Physician Practice Project

Transcription

1 Physician Practice Project This material was prepared by Florida Medical Quality Assurance, Inc., the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. FL20051dFT1D

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3 Physician Practice Resource Manual Doctor s Office Quality Information Technology 8 th Scope of Work August 1, 2005 July 31, 2008

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5 Table Of Contents 1. Introduction Introduction FMQAI Team Members Acknowledgements New Model of Primary Care Road Map to Electronic Health Records 2. Assess Assessment Phase Checklist On-Site Assessment Professional/Patient Assessments (5) Staff Activity Surveys (6) Personal Skills/Needs Assessment The Case for Improvement Assessing Your Practice Measuring Your Practice (4) 3. Plan Plan Phase Checklist Establish the EHR Team Prioritize Ideas/Recommendations Next Steps Timeline Template Change Management and Quality Improvement Processes/Components of a Successful Implementation Critical Success Factors How to Improve/Setting Aims/Measures/Changes Shortening Wait Times: Six Principles for Improved Access Checklist for Implementing Open Access Scheduling Reduce Scheduling Complexity (5) Start On-Time Agreement Office Visit Cycle Time Unplanned Activity Card DOQ-IT Current Return on Investment (ROI) Literature for EHRs 4. Select Selection Phase Checklist Vendor Evaluation Matrix DOQ-IT Vendor Letter of Intent List Contracting Guidelines EHR Vendors AC Report Link (see section 7) RFP Proposal Preparation Link (see section 7) Glossary, Red Flags, & FAQs

6 5. Implement Implementation Phase Checklist Common Implementation Problems Implementation Options Incremental vs. Big Bang Redesign the System 6. Evaluate/Improve Evaluation/Improvement Phase Checklist QualityNet Exchange for Registration for Data Transmission Link (see section 7) DOQ-IT Measures Overview & Data Submission Process Reliability The Model for Chronic Disease Management Patients: Assessment of Care for Chronic Conditions Assessment of Chronic Illness Care (version 3.5) 7. Links To Article And Websites Websites for Accessing Tools Articles for Phases of the Road Map

7 Introduction Information for Healthcare Improvement Quality Improvement Organizations (QIOs), under contract with the Centers for Medicare & Medicaid Services (CMS), are expected to provide assistance to healthcare providers that enables them to develop the capacity for, and to achieve the vision of the program, which is that every person receives the right care every time. QIOs shall accomplish this by working with providers, practitioners, Medicare Advantage organizations, beneficiaries, and other stakeholders in support of quality improvement. Assistance will typically involve seeking to promote improvements in organizational culture, systems adoption and use, and redesign of care processes. FMQAI, formerly Florida Medical Quality Assurance, Inc., Florida s Medicare QIO, is excited to work with the healthcare community to improve care received by Medicare patients in all areas of care delivery. FMQAI s Physician Practice Team will work with physicians and their office staff to assess how electronic clinical information systems can be used to improve the quality and efficiency of care with a focus on e-prescribing, e-registry/care management, and deployment of full electronic health record systems (EHRs). FMQAI will assist physicians to select health information technology products, reorganize workflow and care processes to implement EHRs, and undertake quality improvement projects to realize the benefits of EHRs. Following the steps outlined in this manual will promote the potential for success of your EHR investment and care improvement processes. The road to a successful implementation of EHR is challenging and cumbersome. FMQAI is ready to walk with you along the path to a successful implementation in your practice. FMQAI is also directed to work toward improving indicators of quality for Diabetes, Cardiovascular Disease and Preventive services. The ultimate outcome of the Physician Practice project is to make it possible for Primary Care Practices to transmit quality data, for the targeted indicators, to a secure data warehouse developed by CMS. This will enable CMS to receive real time, accurate data on which they can build a pay for performance reimbursement program. The Physician Practice Team Project Coordinators are excited to be participating in this project. This project has the potential to enhance patient outcomes and improve physician satisfaction with their practice and improve provider s quality of life. We look forward to working with you and your staff to share with you our knowledge and intervention tools to transform your practice into a winning situation for everyone patients, providers and staff. FMQAI Physician Practice Project Team 5201 West Kennedy Boulevard, Suite 900 Tampa, FL Toll Free (800) Telephone (813) Fax (813) W. Kennedy Boulevard, Suite 900 Tampa, Florida fax

