Experience and Potential for Transformational Change in Cancer Care Delivery

1. Experience and Potential for Transformational Change in Cancer Care Delivery David A. Haggstrom, MD, MAS Regenstrief Conference October 3, 2007

10. Importance of measurement PDSA cycles Act Plan Study Do Act Plan Study Do

11. How do we measure cancer care quality? Risk Assessment Diagnosis Cancer Treatment Screening Palliative Care General population Cancer population Longitudinal care Recurrence Surveillance

20. Transformative technology #2: Clinical decision support Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Ave risk / Follow-up of abnormal tests Surveillance colonoscopy ONCWATCH REMINDERS real-time quality performance Cancer screening

22. Transformative technology #2: Clinical decision support Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Low risk / Follow-up of abnormal tests Surveillance colonoscopy Physician specialty General internist +/- gastroenterologist +/- surgeon real-time quality performance Cancer screening REMINDERS

27. Concentration of patients among extended medical staff 73% % of patient received services from extended medical staff 90% % of physician inpatient work at primary hospital 98% 2% >500 2% 48% 50-499 <1% 50% 0-49 Extended medical staff Individual providers Patient panel size

30. Transformative technology #3: Personal health records Risk Assessment Screening Diagnosis Treatment Surveillance Provider -Oncologist -Radiation therapist -Surgeon -Primary Care -Radiologist -Proceduralist -Primary Care -Primary Care -Oncologist -Surgeon -Radiologist -Proceduralist PHR Palliative care Patient/ caregiver Longitudinal care

32. Study/project designs Appropriate care Clinical processes Quality personal health record no personal health record

34. Racial/ethnic differences patient perceptions of quality of care

39. Act Plan Study Do Act Plan Study Do

40. Indy quality performance measure the right things at the right time Act Plan Study Do Act Plan Study Do

47. Importance of measurement PDSA cycles X X Act Plan Study Do Act Plan Study Do

48. Subspecialty care Primary care Unmeasured quality gap Poor Quality Good Quality Shared care

49. Transformative technology #2: Clinical decision support Oncwatch Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance High risk Low risk / Follow-up of abnormal tests Surveillance colonoscopy REMINDERS Physician specialty General internist +/- gastroenterologist +/- surgeon real-time feedback Cancer screening

50. Sample sizes 98% 2% >500 2% 48% 50-499 <1% 50% 0-49 Assessment of providers as group (extended medical staff) Assessment of providers as individuals Patient population size

60. Health care quality improvement or implementation research Poor Quality Health Care Good Quality Poor Quality Good Quality

63. Quality improvement framework Measurement of Cancer Care Quality Organizations Providers Pathway 1: IMPLEMENTATION Good Poor

66. Diagnosis Cancer Treatment Screening Recurrence Surveillance

71. Medicare Medicaid Private Insurance Uninsured Indiana Network for Patient Care Regenstrief Medical Record System (RMRS) General population Cancer population VA INPC State Registry SPIN Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance

72. Risk Assessment Timely Diagnosis Cancer Treatment Screening Surveillance for Recurrence Genomics Risk of Cancer Death

74. Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E VA Medicare Medicaid private insurance Uninsured

75. Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E SPIN

76. Transformative technology #3: Personal health records Risk Assessment Screening Diagnosis Treatment Surveillance Patient/ caregiver Provider Provider Provider Provider Provider Follow-up of abnormal tests may be improved by coordination Survivorship care may be improved by coordination Patient/ caregiver Patient/ caregiver PHR Patient/ caregiver Palliative care Patient/ caregiver Longitudinal care

77. VA

78. Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) R E S E A R C H Q U E S T I O N Genomic risk Health Services Research SEER (20% US) State Registries (Indiana) VA Cancer registries

82. Coordination of care across the continuum Risk Assessment Screening Diagnosis Treatment Surveillance Patient Provider Provider Provider Provider Provider Follow-up of abnormal FOBTs may be improved by coordination Survivorship care may be improved by coordination Patient Patient/ caregiver Patient PHR

86. Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population (xx%) R E S E A R C H Q U E S T I O N Genomic risk Health Services Research SEER (20% US) State Registries (Indiana) VA Cancer registries

87. Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population SEER (20% US) State Registries (Indiana) VA Cancer registries D A T A S O U R C E

88. Unmeasured quality gap Health Care Good Quality Poor Quality Certainty Clinical uncertainty Health Care Quality and Uncertainty

89. How do we measure performance? Risk Assessment Diagnosis Cancer Treatment Screening Recurrence Surveillance General population Cancer population SEER Medicare Longitudinal care State cancer registry Medicaid

94. Coordination of care across the continuum Risk Assessment Screening Diagnosis Treatment Surveillance Patient/ caregiver Provider Provider Provider Provider Provider Follow-up of abnormal FOBTs may be improved by coordination Survivorship care may be improved by coordination Patient/ caregiver Patient/ caregiver Patient/ caregiver PHR