LWW/JACM
JACM-D-14-00014
May 20, 2014
17:4
J Ambulatory Care Manage Vol. 37, No. 3, pp. 199–205 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Leveraging Data to Systematically Improve Care Coronary Artery Disease Management at Geisinger Thomas Graf, MD; Alistair Erskine, MD; Glenn D. Steele, Jr, MD, PhD Abstract: Coronary artery disease is complex chronic disease best managed by a team empowered by actionable data and a comprehensive approach, the ability to improve intermediate outcomes was dramatically enhanced after Geisinger created a system of care to do so. Continuous measurement of critical data elements of process and intermediate outcome measures allows the delivery of actionable information to the most appropriate team member, including the patients and family as team members. Continuous monitoring of the overall program looking for trends and opportunities across sites and regions allows for program enhancements. The comprehensive “all-or-none” bundled approach to care, which has already realized a 300% improvement, will be further enhanced by incorporating additional “Big Data” flows. Key words: big data, CAD, coronary artery disease, disease management, Geisinger
C
ORONARY ARTERY DISEASE (CAD) is a common, complex, and critical chronic disease that necessitates a team approach to optimize the care of patients by comprehensively measuring and improving care and a systematic team approach to care delivery. Engaging “Big Data” solutions carries the promise of even more improvement by moving beyond personalized care goals to personalized care processes and a more comprehensive view of patients through active and passive means. All of this should further enhance our success and allow even more patients to achieve all elements of the “all-ornothing” care bundle.
Author Affiliation: Geisinger Health System, Danville, Pennsylvania. T.G. is on the Merck Medical Home Speaker’s Bureau. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Thomas Graf, MD, Geisinger Health System, 100 N Academy Ave, Danville, PA 17822 ([email protected]). DOI: 10.1097/JAC.0000000000000038
METHODS Designing a model to reliably deliver better care to a population involves individual and population data, physician leadership, an in-depth understanding of the evidence base for optimal care, engagement of all elements of the care team including advanced analytics and the patient as part of the team, continuous measurement and improvement, support for those challenged by the change, and attention to systematic delivery through feedback and compensation (Casale et al., 2007; Graf et al., 2012). Physician-directed teams work to provide all aspects of care in a consistent and reliable manner based on comprehensive data actively pushed to the most appropriate team member when actionable. To do this, the workflow must not rely on the heroic efforts of diligent individuals. The redesign is incorporated into the standard workflow using charting tools, checklists, reminders, and alerts. The electronic health record (EHR) can be a valuable tool in creating a standard workflow, but having an EHR by itself does not accomplish the necessary workflow redesign. 199
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JACM
200
JACM-D-14-00014
May 20, 2014
17:4
JOURNAL OF AMBULATORY CARE MANAGEMENT/JULY–SEPTEMBER 2014
We recognized the need to comprehensively redesign the care we delivered to patients with coronary artery disease in 2006. We established a CAD team to review all CADassociated guidelines including: The American Heart Association and American College of Cardiology guidelines for “Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease” and for “Chronic Stable Angina”; The National Cholesterol Foundation Adult Treatment Panel III guideline; The Center for Disease Control and Prevention adult immunization schedule; and The National Quality Forum standards for ambulatory care. On the basis of these, we developed a system of care to reliably address 9 patient-oriented goals for improving the health of nearly 17 000 of our patients with CAD. These 9 goals are measured in an “all or none” fashion to encourage team-based workflows, addressing all measures in all patients with CAD, not only at each encounter, but continuously. The measures include appropriate blood pressure control (designated at
JACM-D-14-00014
May 20, 2014
17:4
J Ambulatory Care Manage Vol. 37, No. 3, pp. 199–205 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Leveraging Data to Systematically Improve Care Coronary Artery Disease Management at Geisinger Thomas Graf, MD; Alistair Erskine, MD; Glenn D. Steele, Jr, MD, PhD Abstract: Coronary artery disease is complex chronic disease best managed by a team empowered by actionable data and a comprehensive approach, the ability to improve intermediate outcomes was dramatically enhanced after Geisinger created a system of care to do so. Continuous measurement of critical data elements of process and intermediate outcome measures allows the delivery of actionable information to the most appropriate team member, including the patients and family as team members. Continuous monitoring of the overall program looking for trends and opportunities across sites and regions allows for program enhancements. The comprehensive “all-or-none” bundled approach to care, which has already realized a 300% improvement, will be further enhanced by incorporating additional “Big Data” flows. Key words: big data, CAD, coronary artery disease, disease management, Geisinger
C
ORONARY ARTERY DISEASE (CAD) is a common, complex, and critical chronic disease that necessitates a team approach to optimize the care of patients by comprehensively measuring and improving care and a systematic team approach to care delivery. Engaging “Big Data” solutions carries the promise of even more improvement by moving beyond personalized care goals to personalized care processes and a more comprehensive view of patients through active and passive means. All of this should further enhance our success and allow even more patients to achieve all elements of the “all-ornothing” care bundle.
Author Affiliation: Geisinger Health System, Danville, Pennsylvania. T.G. is on the Merck Medical Home Speaker’s Bureau. The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Thomas Graf, MD, Geisinger Health System, 100 N Academy Ave, Danville, PA 17822 ([email protected]). DOI: 10.1097/JAC.0000000000000038
METHODS Designing a model to reliably deliver better care to a population involves individual and population data, physician leadership, an in-depth understanding of the evidence base for optimal care, engagement of all elements of the care team including advanced analytics and the patient as part of the team, continuous measurement and improvement, support for those challenged by the change, and attention to systematic delivery through feedback and compensation (Casale et al., 2007; Graf et al., 2012). Physician-directed teams work to provide all aspects of care in a consistent and reliable manner based on comprehensive data actively pushed to the most appropriate team member when actionable. To do this, the workflow must not rely on the heroic efforts of diligent individuals. The redesign is incorporated into the standard workflow using charting tools, checklists, reminders, and alerts. The electronic health record (EHR) can be a valuable tool in creating a standard workflow, but having an EHR by itself does not accomplish the necessary workflow redesign. 199
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/JACM
200
JACM-D-14-00014
May 20, 2014
17:4
JOURNAL OF AMBULATORY CARE MANAGEMENT/JULY–SEPTEMBER 2014
We recognized the need to comprehensively redesign the care we delivered to patients with coronary artery disease in 2006. We established a CAD team to review all CADassociated guidelines including: The American Heart Association and American College of Cardiology guidelines for “Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease” and for “Chronic Stable Angina”; The National Cholesterol Foundation Adult Treatment Panel III guideline; The Center for Disease Control and Prevention adult immunization schedule; and The National Quality Forum standards for ambulatory care. On the basis of these, we developed a system of care to reliably address 9 patient-oriented goals for improving the health of nearly 17 000 of our patients with CAD. These 9 goals are measured in an “all or none” fashion to encourage team-based workflows, addressing all measures in all patients with CAD, not only at each encounter, but continuously. The measures include appropriate blood pressure control (designated at