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9 The Right Care for Every Patient Every Time FMQAI Physician Practice Project Team Diane Chronis, RN, BS Project Director x 3558 [email protected] Project Coordinators Joan Crosby, RN, MS, CPHIT, CPEHR Project Coordinator, DOQ-IT x 3537, [email protected] Christine Lalios Kuykendall, RHIA, CPHQ Project Coordinator, DOQ-IT x 3592, [email protected] Darleen Luzod, MS, RN HIT Project Coordinator, DOQ-IT x 3811, [email protected] Sharon Sopczak, RN Project Coordinator, Underserved Populations x 3510, [email protected] Laura Gamba, BA, CBA Senior Project Coordinator, Underserved Populations x 3920, [email protected] Kathleen Lightbourne, MPH Project Coordinator, Underserved Populations , x 3562, [email protected] Jan Murray, BSN, RN Project Coordinator, DOQ-IT x 3585, [email protected] Farah Tavakoli, MSHA, MT-ASCP HIT Project Coordinator, DOQ-IT x 3805, [email protected] Chitra Yeshwanth, MS, MPH Project Coordinator x 3319, [email protected] Ancillary Staff JiFeng Ma, Ph.D Statistician x 3861, [email protected] Bonnie Mason Communication Specialist x 3570, [email protected] Cindy Olejnik Administrative Assistant x 3578, [email protected]

10 The Right Care for Every Patient Every Time Physicians Ferdinand Richards, MD Medical Director, FMQAI , Mark Michelman, MD, MBA Clinical Director, FMQAI , R. Scott Hanson, MD, MPH Physician Consultant

11 The Right Care for Every Patient Every Time ACKNOWLEDGEMENT FMQAI has derived much of the material in this tool kit from the following: Institute for Healthcare Improvement Website, The Dartmouth-Hitchcock Medical Center, The work of Mark Murray, MD, MPA and Catherine Tantau, BSN, MPA, who first created and used the Open Access Scheduling processes and procedures. Lumetra California s Medicare Quality Improvement Organization s DOQ-IT Pilot Program We wish to thank the above persons and facilities who have spent time and effort to put together the pieces of the path that give us the greatest potential for successful redesign of Primary Care Office Practice using Electronic Clinical Information.

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13 The Right Care for Every Patient Every Time TWENTY-FIRST CENTURY PRIMARY CARE A personal medical home for each patient Patient-centered care A team approach to care Elimination of barriers to care Advanced information systems, including integrated electronic health records (EHRs) Redesigned, functional offices Whole-person orientation; culturally sensitive care Care provided within a community context Emphasis on quality and safety Enhanced practice finances (through operating efficiencies and new revenue streams) A commitment to provide a specific basket of services Adapted from American Academy of Family Physicians 21 st Century Primary Care Model

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15 Electronic Health Record Roadmap The Right Care for Every Patient Every Time ASSESS PLAN SELECT IMPLEMENT EVALUATION/ IMPROVEMENT BEYOND During this step office processes are assessed and analyzed to identify areas that can be improved. This lays the groundwork for planning and prioritizing EMR selection criteria and office redesign projects. In addition it allows you to have a better picture and understanding of the practice patient profile. During this step the results of the assessment and analysis are utilized to develop the priorities for the EMR system you will select. You will identify a Project Team that will participate in the ongoing process. This team will assist in all aspects of the EMR and redesign processes. During this step, using the criteria and plans from your previous work, your team will narrow down to the three to five vendors whose software most closely match your needs. Demonstration scenarios will be developed and vendors will be invited to demo their product to you Project Team. At the end of this phase your team will select the EMR best suited to your practice. During this step the Project Team will work with the staff to plan for the implementation of your system. This is an important step in minimizing the disruption to your office and a successful implementation. The team should be very active in setting up training and assuring that each staff member is trained appropriately. During this step the impact of the EMR on your practice and staff will be assessed. Process redesign will be reviewed and population management will be discussed and plans will be developed to identify and target the chronic illnesses within your practice. Plans will be generated to manage patients with the most frequently seen chronic illness diagnosis, such as Diabetes, CHF, etc. The ability to transmit data to the CMS Data Warehouse will also be checked. During future years of your practice the continual use of the EMR system to enhance patient care and outcomes will be available to your practice. Measurement of outcomes will assist you and your staff to provide and monitor care using evidence-based criteria on real time data. You will be able to provide data to payers to support your delivered standard of care. This will promote your ability to negotiate pay for performance reimbursements.

