Transcript Improving Quality Improvement with an EHR: Working Smarter

Improving Quality Improvement
with an EHR
Working Smarter, not Harder to
Provide Better Care
TEPR+ 2009
Donald T. Stewart, MD FAAFP
[email protected]
Your Background?
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Physicians
NP or PA providers
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 in a semi-rural Seattle suburb
• Grew to 6 provider practice which was sold to
Swedish Hospital in 2003
• Medical Director of 7-provider clinic in 12-clinic
system 2003 - 2007
• First EMR 1997 on Newton Message Pad.
Migrated to Practice Partner in 2001.
Paperless since 2002
7/17/2015
Sammamish Diabetes and Lipid Clinic, PLLC
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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
• Solo in a Micropractice since July 2007 focusing on
primary care for patients with diabetes and lipid
disorders
7/17/2015
Sammamish Diabetes and Lipid Clinic, PLLC
4
My Patient Centered Medical Home:
Sammamish Diabetes and Lipid Clinic
in Sammamish Washington
View from the Street, via Google
Patient Entrance
Reception Area
What is Quality Improvement?
The Institute for Healthcare
Improvement http://www.ihi.org
provides a tremendous resource for
these issues
Model for Improvement - 3 Questions
(developed by Associates in Process Improvement)
• What are we trying
to accomplish?
• How will we know
that a change is an
improvement?
• What changes can
we make that will
result in
improvement?
• Setting Aims
– Time specific, defined
population, measurable
• Establishing Measures
– Quantitative measures
of things that matter
• Selecting Changes
– Which changes will
actually lead to the
improvement we desire?
Plan-Do-Study-Act
(W. Edwards Deming)
• Testing Changes
The PDSA cycle is a
description of the
process of testing and
implementing changes,
assessing the results,
and then acting upon
them.
Traditional Goals
What is the matter?
• Process goals
– Patients seen on time
– All patients have vital signs
– Medication Lists reviewed every visit
• Outcome goals
– BP < 130/80
– HgbA1c < 7.0
Patient-Centered Goals:
What Matters to the Patient?
• “I receive exactly the care I want and need
exactly when and how I want and need it.”
Only 25% of adult Americans strongly agree
Only 12% of low-income Americans strongly agree
– Respondents are aged 19-69 years, Sept 2005 –
April 2006. From HowsYourHealth.org
Patient-Centered Goals:
What Matters to the Patient
When patients strongly agree that
“I receive exactly the care I want and need
exactly when and how I want and need it.”
They have these attributes of care:
Attributes of Care
in Satisfied Patients
I have one person I think of as my personal doctor
or nurse.
Yes: 95%
No: 60%
It is very easy for me to get medical care when I
need it .
Yes: 85%
No: 10%
Most of the time, when I visit my doctor’s office, it is
well-organized, efficient, and does not waste my
time.
Yes: 80%
No: 20%
The information given to me about health problems
is very good.
Yes: 80%
No: 25%
I am confident that I can manage and control most
of my health problems. Yes: 75%
No: 15%
Patient-Centered, Collaborative Care
• Patient-centered vs doctor-centered care: the
essence of professionalism is putting the patient’s
(not the doctor’s) needs at the center.
• Collaborative care: when members of the healthcare team work with patients to provide
professional, often “evidence-based” support, to
address problems that matter to the patient,
resulting in “activated patients” who have the tools
and confidence to deal effectively with their
problems.
How does this relate to
technology?
No practice can afford to achieve
high levels of quality care within the
traditional, non-technological model
of medical care.
Daily Time Required for Quality
• 2500 patient panel
Grade A & B Preventive Services:
Chronic Disease Management:
Acute Care:
Total time/day:
7.4 hours
10.2 hours
4.6 hours
22.2 hours
• Optimal Panel Size for an 8-hour work day:
2500*8/22.2 = 901 patients
How can Technology Help?
Technology can improve efficiencies
in a medical practice, and can reduce
overhead expenses, but we need to
go “outside the box” for a quantum
leap in progress
The Conundrums
• Not enough PCPs in the pipeline to allow for
one provider for every 901 patients
• No payment structures available to pay for
quality at a rate that incentivizes it
• Patients not motivated to get preventive
services
• Infrastructure that is necessary, without
technology, is quite unaffordable
Technological Aids For Efficiency
• Electronic Health Records
– Once implemented, increase office efficiency and decrease overhead
costs
• Secure Patient Portals
– Ideally built into the EHR, for communication and education
• Registries (best if included in EHR)
– Track patients with targeted illnesses and aid population management
• Automated Patient Recall and Reminders
– To increase the probability that patients will follow-up
• E-prescribing
– Reduce errors, automate refills, automatically document
Technological Aids For Efficiency
• Are all expensive, all require provider and
staff resources, and are all valuable.
