Transcript Slide 1

A Practical Approach to Improving
Quality
TEPR 2007
Donald T. Stewart, MD
[email protected]
Your Background?
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Physicians
Administrators
Nursing staff
Quality improvement facilitators
IT staff
Vendors
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My Background
• Family Practice, started solo from scratch in 1983
after residency
• Grew to 6 provider practice which was sold to
Swedish Hospital in 2003
• Now Medical Director of 7-provider clinic in 12clinic system
• First EMR 1997 on Newton Message Pad Migrated
to Practice Partner in 2001. Paperless since 2002
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My Background
• Participant in Practice Partner Research
Network since 2003
• Participant in Washington State Diabetes
Collaborative 2006-2007
• NCQA Recognized Diabetes Physician
• Going solo again in a Micropractice July 2007
focusing on primary care for patients with
diabetes and lipid disorders
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What do we need to do improve the
quality of chronic disease care?
• Most of us do just fine with the patients who
come in for a scheduled visit for their chronic
problems and follow-up when we tell them to.
• The problem is with the patients who do not
follow-up for scheduled care
• We need to educate them
• We need to keep track of them
• We need to get them back when they need it.
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What Tools do We Need?
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The Chronic Care Model
Workflow modifications
Changes in the practice culture
Registry capabilities
Patient self-management tools
Effective ways to communicate with patients
An Electronic Health Record
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The Chronic Care Model
• Also called the Scheduled Care Model
– Promoted and formulated by Ed Wagner, MD,
MPH of Group Health Cooperative
– Adopted by AAFP and ACP in their new practice
models
– Linked with Pediatric Medical Home model
– Increasingly used in Pay for Performance programs
– Adapted for prevention, behavior change
• http://www.improvingchroniccare.org/
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Components of the Chronic Care
Model
• Community, Health System, and Patient
• Health System Characteristics:
– Delivery system design
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Integrated team
Scheduled care visits with goals and expectations
Access
Communication with patients
– Self-Management Support
– Decision Support
– Clinical Information Systems
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Planned Care Model
Community
Health System
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Organization of Health Care
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
Health System – the Doctor’s Office
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Workflow modifications
Office culture changes
Registry capabilities
The EMR
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Workflow Modifications
Workflow Modifications
• Follow-up Visits
– Scheduled at the time of previous visits
– Totally stable patients at goal: Q 6 months
– Fairly stable patients at or close to goal: Q 3
months
– Patients not to goal: Q 4 – 8 weeks
– Patients given paper to carry back to the reception
desk for scheduling
– If unable to schedule then, tickler for reception to
call the patient at appropriate time to schedule
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Workflow Modifications
• The day before the visit
– MA reviews schedule
– Writes down plan for each patient
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Flu Shot
Pneumovax
Microalbumin/Creatinine
HgbA1c
Lipids, AST, ALT
BMP
– Need to call chronically late patients to remind them
to arrive on time
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Workflow Modifications
• Day of the visit
– Patient arrives 10 minutes early
– Front desk reminds them we need a urine
– MA rooms patient, gets UA, starts HgbA1c, Lipids
if appropriate, vitals
– Shoes off
– Comments on previous self-management goals,
may give summary sheet from last visit
– Doctor sees patient on time
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Workflow Modifications
• Structured Visit – 30 minutes
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Review meds, side effects
Home glucose results, BP
Complications, symptoms
Diet, exercise progress
Fears about the disease
Self management goals and progress
Today’s results, review with graph or chart
Exam
Plan for next visit
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Office Culture Changes
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Office Culture Changes
• Meetings focusing on the issues
– Educating all of the staff about the disease, so
they are aware of the importance
– Sending MAs to classes by CDEs
– Participate in chronic disease collaborative, with
staff participating, too
– Set specific goals, and post results in the
lunchroom
– Reward the staff when the goals are met with cash
bonuses, dinners out to celebrate
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Office Culture Changes
• Receptionist and schedulers very important
– Know who the diabetics are, flagged in charts and
schedules
– Consistent messages to the patients from all staff
– Review of the “outlier” patients through registry
or EMR reporting functions
– Structured contact with them to schedule visit
• Phone calls more effective than letters, so do both
• Registered letters when phone calls do not work
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Office Culture Changes
• Medical Assistants and Nursing Staff
– Reviewing the schedule and plans the day before
– Standing orders for pneumovax, flu shots, all labs
deemed important
– Getting these done as needed with each visit
– Providing the patients with reminders, handouts,
report cards, making sure they schedule their
follow-up visits
– Helping pull in derelict patients during refill
requests and phone triage
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Office Culture Changes
• Administration
– Scheduling meetings, classes, education sessions
– Tracking goals and posting progress
– Making sure the schedule will work and there is
adequate staff coverage to do the job
– Calling patients and getting recalls out
– Providing the tools necessary to make chronic
disease management work
– Financial and other incentives
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Office Culture Changes
• Providers
– “Buying in” to the chronic disease model
