Report of the 8th Annual IAIMS Consortium Workshop

Session 2:

1. Management strategies: What new management strategies does IAIMS enable? (E.g., new MSO approaches, sharing of testing equipment, new ways to provide cross coverage and telephone support?)
2. Data-driven practice modifications: What strategies are most effective in helping providers use data to drive practice modifications?
3. Pathways: What factors must be considered in developing pathways to manage the continuum of health care across an integrated health system?
4. Staff training: What new strategies for training practice staff (e.g., management training, OSHA requirements, etc.) may be facilitated by IAIMS?
5. New methodologies: What are the key components of a methodology that would jointly support (1) process improvement or design across organizational boundaries and (2) the development of IAIMS components to enable the new processes? What are the critical success factors for implementing such a methodology in an integrated health care delivery organization?

• Pathways at Vanderbilt
Susan Erickson, RN, MPH, Assistant Hospital Director & Director, Office of Case Management
Vanderbilt University Medical Center
• How VUMC conceptualizes a pathway: a multi-disciplinary plan reflecting team agreement on best practice; key components of a pathway.
• How we support physician use of data to identify variance in practice patterns and to determine best practice.
• Documentation of the impact of pathways on cost, quality, & patient satisfaction; how pathways are improved.
• The pathway as a tool to support documentation by exception.
• How pathways will assist us with resource management: future input to staff/equipment/ space scheduling and ordering.
• Optimizing the Clinical Information System to Implement Practice Guidelines
Rusty Russell, Ed.D., Jim Hackett, & Terry Burton, M.L.S.
Robert C. Byrd Health Sciences Center, West Virginia University

The Robert C. Byrd Health Sciences Center is exploring ways to optimize the clinical information system to provide decision support based on outcomes research. Problems to be solved include identification of appropriate guidelines, availability of guidelines to care providers in a way that encourages use and compliance, effective outcomes research, and development of an information infrastructure that will encompass and support all of our care sites. The network infrastructure must include our hospitals and clinics, our education and training sites, and our affiliated care providers. Varying levels of information systems service, dependent upon bandwidth and available connectivity, may be employed to provide clinical information. The span of service, based on standards and guidelines, can include pre-admissions testing to follow-up home care and outcomes research. Cost-effective care can be provided through improved telecommunications services; however, current telecommunications industry practices do not favor a cost-effective, wide area approach to clinical systems optimization for cost controls and improved care delivery.

• Affiliate Information Services Development
Bill Stead, M.D., Vanderbilt University Medical Center

VUMC is developing strategies for providing information services to link our central facilities with affiliated and referring providers. We will report on our planning and implementation processes.

Discussion Group 1 Back to top

1. We must track costs and practice profiles. In our institutions, we need to identify the best way for information technology/IAIMS to do that.
2. Pathways:
• What is the best way to develop pathways? Modify existing guidelines, use what you already do, or base it upon evidence-based medicine? Our consensus was to start with existing guidelines, modify as necessary, use evidence-based medicine and outcomes research to test, modify, justify deviations.
• How to implement pathways? How to deal with politics, convince health care providers to view as a learning opportunity and chance to improve practice? Keep practice profiles confidential and anonymous; implement in non-threatening way; ensure that paths allow for legitimate variation in practice.
• How to justify deviations from pathways? Use evidence-based medicine and outcomes research. This should avoid reimbursement and malpractice problems if justified in these ways.
3. Using the Internet to disseminate guidelines and pathways is a mixed blessing - easy to disseminate and link, but contents are constantly changing.
4. The librarian is the appropriate person to track guidelines and pathways, ensure that the most current versions are being used, and maintain Internet links.
5. Pathways and medical education:
• Physicians need to learn how to provide clinical care in a cost-conscious manner while balancing costs vs. benefits.
• What happens when students leave the academic environment? The paths that they have been using will probably not be adaptable to their new practice environment, but the concept of using paths and more generic guidelines should remain.
6. Our model showing the role of national guidelines, local path development, and outcomes research/evidence-based medicine is a circle. (Based upon research, modify pathways and national guidelines; pathways also influence guideline development when guidelines are not sufficient to use for paths.)