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17 EHR Roadmap Practice Name: Date: FMQAI DOQ-IT Team Facilitator: Phone: Physician Champion: EHR Team Leader: Phase Assessment Planning Practice Tasks Recommended for successful movement along the EHR Roadmap Complete IT readiness assessment Assess current workflow (identify pain points) Begin or continue regular staff meetings (at least monthly) Assign physician champion Organize an EHR selection/implementation team Assign an individual (EHR team leader) or team to lead practice changes Commit to: o Full provider engagement to enter data o Workflow changes necessary to maximize results List goals and priorities (include functions and specific provider needs) Translate identified EHR goals into available EHR system functions s and features Identify staff at lower levels of readiness and address their concerns Develop a timeline and project plan Gain support from team members and staff and prepare staff for changes Optional: Write RFI/RFPs Complete a cost/benefit analysis and ROI for an EHR system Milestone Checklist To demonstrate measurable movement along the EHR Roadmap (check the box as each milestone is completed; sign and date when all tasks in phase are complete) IT readiness assessment Readiness/next steps reviews Physician champion assigned Team leader assigned for practice changes Current workflow processes assessed Give signed participation agreement to FMQAI Proposed implementation target date Initials: Date Phase Completed: Practice has identified goals, priorities and any staff concerns EHR goals and associated system functions are listed Business plan developed, includes such items as: - Target implementation schedule/timeline - Estimates of EHR budget and ROI - Measurable EHR goals Initials: Date Phase Completed: Tools and Services Provided by FMQAI See Physician Practice Project Manual Section 2 See Physician Practice Project Manual Section 3

18 Evaluation Implementation Selection Attend structured demonstrations at Vendor Fair Evaluate vendors and create short list of 2-3 vendors Review EHR systems by: o Run vendors through a practice specific case cenario o Going on at least one site visit o Obtaining at least three vendor references Identify and select vendor for hardware, office wiring, and necessary network support for all services and products not included in EHR Negotiate contracts including all aspects of implementation, training, and technical support Continue workflow assessment and changes Draft EHR system implementation plan and timetable Assign data manager/administrator Assure data conversion and testing completed Assure interfaces completed and tested for: Laboratory Radiology Practice Management (billing and scheduling) Referrals Assign a go-live date Train staff Celebrate success and address problems Conduct post go-live reviews of implementation Conduct additional staff training as needed Evaluate EHR system goals met to date Verify vendor has provided technical infrastructure to capture clinical measures for future data submission Negotiate contracts and financing EHR vendor selected Hardware vendor selected Vendor selected for office wiring and cabling needs that are not included in EHR package Initials: Date Phase Completed: Implementation plan completed Contracts completed and signed Data manager assigned Data conversion and testing completed Interfaces tested and working properly Go-live completed and celebrated Vendor will be the primary driver of this phase; therefore vendor should be thoroughly engaged in all aspects of the implementation. Initials: Date Phase Completed: Post go-live reviews for EHR goals, implementation and additional staff training completed Schedule additional staff training Data capture verification completed with vendor Data submission to CMS Assess full use of EHR system and address lags Initials: Date Phase Completed: See Physician Practice Project Manual Section 4 See Physician Practice Project Manual Section 5 See Physician Practice Project Manual Section 6 Improvement Commit to continuous review of clinical and administrative processes Identify and target additional care management and process improvement opportunities Use EHR to optimize practice of evidence-based medicine Continue submission of data to CMS Re-analyze clinical and administrative processes Review performance reports Identify quality improvement opportunities Re-design work processes to use EHR clinical decision support tools with each patient encounter Initials: Date Phase Completed: See Physician Practice Project Manual Section 6

