The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!

What did they do? Like many of the successful practices in the collaborative they created a new creature – the chronic disease coordinator.

Their story is on our new sister site at

http://stories.apcc.org.au/2009/11/the-rise-and-rise-of-the-chronic-care-coordinator/

But, alas, it has been usurped by the Smartpen. (http://smartpen.com.au) – A computer in a pen!

With the Smartpen , you can take notes, like an ordinary pen. (the Smartpen requires special paper, which you can print yourself)

Unlike a normal pen, the Smartpen also contains a microphone and an infrared camera. It records whatever is being written and makes an audio recording of what is being said at that same time.

At any subsequent time, you can touch your Smartpen on the particular written words on the page, and it will playback what was being said at the time.

So, in a consultation, if you make a note ‘abdominal pain’, you can later touch that word with your pen and it will replay what your patient actually said.

At a lecture, you can make brief notes, and if you later need clarification you can touch the appropriate word (or diagram) and you will hear the explanation given by the lecturer at the time you made the note.

How about that?

Furthermore, at the end of the day you plug your pen into your computer (!) All the pages you have written are automatically uploaded into the computer, and stored. No scanning required. The audio file is also uploaded, so you can still click on any word on the page (with your mouse), and hear what was happening at the time. You can also search your stored pages for particular words.

So, don’t take your laptop to a meeting – just your smartpen and the special pad.

(I’m not sure that I’ve ever gone back and looked at any notes I’ve made in a lecture. Perhaps with the smartpen I would.)

For those docs still using paper records, perhaps they could write their notes on the special paper and then automatically load them into the computer at the end of the day.

The smartpen does some other cool things that enable you to show off with style, always an important consideration with a new gadget. Draw a piano keyboard on a page, and then actually play it with your pen. Write 10 x 4, and the smartpen will come out with 40.

Can you think of a use for the Smartpen to improve your practice?

Let us know below.

Australians will have 90,000 heart attacks in 2009. 10,000 of us will die as a result – the majority before they reach hospital. According to a recent Access Economics report, it is projected that this will cost the economy $17.9 billion dollars!

As Dr Annete Katelaris writes in her blog

“While this is shocking, what really scares me is the response of the coalition of cardiac groups and the Heart Foundation. While they gave mention to the need for primary prevention, they seem to have almost exclusively focused on the need to improve acute care and secondary prevention.”

More ambulances, coronary angiograms and cardiologists. Stat!

But hang on – premature vascular disease is largely preventable. Appropriate intervention in high risk people can lead to a 55% risk reduction. That’s a $9 billion dollar saving!

What are your chances of having a heart attack in the next five years?

The absolute cardiovascular risk is used to weigh up the costs versus the potential benefits of a wide range of interventions, some of which (such as lipid lowering medications) use up a significant proportion of Australia’s PBS spending.

How accurately can we assess someone’s risk? And how important is it?

Last week I was in New Zealand, and caught up with Sue Wells, who “used to be a doctor but now works in an office”, according to her sons. She is the clinical co-ordinator of the University of Auckland’s PREDICT CVD-Diabetes program. This program is based on a Maori/non-Maori partnership and is supervised by Prof Rod Jackson, who pioneered the colour CVD risk charts in the 1990s. Their team of primary and secondary care clinicians and IT specialists form a national guidelines group that is producing the world’s best tools for assessing vascular risk.

The PREDICT program also demonstrates the value of a fundamental eHealth building block – one that Australia still lacks, yet New Zealand has had for 17 years! More on that later.

The Predict-CVD Program

Sue says “if a risk-based prevention approach is to work, CVD risk prediction must be accurate.”

Until now, The Framingham Study has been the basis for assessing cardiovascular risk. She asks “Did you know that the Framingham study included only around 5200 people, followed up for about 12 years? They were by and large middle-class and middle-aged and mostly male, and of mainly European ethinic background.”

New Zealand has a comprehensive approach to risk assessment, and their PREDICT program has been running since Aug 2002. As of January this year, 115000 assessments had been conducted on 74,402 individual patients by 1300 clinicians (GPs and practice nurses). 9000 of these patients have a prior history of CVD. Mean follow-up so far is 2 years.

So far, that is 20 times as many patients as were involved in the Framingham Study!

The PREDICT tool is built in to the GP software used in New Zealand. Most of the fields are ‘auto-populated’. It is also available on the Web.