Our recommendation: try model with national guidelines (e.g. ACOG, NIH, AUCPR), adapt to path (e.g. University of Washington activities) at IAIMS site, test.



7. Postscript: Read the proceedings of the 1996 AMIA Annual Fall Symposium. There were lots of sessions and posters on guidelines implementation and collaborative activities (e.g., poster 16, p. 826, describing several IAIMS institutions working collaboratively, provides an alternative model).

1. Role of librarians/libraries in developing/managing pathways.
2. How to capture the clinical encounter effectively?
3. Pathways: How to develop and implement - how to develop as a group (collaboratively), how to deal with administrative issues and politics (for development and implementation), and how to implement in non-threatening manner?
4. Model for pathway development: Base on existing guideline, replicate what you're already doing or use evidence-based medicine.
5. Security issues for medical record.
6. Using outcomes research to enhance practice competitiveness.
7. Using information technology to support the health care practitioner - how to make it all work?
8. What is the core information technology to make it work? What standards and protocols are needed? We should not start from scratch; we need to do this collaboratively.
9. Identify the institutional initiatives needed to prepare to do IAIMS.
10. How to facilitate physicians work?
11. How to tie outcomes research into pathways and institutional culture?
12. What is the role of national guidelines in pathway development?
13. Pathways: Don't force them on health care providers. They must be non-rigid, flexible; we must educate health care providers to use them effectively.
14. Practice profiles: Insurance companies will do this. Its better for the institution to have role. We must demonstrate benefit to health care providers, e.g., as an educational opportunity, a change to provide better care. Note: Reports should be confidential, anonymous.
15. Deviations from pathway: How to capture information in record accurately to reflect legitimate causes for practice variations? What are confounding variables? When care does deviate from path, how can we protect the health care provider and the institution from reimbursement problems and malpractice risk? (Role of evidence-based medicine to help document variations in practice.)
16. How to maintain the currency of paths and guidelines?
• Role of librarian in identifying paths and guidelines, ensuring that most current ones are used, checking on URLs, etc.
17. Reducing costs: First must identify what the real costs are (overhead, profit margin)(documentation vs. fraud). What is the role of information technology in helping the institution identify the real costs?
18. Pathways and medical education (an interesting side discussion).
• How does medical education need to change to teach medical students to provide cost conscious and cost effective care, as well as how to deal with managed care environments? We noted variations in current education from a single course to complete MD/MBA programs; the latter is probably overkill for most MDs. Education needs to be holistic; students need to learn to incorporate cost consciousness and cost-benefit analysis into their clinical decision making processes.
• Need to teach how to practice collaboratively (to prepare for managed care)(cost savings).
• What happens to the student who has been using paths in training once the training is over? Consensus was that the specific path was not transferable but using a path may be, i.e., value of generic guidelines that could be adapted at the local level.
• Can there be a central depository for paths? (or since they are primarily applicable to a specific institution, are the development processes and concepts more important to capture?)
• Can we use information technology to attach guidelines to the medical record similar to LATCH?
• What is the role of the Internet to share paths, guidelines? How can we time-stamp versions of guidelines used to protect against malpractice?
• What is the role of evidence-based medicine vs. cost-effective care in pathway development and use?

Discussion Group 2 Back to top

1. There is an opportunity to do developmental work in the area of guidelines use for outcomes management and practice/management improvement, including the IAIMS role in providing information and management mechanisms.
2. Computer-aided training technology has the potential to provide information at critical points in the healthcare system.
3. Reengineering tools are needed to help with process change--perhaps adapted to healthcare systems.

1. Develop a working group/study section to analyze this issue and the potential for collaboration in developing standards and/or assessment tools.

Extemporaneous discussion centering on these questions/interests:

1. What information services can we deliver through IAIMS that will improve practice competitiveness by reducing practice overhead?
2. Pathways and how evolving for variance analysis and outcomes; how to manage who gets what information.
3. Data-driven practice modifications; uniformity of vocabularies.
4. How these things have to be done differently or not; what we need to know in academic environments (research and education).
5. Balancing needs of different groups; where to put resources to meet the different needs of student researchers.
6. Re-engineering; staff training.
7. Staff training in new methodologies.
8. Development of educational opportunities; what resources are needed.
9. Clinical part of IAIMS concept.

