Information system support as a critical success factor for chronic disease management: Necessary but not sufficient

https://doi.org/10.1016/j.ijmedinf.2006.05.042Get rights and content

Abstract

Improvement of chronic disease management in primary care entails monitoring indicators of quality over time and across patients and practices. Informatics tools are needed, yet implementing them remains challenging.

Objective

To identify critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice.

Design

A prospective case study of positive deviants using key informant interviews, process observation, and document review.

Setting

A chronic disease management (CDM) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline-based flow sheet.

Participants

Thirty community-based physician participants using predominately paper records, plus a project management team including the physician lead, project manager, evaluator and support team.

Analysis

A critical success factor (CSF) analysis of necessary and sufficient pathways to the translation of knowledge into clinical practice.

Results

A web-based CDM ‘toolkit’ was found to be a direct CSF that allowed this group of physicians to improve their practice by tracking patient care processes using evidence-based clinical practice guideline-based flow sheets. Moreover, the information and communication technology ‘factor’ was sufficient for success only as part of a set of seven direct CSF components including: health delivery system enhancements, organizational partnerships, funding mechanisms, project management, practice models, and formal knowledge translation practices. Indirect factors that orchestrated success through the direct factor components were also identified. A central insight of this analysis is that a comprehensive quality improvement model was the CSF that drew this set of factors into a functional framework for successful knowledge translation.

Conclusions

In complex primary care settings environment where physicians have low adoption rates of electronic tools to support the care of patients with chronic conditions, successful implementation may require a set of interrelated system and technology factors.

  • What was known before the study

    • Known gaps in the care of patients with the chronic conditions of diabetes, congestive heart failure and depression highlight the need for improved practice and knowledge translation among primary care physicians.

    • Clinical leadership and adequate resources are critical to successful knowledge translation in clinical settings.

    • The Institute for Healthcare Improvement breakthrough series has been successfully applied in US primary care settings.

  • What the study has added to the body of knowledge

    • Information and communication technology was a key dimension of success in a comprehensive quality improvement framework for knowledge translation.

    • Health care delivery system reform, partnerships, project management, and practice models were also necessary.

    • Factors that indirectly contributed to knowledge translation through the success of the information system were: (1) listing and tracking patients, (2) allowing data sharing, (3) demonstrating performance improvement, (4) integration with workflow and (5) requiring minimal investment by physicians.

Introduction

Most primary care physicians in the Victoria, British Columbia, the city that first instituted a School of Health Information Science in Canada over 20 years ago, continue to provide clinical care to their chronic disease patients largely without the benefit of computerized support. In 2003, three developments in informatics matured and converged in a collaborative of 30 physicians who embraced the use of informatics for chronic disease management (CDM): (1) a secure and accessible web-based environment, (2) evidence-based decision support tools, and (3) quality improvement (QI) processes. The results were measurable improvements in their practice within a year: the proportion of diabetic patients with hemoglobin A1c blood levels under 8% (indicating good blood sugar control) rose from 62% to 88%; the proportion with lipids meeting target values increased to from 71% to 83%; and a triple index for diabetics management comprised of controlled blood glucose, blood pressure and cholesterol increased from 18.6% to 37.6%. This latter compares favorably to published rates of 7.3% (95% confidence interval, 2.8–11.9%) of adults with diabetes meeting triple index recommendations in the 1999–2000 US National Health and Nutrition Examination Survey (NHANES) [1].

This CDM collaborative won the 2004 Canadian Annual 3M Health Care Quality Team Award for results-oriented projects “that show evidence of sustainable improvements in programs and services achieved through quality teamwork” [2]. The developers of the Collaborative's web-based “CDM toolkit” won the Innovation and Excellence award at the Strategies for Public Sector Transformation Conference for 2004 [3]. Use of the CDM toolkit continues to diffuse throughout British Columbia.

Informatics researchers from the University of Victoria, School of Health Information Science conducted a critical success factor (CSF) analysis to understand how this achievement can be reproduced in other jurisdictions. The need for emulation is great. Research has shown that patients with chronic conditions receive only about 55% of the care recommended on the basis of the best available research evidence [4].

This is particularly problematic for diabetes because it has long been recognized that intensive treatment of diabetes decreases complications like blindness, amputation and kidney failure that are associated with heavy burden of illness and major care costs [5]. Also there is growing recognition of the burden of illness in diabetics related to cardiovascular disease [6]. This paper presents our findings of the determinants of implementation success.

Section snippets

Methods

Qualitative interview-based narratives, mapping and analysis of texts and observation of CDM collaborative meetings were used to understand how knowledge (evidence) was successfully translated into project policy and physician practice in CDM.

Results

Seven components of direct CSFs were identified following coding of 325 passages. These were: project management (21), information and communication technology (56), health delivery system (46), working partnerships (12), funding (48) and models (39), and a number of indirect factors or attributes of the direct CSFs that influence QI (51). The factors are not entirely mutually exclusive categories. How the components emerged as themes in the data is depicted in Fig. 1.

The quality improvement

Conclusion and implications

This study identified a framework of factors critical to the successful implementation of a technology-enabled primary care physician CDM collaboration. The strength and applicability of the case study analysis we report in this paper does not seek to establish impact. The physician collaborative had already demonstrated improved practice quantitatively against indicators obtained from evidence-based guidelines by goal setting and monitoring performance using decision support tools. In this

Acknowledgements

The Canadian Institute for Health Research funded University of Victoria researchers through their Knowledge Translation Fund. The Primary Health Care Transition Fund, the BC Ministry of Health and Vancouver Island Health Authority supported the CDM collaborative.

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