Why have one thousand GPs used PREDICT? Sue would say that is because it provides both ‘evidence-in’ – to improve individual patient care – and ‘evidence-out’ – to improve practice-relevant evidence.

Evidence-In

When you do a risk-assessment on a patient using PREDICT, the program uses its database of clinical evidence to provide a number of support tools that make it easier to manage that patient. These tools include a great deal of education material targeted to that patient and their individual risk factors.

For example, Sue was concerned that young patients with a number of risk factors, such as smoking, still have a low 5 year absolute risk profile, and are falsely reassured. So the team developed ‘Your Heart Forecast’, which calculates current risk, but also ‘heart age’ and graphs a likely future profile. You can demonstrate to a patient that by modifying their risk factors they can improve their likely outcome. Even though their current risk might be low, their future may be less than rosy.

The tool is at http://www.yourheartforecast.org.nz/index.asp?pageID=2145872462

The Educational Support tools are at http://www.yourheartforecast.org.nz

Evidence-Out

The data entered into the tool is also automatically sent to the PREDICT database of patients at Auckland University, thus providing more evidence to improve the accuracy of health prediction, assess the effects of heath care, and aid in population health planning.

This improved evidence feeds back to improve the tool used in general practice, and thus completes the loop!

The NIH

We mentioned that there is a fundamental eHealth building block that enables the PREDICT system, that is not currently available in Australia. What is it?

The ‘National Health Index’ was introduced in New Zealand in 1992 (!) to be ‘the cornerstone of heath information’

From the Ministry of Health -
http://www.moh.govt.nz/moh.nsf/indexmh/sectorservices-claims-nhi

“The National Health Index number (NHI number) is a unique identifier assigned to every person who uses health and disability support services in New Zealand. A person’s NHI number is stored on the National Health Index (NHI) along with that person’s demographic details. The NHI and associated NHI numbers are used to help with the planning, co-ordination and provision of health and disability support services across New Zealand.

The NHI is associated with the Medical Warnings System (MWS), and is designed to warn healthcare providers of any known risk factors that may be important when making clinical decisions about individual patient care.”

In Australia, we can’t ‘track’ a patients care from clinic to laboratory to hospital because we do not have a way of uniquely identifying that patient (It’s almost OK if your surname is ‘Lembke’, or ‘Haikerwal, but a problem if it is ‘Jones’, or even ‘Wells’). It is in fact illegal to use the Medicare number for this purpose! This means that care can often be disjointed – health information is not readily available wherever and whenever it may be needed.

In NZ they can track what happens to every person. In the case of the PREDICT program they can do this anonymously, using the ‘encypted NHI’, or eNHI. This is the version of the NHI that has been de-identified, and is therefore used in research. The eNHI is encrypted in such a way that we can be sure it is always referring to the same person, but it cannot be linked back to that person’s name and address.

Linkage of Risk to Outcomes

The eNHI enables the PREDICT team to find out how accurate their predictions are, and then modify the weighting given to various risk factors to improve future predictions. (This sounds like a good skill set for developing a system to predict the results of horse races. If the team all retire early, we will know that they have been moonlighting)

When a GP uses the PREDICT tool to perform a cardiac risk assessment, the data (with the appropriate eNHI) is sent to the team at the University of Auckland. The eNHI is also sent to the New Zealand Health Information Service ( http://www.nzhis.govt.nz/), which collates a range of databases including hospital admissions and deaths. If at some future time that patient subsequently has a heart attack or dies, the Health Information Service feeds the outcome data for that patient back to the PREDICT team, so they can determine which of the patients in their database have in fact had a cardiac event.

Were we right?

The data is coming in. There have been 5000 events in 3200 of the 115,000 individuals tested so far. 1225 of these events have been fatal.

So far in this PREDICT cohort, 70% of the people tested have been in the low risk group, and they make up 24% of those who have had a cardiac event. 11% of those who have had an event have been of moderate risk, and 11% from the high risk group, which leaves a whopping 54% who have had a previous heart or stroke event. (this is the group we have been working with in our CHD collaborative). When a patient has a second PREDICT assessment done, the team can calculate how a change in risk factors affects outcomes.

The PREDICT program allows us to calculate which factors are most important in determining cardiovascular risk. Sue says that the Framingham figures are in fact not shaping up too badly, on average. However, they tend to overestimate the risk for most people, but underestimate the risk for some ethnic groups, including Maori and Pacific Islanders.

