When Durham-based Duke University and the Durham, NC, community launched Durham Health Innovations (DHI) in April 2009, they knew they were embarking on a groundbreaking project that would use medical informatics to identify chronic disease interventions and improve the health of patients. But at some point during the recently completed planning stages of the project, team members realized that they had stopped talking about patients—and started talking about communities.
"We realized that we were doing a whole lot of work on individuals," says Lloyd Michener, MD, chair of the Department of Community and Family Medicine at Duke. "Until this project, we hadn't clearly seen how individuals were part of the same networks, the same communities, and the same neighborhoods. In many cases, it makes sense to do things at the community and neighborhood level rather than one at a time at an expensive doctor's office."
The project uses data from Duke's electronic medical records (EMR) system. The university runs customized software that assigns geographic locations to the data, also known as geocoding. This HIPAA-compliant process lets team members look at areas of disease clustering.
The technology allows DHI to track progress and create interventions to prevent health problems from worsening in real time, says Gayle Harris, public health director in Durham County and member of the DHI oversight committee. The disease clustering maps are "amazing," says Harris, adding that they helped DHI identify disease hot spots at the neighborhood level.
"We shared the data with community members so they could see the patterns of illnesses that were affecting the community and the burden that imposed and talk about the interventions they would like to implement," says Michener. "It helped the communities galvanize and come together to find solutions."
Ten disease-based project teams, composed of diverse members from the Duke health system and the Durham community, used the data to develop plans to reduce death or disability from specific diseases and improve overall health outcomes.
"This is actually fairly exciting," says Michener. "With all the talk about unhappy doctors and patients and healthcare not working, this feels like people starting to take control of their own destiny and saying we can do better."
DHI project teams are now in the process of implementing their plans to evoke long-term change in the community. This month, Medicine on the 'Net® took the opportunity to follow up with them on the progress that they've made this past year.
It takes a village to improve health outcomes Michener was impressed by the deep level of interest that the project created in the tight-knit Durham community.
The project involved nearly 1,000 participants from Duke, the community, and 90 agencies who volunteered to work together to develop a better way of providing healthcare.
"This really brought the community together," Michener says. Team members involved in the project discovered that there were groups in the community that were working on similar issues, but that they weren't aware of one another's existence. "I couldn't count how many groups were working on obesity in the Durham community," he says. "The project let people connect and coalesce."
One of the teams has started working with a free clinic in the community to provide mammograms and cancer screenings using grant funding, says Harris. This opportunity came about because the project united people who wouldn't normally work with one another, she says. It helped them tap into current resources to put something in place that had been missing.
There was initial friction within the project teams from time to time as team members would attempt to determine who should be leading a particular effort, says Michener. Ultimately, however, everyone realized that the project was for the Durham community and not for one particular research or community group, he says.
"When the teams started working together, they realized they were more similar than they were different," Michener says. Finding and identifying the "enormous strengths" in the community allowed Duke project team members to support the community rather than impose their academic views upon it, he explains.
"Duke faculty members have learned just how talented and strong community members can be and what good partners they can make," Michener says.
Project team members have garnered a new understanding of their community and have come away from the project feeling energized and ready to set their changes in motion.
"We've made a point of saying that health is everyone's business and it's going to take all of us," says Harris. "With that ongoing message, people will see that they have a part to play."
Targeting obesity—one child at a time
The obesity committee decided to tackle obesity in the Durham school system. The team believes that this will also allow them to affect change in parents, teachers, and other members of the community. They selected a target school as part of their first-year effort, and it has been cooperating with their efforts.
"The school system was the lowest-hanging fruit in terms of the obesity project," says David Reese, MBA, chief operating officer of the Inter-Faith Food Shuttle and vice chair of the Partnership for a Healthy Durham, where he co-chairs its obesity and chronic illness committee.
"It was a demographic in which we had the ability to affect the greatest change." Duke's EMR system did not store data on weight checks, and some of the children were not in the Duke system. As a result, the team needed to visit the school to gather the vital data that were missing. They collected the heights and weights of all the students at the target school to identify overweight children.
They are currently in the process of implementing a nutrition-based cooking class called Operation Frontline. The school is also applying for a USDA grant that could provide healthy fruit and vegetables to the school.
Reese says the team will move cautiously and at a sustainable pace during the first year. He is optimistic about the project and believes it will yield "tremendous results." Without the project, he says efforts to tackle this obesity in the community would continue to be fragmented.
Creating a community health system
One unexpected outcome from the project was the community's support of having their healthcare data shared across providers. "They were actually comfortable with data being shared and aggregated so we could look at how problems affected their neighborhoods," says Michener.
In one example of data sharing, project team members discussed the benefits of creating a common, patient-centered medication list so they didn't have to reiterate their list of medications to every healthcare worker they saw.
Although members of the community support data sharing, they don't want a specific EMR to tie them down, especially one owned by Duke. Likewise, Duke doesn't want the responsibility that comes with owning large amounts of patient data.
Duke has already determined that it currently stores too much information and is trying to limit it to 20 to 50 data points. As a result of project team discussions, DHI team members no longer believe they need a single electronic medical record system for Durham county. Instead, they are now discussing how to create a common health record that allows them to share and aggregate data in their community.
"That's a major conceptual shifting," says Michener. If DHI can develop a common health record, he says annoyances such as medication lists will become a thing of the past. Such a health record could update and share medication lists across multiple providers.
"We're actually looking at a wireless community in which health related data is shared—with permission—freely across the health system," says Michener. "It's a rethinking of healthcare. Chronic disease is a major problem in healthcare. You can't just deal with this in the hospital and medical setting. You have to include the churches, schools, the health department, and the workplaces in the environment."
In addition to the Duke data, the project teams determined that they want to collect information from non– health system sites such as workplaces and schools (with permission) and upload the data to a single database.
"There's still a lot of work to be done, but the whole notion of having a plan that the community embraces is just such a good thing," Harris says.
Implementation phase begins
In the past, Duke used its EMR data to implement successful changes in the community, such as developing common management plans for childhood asthma that immediately lowered emergency room visits.
Some of the project team interventions will move just as quickly, whereas others will happen over time. For example, the cardiovascular disease interventions will be in place in a matter of months, due in part to the strong cardiovascular department at Duke.
"On the other hand, obesity is probably the most difficult area to intervene on," says Michener. "I think we'll see the schools, the health department, and the county moving fairly aggressively to see what they can do about childhood obesity. The outcomes of that may take longer to measure."
According to Reese, the interventions the DHI team members implement to reduce obesity will likely set off a chain reaction, since obesity plays a role in so many chronic illnesses, particularly diabetes.
Project expansion
Each of the 10 project teams received $100,000 to help them accomplish their work. Funding came from grants from the National Institutes of Health and Duke Medicine. A key feature of the project is that they are not asking for new money to implement the changes; however, several of the teams have collected enough data to seek additional funding.
According to Michener, the project is about taking the money that the United States spends on healthcare and reallocating it so that it's more effectively used to prevent diseases. The recent passage of healthcare reform and the possibility of grant funding may lend some support to the DHI project.
Michener states that the health reform legislation sets aside funds for projects like DHI's.
He believes the project has the potential to become a role model for the entire country. DHI is in the process of sharing its project's best practices at conferences and through published papers.
"If all this does is make Durham healthier, we'll be happy; but that's not the point," says Michener. "The real point is to figure out how to make healthcare better. Over the next year or two, we'll be coming up with outcomes to tell whether our great ideas actually do make a difference. We think they will, but we have to prove it."
Cynthia Johnson is the editor of Medicine On The 'Net, a monthly newsletter from HealthLeaders Media.