The Kentucky Diabetes and ObesityCollaborative (KDOC)

Kevin Pearce, MD, MPHUK Department of Family and Community Medicine

Jeff Talbert, PhDUK Department of Pharmacy Practice and Science

Mark Dignan, PhD, MPHUK Department of Internal Medicine

David Bolt, MA Kentucky Primary Care Association

F. Douglas Scutchfield, MDUK College of Public Health

Supported by NIH grants:NIDDK # 1RC4DK809866NCATS # UL1TR000117

The Kentucky Diabetes and Obesity

Collaborative (KDOC) KDOC partnering organizations • Kentucky Primary Care Association (KPCA)

• Individual FQHCs• Kentucky Medicaid• University of Kentucky

• Academic Health Center • Center for Clinical and Translational Science• Center for Public Health Systems and Services

Research

Overarching goal: Activate new collaborations to improve

quality and create opportunities for research

PayersQI

Cost-Effectiveness

KPCAQI

Support IPAGain-sharing

ACA Expansion

UKDevelop

Community Based

Translational Research Network

The Kentucky Diabetes and Obesity

Collaborative (KDOC) Vision: Develop a healthcare data repository that will be used to improve the health of Kentuckians via QI activities and research.

The KDOC data repository will bring together up-to-date clinical data from multiple primary care safety-net providers, plus Medicaid claims data, all linked at patient level. Secure web-based portals and special software will facilitate use while maintaining appropriate levels of privacy and security.

The Kentucky Diabetes and Obesity

Collaborative (KDOC) Project Rationale• High prevalence of obesity and diabetes in a

large rural and medically-underserved population; much of which relies on “safety-net” providers, such as FQHCs

• Utility of being able to monitor and use clinical and claims data linked at patient level, and across healthcare facilities

• Built-in utility for more broadly improving healthcare

The Kentucky Diabetes and Obesity

Collaborative (KDOC) Project goals • Develop a secure data repository

• clinical data from rural PCPs• Linked Medicaid claims data

• Develop secure, user-friendly data interfaces for providers and researchers

• Assess related training and support needs, and provide the training/ support to KDOC users

• Facilitate research and healthcare QI collaborations

The Kentucky Diabetes and Obesity

Collaborative (KDOC) Project goals (cont’d)

Address gaps in generalizable knowledge about:• The effective use of HIT for chronic care

coordination and related research in rural settings

• Systems-oriented collaborative QI strategies for improving the management of chronic conditions in primary care

• Effectively connecting AHC-based researchers and rural health disparity populations

Participating Federally-Qualified Community Health

Centers Eight Community Health Centers (FQHCs) serving 39 mostly rural Kentucky counties; diabetes prevalence as high as 17% and obesity prevalence as high as 51% 2 to 15 clinic sites / FQHC with 6 to 31 providers / FQHC19,900 to 143,000 annual patient visits per FQHCApprox 124,000 patients served by the 8 FQHCs, total Five different EMR brands across the 8 FQHCs; time since EMR implementation: from < 1 year to several years

KDOC 3-Yr Project Approach1. Establish leadership, steering and advisory

groups2. Simultaneously pursue interpersonal and

technical aspects of KDOC developmentInterpersonal

build KDOC-specific collaborative relationships (BAAs, MOUs)establish stakeholder priorities for HIT tools and functionsunderstand stakeholder opportunities and barriers related to collaboration around QI and research

TechnicalUnderstand technical aspects of data storage and sharing capabilities of each EMR systemestablish HIPAA compliant methods for developing and using the KDOC Data Warehouseexplore utility of KHIE for KDOCbuild or buy user-friendly data interfaces for QI and research

KDOC Project Approach (cont’d)3. Simultaneously: (a) Obtain IRB approval for data transmission, storage, and general use (b) design and pilot a DM QI project involving the FQHCs 4. Populate KDOC data repository with clinical data from each FQHC, and with Medicaid claims data for matching time periods; data de-identified but coded for linkage at patient level 5. Simultaneously: (a) Perform pilot clinical QI project(b) facilitate use of KDOC infrastructure for research Throughout: plan for sustainability of infrastructure

KDOC Focus Groups

Conducted at 6 FQHC offices in rural Kentucky

Included providers, office staff, IT representatives

45-60 minutes

Tape recorded, transcript analysis

Focus Group Discussion Topics

Perceptions about obesity and diabetes rates in rural KentuckyPerceived role of research in prevention and control of diabetes and obesity…probing:

Experience with research Barriers and facilitators of research with rural FQHCs What is needed to increase participation in research

Communication and collaboration between providers and researchersImplementation of Evidence Based Practices in DM mgmt

Focus Group Findings• There is interest in participating in and promoting research

in FQHCs (and in partnering with UK)

• Research is most likely to be successful when initiated by researchers

• Participating with KDOC can help FQHCs with capturing clinical data, developing reporting, and perhaps QI

• Use of EHR, or similar mechanism, for data collection is preferred – something that can be integrated into the flow of the practice

• FQHCs not hesitant to share data as long as patient privacy protections are in place

More Focus Group Findings

• Mild concern that KDOC will not be able to deliver information needed for HEDIS reporting – concern about responsiveness of KDOC to changes in guidelines

• FQHC experience with EHRs and government has been mixed• Ability to better manage practice is a plus• Concern about monitoring by those outside the practice is a concern

• Employee time for research is a barrier, need outside resources and staffing

• IT assistance is needed for most projects• Research partnerships are built on trust between patients

and clinics – and then researchers

Technical Strategy

KDOC vision: build QI tools that also serve as a research platform

FQHCs – de-identified data beyond own site—need for regional benchmark and peer comparisonUK-infrastructure for rural translational research network

8 initial FQHCs: using 5 EMR vendorsKentucky Medicaid as a project partner

Technical Process

Diverse site technical infrastructure

Very vendor dependent (new EMR users)Limited site IT staff (contractors, part time, busy with day job)Limited site database capacity (required flexible after hours connectivity, multiple small reports)

Process: 1)Special KDOC data extracts 2)Core database access 3)Core EMR reporting tool

Technical Workflow

Complete regulatory documents

Select data extraction process

Load into ETL staging area

ETL process to standardize data models

Load into KDOC data repository-enable Tableau reporting tools

Regulatory: QI/ operations use

All sites have MOU and BAA with UKSites limited access to their own data, with regional and national benchmarks for most measures Research use requires additional limits and protections

Regulatory: using data for research

BAA and MOU required for each siteIRB #10-0493 The Kentucky Diabetes and Obesity Collaborative (KDOC)Uses UK EDT third party “honest broker”

Researcher access to de-identified data IRB #13-0275-F6A, Kentucky Diabetes and Obesity Collaborative (KDOC)All users sign DUA, Complete HIPAA trainingData Use Advisory Committee reviews research protocols

DUAC: Data Use Advisory Committee

Address concerns over use of dataFunction to advise on research data used from the collaborationComposed of providers and administrators representing sitesAll research protocols will be reviewed by committee

KDOC Data Repository: Claims Data Progress and

Challenges

Medicaid MCOs established during first project yearNow working with Ky Medicaid QA/QI Department to goal of having claims data linked to clinical data in repository with proper security

Reporting Tools for QI

Intent: develop custom reporting toolsGo beyond current reporting platforms (greater flexibility than ‘canned’ reports)Adopted Tableau analytic platformAllows dashboards that are dynamic and interactive---allows visualization of data to generate new questions

Diabetes Care Monitoring

Tableau reporting models

Hypertension Care Monitoring

Conclusions so far

Interfacing with EMRs for data transfer into a shared repository cannot yet be standardized. EMR vendor characteristics and practice-based concerns must be addressed one-by-one Expert technical assistance is required for practices to share clinical data for QI or research EMR Vendors should be at the table from the beginning

Conclusions so far

Benefits for each collaborating practice, payer and research stakeholder cannot all be anticipated; they will fluctuate, but staying focused on benefits and value to each stakeholder is essential

e.g. Initial QI focus on UDS reporting, but later expanded to HEDIS measures and MCO gain sharing

Research and QI uses require different restrictions and protections…..development of shared trust among stakeholders across organizations is critical

And the biggest lessons…

Building a shared healthcare data repository for multiple stakeholders:

is a very complex undertaking that takes much longer than you imagine it willhas reward potentials that will grow and evolve takes you outside your comfort zone, links you with fascinating new colleagues and opens up new vistas

Next steps

Expand into a much larger co-op that stakeholders can use for

QA/QIQuality indicator capture and reporting Gainsharing with payersResearch

Questions?