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Increasing screening for osteoporosis

Increasing screening for osteoporosis. Team 1 - 10/2013 Thanks to Georgia Carlson and N Topeka staff. Increasing screening for osteoporosis. Increase parsable documentation of fulfillment of patient choice for screening by USPSTF osteoporosis guidelines by 25% within 3 months .

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Increasing screening for osteoporosis

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  1. Increasing screening for osteoporosis Team 1 - 10/2013 Thanks to Georgia Carlson and N Topeka staff

  2. Increasingscreening for osteoporosis • Increase parsabledocumentation of fulfillment of patient choice for screening by USPSTF osteoporosis guidelines by 25% within 3 months • This is your operationalized version • The elevator version is the project title

  3. Baseline data • Sometimes only a single baseline measurement is available • Made by QI Tools at OpenCPU

  4. Baseline: Fishbone or Ishikawa diagram (cause and effect diagram) • Made by QI Tools at OpenCPU

  5. Baseline flow chart • Made by LucidCharts • PNG file downloaded from Lucid

  6. Process map: baseline (optional) • Made by QI Tools at OpenCPU

  7. Stakeholder analysis • Stakeholder’s impression of barriers • Doctor.: Clarity of evidence-based guidelines for f/u • Nurse: • Hassle to input dx of tobaccoism in EHR=multiple clicks • Reluctance to persistently ask about smoking cessation • Lack of knowledge regarding billing for counseling • Stakeholder’s impression of benefits from improvement • Doctor: Better cessation rates/counseling=more $$ • Nurse: More likely to ask and document if aware of $$ • Stakeholder’s impression of solutions • Doctor: All interventions seem reasonable and appropriate. • Nurse: Willing to try new EHR documentation, concern that “not willing to quit, not counseled” will not be used

  8. Chart review • We manually reviewed 50 charts for • Presence of asthma in promoted Problem lists • Criterion: ICD9 • Criterion: Excluded free text • Parsable documentation in Health Maintenance of • PFTs/spiro with pre/post testing or methacholine challenge • Criterion: Excluded free-text entries • Scanned documents • PFTs/spiro • Presence of hyper-reactivity by pre/post testing or methacholine challenge

  9. Pareto chart • Made by QI Tools at OpenCPU • Sometimes sorted bar-chart is better

  10. Interventions • March 2011 • All anticoag patients cared for by residents • Single provider receives all results • Cypress patients • Nurses verify doses when pt arrives for lab draw • May 15, 2011 • All anticoag patients cared for by residents • Registry for identified late patients • June 8, 2011 • Cypress patients • Point of care testing

  11. Blood is drawn POCfor INR by lab or home health or other Patientcontacted EHR queried weekly for pts without INR > 30d Flow chart: revised > 30 d Result is sent to Cypress Clinic Result entered into EHR Nurse enters results into EHR Nurse forwards results to PA PA contacts the patient Patient reports warfarin use and factors such as diet, medications, etc Clinician & patient make decisions: Use Warfarin by Wichita nomogram Warfarin dose adjusted INR f/u scheduled

  12. Lit search: Clinical Evidence • USPSTF Guidelines (http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm) • Comparison of different screening tools (FRAX®, OST, ORAI, OSIRIS, SCORE and age alone) to identify women with increased risk of fracture. A population-based prospective study (PMID: 23669650) • Bone-Density Testing Interval and Transition to Osteoporosis in Older Women (PMID: 22256806) • Better would be to include a quantitative estimate of benefit

  13. Lit search: Implementation Evidence • Mailed intervention and self-scheduling improves osteoporosis screening compliance • Control group: 5% • Mailed letters: 17% • J Bone Miner Res. 2013. PMID: 22836812 • Electronic Standing Orders Highlight Care Gaps and Allow Nonphysicians to Address Them • DEXA rose from 45% to 52% • http://innovations.ahrq.gov/content.aspx?id=3140 • Try to quantify benefit

  14. Intervention 1:Improved Documentation • 4 main categories • Concise • RN-approved • Star: automatic drop-down to A/P • ICD-9 code and G-billing code for appropriate counseling • Bill code every time, but will not be billed after max allowable

  15. Intervention #2: Patient Information Information to be sent by PCP Resident

  16. Results: projected monthly income

  17. Results: • Unusual to have this slide • Made by QI Tools at OpenCPU

  18. Summary • Initial results suggest an improvement occurred • Revenue positive

  19. Recommendations for future teams • Can G-code be used for quarterly billing for anticoagulation?

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