– Believing that they do have responsibility for their
patient’s success and compliance
– Relinquishing control by giving standing orders
– Accepting and agreeing on treatment goals
– Accepting all of the staff as part of the team
– Rewarding staff for success
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Registries and Registry
Capabilities
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Registry Capabilities
• Database of patients with the problems you
are interested in following
• Useful for identifying the patients you never
see because they fail to come in
• Tracks specific outcomes measures
• Reports that give you feedback on which of
your goals you need to work harder to meet
• A way to compare performance of physicians
and practices to each other
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Registry Examples
• CDEMS: Chronic Disease Electronic
Management System
http://www.cdems.com/
• Microsoft Access database, lots of reporting
functions, very well supported, and free
• Can be adapted for any chronic disease
• MAs can print flow sheets for documenting
each visit, and give copies to the patients
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California Healthcare Foundation
• For an excellent review of 16 registry products
by the California HealthCare Foundation, try
this:
http://www.chcf.org/documents/chronicdise
ase/ChronicDiseaseRegistryReview.pdf
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The Electronic Health Record
Paper vs EHR
Paper Record
• Not enough information
• Information not accessible
• Illegible
• Not safe
• Hard to keep up
• Hard to identify trends
• Sticky Notes
• Reporting requires
additional tools
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EHR
• Too much information
• Available 24/7
• Legible
• Built-in reminders, drug
interaction warnings
• Built-in trending
• Messaging
• More and more with
integrated reporting
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Registries vs EHRs
Advantages
Registries
• Designed for population
management
• Target patients with chronic
conditions
• Built-in guidelines &
protocols
• Risk Stratification tools
• Low cost
• Rapid implementation
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EHRs
• Designed for patient care
• Opportunistic care at every
patient visit
• Documentation tools
• Templates & Flowsheets
• Communication tools
• Clinical information support
• High cost
• Slow implementation
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Registries vs EHRs
Disadvantages
Registries
• Data limited to pre-defined
conditions
• Limited recording of patient
interactions
• Limited flexibility
• Disease and population
focus, not patient-focused
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EHRs
• Tend to deal with individual
patient interactions
• Less advanced chronic
disease management
functionaliy
• Less advanced population
management functionality
• Expensive
• Difficult to maintain
• Long implementation time
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EHR Tools - general
• No time wasted looking for charts or lab
reports or in doing double data entry
• You should chose an EHR with built-in registry
capabilities, or at least ease of generating the
data you want
• The EHR can remind you at the time of care
what services are overdue for the patient
whose own agenda was an urgent care visit.
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EHR Tools – at the time of visit
• Remind the provider of what needs to be
done
• Reminding the provider when not to goal
• Formulary compliance
• Presenting data to patients
• Patient education materials
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EHR Tools – without a visit
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Scheduling patients
Documenting phone contacts and Rx refills
Order entry and tracking
Lab letters, patient reminders
Messaging and workflow
Information access when on call
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EHR Financial Incentives
• More reimbursement through better
documentation
• Greatly increased operating efficiency of the
office
• Documenting quality for better patient
acceptance
• Pay for Performance
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EHR Basic Issues
• Templates vs free-form data entry
– Templates for data you want to analyze or
remember
– Free-form to personalize the note.
• Voice recognition vs typing
– Learn to type (though voice keeps getting better)
• Pen based systems
– Slick, but handwriting recognition is much slower
than typing
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Diabetic Data You Care About
(that you want to automagically go
into your visit note)
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Diagnosis Date
Diabetes Educator
Endocrinologist
Frequency of glucose
monitoring
• Frequency of blood
pressure testing
• Frequency of exercise
• Diet
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• Symptom Status
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Painful Neuropathy
Numbness
Hypoglycemic episodes
Sexual function
• Patient Concerns
– Amputation
– Blindness
– Renal failure
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Patient-Centered Data
• Fears about their disease process (what
motivates them)
• Exercise behaviors (type and frequency)
• Smoking Status
• Diet behaviors
• Self-management goals (specific goals,
roadblocks, timeframe, confidence they will
succeed)
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Disease-Aware Templates
• Ideally, you want the EHR to remind the
providers, reception staff, and medical
assistants when a patient with a targeted
problem arrives
• Integrated Systems do this best
• The next two slides give examples for MA
check-in templates for patients with diabetes
and without diabetes
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.D: 04/04/06 : 12:19am
.T: «*»Visit & Vitals
MA: «req» «&Cindi» «&Anita» «&Barbara» «*Corey»
«&Monika» «&Virginia» «*Marilyn»
Type of Visit: «*OV» «*BP» «*UA» «*AllerShot»
«*Immu» «*FluShot» «*OtherShot» «*EKG» «*Weight»
Treating provider today: «REQ» «*DTS» «*CML» «*LLC»
«*GHP» «*DYP» «*CCL» «*SPF»
.V1: Syst. BP «*» : Diast. BP «*» : P. «*» :
.V2: T «*» : Ht. «*» : Wt. «*» :
.V3: OFC «*» : Resp. «*» :
.L: Visual Acuity OD: «del» «*WithCorr» «*NoCorr»
.L: Visual Acuity OS: «del» «*WithCorr» «*NoCorr»
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MA: «req» «&Cindi» «&Anita» «&Barbara» «*Corey» «&Monika» «&Virginia» «*Marilyn»
DiabetesDxDate: 12/2001 on 07/16/2002
«***************POSSIBLE DIABETIC PATIENT***************...»