It was interesting for me to learn that adding ‘Family History’ into the calculations does not tend to add any further predictive value, whereas almost everyone would benefit from lowering their blood pressure. The PREDICT program remains a work that is continually improving.

In Australia

The first Australian guidelines for calculating absolute cardiac risk were published earlier this year as an initiative of the National Vascular Disease Prevention Alliance.

These guidelines continue to be based on the Framingham data. It will be interesting to revisit this discussion when the NZ PREDICT-CVD data extends out a few more years.

There is currently a discussion in Australia about the role of a Healthcare Identifier.

http://www.health.gov.au/eHealth/consultation

Hopefully we will soon introduce a unique patient identifier, only 17 years behind our Kiwi friends.

In the meantime, the work of the Predict team reminds us that cardiovascular risk assessment and management of risk factors should remain a national priority.

As Sue Wells reminds us

“We could prevent or delay 50% of the CVD events in the next five years if we assessed everyone for cardiovascular risk and managed them appropriately.”

“The real heroes for me are the 1300 GPs and nurses caring for their patients. We have only orchestrated a supportive IT program around this care that serves general practice at the time of decision making, for quality improvement activities and for improving what we need to know to care more accurately (risk prediction). From collective action which started out quite small…amazing things are possible”

The capacity for delayed gratification is an important predictor of ’success’.

In this short presentation, Joachim de Posada reports on a longitudinal experiment involving 4 year old children, a marshmallow, and fifteen minutes!

Joachim de Posada says, Don’t eat the marshmallow yet:

(Via TED talks Riveting talks by remarkable people)

The PocketMod v2.0

Ken Whyte has been using a folder up piece of paper for years. Thanks to Anton for pointing us to the 2009 version –

PocketMod: The Free Recyclable Personal Organizer

Customise, print out and fold your own groovy hipsterPDA notebook.

What do you think?

I always read the Presentation Zen postings, and highly recommend the book of the same name by Garr Reynold’s.

The key to good presentations is the same as the key to good design.

One of these principles is to:

always look at things from the audience’s point of view

• What are they interested in?
• What is relevant to them?
• What one thing do you want them to take home from your presentation?
• What do they already know? Or not know?

Reported (and comments) in: Journal Watch:

When patients are readmitted to the same hospital within two weeks under the care of different physicians, it was more likely than not that there would be no communication between the two teams.

In fact, half the time the team that first treated the patient was not even aware that they had been readmitted.

The study concludes -

Conclusion: Physicians are frequently unaware of patient readmissions and often do not communicate when readmissions occur. This communication is often desired and frequently results in the exchange of important patient information. Further work is needed to design systems to address this potential discontinuity of care.

The Medical Home

“The better the primary care, the greater the cost savings, the better the health outcomes, and the greater the reduction in health and health care disparities.” 1

Australia, through the National Health and Hospitals Reform Commission, is seeking the best way to deliver health services into the future.

In the collaborative program, practices have been challenged to deliver evidence based care to every single patient, every single time.

In answering this challenge, a model of care has been developed by practices which is comprehensive, team based, systematic, proactive and patient-centred. At the core is a rich therapeutic relationship between a patient and a particular doctor and the team that supports them.

We would contend that ‘the General Practice’ unit remains the best block from which to build Australia’s primary care system. Organised and well-resourced general practice can deliver the best health outcomes, with most efficiency, and with the greatest equity.

Is there international evidence for this ‘collaborative model’?

The American Board of Family Medicine has been advocating for ‘the medical home’ to form the basis of their health system.

A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes.

We would recognise ‘a medical home’ as ‘a general practice’.

Therefore, this recent study published in the The Journal of the American Board of Family Medicine is of interest: The Medical Home: Growing Evidence to Support a New Approach to Primary Care.

This literature review looked at over 200 references, reports, and books evaluating the medical home and patient-centered primary care.

Their conclusions:

Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes.
Community/provider boards may be required to safeguard the public interest.

Going a step further, The American College of Physicians calls for an Advanced Medical Home.

Practices and physicians that adopt the advanced medical home structure-

• a) use evidence-based medicine and clinical decision support tools to guide decision-making at the point-of-care based on patient-specific factors
• b) organize the delivery of that care according to the Chronic Care Model (CCM), but leverage the core functions of the CCM to provide enhanced care for all patients with or without a chronic condition
• c) create an integrated, coherent plan for ongoing medical care in partnership with patients and their families
• d) provide enhanced and convenient access to care not only through face-to-face visits, but via telephone, email and other modes of communication
• e)identify and measure key quality indicators to demonstrate continuous improvement in health status indicators for individuals and populations treated
• f)adopt and implement technology to promote safety, security, information exchange and portals for patient access to their health The information
• g)participate in programs that provide feedback and guidance on the overall performance of the practice and its physicians.

