills
•
Systems
!
!
&
)
'(
)
!
Research Synthesis,
Guidelines, EBJs, …
!
“Just in Time” learning:
Intern’s information needs
• Setting: 64 residents at 2 New Haven hospitals
• Method: Interviewed after 401 consultations
• Questions
– Asked 280 questions (2 per 3 patients)
– Pursued an answer for 80 questions (29%)
– Not pursued because
Glasziou, Haynes, EBM 2005
“Just in Time” learning
The EBM Approach to Education
• Shift focus to current patient problems
(“just in time” education)
– Relevant to YOUR practice
– Memorable – and behaviour changed!
– Up to date
• Skills and resources for best current answers
• Lack of time
• Forgot the question
• Sources of answers
– Textbooks (31%), articles (21%), consultants (17%)
Dave Sackett
7
Treatment of Ignorance
Teaching EBM: a systematic
review of 23 controlled studies
• Integrated teaching
– Real patients
– Current problems
• Results in better
–
–
–
–
Knowledge
Skills
Attitudes
Behaviour
Implications for practice
Interactive workshops can improve
professional practice. Lectures alone
are unlikely to change professional
practice
s
ay
Epidemiological
Biomedical
Psychosocial
Socio-cultural
issues
Patient values
other evidence
Patient's
prognosis & comorbidities
ce g ”
en in
id now
Ev of k
‘w
Funder issues
nt
tie
Pa
• Roger’s work in rural sociology
• Greenhalgh T, et al. A systematic
review of the literature on diffusion,
dissemination and sustainability of
innovations in health service
delivery and organisation. London,
NHSSDO Programme, 2004
• EPOC reviews
Po
lic
Dissemination and diffusion
What do we know?
y
Coomarasamy, BMJ 2004;329:1017
t
ac
r
P
er
n
o
iti
8
s
ay
Funder issues
Biomedical
Psychosocial
Socio-cultural
issues
other evidence
Patient values
ce g ”
en in
id now
Ev of k
‘w
Po
lic
y
Epidemiological
nt
tie
Pa
Patient's
prognosis & comorbidities
t
ac
r
P
on
iti
er
!
%&)
!
"
#
!
$% & " '
%
'(((
9
healthcare, practice evaluation
• Function of GP IT
– Environment
– Business drivers
– Prerequisites for meaningful IM
– IT microenvironment
• Role of Government
– Regulatory requirements
Dr. Khin Than Win
Environment
• 22 000 GPs
• Reactive model of care
– financed by FFS
– trending to planned care financed by blended
payments
• Main issues include
– workforce inc part time GPs, old GPs
– red tape
• Trending to larger more sophisticated
practices
• Role of Divisions of General Practice
– Data collection and aggregation
Business Drivers
• Patient demand
– ageing population with chronic disease
• Greater demand on hospitals
– sicker patients in community
• Greatest financial rewards to GPs who can
see patients in the shortest time
• Commonwealth incentives
– add to workload rather than replace it
1
Prerequisites for population
based IM
Role of government
• Pay Medicare rebate for FFS activity
• 2001 incentives for GPs to computerise
• Encourage population-based approach to
health
“Mrs. Marshall, get on the
scale…”
•
•
•
•
Coding
Messaging standards
Unique IDs
System of capitation
Better, Cheaper
Care
HealthHero
Home-based Telemedicine for Uninsured, High-risk Diabetic Population
Inpatient Admissions
Emergency Room Encounters
Outpatient Visits
32%
34%
49%
(Diabetes Technology & Therapeutics Journal, 2002)
Vocera
Epocrates
Asthma Self-management for High-risk Pediatric Population*
Activity Limitation
High Peak Flow Readings
Urgent Calls to Hospital
(p = .03)
(p = .01)
(p = .05)
(Arch Pediatr Adolesc Med. 2002)
CHF Solutions
Alere
HealthHero
Visicu
Care Coordination: Hypertension, Heart Failure, COPD, and Diabetes*
Emergency Room Visits
Hospital Admissions
Hospital Bed Days of Care
Nursing Home Admissions
Nursing Home Bed Days of Care
40%
63%
60%
64%
88%
(Disease Management, 2002)
2
Remote Management of Chronic
Disease
• Highly cost-effective vs. standard care
– 32% reduction in hospitalizations
– 25% cost savings of approximately $1,800/patient
• Effective and efficient care management
– Leverages use of RNs
– Targets care to those who need it
Knowledge Gaps
between what is known and what is done
• What are the “gaps” between research and
practice?
• Why do such “gaps” exist?
• How can we close a specific gap?
• How can we close all gaps?
• Improvement in patient quality of life
– Fewer hospitalizations
– Increases patient education and contact with care
Remote Physiological Monitoring: Innovation
managers
in the Management of Heart Failure July 2004
www.nehi.net
– High patient satisfaction levels
Knowledge Gaps
The Epidemiology of Ignorance
in Health Care
• What “gaps” between research and practice
are you involved in?
• What do we know about what we know?
between what is known and what is done
– Prevalence & Incidence
– Aetiology/Causation
– Prognosis
– Treatment
3
Is bed rest ever helpful?
A systematic review of trials*
Many “Leaks” from research & practice
• 10 trials of bed rest after spinal puncture
– no change in headache with bed rest
– Increase in back pain
• Protocols in UK neurology units - 80% still
recommend bed rest after LP
Aware Accept Target Doable Recall Agree Done
Valid
Research
Serpell M, BMJ 1998;316:1709–10
If 80% achieved at each stage then
0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21
• …evidence of harm available for 17 years
preceding...
