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public policy development for caring chronic diseases
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1
Public Policy and Health Policy
นพ. ชู�ชู�ย ศรชู�น� [email protected]
[email protected] Facebook , Twitter : Morchuchai
2
What is ‘policy’?
a course of action or inaction (Heclo 1972)
a course of action adopted and pursued by a government, party, rulers, statesman (Oxford English Dictionary)
a set of interrelated decisions … concerning the selection of goals and the means of achieving them within a specified situation … (Jenkins 1978)
decisions taken by those with authority and responsibility for a given policy area (Buse et al 2005)
any course of action followed primarily because it is expedient or advantages in a material sense
นโยบ�ยส�ธ�รณะ ( Public Policy ) กั�บส�ขภ�วะของประชู�กัร
นโยบ�ยด้��นส�ธ�รณส�ข (Public Policy) นโยบายเพื่�อการดำ�าเน�นสาธารณส�ข ที่�เป็�นเร�องที่�เก�ยวข�องที่างดำ�านส�ขภาพื่โดำยตรง
นโยบ�ยส�ธ�รณะเพ��อส�ขภ�พ (Healthy Public Policy) นโยบายสาธารณะที่�แสดำงความห่$วงใยอย$างชั'ดำเจนในเร�องส�ขภาพื่ พื่ร�อมที่�จะร'บผิ�ดำชัอบต$อผิลกระที่บที่างส�ขภาพื่ ที่�อาจเก�ดำข+,นจากนโยบายน',น ขณะเดำ�ยวก'นก-เป็�นนโยบายที่�ม�$งสร�างเสร�มส�งแวดำล�อมที่',งที่างส'งคม และกายภาพื่ที่�เอ�,อต$อการม�ชั�ว�ตที่�ม�ส�ขภาพื่ดำ� และม�$งให่�ป็ระชัาชันม�ที่างเล�อก และสามารถเข�าถ+งที่างเล�อกที่�ก$อให่�เก�ดำส�ขภาพื่ดำ�ไดำ�
4
ระด้�บของนโยบ�ย• นโยบ�ยของร�ฐบ�ล-แถลงกั�รณ$ของน�ยกัฯ• กัฎหม�ย พรบ พรกั กัฎกัระทรวง ประกั�ศ • แผนพ�ฒน�เศรษฐกั�จและส�งคมแห/งชู�ติ�• แผนแม/บทแห/งชู�ติ� • บ�ญชู2ย�หล�กัแห/งชู�ติ�• ชู�ด้ส�ทธ�ประโยชูน$ของระบบประกั�นส�ขภ�พ
• กัฎหม�ย กัฎระเบ2ยบในระด้�บจ�งหว�ด้ • แนวท�งระด้�บเขติติรวจร�ชูกั�ร • มติ�ของคณะกัรรมกั�รจ�งหว�ด้ อ�เภอ
• แนวท�งกั�รค�ด้เล�อกัเวชูภ�ณฑ์$ของโรงพย�บ�ล• Clinical Practice Guidelines, Standard Operating Procedures (SOP) เชู/น Laboratory manuals
•กั�รจ�ด้ง�นประชู�มว�ชู�กั�ร
นโยบ�ยระด้�บชู�ติ�
นโยบ�ยระด้�บพ�5นท2�
นโยบ�ยระด้�บองค$กัร
5
Policy diagram
Input Process
By product
Input Human resources Financial resources Instruments Technical knowledge
Output
Outcome Effect Impact
Short term Long term
6
The Policy Triangle
Walt G and Gilson L, Reforming the health sector in developing countries: the central role of policy analysis, Health Policy and Planning 1994; 9: 353-70
Actors
Context
Content Process
แนวท�งกั�รสร��งนโยบ�ยส�ธ�รณะเพ��อส�ขภ�พ : 8 Elements
ฉุ�กเฉุ�น
โรคเร�5อร�ง
ส�ขภ�พจ�ติ
พ�ฒน�กั�รเด้6กั
ผิ1�ส1งอาย�
ฟื้85 นฟื้�ผ��พ�กั�รว�ย
ร�/น
ภ�ค2ส�ขภ�พ
ม�ลน�ธ�ส�ธ�รณส�ขแห/งชู�ติ� 2553
Relationships between the functions and objectives of health systems
Performance framework (WHO, 2000)
Global Attention to Health Systems
‘6 Building Blocks’
Source: World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.