19 The Right Care for Every Patient Every Time Assessment Phase Checklist TASK On-Site Practice Readiness Assessment with EHR On-Site Practice Readiness Assessment without EHR Professionals Primary Care Staff Satisfaction Survey DATE STARTED DATE COMPLETED SENT TO FMQAI INITIALS Primary Care Practice Profile Patients Patient/Family Satisfaction with Primary Care Practice Access Survey Point of Service Patients Primary Care Practice Patient Viewpoint Survey (Choose one o f these two) Patients Through the Eyes of Your Patients Staff Activity Surveys Provider Activity Survey RN Activity Survey LPN Activity Survey MA Activity Survey Receptionist Activity Survey Activity Survey Personal Skills Needs Assessment Microsystems Resources Case For Improvement Assessing Your Practice Discoveries and Actions Measure 3 rd Next Available Appointment Measure Daily Demand Measure No Show Rate New Patient Panel Size Document Review

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21 On-Site Practice Readiness Assessment With EHR Contact Information Practice Name: Team Member Completing Assessment: Physician Practice Staff Interviewed: Assessment Date: CMS Required Scoring Information 1. Is the practice affiliated with an IPA or a large medical group? Yes No 2. What types of technology is the practice currently using on a regular basis? 3. Does the practice conduct regularly scheduled all-staff meetings (including providers)? Yes No 4. Please indicate staff s current attitude towards the EMR/HIT system: 5 = Very positive, 4 = Positive, 3 = Neither positive or negative, 2 = Somewhat negative, 1 = Very negative Physicians Mid-level providers Clinical Staff Office Manager Administrative staff Does the practice use the EMR/HIT system to identify patients with one or more chronic conditions or who require preventive services (e.g., identify patients due for influenza vaccination or patients with diabetes who require a HbA1c test)? Yes No Don t Know If yes, what does the practice do with the data? Submit for Pay-for-Performance programs. Yes No Create reports to use for peer review and feedback Yes No Create reports to use for performance improvement projects Yes No Schedule preventive services Yes No Other, please verify: FMQAI Data Collection Name of PMS System: Name of EMR System: Date began using? Date began using: Are they integrated? Yes No Interfaced? Yes No Do all staff and providers use the EMR system? Yes No Do all staff and providers use the system in the same manner? Yes No On-site Assessment 1

22 What components of the Eight Core Capabilities do your EMR: Health Information and Data: Immediate access to key information, i.e. diagnoses, allergies, lab results and medications. (Patient summary sheet, problem list, medication list, lab results, etc.) Result Management: Ability to quickly access test result, both new and past, in multiple settings. (PDA or other access when away from the office home, hospital, nursing home, etc.) Order Management: The ability to enter and store orders for prescriptions, tests and other services. (Direct order messaging to labs, diagnostic facilities, hospital, etc.) Decision Support: Ability to use reminders, prompts and alerts, computerized decision-support re: screening, drug interactions and evidence-based medicine. Electronic Communication and Connectivity: Efficient, secure and readily accessible communication among providers and patients. (Secure for patient and physician communication, Web Site with Patient portal, on-line scheduling, etc.) Patient Support: Patient access to health records, interactive education and help to carry our home monitoring and self-testing (on practice web site through patient portal, etc.) Administrative Processes: Scheduling, registration, and billing. Reporting: The ability to electronically store and retrieve uniform data standards. POSSESS USE How is documentation done in this practice? Template Dictation Typing Voice Recognition Other, specify: Does this practice use E-Rx? Yes No How? Printed Faxed E-Fax Electronic Transmission Does your office staff need additional EMR training to further utilize the EMR for these documents? Yes No Does this practice have interfaces for Lab results? Quest LabCorp Other Is this practice using any direct digital equipment access? (Check all that apply.) Vital Signs EKG Other Does this practice have access to their hospital portal for downloading information? Yes No What can they access? Does this practice have an efficient scanning system for paper management? Yes No Describe the process. On-site Assessment 2

