The federal government’s Beacon Program provides funding to 17 communities that have already made inroads in the development of secure, private, and accurate systems of electronic health record (EHR) adoption and health information exchange. This is the fifth in a series of Health Affairs Blog posts in which leaders of several Beacon communities discuss their experiences over the first year of the program. Earlier posts in the series were authored by leaders of the Tulsa, Central Indiana, Colorado, SE Minnesota, and Inland NW Beacon community.
Nestled in the northwest corner of Mississippi, the 18-county region following the path of the Mississippi River known as the Delta is home to the crossroads, Blues music and fertile farmland. The Delta is also home to some of the nation’s worst health problems. The prevalence of diabetes there reaches 13 percent, and more than 70 percent of all adults are overweight or obese. Five of the nation’s 20 poorest rural counties — Issaquena, Leflore, Sharkey, Sunflower and Washington — are in the Mississippi Delta. Because of the region’s poverty, it is no surprise that its residents lack of access to appropriate health care, and health outcomes are poor.
The counties within the Delta share demographics that impact the health of their residents: they are located in rural areas, poverty levels are high and a high percentage of residents are African American. These factors make these counties particularly vulnerable to the disease burden that accompanies our nation’s racial and ethnic health disparities. The Mississippi Delta includes only 20 percent of the state’s population, yet it is responsible for lowering the state’s economic and health measures to the point that Mississippi is at the bottom of many national rankings.
The Delta Health Alliance (DHA), founded in 2006, is changing health care in the Mississippi Delta by improving access to health care and educating people to improve their lifestyles. DHA accomplishes this mission by linking the three major universities that serve the Delta with the University of Mississippi Medical Center and with the Delta Council, the region’s economic development organization; by using the latest evidence from science, medicine, and public health to define our programs; by regularly assessing every one of our initiatives on the basis of objective statistical data; and by accomplishing our work through community partners, recognizing that long-lasting change only occurs from the bottom up.
The Lessons Of Hurricane Katrina
Devastation from Hurricane Katrina in August 2005 highlighted the critical importance of a stable and resilient state healthcare infrastructure. A large number of Mississippians’ paper medical records were displaced. As healthcare professionals struggled to reconstruct medical histories, the need for reliable access to health information was made painfully clear.
Hurricane Katrina focused Mississippi’s attention on the need to electronically protect medical records and establish connectivity among providers across locations. Health providers in the Delta heeded the lessons taught by Katrina. Despite the socio-economic challenges present in the Delta, or perhaps because of them, clinicians there have readily adopted new health information technologies, appreciating how up-to-date health information and best practices can positively impact patient outcomes.
Using Health IT To Enable Pharmacists To Transform Diabetes Care And Prevention In The Delta
The Delta Health Alliance Better Living Utilizing Electronic Systems (DHA BLUES) Beacon Community focuses in the medically underserved, Mississippi Delta region on addressing the effects of diabetes and its complications through clinical interventions and health information technology. The immediate goal is simple: make use of the latest in direct care practices and information technologies to improve health care in the Mississippi Delta. The long term goal is more profound: transform the health care system by redirecting more of the existing resources into patient care and out of administration and record keeping.
One program with a HIT component is the University of Mississippi School of Pharmacy Medication Therapy Management (MTM) and Medication Adherence project. Recognizing that patients and providers need additional resources to target those with uncontrolled diabetes, asthma, and inappropriate medication use, the pharmacy school implemented the Delta Pharmacy Patient Care Management Project in July 2008. The program is structured to evaluate the impact of pharmacists on clinical, economic and humanistic outcomes in the region through the provision of Medication Therapy Management (MTM) services and disease-specific education.
At each MTM encounter, a systematic assessment of the patient’s drug related needs and previous medication experience is conducted to identify, resolve and prevent medication-related problems. An individualized care plan is developed, and a follow-up evaluation is completed. In the project’s first two and one-half years, MTM pharmacy services have been implemented in 14 community pharmacies, one private physician group and one federally qualified health center in ten Delta counties.
The UM School of Pharmacy MTM and Medication Adherence project within the Delta BLUES Beacon Community focuses efforts on improving diabetic patients’ medication adherence in a private practice, the Indianola Family Medical Group. In this model, an on-site pharmacist becomes an integral member of the patient’s treatment team and works directly with the clinic’s other care providers to provide education, screenings, and medication management. Bi-monthly telephonic assessments are performed to assess adherence and document it in the patient’s electronic health record.