Care Management for Chronic Diseases
Health Policy and Healthy Public Policy Development
Diseases or Service Response Health System Response
Care Management : Chronic illness
Insurance Model Utilization review, quality assurance
function Compliance and access orientation No integration
Care Delivery Model Develop standard tools: CPG, care map Linear integration
Security (Continuum Care) Model Community health care, optimum care
site Continuous quality improvement Promote wellness and community health
status Multidimensional integration
12
พ�ฒน�กั�รท�งเศรษฐกั�จ ส�งคม เทคโนโลย2 กั�บกั�รพ�ฒน�นโยบ�ยคว�มเข�มแข6งระบบ
“ ” ส�ธ�รณส�ข โรคเร�5อร�ง
2005
โครงสร��งประชู�กัรท2�เปล2�ยนแปลงประเทศไทยท2�เปล2�ยนแปลง
Generation 2010 2020 2030
Baby Boomer( 50 ป: ข;5นไป)
6,462 - -
Gen X(31 - 49 ป:) 15,742 15,742 -
Gen Y(18 - 30 ป:) 3,750 3,750 3,750
Gen M - 6,462 22,204
Prevalence Hypertension: 23% male, 21% female All samples are hypertensive, >140/90 mmHg,
Effective coverage of hypertension, adult >15 yr. 2003
Source: National Health Exam Survey
6
12
11
19
5
5
77
64
0% 20% 40% 60% 80% 100%
Male (N=7,544)
Female (N=7,580)
treated + well control Treated, not well controlledDiagnosed, no treatment Not diagnosed
Prevalence DM: 6% male, 7% female All samples have FBS, >126 mg/dl
Effective coverage of DM, adult >15yr. 2003 Source: National Health Exam Survey
9
15
24
34
2
2
66
49
0% 20% 40% 60% 80% 100%
Male (N=2,045)
Female (N=2,601)
treated + well control Treated, not well controlledDiagnosed, no treatment Not diagnosed
19
คนชู�5นกัล�งในไทยป: 2533-2549
0
2
4
6
8
10
12
14
16
2529 2531 2533 2535 2537 2539 2541 2542 2543 2544 2545 2547 2549 2550
69-346 บาที่/ว'นเส�นความยากจน-346 บาที่/ว'น
จ�นวนคร�วเร�อนชู�5นกัล�ง แยกัติ�ม 2 น�ย�ม จ�านวนคนชั',นกลางอย1$ระห่ว$างน�ยามที่',งสอง ค�อ 12-
15 ล�านคร'วเร�อน
ประเทศไทยท2�เปล2�ยนแปลง
20
ร�อยละคร�วเร�อนท�กักัล�/มท2ม2อ�ปกัรณ$อ�นวยคว�มสะด้วกั
เทศบ�ล
นอกัเทศบ�ล
รถยนต2ส$วนบ�คคล
รถบรรที่�กเล-ก / รถป็3กอ'พื่ / รถต1�
เตาอบไมโครเวฟ
เคร�องป็ร'บอากาศ
เคร�องซั'กผิ�า
รถจ'กรยานยนต2
ว�ที่ย�
เคร�องเล$นว�ดำ�โอ / ว�ซั�ดำ� / ดำ�ว�ดำ�
ต1�เย-น
โที่รศ'พื่ที่2เคล�อนที่�
ห่ม�อห่�งต�มอาห่าร
โที่รที่'ศน2
0 10 20 30 40 50 60 70 80 90 100
17.59
21.19
22.89
26.74
57.71
60.77
68.02
78.51
85.73
88.14
91.04
96.44
รถยนต2ส$วนบ�คคล
เคร�องป็ร'บอากาศ
เตาอบไมโครเวฟ
รถบรรที่�กเล-ก / รถป็3กอ'พื่ / รถต1�
เคร�องซั'กผิ�า
ว�ที่ย�
เคร�องเล$นว�ดำ�โอ / ว�ซั�ดำ� / ดำ�ว�ดำ�
โที่รศ'พื่ที่2เคล�อนที่�
รถจ'กรยานยนต2
ห่ม�อห่�งต�มอาห่าร
ต1�เย-น
โที่รที่'ศน2
0 10 20 30 40 50 60 70 80 90 100
4.81
5.19
7.12
19.70
41.56
56.64
66.63
74.54
77.68
81.77
83.01
94.71
ความต�องการส�งอ�านวยความสะดำวกที่�าให่�ตลาดำส�นค�าอ�ป็โภคบร�โภคให่ญ่$และ
ขยายต'ว เชั$น เคร�องใชั�ไฟฟ8า ยานพื่าห่นะ อาห่ารแป็รร1ป็ เก�ดำการผิล�ตและการจ�าง
งานในป็ระเที่ศ
คร'วเร�อนม�ค$าใชั�จ$ายที่�เก�ยวข�องก'บ การเร�ยนร1 �เพื่�มมากข+,น เชั$น ดำ�าน
การส�อสาร และการเดำ�นที่างใน โอกาสพื่�เศษ รวมที่',งการลงที่�นดำ�าน
คอมพื่�วเตอร2และเชั�อมต$ออ�นเที่อร2เน-ต
ประเทศไทยท2�เปล2�ยนแปลง
เศรษฐกั�จไทยข;5นกั�บเศรษฐกั�จโลกั253
3253
9254
0254
1254
3254
7
กั�รบร�โภครวม 65.9
62.8
62.6 63.3
63.2
63.6
• ภ�คเอกัชูน 57.1
54.4
54.4 53.8
54.0
54.9
• ภ�คร�ฐบ�ล 8.8 8.4 8.2 9.6 9.2 8.6
กั�รลงท�นรวม 39.1
42.5
34.2 21.3
19.9
22.5
• ภ�คเอกัชูน 33.2
32.1
22.7 12.1
12.5
16.4
• ภ�คร�ฐ 5.9 10.4
11.6 9.2 7.4 6.1
ส/งออกัส�นค��และบร�กั�ร
36.5
42.0
45.7 55.3
64.7
65.7
น�เข��ส�นค��และบร�กั�ร
41.54
49.2
44.3 38.8
49.8
54.0
ท2�ม� : สศชู.
ประเทศไทยท2�เปล2�ยนแปลง
คนไทยบร�โภคน5�ติ�ลเพ��มข;5น
ข�อม1ล ส�าน'กงานคณะกรรมการอ�อยและน�,าตาล ค'ดำจากรายงานการสาธารณส�ขไที่ย พื่.ศ. 2544-2547
Top ten: DALYsTop ten: DALYs
% of Total 52.61 42.83
Rank DiseaseDALY('000)
% %DALY('000)
Disease
1 HIV/AIDS 645 11.3 7.4 313 Stroke2 Traffic accidents 584 10.2 6.9 291 HIV/AIDS3 Stroke 332 5.8 6.4 271 Diabetes4 Alcohol dependence/harmful use 332 5.8 4.6 191 Depression5 Liver and bile duct cancer 280 4.9 3.4 142 Ischaemic heart disease6 COPD 187 3.3 3.0 125 Traffic accidents7 Ischaemic heart disease 184 3.2 3.0 124 Liver and bile duct cancer8 Diabetes 175 3.1 2.8 118 Osteoarthritis9 Cirrhosis 144 2.5 2.7 115 COPD
10 Depression 137 2.4 2.6 111 Cataracts
Male Female
DALY
Burden attributable to risk factors, 1999-2004
9.4%
8.1%
5.7%
5.5%
4.5%
3.7%
2.2%
1.7%
1.3%
0.9%
0.9%
0.5%
0.3%
0.3%
0.2%
13.8%
5.8%
5.1%
5.0%
4.2%
3.9%
2.3%
1.4%
1.2%
3.6%
1.4%
0.7%
0.7%
0.4%
0.3%
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0%
Unsafe sex
Alcohol
Tobacco
Blood pressure
Not wearing helmet
Obesity
Cholesterol
Fruit & vegies
Physical inactivity
Illicit drugs
Air pollution
Water & sanitation
Malnutrition - int standard
Not wearing seatbelt
Malnutrition - Thai standard
% of total burden
2004
1999