• But, they do not solve the problem of
how to provide care that matters to the
patient in a cost-effective way.
• We need use technology to involve the
patients themselves in the process
Automated History Taking
• Instant Medical History:
– a commercial software which integrates with most
if not all EMRs, and which allows the patient to
enter the history, ideally before the visit from
home, in an unhurried way. It can also be run from
a kiosk in the reception area.
– IMH can automatically run research-validated
screenings on the patient triggered by the
answers given to the questions it asks.
Advantages of Instant Medical
History
• Low cost
• High levels of patient satisfaction
• More compulsive and thorough than most
providers have the time to be
• Collects not only the history, but also what
matters to the patient using validated tools
• No staff time or provider time necessary – all
the work is done by the patient
Now, imagine a way to provide:
• patients with the information they want in
real time
• providers with patient data that matters to
the patient summarized for their care
• stratified in behaviorally sophisticated
categories (e.g. confidence)
• cumulated patient-centered data to improve
all patient care and your office practice
processes
Imagine the patient doing that for you
and also loading a simple registry for
you to sort your patients based on:
• Demographics: name, age group, gender, financial
status
• What matters: pain, emotion, confidence, meds
that make the patients ill, more than one MD,
• What is the matter: high BP, diabetes, angina,
CHF, history of stroke, respiratory disease, last BP, last
cholesterol if 50+, last sugar if diabetes
• Prevention:
mammogram, bowel cancer
screening, Pneumovax
HowsYourHealth.org
20+ Years of research/testing
pedigree
Dartmouth Medical School
(John Wasson MD)
HowsYourHealth.org
• Free for patients; nominal charge for clinicians
when customized
• Collects information on general health status
but also information on what matters to the
patient using validated tools
• Perhaps the best over-all measure of Quality
of Care yet developed
• No staff time or provider time necessary – all
the work is done by the patient
Action Form
Generated for each individual patient
providing summary of issues that
matter to the patient as well as
issues that should be addressed
Population Summary Report
Advantages of HowsYourHealth.org
• Patient assessment and feedback system
– Unmask the true patient needs and agenda that might
undercut your best efforts
– Automatically tailors information to your patient’s needs
and chronic conditions
– Additional versions for hospitalized and very sick/frail
patients
– Meets or supports many requirements for CMS/NCQA
Medical Home designation
Advantages of HowsYourHealth.org
• Patient Portal for Best Information, Links,
Problem-Solving and Shared Decision-Making
– Non-commercial, well-tested tools and information that saves
you time while you better inform your patients
– Behaviorally Sophisticated Methods to Improve Patient
Outcomes
• Portable Personal Health Record for Your Patients
and Your Records
– Minimize risks and frustrations of fragmented information
Advantages of HowsYourHealth.org
• Patient Registry that Your Patients Complete for
You
– With one click list your patients/addresses by
condition, abnormal lab, functional limit, screening
not done
– Sort and contact patients by behaviorally useful
categories such as lack of confidence with self
management
Advantages of HowsYourHealth.org
• Practice Improvement System that Instantly and
Automatically Gives You Performance Data
– Patient experiences and bio-clinical measures offered with
several national standards
• Customization options so that HowsYourHealth fits what
you and your patients need
– Add questions, change reports, import format for Electronic
Health Record
• Patient Pre-Visit Planner and “Reviewer of Systems” for
Your Patients and Payer
– Makes an office visit more efficient and your billing more
complete
Model for Improvement :
a new look
• What are we trying
to accomplish?
• How will we know
that a change is an
improvement?
• What changes can
we make that will
result in
improvement?
• Setting Aims
– Based on What Matters
to the Patients
• Establishing Measures
– Through web-based
assessments like Hows
YourHealth? and IMH
• Selecting Changes
– PDSA cycles with
prompts in EHR, web
portals and even visit
scheduling.
Questions?
7/17/2015
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Sammamish Diabetes and Lipid
Clinic, PLLC