23 Does this practice use the messaging/task system to communicate with staff and in-house providers/departments? Yes No Does this practice track referrals on the computer? Yes No Describe the process. Quality Improvement/Population Management Is this practice carrying out any Quality Improvement processes at present? Yes No What are they doing in this area? How does this practice identify patients with specific diseases? Yes No Explain. Does this practice print lists of patients who are overdue for specific care? Yes No Describe how these lists are used. Does this practice use a registry to monitor and manage chronic illness care? Yes No Please check all that apply: Diabetes C-V Disease Hypertension CHF Asthma Coumadin use Preventive screening MI Cholesterol COPD Depression Other, specify: Be more specific about process: Does this practice create and print reports from the EMR (not PMS) to monitor care your patient s receive? Yes No What? Does this practice monitor provider performance based on designated measures? Yes No Policy. Involved in any P4P bonus programs? Yes No What companies? Does this practice use disease specific templates to facilitate and improve patient care? Yes No Which disease? On-site Assessment 3

24 Is this practice doing any Population Management? Yes No If so, what? Which groups? Does this practice use Group Visits? Yes No What group? Does this practice use Open/Advanced Access scheduling? Yes No What are their goals for QI? What are their goals for PM? How much time and effort are they willing to devote to QI? Data Transmission Is this practice willing to transmit data to Medicare s Secure Data Warehouse when this is developed? Yes No On-site Assessment 4

25 # Use a separate sheet of paper to complete long processes. Complete step by step appointment to check out process.# Complete step by step prescription refill process.# Complete step by step telephone triage process.# On-site Assessment 5

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27 On-Site Practice Readiness Assessment Without EHR Contact Information Practice Name: Team Member Completing Assessment: Physician Practice Staff Interviewed: Assessment Date: CMS Required Scoring Information 1. Who will lead the practice s EMR/HIT system implementation? (Check all that apply.) Physician(s) Office Manager Mid-Level Provider(s) Administrative staff (e.g. Medical Records) Clinical Staff (e.g. RN, MA, etc.) 2. Does the practice currently have an EMR/HIT implementation project manager? Yes No If yes, how many hours per weeks will be devoted for managing the project? If no, does the practice plan on designating a project manager to the project? Yes No 3. Has the practice engaged a health information technology consultant in addition to QIO staff? Yes No If no, does the practice plan to hire a consultant? Yes No STAFF 4. Does the practice conduct regularly scheduled all staff (including providers) meetings? Yes No If yes, how often does the practice staff meet? Weekly Monthly Quarterly Annually Other, please specify: 5. Has the practice tried to address workflow issues or operational inefficiencies in the past? Yes No If yes, how successful were these efforts? Very successful Some what successful Neither successful or unsuccessful Some what unsuccessful Very unsuccessful 6. Has the practice tried to implement clinical information systems, such as EMR or electronic prescribing, in the past? Yes No On-site Assessment 1

28 7. How receptive has staff been to efforts to implement clinical information systems or other practice changes? Very receptive Some what receptive Neither receptive or unreceptive Some what unreceptive Very unreceptive 8. Does the practice have other projects either currently going on and/or starting soon that might affect the planning for and/or success of the EMR/HIT implementation project? Yes No If yes, please specify: 9. Please indicate the current status of the practice s EMR/HIT system implementation efforts: CHOOSE: I (see below) II (see page 3) I. Beginning the process of selecting a system. Date process began: I a. For each of the groups listed below, please indicate their level of support for an EMR/HIT system: 5 = Very supportive, 4 = Somewhat supportive, 3 = Neither supportive or unsupportive, 2 = Somewhat unsupportive, 1 = Very unsupportive. Physicians Mid-level providers Clinical Staff Office Manager Administrative staff I b. Please indicate which of the following EMR/HIT implementation related activities the practice has either done or plans to do (Check all that apply.). Have done Plan to do No plans Establish a multidisciplinary implementation team. Identify practice s inefficiencies, problems. Map out and analyze key and/or problematic processes/workflows. Develop written list of EMR/HIT system requirements. Involve staff in EMR/HIT system selection process. Assess technical proficiency of staff and address identified needs. I c. What would you and your staff like to gain from participating in the program? On-site Assessment 2