ล�าดำ'บป็:จจ'ยเส�ยงที่�ก$อให่�เก�ดำภาระโรคจากมากไป็ห่าน�อย ไดำ�แก$ การม�เพื่ศส'มพื่'นธ2ที่�ไม$ป็ลอดำภ'ย แอลกอฮอล2 บ�ห่ร� ความดำ'นเล�อดำส1ง การไม$สวมห่มวกและคาดำเข-มข'ดำน�รภ'ย ภาวะน�,าห่น'กเก�นและโรคอ�วน ระดำ'บโคเลสเตอรอลในเล�อดำส1ง การบร�โภคผิ'กและผิลไม�น�อย การขาดำการออกก�าล'งกาย การใชั�สารเสพื่ต�ดำ มลพื่�ษที่างอากาศ การขาดำน�,าสะอาดำ การส�ขาภ�บาลและส�ขอนาม'ยที่�ไม$เห่มาะสม และภาวะที่�พื่โภชันาการ
โลกัท2�เปล2�ยนแปลง
Information medicine “Knowledge is power” Medical process:
information process Delocalised, distributed
and direct Decision support,
information management, identity technology,imaging, visualisation, sensors,telemedicine
The home as treatment location
The Internet Patient
Decision Support Systems
Diagnosis, data analysis, reminders, memory empowerment, ”second opinion”
Interactive broschures, simulations, smart objects, ”the digital doctor”
Benefits patient participation, handle information overload
Problems: conservative, silent knowledge,integration with patients and organisation
Imaging
Scanning + fast visualization+ information fusion
Non-invasive exploration Direct information to doctors Shorten the treatment chain,
reduce sidetracks Requires change in routines
Sensors and Telemedicine
Trends More conditions measurable, smaller, cheaper, plentiful, more functions per chip More intimate and biological, both non-invasive and implanted Active ”smart” sensors/actuators, wireless communication
Pathogen sensors, automated medication
Moves the location of diagnosis and treatment to the periphery
Information overload, privacy, security, training
Cybersurgery Surgery supported by information
technology Remote surgery Direct visualisation Augmented reality Robotics
Economy? Stumbles on organisation issues
Minimal Access Surgery
More and more applications Faster recovery Faster surgery redistributes medical
personell Need of a new kind of operating
theatre? Strong link to VR and robotic surgery
Biotech medicine
Regenerative medicine Rational drug design Bionics Genetic testing Vaccines Enhancing medicine
The New Pharmacology
Rational design Based on genomics, simulation and
knowledge of basic processes Generics threatened, business
models in pharma threatened Blurs the borders between palliative,
curative, preventative and enhancing medicine
Prosthetics and Neurointerfaces
Neurointerfaces rapid development (~300 electrodes, permanent)
Prosthetic research underfinanced Large gains for small groups
Genetic Testing
Cheap, fast genetic tests many conditions
How many wants to test? How does the health system respond?
