1 / 66

A Practical Approach to Improving Quality TEPR 2007 Donald T. Stewart, MD DonSSammamishDiabetesAndLipid.Org

Your Background?. PhysiciansAdministratorsNursing staffQuality improvement facilitatorsIT staffVendors. 3/1/2012. Sammamish Diabetes and Lipid Clinic, PLLC. 2. My Background. 3/1/2012. Sammamish Diabetes and Lipid Clinic, PLLC. 3. . Family Practice, started solo from scratch in 1983 after residencyGrew to 6 provider practice which was sold to Swedish Hospital in 2003Now Medical Director of 7-provider clinic in 12-clinic systemFirst EMR 1997 on Newton Message Pad Migrated to Practice Part30218

dea
Download Presentation

A Practical Approach to Improving Quality TEPR 2007 Donald T. Stewart, MD DonSSammamishDiabetesAndLipid.Org

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. A Practical Approach to Improving Quality TEPR 2007 Donald T. Stewart, MD DonS@SammamishDiabetesAndLipid.Org

    2. Your Background? Physicians Administrators Nursing staff Quality improvement facilitators IT staff Vendors 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 2

    3. My Background 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 3

    4. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 4

    5. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 5 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.

    6. What Tools do We Need? 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 6

    7. 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/ 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 7

    8. Components of the Chronic Care Model Community, Health System, and Patient Health System Characteristics: Delivery system design Integrated team Scheduled care visits with goals and expectations Access Communication with patients Self-Management Support Decision Support Clinical Information Systems 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 8

    10. Health System – the Doctor’s Office Workflow modifications Office culture changes Registry capabilities The EMR 3/2/2012 10 Sammamish Diabetes and Lipid Clinic, PLLC

    11. Workflow Modifications

    12. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 12

    13. Workflow Modifications The day before the visit MA reviews schedule Writes down plan for each patient Flu Shot Pneumovax Microalbumin/Creatinine HgbA1c Lipids, AST, ALT BMP Need to call chronically late patients to remind them to arrive on time 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 13

    14. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 14

    15. Workflow Modifications Structured Visit – 30 minutes 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 15

    16. Office Culture Changes 3/2/2012 16 Sammamish Diabetes and Lipid Clinic, PLLC

    17. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 17

    18. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 18

    19. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 19

    20. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 20

    21. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 21

    22. Registries and Registry Capabilities 3/2/2012 22 Sammamish Diabetes and Lipid Clinic, PLLC

    23. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 23

    24. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 24

    25. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 25

    26. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 26

    27. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 27

    28. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 28

    29. California Healthcare Foundation For an excellent review of 16 registry products by the California HealthCare Foundation, try this: http://www.chcf.org/documents/chronicdisease/ChronicDiseaseRegistryReview.pdf 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 29

    30. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 30

    31. The Electronic Health Record

    32. 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 EHR Too much information Available 24/7 Legible Built-in reminders, drug interaction warnings Built-in trending Messaging More and more with integrated reporting 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 32

    33. 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 EHRs Designed for patient care Opportunistic care at every patient visit Documentation tools Templates & Flowsheets Communication tools Clinical information support High cost Slow implementation 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 33

    34. 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 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 34

    35. 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. 3/2/2012 35 Sammamish Diabetes and Lipid Clinic, PLLC

    36. 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 3/2/2012 36 Sammamish Diabetes and Lipid Clinic, PLLC

    37. EHR Tools – without a visit Scheduling patients Documenting phone contacts and Rx refills Order entry and tracking Lab letters, patient reminders Messaging and workflow Information access when on call 3/2/2012 37 Sammamish Diabetes and Lipid Clinic, PLLC

    38. EHR Financial Incentives More reimbursement through better documentation Greatly increased operating efficiency of the office Documenting quality for better patient acceptance Pay for Performance 3/2/2012 38 Sammamish Diabetes and Lipid Clinic, PLLC

    39. 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 3/2/2012 39 Sammamish Diabetes and Lipid Clinic, PLLC

    40. Diabetic Data You Care About (that you want to automagically go into your visit note) Diagnosis Date Diabetes Educator Endocrinologist Frequency of glucose monitoring Frequency of blood pressure testing Frequency of exercise Diet Symptom Status Painful Neuropathy Numbness Hypoglycemic episodes Sexual function Patient Concerns Amputation Blindness Renal failure 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 40

    41. 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) 3/2/2012 41 Sammamish Diabetes and Lipid Clinic, PLLC

    42. 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 3/2/2012 42 Sammamish Diabetes and Lipid Clinic, PLLC

    43. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 43

    44. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 44

    45. 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 3/2/2012 45 Sammamish Diabetes and Lipid Clinic, PLLC

    46. 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 46

    47. 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 3/2/2012 47 Sammamish Diabetes and Lipid Clinic, PLLC

    48. 3/2/2012 48 Sammamish Diabetes and Lipid Clinic, PLLC

    49. Flowsheets 3/2/2012 49 Sammamish Diabetes and Lipid Clinic, PLLC

    50. 3/2/2012 50 Sammamish Diabetes and Lipid Clinic, PLLC

    51. 3/2/2012 51 Sammamish Diabetes and Lipid Clinic, PLLC

    52. 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 3/2/2012 52 Sammamish Diabetes and Lipid Clinic, PLLC

    53. 3/2/2012 53 Sammamish Diabetes and Lipid Clinic, PLLC

    54. 3/2/2012 54 Sammamish Diabetes and Lipid Clinic, PLLC

    55. 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 3/2/2012 55 Sammamish Diabetes and Lipid Clinic, PLLC

    56. 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 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 56

    57. 3/2/2012 57 Sammamish Diabetes and Lipid Clinic, PLLC

    58. 3/2/2012 58 Sammamish Diabetes and Lipid Clinic, PLLC

    59. Process Measures 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 59

    60. Outcomes Measures 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 60

    61. Process Measures 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 61

    62. Outcomes Measures 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 62

    63. Practice Partner Research Network 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

    64. 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

    65. 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 3/2/2012 Sammamish Diabetes and Lipid Clinic, PLLC 65

    66. Questions? 3/2/2012 66 Sammamish Diabetes and Lipid Clinic, PLLC

More Related