29 I d. Please indicate how likely the following will be obstacles to the practice s implementation of an EMR/HIT system. 5 = Very likely, 4 = Some what likely, 3 = Neither likely nor unlikely, 2 = Some what unlikely, 1=Very unlikely Availability of funds Experience with IT Physician/Mid-level provider support Clinical staff support Office manager support Administrative staff support Inadequate project management Technical proficiency of staff Inability of physicians/mid-level providers to enter data in the system Insufficient time to select and implement a system Lack of IT infrastructure to support system Other, please specify: II. In the process of implementing a system. Date vendor/system selected Name of vendor II a. Please indicate which of the following activities the practice completed during its EMR/HIT selection process (Check all that apply.). Established a multi-disciplinary implementation team. Yes No Identified practice s inefficiencies, problems, etc. Yes No Mapped out and analyzed key and/or problematic processes and workflows. Yes No Developed a written list of EMR/HIT system requirements. Yes No Involved staff in EMR/HIT system selection process. Yes No Communicated to staff the overall goals and reasons for implementing an EMR. Yes No Assessed technical proficiency of staff and developed plan for addressing identified needs. Yes No II b. Does the practice have a written project plan for implementing the EMR/HIT system? Yes No II c. Does the practice have a formal written training plan for implementing the EMR/HIT system? Yes No II d. Please indicate how likely the following will be obstacles to the practice s implementation of an EMR. Physician/Mid-level provider resistance Clinical staff resistance Office manager support Administrative staff resistance Inadequate project management Inadequate training on EMR/HIT system Inability of physicians/mid-level providers to enter data and use system Insufficient time to implement a system Insufficient funds for consultants/training Other, specify II e. What would you and your staff like to gain from participating in the program? On-site Assessment 3

30 FMQAI Data Collection Does Practice have multiple locations? Yes No How many? Can a patient visit all location? Yes No Number of exam rooms: Treatment Rooms: STAFF Total FTE s: Physicians MA Phlebotomist Front Desk Referral Coord. LPN Billing RN Management Other Is your staff cross-trained to maximize the efficiency of your office? Yes No How do you cover call-ins and vacations? Does the staff s assignments make maximum use of their education/training? Yes No Estimate the total time, each day, that administrative staff spends doing inefficient tasks (looking for charts, redoing work, calling facilities for results, etc) CHARTS Estimate average time to pull a chart (includes any prep needed). Estimate average time to locate misplaced charts. When are charts pulled for appointed patients? Are these charts prepared prior to patient check-in? Yes No Where are they placed? Who most often pulls charts? How often are charts misplaced? How many patients are seen without their chart? Identify the process for finding a misplaced chart? Charts pulled per day: Appointments Billing Prescription refills Referrals Lab results Non-patient Rad./diagnostic results (Pharm, Insurance company, etc.) Other - list: Who files loose papers into chart? Who files charts to the shelf? On-site Assessment 4

31 LABORATORY Does office do waived* labs in-house? Yes No Does office do phlebotomy in-house? Yes No Who does this? Average number of labs ordered per day. Average number of labs drawn per day. * Simple test for which a license is not required, just a certificate of waiver. Includes U/A dipstick, finger stick glucose, cholesterol, hemoglobin/hematocrit, etc. Estimate percentage of lab referrals made to: Quest LabCorp In-house Local hospital Other Estimate the percentage of lab results received by the following methods: Electronic (E-fax, Lab computer, etc.) Regular fax Hard copy (office printer, delivered) Other RADIOLOGY/DIAGNOSTIC TESTS Does the office do any in-house x-rays? Yes No Who does this? How many per day? How many Radiology or other diagnostic tests are ordered per day? How are the results received for these tests? Electronic (E-fax, Lab computer, etc.) Regular fax Hard copy delivered Other Generally, Who completes the requisitions for labs, radiology, etc.? Physician MA Front desk Other How often does staff need to call for test results? Lab Radiology (MRI, CT, Sonogram, etc.) Other (Cardiology, Neurology, Pulmonary, etc.) How many calls for reports are made in a week? Lab Radiology Other Estimate the time it takes to call for results (any test) daily. On-site Assessment 5