Benefits: More individually adapted, good for preventative medicine and pharmacogenomics
Problems: Interpretation, too much faith in genetics, diagnosis develops faster than treatment, breaks information monopolies
Reproductive Medicine
Reproduction as a right? We are willing to spend enormous
sums on our children and their health
Genetic testing, preventative medicine
Perinatal medicine
The New Vaccines
Vaccines for treatment instead of just prevention
Immune system control Vaccines against
Allergies Diabetes Autoimmune illnesses Metabolic illnesses Cancer Narcotics
Neurotechnology
The brain/mind increasingly visible New pharmacology + understanding
of brain leads to treatment of many mental disorders
Hybrid therapies
Nanotech medicine NBIC convergence Enhancement of previous
technologies Reduced price Increased effectiveness Increased portability Active and smart devices and drugs
Development gradual and enabled byprevious technologies.
Chronic Care Model กั�บกั�รพ�ฒน�นโยบ�ยส�ธ�รณะ
Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305 Copyright ©2004 BMJ Publishing Group Ltd.
Components of Chronic Diseases Management
Population ScreeningUsing claims/clinical data to identify patients for disease management
Patient Risk ManagementSurveying patients about disease status/burden to identify for disease management
Team-Based CareUsing formalized teams to increase collaboration of care
Alternative EncountersProviding opportunities outside of the face-to-face encounter for relationship
Cross-Consortium CoordinationManaging across sites and settings to improve care continuity
Patient EducationTeaching patients about their disease
Outreach/Case ManagementTracking patients and their status proactively
Decision Support At the Point of CareTranslating disease management guidelines to patients-specific recommendations for clinicians.
Guidelines/ProtocolProviding information to clinicians on recommended clinical management
Performance FeedbackMeasuring performance in delivering desired care and achieving improved outcomes
Full Integration: Population Based and Chronic Care Case Based Model
Lifestyle interventions
Low risk At riskDisease
ManagementDiseaseSymptomsEarly Signs
Preventive Services Case Management
Screening
Primary and SecondaryPrevention
Acutetreatment
DiseaseManagement
HEALTH IMPROVEMENTDISEASE MANAGEMENT
HEALTH MANAGEMENT
POPULATION-BASED CASE-BASED
Chronic Illness and Medical Care
Primary care dominated by chronic illness care
Clinical and behavioral management increasingly effective BUT increasingly complex
Inadequate reimbursement and greater demand forcing primary care to increase throughput—the hamster wheel
Unhappy primary care clinicians leaving practice; trainees choosing other specialties
Loss of confidence in primary care by policy-makers and funders
But, there are new models of primary care and growing interest in changing physician payment to encourage and reward quality
People-centred care
World Health Report: 2008
โรงพย�บ�ลส/งเสร�มส�ขภ�พติ�บลTambon Health Promotion Hospital
Coordinate with other partners - central government + local authority + community + private sector,
Working in community – home ward, Proactive, outreach services based on
community health needs, Care coordination – horizontal and
vertical levels and case management system
What Patients with Chronic Illnesses Need
A “continuous healing relationship” with a care team and practice system organized to meet their needs for:
Effective Treatment (clinical, behavioral, supportive),
Information and support for their self-management,
Systematic follow-up and assessment tailored to clinical severity,
More intensive management for those not meeting targets, and
Coordination of care across settings and professionals
Toward a chronic care oriented system
Reviews of interventions in other conditions show that practice changes are similar across conditions
Integrated changes with components directed at:
i use of non-physician team members,i planned encounters, i modern self-management support,i Intensification of treatment i care management for high risk
patientsi electronic registries
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformationSystems
Self-Management Support
Health System
Resources and Policies
Community Health Care Organization
Chronic Care Model
What distinguishes good chronic illness care from usual care?
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice Team
Assessment of self-management goal attainment and confidence as well as clinical status
Adherence to guidelinesTailoring of clinical management by stepped
protocol (Treat to target)Collaborative goal-setting and problem-solving
resulting in a shared care planPlanning for active, sustained follow-up
Informed,ActivatedPatient
ProductiveInteractions
PreparedPractice Team
How would I recognize aproductive interaction?
What characterizes an “informed, activated patient”?
Informed,ActivatedPatient
They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.
Self-Management Support
Goal
To help patients take a more active
role and be more competent
managers of their health and
healthcare.
