Medical informatics is playing a significant role in a unique, newly-launched partnership between Durham-based Duke University and the Durham, NC, community. The goal of the partnership, known as Durham Health Innovations (DHI), is to improve the health of everyone living in Durham County by using medical informatics to identify interventions for community members whose needs aren't being met successfully by conventional methods.
"The informatics side of this project is deeply embedded," says Lloyd Michener, MD, chair of the department of community and family medicine at Duke. "The entire project requires a very robust backbone and system. This is an example of what you can do with really good information systems and analytic tools. You're basically doing real-time epidemiologic studies."
The data the partnership uses comes from Duke University's electronic medical records (EMR) system, which is a variation of the system developed by San Francisco-based McKesson. Duke has implemented the system in all of their office practices.
The university collects the data from the EMR and runs customized software on it that assigns geographic locations to the data, also known as geocoding. This process, which is HIPAA-compliant, allows them to look at areas of disease clustering in order to treat specific diseases or disorders prevalent in areas within the community.
"What we're doing that's unique is that, rather than looking at one disease or one subpopulation, we're doing this as a system experiment of how we can look at the health needs of our entire quarter-million people in Durham County and redesign how the system works to improve health," says Michener.
The plan includes 10 individual projects aimed at reducing death or disability from specific diseases or disorders prevalent in the community. The focus of the teams on particular health problems was determined by the community, not by Duke University.
The projects include: adolescent health, asthma, cancer, heart disease, diabetes, HIV and sexually transmitted diseases, maternal health, pain management, substance abuse, and seniors' health.
Each project team receives $100,000, which is distributed among team members to help them accomplish the work. Funding for the projects comes from grants from the National Institutes of Health (NIH) and Duke Medicine. One surprising aspect of the project is that they are not asking for new money to implement the projects. According to Michener, all the teams must reallocate existing money to achieve better outcomes.
A model project
Communities currently track their health status through periodic health department or Centers for Disease Control and Prevention (CDC) surveys. These surveys typically rely on data that comes from individual practices, hospitals, and emergency rooms, which aren't aggregated to look at disease patterns or clusters.
By the time the survey results are released, they may no longer contain timely and relevant information. By comparison, Michener says that Duke has primary data that they can aggregate to look at disease frequency pattern, and severity, so that they can intervene immediately.
According to DHI, the health of Durham county residents is comparable to that of most other residents in other parts of the state. However, North Carolina still ranks in the bottom 20% of all states in terms of life expectancy and functional status.
Michener believes that the project could become a model for the entire country. While health systems such as Kaiser and Intermountain have conducted similar projects, Michener says that they only benefit those seen by that particular health system.
"We're trying to do it for the whole county, including folks who aren't primarily our patients," he says. "We don't know of anyone else who's tried to do a scale experiment for a quarter of a million people. You have to be a big enough healthcare provider that you can affect the whole community."
Data helps project members impact ER rates
The data has already been used to implement successful changes in the community. Recently, the data revealed that there were children with asthma who were visiting the emergency room once or twice every couple of years. However, when they viewed the information in aggregate form, the numbers were much larger in Durham than in other communities.
When researchers ventured out into the community to find out why, they discovered that families were being given different asthma control by different healthcare providers, causing confusion. As a result, they were visiting the emergency room more often.
"We came to an agreement across all the practices, both Duke and non-Duke, on common management plans for asthma that we all use now," says Michener. "And ER rates dropped."
In another example, Michener says researchers looked at low-income senior citizens in Durham County and discovered that they, too, were visiting the emergency room far too frequently. He says the elderly residents were putting things off and weren't getting their medications refilled; therefore, they were getting sick and visiting the ER more often.
To remedy the situation, Duke put teaching assistants and nurse practitioners armed with laptops into elderly apartment buildings to conduct door-to-door health visits. The laptops allowed them to communicate with a patient's primary care provider.
According to Michener, inpatient utilization dropped 68% in one year as a result.
"Every one of these folks had doctors," says Michener. "But they couldn't get to the office."
The project did not save money, because the elderly patients started getting their medications refilled. But, Michener says that for the same amount of money, they now have people who are much healthier and not visiting the ER nearly as often.
A true partnership
According to Michener, the project is unique in that team members include members from the Duke health system and members of the Durham community. His theory is that they can be more successful together than they can be separately. Each team has one project manager, nurses, health administrators, primary care providers, researchers, health department members, social services representatives, and community members.
"We tried to include a spectrum of folks from our wonderfully diverse county," says Michener.
Both Duke and non-Duke physicians have embraced the project and some serve on the project teams as members. "There are very few doctors who don't want to see their patients get better care," says Michener. "And there are very few patients who don't think the system couldn't be improved."