32 Describe the process used to follow up on lab reports: Abnormal Routine Does this process ever fail to complete the notification: Yes No How often? PRESCRIPTIONS Are any prescriptions renewed based on a written policy? Yes No Are calls accepted from patients requesting refills? Yes No Estimate the average number of new (non-refill, non-renewal) prescriptions written daily by all providers. Estimate the average number of refill, renewal prescriptions that are written daily by all providers. How often does a pharmacy call to clarify a prescription (or ask that it we rewritten) because it was not legible? REFERRALS Estimate the average number of referrals processed each week. How are these processed? Telephone % Fax % Computer % What is the range of time to complete a referral? to TRANSCRIPTION Do any providers use transcription? Yes No What is your transcription turn around time? Do you ever see patients without the most recent dictation? Yes No What is the average cost of transcription per month? OFFICE PROBLEMS Please list the three most serious problem processes in your office. 1) 2) 3) ELECTRONIC MEDICAL RECORDS What vendors have you reviewed or demo d? On-site Assessment 6

33 QUALITY IMPROVEMENT Does the office have any formal QA program? Yes No If so, in what areas? (Select below) Billing/coding accuracy Diabetes CAD CHF Hypertension Coumadin use Preventive screening Immunizations Asthma COPD Other, specify: Do you have documentation of the 5 most prevalent chronic diseases in the practice? Yes No Please list them: Have you considered any of the following changes to your practice? Open/Advanced Assess Scheduling Yes No Group Visits Yes No Education classes Yes No Use of planned visits Yes No Are you willing to invest time and staff in improving the quality of your patient care processes? Yes No Are you willing to voluntarily transmit data to the secure CMS Warehouse? Yes No On-site Assessment 7

34 # Use a separate sheet of paper to complete long processes. Complete step by step appointment to check out process.# Complete step by step prescription refill process.# Complete step by step telephone triage process.# On-site Assessment 8

35 Professionals Creating a joyful work environment starts with a basic understanding of staff perceptions of the practice. All staff members should complete this survey. Use a tally sheet to summarize results. Ask all practice staff to complete the Staff Survey. Often you can distribute this survey to any professional who spends time in your practice. Set a deadline of one week and designate a place for the survey to be dropped off. You may have an organization-wide survey in place that you can use to replace this survey, but be sure it is CURRENT data, not months old, and that you are able to capture the data from all professionals specific to the Primary Care Practice workplace. Primary Care Staff Satisfaction Survey 1. I am treated with respect every day by everyone that works in this practice. Strongly Agree Agree Disagree Strongly Disagree 2. I am given everything I need tools, equipment, and encouragement to make my work meaningful to my life. Strongly Agree Agree Disagree Strongly Disagree 3. When I do good work, someone in this practice notices that I did it. Strongly Agree Agree Disagree Strongly Disagree 4. How stressful would you say it is to work in this practice? Very stressful Somewhat stressful A little stressful Not stressful 5. How easy is it to ask anyone a question about the way we care for patients? Very easy Easy Difficult Very difficult 6. How would you rate other people s morale and their attitudes about working here? Excellent Very Good Good Fair Poor 7. This practice is a better place to work than it was 12 months ago. Strongly Agree Agree Disagree Strongly Disagree 8. I would recommend this practice as a great place to work. Strongly Agree Agree Disagree Strongly Disagree 9. What would make this practice better for patients? 10. What would make this practice better for those who work here? 2003, Trustees of Dartmouth College, Nelson 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005