Community Resources and Policies
Goal
To help patients access effective and
useful services and resources in the
surrounding community.
What characterizes a “prepared” practice team?
PreparedPractice Team
Practice team and interactions with patientsorganized to help patients reach clinical targets and self-management goals..
Delivery System DesignGoal
To organize practice staff, schedules
and other systems to assure that
all patients receive planned,
evidence-based care.
Decision Support
Goal
To assure that clinicians and other
staff have the training, scientific
information and system support to
routinely provide evidence-based
(adhere to guidelines) and patient-
centered care.
Clinical Information System
Goal
To assure that clinicians and other
staff have ready access to patient
information on individuals and
populations to help plan, deliver
and monitor care.
Health Care OrganizationGoal
To assure that practices within the
organization have the motivation,
support and resources needed to
redesign their care systems.
Challenges in Implementing the CCM
Practices spent considerable time searching for/developing tools
Some practices felt intimidated by taking on the whole model – asked for a sequence
Many changes were made in ways that were not sustainable logistically or financially (e.g., double data entry)
CCM elements implemented as “special events” rather than part of routine care
Many achieve process improvements but outcomes don’t change
Self-Management Supportand Community Resources
Ecological Model of Health Behavior
Community, Environment, Policy
Systems, Organizations, Businesses
Family, FriendsPeer Groups
Individual
Clinical Information Systems and Decision Support
A Model for Effective Chronic Illness Care
Self-ManagementSupport
DeliverySystemDesign
DecisionSupport
ClinicalInformationSystem
Health SystemOrganization of Health Care
CommunityResource and Policies
Informed,Activated Patient
Prepared,ProactivePractice team
Productive
Interaction
Functional and Clinical Outcomes
Clinical Information Systems
Provide reminders for providers and patients.
Identify relevant patient subpopulations for proactive care.
Facilitate individual patient care planning.
Share information with providers and patients.
Monitor performance of team and system.
Barriers to CIS use
Lack of perceived valueCompeting business and
productivity demandsLack of office flow expertiseLack of information supportLack of leadership support
What is the Issue?
Functionality!
Whatever you use should be able to deliver information that supports:
population planningclinical summaries at the visit individual care planningremindersperformance feedback
Necessary functions for chronic care
be organized by patient; not disease, but responsive to disease populations
contain data relevant to clinical practice
assist with internal and external performance reporting
guide clinical care first, measurement second!
Everyone, including senior leadership understands the clinical utility and supports the time involved in upkeep.
Data forms are clear, data entry role is assigned, data review time allotted.
Data entered and retrieved are clinically relevant, and used for patient care first, and measurement second.
Data can be shared with patient to improve understanding of treatment plan.
Keys to Success from Others That Have Implemented Registries
The Implications of Social Media
The Networked World
Investors
Customers
Prospects
Press/AnalystsPartners
Employees
Potential Employees
Influencers
MESSAGES
Competitors
No. Rank Country
Number of Facebook
users March 2009
Number of Facebook users 31st
March 2010
12 month growth %
4 8 Philippines 1,026,300 11,561,74
0 1027%
5 15 India 1,561,000 7,809,800 400%
6 19 Malaysia 1,197,560 5,552,660 364%
7 23Thailand
284,340
2,895,320
918%ศ�นย$เทคโนโลย2ส�รสนเทศและกั�รส��อส�รส�น�กัง�นปล�ด้กัระทรวงคมน�คม
Facebook usage statistics - March 2010 (with 12 month increase figures)
จ�นวนผ��ใชู� Facebook ท��วโลกั465,562,160 คน
จ�นวนผ��ใชู� Facebook ในประเทศไทย3,757,340 คน ค�ด้เป<น 0.81% ของท��วโลกัFemale
2,069,44055.8%
Male 1,636,040
44.2%
Thailand Male / Female
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Facebook usage statistics - March 2010
<= 1336,220 (1.8%)14 – 17271,980(13.1%)18 – 24778,400(37.6%)25 – 34714,840(34.5%)35 – 44189,680(9.2%)45 – 5454,820(2.6%)55 – 6413,660(0.7%)65+ 9,780
(0.5%)
Thailand Age Distribution
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Facebook usage statistics - March 2010
2 side to consider
18 file and OPD individual record
HCIS , JHCIS, HosXP, etc.