What would you say in your submission to the National Hospital and Health Reform Commission? Comments welcome below.

More on the Medical Home :

• American College of Physicians: Medical Homes & Patient Centred Care
• Joint Principles of the Patient-Centered Medical Home
• Medical Home on Wikipedia
• Deloitte: The Medical Home: A Solution to Chronic Care Management?

Epstein AJ. The role of public clinics in preventable hospitalizations among vulnerable populations. Health Serv Res 2001; 36: 405–20

Hot Dogs and Soda

New York has 500,000 diagnosed people with diabetes, and is considered pro-active in diabetes care.

How are they going?

Not so well, according to a recent study. 90% are not meeting their targets for HbA1C, Cholesterol and Blood Pressure.

…many of New York City’s medical institutions are failing to meet nationally recognized standards for managing diabetes.

Hot Pastrami on Rye, anyone?

The new study stresses the need to create environments that foster healthy eating and encourage physical activity. Chronic disease is common in settings where junk food abounds, fresh produce is scarce, and opportunities for physical activity are lacking. Conversely, environments that encourage exercise, discourage smoking and provide better food choices can improve people’s health. Physical activity and nutrition programs have been shown to reduce the progression to diabetes in those at highest risk by 60%

Reported in Diabetesincontrol.com

The IHI developed the original ‘breakthrough collaborative’ model from which the APCC has been developed.

About 10,000 delegates (including Dale Ford) attended the recent 20th Annual National Forum on Quality Improvement in Health Care in Nashville. How was it, Dale?

Only a few thousand attend the smaller ‘Redesigning the Clinic Office Practice’ conference each year, and I have been fortunate enough to attend on two occasions. This year it will be held in Vancouver, in March.

Anybody going?

The IHI also hosts a number of web based mini-collaboratives that it calls Web&ACTION (?), and the next of these begins on Feb 12th. You may be interested.

It is titled ‘Using Practical Tools and Methods to Create an Efficient Office Practice’, and consists of three web based seminars with assignments during the action periods in between.

The ‘blurb’ is quoted below, in a footnote to this email.

Our access may be limited due to time zone differences (12 noon ‘Eastern Time’ is 4am here) and the need for a telephone dial-in to participate fully (though Skype may do).

The cost is US$295.

Information is at
http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/UsingPracticalToolsCreateAnEfficientOfficePractice.htm

If you participate we’d be happy for you to share generously.

There are also a number of free resources including on-demand presentations available through the IHI site.
(There is a rather involved registration process even for free resources)

Don Berwick’s keynote talks are always good value. At Nashville his talk was entitled ‘Tense’
http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/OnDemandPresentationTense.htm

I’ve just enrolled in On Demand: The Right Treatment for the Right Patient Every Time – Applying Reliability Science to Health Care.
http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/OnDemandPresentationReliability.htm

I’ll let you know how it goes.

IHI also have a number of ‘white papers’ that you may find relevant.
They are at http://www.ihi.org/IHI/Results/WhitePaper

You may be interested in Going Lean in Health Care

As always, I’d welcome your feedback

The Blurb for the upcoming web&ACTION series follows

Every office practice wants to provide the best patient-centered, evidence-based care possible to each patient, each visit. But far too often daily work is plagued by busy caseloads, chaotic environments, and wasteful processes. Staff become so overwhelmed that there is no chance to find the breathing room necessary to focus on providing optimal care.
The Institute for Healthcare Improvement (IHI) has created a new Web&ACTION, Using Practical Tools and Methods to Create an Efficient Office Practice, to help office practices find and eliminate waste. Participants in the program will learn how to use simple tools and methods centered on Lean principles such as identifying the value stream, design for continuous flow, and removing bottlenecks and waste.

The goals of this work include:

• Focusing more fully on providing ideal patient-centered, evidence based care
• Decreasing cycle times
• Increasing efficiency, and patient and staff satisfaction
Expert faculty will help teams think about their current office systems, and then develop and implement plans for making them efficient and practical.

For more information, please visit:
http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/UsingPracticalToolsCreateAnEfficientOfficePractice.htm