Question 1: Management Strategies

1. Documenting by exception and variances.
2. Providing information other than variance--information to effect behavior change.
• does anything take precedence over guidelines?
• what is the rationale for guidelines?
• motivation for guidelines compliance--overcoming resistance
• education as motivator for use/compliance--anonymous comparisons
• Utah model for drug selection
• feedback for others than outliers
• policies for verifying problem
• policies and procedures for education--useful steps that need to be taken (continuous, non-punitive feedback)
3. Ideal of "understanding the process" to move everyone toward the best practice; leads to identifying steps that lead to best practice and rationale for following.
4. Real-time systems to document care and what needs to be done on subsequent visits.
5. Capturing transcriptions.
6. Problem knowledge couplers--electronic record follows patient to point of having problem solved.

1. Research perspective--how people use vocabularies; what structure makes them useful.
2. Enabling automated data collection.
3. Uses of aggregate data.
4. Knowledge coupler as data driven practice modification enabler/methodology.

Question 3: Pathways

1. Individual practice variance--how to get people to follow guidelines?.
2. How to mandate without appearance of cookbook medicine?
3. Involve local physicians.
4. Managed care influence; impact on where patients are going; need to stay within requirements of managed care contractors.
5. Imperative to get cultural change among providers to come to consensus on guidelines.
6. Where does IT fit in this?
• Mediators? Feedback on whether or not needs are being met in regard to guidelines.
• Immediate on-line report on what outcomes have/have not been met.
7. Integration of clinical paths and guidelines with medical record.
8. Order sets based on pathways and documentation of outcomes.
9. Adjusting guidelines to local practice. Are there formal guidelines or is it ad hoc cost-accounting of guideline development process? Is it affordable to do this and/or modify locally? Cost of developing outcomes database--should it be enterprise wide?
10. Local guidelines vs. following national (AHCPR).
11. Following most common--greatest potential--followed by hardest/critical procedures.
12. Making/continuing progress after initial success of taking on easiest and high risk problems. What do you do to continue reducing costs?
13. How far can costs be cut?--documenting when enough is enough.
14. Acceptance of computer-aided decision tools--what is their role? --are they as good as physician mentors?

1. Computer-based training; self-paced, documented. Cost a downside.
2. IAIMS infrastructure can provide access and documentation.
3. Computer-aided instruction good for "training"--may not be as good for "education."
4. Access to rule and procedure information.
5. Ambulatory practices--ease of information access (IAIMS concept)--can provide training in downtime or when needed.
6. Easier to do training when people already know how to use computers.
7. Need for adequate training facilities (e.g., more than 50 people at time).
8. Has IAIMS made it easier to do?
9. Move from teaching technology to training workgroups how to do things better.
10. Earmark of IT budget for training? In other budgets?
11. Drop-in training to reach people who don't have time to get started.
• Out-of-library training.
• Departmental contact people to ease "reluctance to get started."
12. On-line tutorial on how to create individualized order sets. Get vendors to make it part of service.

1. What tools are available to help with reengineering processes--like CASE tools?

Discussion Group 3 Back to top

This summary provided by Linda Cooperstock:

• Activity based cost accounting - standards, scale to insure consistency.
• Consortial buying to leverage costs.
• Identify and optimize roles of different facilities.
• Measure success and reward all players - people oriented.
• Improve reimbursement scheme - would a business model work?
• Pragmatic, visionary leader.
• Adopt goals/objectives for clinical outcomes.
• Referral guidelines shared by payer, provider, and consultant.
• Develop regional or national standard for patient privacy guidelines.
• Define who provides the infrastructure - look to partnerships.

• Shared knowledge bases within a region.
• Consumer web pages.
• Common set of objects, vocabulary, and data exchange standards.

• Distribute a patient education model that can be customized.
• Community master patient index with centralized encounter database.
• Community shared network and common interface engine - what is the community; how is the interface selected?
• Ability to schedule into other systems while patient is in office.
• Link from employers through payers for benefits, pay (www.healtheon.com).

• Modularize and standardize.
• Build consensus and jointly administer training for end users.

• All systems in the future should be based on Internet/Intranet model.
• How to use Internet connectivity to all houses and facilities (www.athome.com)?