*Allen, Glasziou, Del Mar. Lancet, 1999
Knowledge Gaps
between what is known and what is done
• What “gaps” between research and practice
are you involved in?
• Why does the “gap” exist?
– (list several possibles causes)
Not
Organised
What do you think about “flight socks?”
0
Aware Accept Target Doable Recall Agree Done
1
2
3
4
5
6
7
4
JASPA*
Causes
(Journal associated score of personal angst)
1. Too much information
2. Too much information
3. Too much information
J: Are you ambivalent about renewing your JOURNAL
subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?
P: Are you surrounded by PILES of PERIODICALS?
A: Do you feel ANXIOUS when journals arrive?
YOUR SCORE? (0 TO 5)
* Modified from: BMJ 1995;311:1666-1668
Size of Medical Knowledge
Rule 31 – Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
• NLM MetaThesaurus
• Diagnosis Pro
1 per day for
25 years
– 9,200 diseases
– 20,000 abnormalities (symptoms, signs, lab, Xray,)
– 3,200 drugs (cf FDAs 18,283 products)
2500000
Medical Articles per Year
– 875,255 concepts
– 2.14 million concept names
5,000?
per day
2000000
1500000
1,500
per day
1000000
500000
55 per
day
0
Biomedical
MEDLINE
Trials
Diagnostic?
5
Organising I:
systematic reviews - 20% done for therapy
And the information we need
is widely scattered
!
"
Reviews and protocols for reviews on
The Cochrane Database of Systematic Reviews
Issue 1/2005
#$
New protocols
Existing protocols
New reviews
Updated reviews
Existing reviews, not incl updates
3800
3600
%&'
%%&
!
*
*
Alderson, 2005
4000
3400
3200
('
(&)
+
,
-..
/ 0(
3000
2800
2600
2400
2200
1
1"
#
2000
/
"
1800
"
"
1600
1400
1200
(&
1000
2 " 3
%45
800
600
400
200
between what is known and what is done
2004/2
2003/4
2004/1
2003/2
2003/3
2002/3
2002/4
2003/1
2001/4
2002/1
2002/2
2001/1
2001/2
2001/3
2000/3
2000/4
1999/4
2000/1
2000/2
1999/1
1999/2
1999/3
1998/3
1998/4
1997/4
1998/1
1998/2
1997/1
1997/2
1997/3
1996/1
1996/2
1996/3
1995/1
Knowledge Gaps
1995/2
0
The Prognosis of Ignorance is Poor
• What “gaps” between research and practice
are you involved in?
• Why does the “gap” exist?
• What would you do to “fix” the gap?
Not
Organised
0
Aware Accept Target Doable Recall Agree Done
1
2
3
4
5
6
7
6
Prevention & Treatment
Evidence-Based Medicine
•
Questioning
•
Skills in EBM
•
Evidence Resources
•
Time (substitution)
Myth, opinion,
poor research
Patient Choice
•
Decision Aids
•
Education
•
Compliance aids
Aware Accepted Applicable Able Acted on Agreed Adhered to
Where is your
main activity?
"
#$
%
Quality Improvement
•
Skills
•
Systems
!
!
&
)
'(
)
!
Research Synthesis,
Guidelines, EBJs, …
!
“Just in Time” learning:
Intern’s information needs
• Setting: 64 residents at 2 New Haven hospitals
• Method: Interviewed after 401 consultations
• Questions
– Asked 280 questions (2 per 3 patients)
– Pursued an answer for 80 questions (29%)
– Not pursued because
Glasziou, Haynes, EBM 2005
“Just in Time” learning
The EBM Approach to Education
• Shift focus to current patient problems
(“just in time” education)
– Relevant to YOUR practice
– Memorable – and behaviour changed!
– Up to date
• Skills and resources for best current answers
• Lack of time
• Forgot the question
• Sources of answers
– Textbooks (31%), articles (21%), consultants (17%)
Dave Sackett
7
Treatment of Ignorance
Teaching EBM: a systematic
review of 23 controlled studies
• Integrated teaching
– Real patients
– Current problems
• Results in better
–
–
–
–
Knowledge
Skills
Attitudes
Behaviour
Implications for practice
Interactive workshops can improve
professional practice. Lectures alone
are unlikely to change professional
practice
s
ay
Epidemiological
Biomedical
Psychosocial
Socio-cultural
issues
Patient values
other evidence
Patient's
prognosis & comorbidities
ce g ”
en in
id now
Ev of k
‘w
Funder issues
nt
tie
Pa
• Roger’s work in rural sociology
• Greenhalgh T, et al. A systematic
review of the literature on diffusion,
dissemination and sustainability of
innovations in health service
delivery and organisation. London,
NHSSDO Programme, 2004
• EPOC reviews
Po
lic
Dissemination and diffusion
What do we know?
y
Coomarasamy, BMJ 2004;329:1017
t
ac
r
P
er
n
o
iti
8
s
ay
Funder issues
Biomedical
Psychosocial
Socio-cultural
issues
other evidence
Patient values
ce g ”
en in
id now
Ev of k
‘w
Po
lic
y
Epidemiological
nt
tie
Pa
Patient's
prognosis & comorbidities
t
ac
r
P
on
iti
er
!
%&)
!
"
#
!
$% & " '
%
'(((
9
