Transcript The Use of Tracking Codes to Monitor Smoking Cessation

Technological Innovations to Improve
Tobacco Cessation
In Health Systems
Charles J. Bentz MD
Medical Director: Tobacco Cessation and Prevention
Providence Health System: Oregon
Providence Health System: Oregon
Employees:
Active Medical Staff:
Providence Health Plan (HMO):
Providence Preferred (PPO):
Licensed Beds (acute & long-term):
Admissions:
Births:
Outpatient visits:
11,954
1,967
321,621
362,979
1,474
59,188
8,965
2,054,612
Providence Health System Task Force on
Tobacco Cessation and Prevention
•
•
•
•
•
•
•
•
•
Physician Leader
•
Access Services
•
Respiratory Care
•
Health Services Integration •
Long Term Care
•
Human Resources
•
Behavioral Health
•
Employer Health
•
Prov-RN
•
Health Education
Research Analyst
Home Care
Quality Management
Women & Children’s Program
Diabetes Disease Management
Pharmacy
C.O.R.E
Community Health Worker
SMOKING CESSATION AND PREVENTION: 2002
Community
•TOFCO
•Oregon Quit Line
•Legislation
Hospital-Based
•Inpatient Program
•Behavioral Health/CD
Health System
•AAHP Awards
•Funded Research
•NCQA Accreditation
Target Groups
•Women & Children
•HRA, High Risk
•Disease Management
•PHS employees
•Web-Based
Cessation
(who wants to quit)
Providers
•5 A’s Training/Education
•Reimbursement
•Physician Leadership
•Group Classes
•Free Medications
•Telephone Support
•Self-Help Materials
•Prov-RN
SMOKER
Clinics
Evaluation
•C.O.R.E.
•Programs
•CQI
•5 A’s Training
•EMR Resources
•Resources: Primary Care,
Specialties, Pediatrics, OB/GYN
Smoking Prevalence in PHP vs. Oregon
24%
23%
22%
21%
20%
19%
18%
17%
16%
15%
'88
'89
'90
'91
'92
'93
State of Oregon (BRFS)
'94
'95
'96
'97
'98
'99 2000
Providence Health Plan: Oregon
HEDIS Tracking Code Pilot Project
• Develop codes to track prevention and disease management
• Implement Tracking Codes in Two Offices
– Paper Chart Based office
• Paper “CPT-like” billing codes for tobacco cessation
– Smoker: Current, Recent Quit, Remote Quit, Never, Advice to quit
– Electronic Medical Record (EMR) Based office:
• Same measurements as in paper-clinic
– Observation Headings in EMR database and encounter forms
• CQI process evaluation of implementation
• External Validation of TR Codes: Chart Review
Immunizations
PaperBased
Tracking
Codes
TR700
TR701
TR702
TR703
TR704
TR705
TR706
TR707
TR708
TR709
TR710
TR732
DtaP (DTP ACELL)
DTP
DT
Tetanus
Mumps
Measles
Rubella
MMR
Measles & Rubella
Rubella & Mumps
MMRV
Pneumococcal
TR711
TR712
TR713
TR716
TR718
TR019
TR720
TR724
TR732
TR737
TR724
TR021
DTP w/Polio
OPV
Polio (inj)
Varicella
Tetanus & DT (adult)
Diphtheria
DTP/HIB
Influenza
Pneumococcal
HIB
Influenza
Prior Hx Varicella
Diabetic Indicators
Hemoglobin A1c Level
TR800
TR801
TR220
TR221
TR203
TR202
TR201
TR200
Dilated retinal exam
Foot exam
Negative both micro & macroalbuminuria
Positive either micro & macroalbuminuria
> 9.0
>8<9.0
>7<8.0
<7.0
Smoking Indicators
Counseling
TR001 Smoker
TR002 Non-smoker/remote quitter (>6 months)
TR003 Recent quitter (<6 months)
TR100 Smoking cessation
TR101 Substance abuse
TR102 Sexually transmitted disease
Disease management/prevention
LDL Cholesterol Level
TR600
TR601
TR602
TR603
TR301
TR232
TR231
TR230
TR229
Cholesterol and lipid drug management
Beta Blocker after MI
Aspirin use
ACE Inhibitor Use
Lead Screening Questionnaire
Women’s health
TR520
TR521
TR010
TR011
TR500
TR510
Mammography
PAP Smear
Prior total hysterectomy
Bilateral mastectomy
Prenatal visit
Postnatal visit
>160
>130<160
>100<130
<100
Paper Chart Environment: Flow of preventive care data
Financial Incentive (quality bonus)
(Tracking Codes)
Preventive care
(Medical Office)
Office billing
dept
(Feedback on
preventive care)
Claims
processing
(Health Plan)
Electronic Medical Record (EMR) Environment:
Flow of preventive care data
HEDIS/Quality Bonus incentive
Preventive Care
(Medical office)
EMR
Fee ticket
(billing service)
(Direct reporting to Health Plan)
(Feedback on
preventive care)
Claims
processing
(Health Plan)
Percent of Patients with Documentation about
Tobacco Use in the Paper-Based and EMR Clinics
Percent of Patients with Documentation
100%
90%
88%
80%
79%
80%
70%
60%
50%
45%
42%
42%
Jul-99
Aug-99
40%
30%
20%
10%
0%
Jun-99
Paper Clinic
EMR Clinic
Summary: Paper-Based Record
•
•
•
•
•
•
Paper Tracking Codes CAN WORK
Data loss was an issue
MCO delay (feedback vs. reporting)
Physician memory: Double documentation
Time intensive, wide practice variation
Single Health Plan Only
Summary: Electronic Medical Record
•
•
•
•
•
•
Much easier data collection
Measurement built right into practice
Entire clinic population vs. one health plan
50% provider turnover during study period
Issues of data ownership (private practice)
Return on investment (ROI) of EMR
Using Logician™ (EMR)
Using Logician™ (EMR)
Paper Quit
Line
Fax Form
Electronic Quit Line Fax Form
Providence Health System
Inpatient Smoking Cessation
ACCESS SERVICES
Systematic Identification of Current Smokers
RESPIRATORY CARE
Daily Census of Inpatient Smokers
INTERVENTION
Assessment by Trained Therapist
"Do you need help while in Hospital?"
"Are you interested in remaining Smoke-Free?"
Referral
Survival Kit
Pharmacotherapy
Notification of PCP
Quit Line
Classes
Resources
Distraction Aids
Pharmacist-Based
Guideline
Personal Letter
Resources
Systematic vs. Non-Systematic:
PHS Inpatient Cessation Program
10000
8000
6000
4000
2000
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
Face to Face Interventions with Hospitalized Smokers
Data: HBOC
Inpatient Program Database
Percent of Inpatient Admissions who have Tobacco
Status Ascertainment: PSA Hospitals
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
Jun- Jul-00 Aug- Sep00
00
00
PMH
Oct- Nov- Dec00
00
00
Jan01
Feb- Mar- Apr- May- Jun- Jul-01 Aug01
01
01
01
01
01
PPMC
PSVMC
“You can’t improve…
what you can’t measure”
•
•
•
•
•
•
•
•
Seek usefulness (not perfection) in measurement
Balance process and outcome measures
Keep the measurement simple
Use qualitative and quantitative data
Operational definitions of the measures
Measure small, representative samples
Build the measurement into daily work
Develop a measurement team Nelson EC, Annals Int Med. 1998, 128:460-466