Currently, the pharmacist conducts MTM visits in the Indianola clinic three days per week. Many enrolled patients in the program have a baseline A1c of 9 percent — a dangerously high level – or greater, and cholesterol and blood pressure readings for many patients are also elevated. All members of the healthcare team use the electronic health record (EHR) to improve communication among providers. Using the EHR, the pharmacist can run reports of patients with A1cs greater than 9 percent who may benefit from the program, provide the MTM/adherence intervention and document the encounter. A team of pharmacists and student pharmacists work on this project, which began in March with funding from the BLUES Beacon Community. In years 2 and 3 of the three-year grant, the scalable, reproducible model will expand to more patients in a larger geographic region.
Interventions such as the one being employed by the Delta BLUES Beacon Community are cost-effective methods of improving medication adherence. Through these interventions, pharmacists can meet patients’ immediate and ongoing needs for information and advice on medicines. Health care providers will see reduced overall cost. “Having high-risk patients receive additional intervention and connecting that intervention through the EHR is imperative to affecting health outcomes,” says Dr. Karen Fox, President and CEO of the Delta Health Alliance. “By focusing on medication adherence, patients can receive critical education for self management of their disease, in addition to the close monitoring of their pharmaceutical needs. The program puts another tool in doctors’ medical bags for them to use.”
Saving Money And Improving Health
By providing patient-centric care, the potential exists to greatly impact health outcomes.The pharmacist receives an e-referral for high-risk patients and follows a prescribed template of care, individualizing it to each patient’s situation. For example, in the Delta only 1 percent of diabetic patients receive foot exams from a health care provider. The pharmacist utilizes the medical record in the EHR to see if one has been provided within the past year. If not, the pharmacist performs the exam and documents this intervention in the EHR. “This model integrates the pharmacist in a direct patient care role as part of the healthcare team in the clinic,” explains Dr. Leigh Ann Ross, the School of Pharmacy’s Associate Dean for Clinical Affairs. “This provides additional services and resources for patients and primary providers in this area of our state, which is one of the country’s poorest and unhealthiest.”
The use of the EHR keeps all providers connected and informed so that results are shared in a timely manner and duplication of services is avoided. To illustrate this key economic component, consider that one inpatient hospital day costs $1,853 for a patient with diabetes. An office visit where diabetes is the primary diagnosis costs $132. Therefore the potential exists to save $1,721 by avoiding a hospital admission and directing care to the primary care provider’s clinic. This type of savings is of tremendous benefit to the resource-poor Delta, where most counties are designated health professional shortage areas.
The DHA’s EHR system includes several modules designed specifically for our patients, mindful of their lack of access to adequate transportation and of traditional regional cooking techniques. Educational print-outs have been customized to be sensitive to the culture of the communities and to broaden the confines of conventional nutritional ideas. By including the pharmacist as a member of the healthcare team and the EHR as a means for communication, the clinic moves towards becoming a patient-centered medical home.
During each bi-monthly call, the pharmacist or pharmacy student assesses the patient’s level of adherence with each medication, identifies and discusses reasons for non-compliance, and identifies any potential or actual medication-related problems. Less severe problems are addressed by counseling during the call. Patients with more complicated problems requiring longer face-to-face consultations are referred for follow-up in the MTM program or to their primary care providers. The phone calls last approximately 20 minutes, and each call is documented in the patient’s EHR to improve continuity of care.
The Mississippi Delta BLUES Beacon Community compliments infrastructure development currently underway to connect the region’s health systems through health information exchange (HIE). Since the region lacks the infrastructure needed to connect all of its health systems, the BLUES Beacon Community provides some of the infrastructure to offset costs for a robust HIE that will soon connect to the state HIE. Successful integration of health information technology into existing care delivery systems is considered by the BLUES Beacon Team to be one of three critical components to achieving patient centric care with a patient-centered IT system, or electronic health record home.
By itself, HIT is simply a tool, whose value is wholly dependent upon its ability to reliably fulfill its function and meet the needs of the health care provider team. It is not enough to simply implement these technologies, although that in and of itself is a huge task; the BLUES Beacon Community will show that utilizing this kind of technology in very specific ways will improve health outcomes in the Delta. The Delta BLUES Beacon Community provides practice and workflow redesign to primary care providers.
The key is for everyone to work together toward the common goal of changing the way health care is delivered. Bringing about that change, nurturing that change, and building on that change is what the Delta Health Alliance and the Delta BLUES Beacon Community are all about.