"A difference can be made if you can get people behind it."
Sharon Elliott-Bynum, RN, PhD is a Durham resident and co-founder of CAARE, Inc., a community-based service organization. She volunteers with several groups to work to diminish health disparities in Durham. The organization offers education as well as prevention, screening, and treatment through their newly-opened free clinic, which is staffed by volunteer nurses and physicians.
"What I've done is created a community model that has everything under one roof," she says. "My goal was to enhance the services available and to fill in gaps—sort of become a safety net provider."
The DHI steering committee invited Elliott-Bynum to participate in their project based on her experience working on healthcare issues in the Durham community. She is contributing her talents to the cardiovascular, cancer, HIV, diabetes, and maternal and child teams.
The partnership will allow project team members from Duke and the community to work together to share best practices and learn from one another. For example, Elliott-Bynum says she looks forward to the research data that she will have access to during the project. Before, volunteers for non-profit organizations have relied on their instincts and what they have seen in the community in order to pinpoint their interventions.
"We see what poverty is and we've seen what it looks like," she says. "We've never been able to truly see it from a geo-spatial standpoint. If you have the ability to retrieve the data, you could paint a full picture. You have a broader sense of what it really looks like. Community partners have always done good work, they've always been very passionate, but they've never been able to put in a research based, evidence-based model so that people could really respect it."
At the same time, she says that Duke will also learn a great deal from the community members involved in the project. While their research teams have had access to money for their projects, she says that they have accomplished a great deal with little or no money.
"I think there is a seasonal change happening in Durham where the institutions realize that in order for them to perform effective research, they have to connect with the community," she says. "That's a totally new approach to doing things. I think the outcomes are going to be so much better because you've got the buy in at the front end."
According to Elliott-Bynum, when the research money comes and goes, the community must be able to sustain the interventions put in place. She also believes that institutions should disseminate outcomes from their research findings so that communities can use them to improve their health.
"I think it's going to be a paradigm shift," she says. "A difference can be made if you can get the people behind it. We'll make it work, especially if it's going to benefit our community as a whole."
Planning a new model to help Durham battle obesity
David Reese, MBA is the chief operating officer of the Inter-Faith Food Shuttle. He also vice-chairs the Partnership for a Healthy Durham and co-chairs their obesity and chronic illness committee.
Reese describes the partnership between Duke and the community as "very significant." He says Duke is looking to create a healthier community, not just a healthier demographic of patients that they want to serve. He believes this attitude will improve the relationship between Duke and the community as a whole.
He is a member of the DHI obesity team. His team is using a socio-ecological framework and focusing on the chronic care model. By helping Durham residents reduce obesity, Reese believes the team will be able to affect a lot of the chronic illnesses that are associated with it, particularly diabetes.
Although they are still in the planning phase of their interventions, Reese says that one of the goals that the team has is to standardize the messages that patients get from their providers.
"We realize that with lower income folks, you have transient populations," he says. "People will move from provider to provider. But, hopefully, if they are getting the same consistent messaging, it will eventually work well with the intervention and the loss of body mass as a whole."
Like Elliott-Bynum, Reese is impressed at the resources and data that Duke has made available to project team members. "I'm actually overwhelmed by the amount of information that's being made accessible," he says. "Never before has all of this information and all of these technical services been made available to come to a common goal."
The city and its residents have been the focus of many research studies in the past, so they are no strangers to the process, says Reese. The team is gathering information by conducting focus groups with the community to help them determine what barriers they face when it comes to obesity. Reese says they are going to be watchful that the project teams do not ask the same questions and duplicate efforts, which could result in research fatigue.
"With this model, we really want to engage the community in the process," he says. "Everyone gets told what they should do and if that was working, we would have conquered obesity as a whole."
The teams, which began meeting at the end of April, have to work together to determine what sort of changes they wanted to try to accomplish to improve health outcomes. They also have to determine what it is going to cost to make the changes. They have eight months to complete their design work and financial analysis before presenting their plans. Once the planning stage is complete, the teams will put their changes in place to evoke long-term changes in the community.
DHI Project Teams
The DHI includes 10 individual projects aimed at reducing death or disability from specific diseases or disorders prevalent in the community. The projects are as follows:
- Adolescent health
- Asthma
- Cancer
- Heart disease
- Diabetes
- HIV and sexually transmitted diseases
- Maternal health
- Pain management
- Substance abuse
- Seniors' health
Cynthia Johnson is the editor of Medicine On The 'Net, a monthly newsletter from HealthLeaders Media.