«del»Influenza: X on 09/29/2005
«del»To Update Influenza, Click the following: «del» «*LastFlu»
«del»Pneumovax: 06/03/02 on 06/03/2002
«del»To Update Pneumovax, Click the following: «del» «LastPneumo»
LastEyeExam: 8/04 on 10/21/2004
.L: LastEyeExam: «del»
.L: *Ophthalmologist: «del»
.L: *Optometrist: «del»
«del»HEMOGLOBIN A1C: 6.2 on 03/06/2006
«del»GLUCOSE, FASTING: 111 on 03/06/2006
«del»CHOLESTEROL: 123 on 03/06/2006
«del»HDL CHOLESTEROL: 47 on 03/06/2006
«del»LDL CHOLESTEROL: 68 on 03/06/2006
«del»TRIGLYCERIDES: 123 on 03/06/2006
«del»ALT: 34 on 09/26/2003
«del»MICROALBUMIN, UR: 20 on 08/03/2001
«del» «*****No MICROALBUMIN/CREATININE Recorded -- Please get one per standing orders*****...»
«**** Please Have Patient Remove Shoes*****...»
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Custom Data Entry Forms
• EMRs can be modified by adding custom
forms to record structured data
• Examples might include a PHQ-9 asthma
symptom severity score, monofilament exam
• With custom forms, you can store the data
without cluttering up the progress note
• Custom forms can allow patients to enter
some of the data themselves, in a format that
can be stored and used for reporting or
presented in a useful format such as in flow
sheets
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Order Sets
• With disease-aware templates, providers will be
presented appropriate sets of orders appropriate
to the patient care
– Blood test orders
– Referrals
– Immunizations
• Decision support
– Specific treatments: ACEI’s if Microalbumin/Creatinine
elevated
– Complex changing therapy: Insulin
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Flowsheets
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Health Maintenance Reminders
• Alerts for tests or interventions that need to
be done at intervals
– Screening tests: pap smears, mammograms
– Immunizations that are due
– Disease-Specific tests: HgbA1c, echocardiogram
• Alerts visible when chart is opened
• List of HM reminders set to be delivered
– to in-basket of provider
– Delegated support staff
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Reporting
• Reports built-in to the EHR – disease reporting
growing by leaps and bounds.
• Reporting has several goals
– Identify outliers
– Identify performance deficiencies
– Motivate staff and providers
• Reports shared as part of a network
– Comparing results to others locally
– Comparing on a national level
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Report Types
Population Reports
• Compare performance
against guidelines
• Identify deficiencies in care
• Use to set goals and
workflow changes, bonuses
for staff
• Start with process reporting
• Move to results reporting
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Patient-Level Reports
• Identify individual outliers
• Target and risk-stratify
patients
• Use for recalls and targeted
education and other
interventions
• Keep patients from “slipping
through the cracks” in the
system
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Process Measures
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Outcomes Measures
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Process Measures
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Outcomes Measures
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Practice Partner Research Network
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Quality Research Network coordinated by Medical
University of South Carolina
Agency for Healthcare Research and Quality funding
– Future funding guaranteed by PP
10+ years experience, over 25 peer-reviewed
articles
960,000 patients --- 7,700,000 patient contacts
Quality Reports available to all Practice Partner
users
How PPRNet Works
• See patients using Practice Partner
• Enter your data any way you want to
• Send in a data extract every quarter
– (5 minutes of operator time to do this)
• Receive Quality Report and Patient Level
Reports a month later
• Meet with your group and decide what to
change
Summary
• To Achieve Success at Chronic Disease
Management, you need:
– Chronic Care Model
– Workflow changes
– Office culture changes
– Registry capabilities
– EHR helpful, but not necessary
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Questions?
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