Report for claim
New media , Social network
Tele consultation
The Social Media Ecosystem Blogs Wikis Facebook , twitter Podcasts Videocasts / Vlogs Moblogs MMS Internet telephony
i.e. skype™
Tools that facilitate:
Communication Engagement Transparency Trust
Tools that are: Complementary to
traditional communication activities
Used by organizations who recognize the social characteristics of effective communication
What’s Social About Health Behavior?
Asymptomatic Screenings Lifestyle Modifications Cessation of Addictive Behaviors Medical Regimen Compliance Precaution Adoption
e-Health Tools and Functions Health
Information Behavior change Self-
management On-line
communities
Decision support
Disease management
Healthcare tools
Office of Disease Prevention and Health Promotion, DHHS. Expanding the Reach and Impact of Consumer e ‑Health Tools. 2006.
e-Health Tools: Behavior Changes
Improve dietary habits Increase physical activity levels Reduce heavy drinking Decrease disordered eating
behaviors Improve adherence to treatment
protocols Impact on health care utilization and
costs?Office of Disease Prevention and Health Promotion, DHHS. Expandingthe Reach and Impact of Consumer e ‑Health Tools. 2006.
Mobile Technologies for Change: m-Change and Obesity
The appropriate model for obesity and weight management is tailored information according to design principles suggested by Social Cognitive Theory and the Social Marketing Model.
The health behaviors to target are self-monitoring of diet and physical activity.
The devices are Web-enabled “smart” cellular telephones and wireless PDAs.
JT Tufano & BT Karras. Mobile eHealth Interventions for Obesity:A Timely Opportunity to Leverage Convergence Trends. Journalof Internet Medical Research 2005;7(5):e58).
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Decision Support
Embed evidence-based guidelines into daily clinical practice.
Integrate specialist expertise and primary care.
Use proven provider education methods.
Share guidelines and information with patients.
What is evidence-based medicine?
Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence.
The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.
McMaster University
Evidence-based practice
Customize guidelines to your setting Embed in practice: able to influence real
time decision-making Flow sheets with prompts Decision rules in EMR Share with patient Reminders in registry Standing orders
Have data to monitor care
Stepped Care
Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more)
First choice medication Either increase dose or add second
medication, and so on Includes referral guideline
Going beyond consultation: integrating specialist expertise
Shared care agreements Alternating primary-specialty visits Joint visits Roving expert teams On-call specialist Via nurse case manager
Effective educational methods
Interactive, sequential opportunities in small groups or individual training
Academic detailing Problem-based learning Modeling (joint visits)
Effective educational methods Build knowledge over time Include all clinic staff Involve changing practice, not just
acquiring knowledge
Evans et al, Pediatrics 1997;99:157
The Patient as Partner
Principles of CIS &DS
Other Choices for Patient Decision Support
PBGH Evaluation of Consumer Decision Support Tools June 2007
Ways to share guidelines with patients
Stoplight tools Expectations for care Wallet cards Web sites Workbooks
Informed,EmpoweredPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformationSystems
Self-Management Support
Health System
Resources and Policies
Community Health Care Organization
Chronic Care Model
Specifics of System Design
Workforce Development Up front training and Admin Support Professional development
Integration of Complementary Medicine
Micro system optimization
Micro System Optimization
Clinical Doctor, Nurse Case Manager Support groups Behavorist Pharmacist, Nutrition, H. Ed.
Demand* Complex health problem*Explosion of
knowledge and technology
*Health care reform*Expand the scope of
nursing
Supply *Shortage of health
care personnel, both
quantity and quality
*Malutilization especially
nurse
Unsafe both nurses and patients/clients
Paradox