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37 Primary Care Practice Profile A. Purpose: Why does your practice exist? Site Name: Site Contact: Date: Practice Manager: MD Lead: Nurse Lead: B. Know Your Patients: Take a close look into your practice, create a high-level picture of the PATIENT POPULATION that you serve. Who are they? What resources do they use? How do the patients view the care they receive? Est. Age Distribution List Your Top 10 Top Referrals (e.g. % of Patients: Diagnoses/Conditions GI Cardiology) Patient Satisfaction Scores Birth-10 years Experience via phone years Length of time to get your appointment years Saw who patient wanted to see years Satisfaction with personal manner years Time spent with person today 80 + years % Females Est. # (unique) pts. In Practice Disease Specific Health Outcomes, pg 24 Diabetes HgA1c = Hypertension B/P = LDL <100 = Patients who are frequent users of your practice and their reasons for seeking frequent interactions and visits Other Clinical microsystems you interact with regularly as you provide care for patients (e.g. OR, VNA) 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005 % Excellent Pt Population Census: Do these numbers change by season? (Y/N) # Y/N Patients seen in a day Patients seen in last week New patients in last month Disenrolling patients in last month Encounters per provider per year Out of Practice Visits Condition Sensitive Hospital Rate Emergency Room Visit Rate *Complete Through the Eyes of Your Patient, pg 9 C. Know Your Professionals: Use the following template to create a comprehensive picture of your practice. Who does what and when? Is the right person doing the right activity? Are roles being optimized? Are all roles who contribute to the patient experience listed? What hours are you open for business? How many and what is the duration of your appointment types? How many exam rooms do you currently have? What is the morale of your staff? Current Staff Enter names below totals Use separate sheet if needed MD Total NP/PAs Total RNs Total LPNs Total LNA/MAs Total Secretaries Total FTEs Comment/ Function 3 rd Next Available Cycle Time Days of Operation Hours PE Follow-up Range Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you offer the following? Check all that apply. Group Visit Web site RN Clinics Phone Follow-up Phone Care Management Disease Registries Protocols/Guidelines Appoint. Type Duration Comment: Others: Staff Satisfaction Scores % How stressful is the Do you use Float Pool? Yes No practice? % Not Satisfied Do you use On-Call? Yes No Would you recommend it as a good place to work? % Strongly Agree *Each staff member should complete the Personal Skills Assessment and The Activity Survey, pgs D. Know Your Processes: How do things get done in the microsystem? Who does what? What are the step-by-step processes? How long does the care process take? Where are the delays? What are the between microsystems hand-offs? 1. Track cycle time for patients from the time they check in until they leave the office using the Patient Cycle Time Tool. List ranges of time per provider on this table, pg 16/17 2. Complete the Core and Supporting Process Assessment Tool, pg 18 E. Know Your Patterns: What patterns are present but not acknowledged in your microsystem? What is the leadership and social pattern? How often does the microsystem meet to discuss patient care? Are patients and families involved? What are your results and outcomes? Does every member of the practice meet Do the members of the practice regularly What have you successfully changed? regularly as a team? review and discuss safety and reliability What are you most proud of? How frequently? issues? What is your financial picture? What is the most significant pattern of variation? *Complete Metrics that Matter, pgs 23-24

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39 Patients Patients have valuable insight into the quality and process of care we provide. Real time feedback can pave the way for rapid responses and quick tests of change. This Point of Service Survey can be completed at the time of the visit to give real time measurement of satisfaction. Use the Primary Care Profile to review Know Your Patients. Determine if there is information you need to collect or if you can obtain this data within your organization. Remember the aim is to collect and review data and information about your patients and families that might lead to a new design of process and services. Conduct the Patient/Family Satisfaction Survey for 2 weeks with families if you currently DO NOT have a method to survey families. If you have a method, be sure the data is up to date and reflects the current state of your practice. Patient/Family Satisfaction with Primary Care Practice Access Survey Point of Service Date: Think about this visit. 1. How would you rate your satisfaction with getting through to the office by phone? Excellent Very Good Good Fair Poor 2. How would you rate your satisfaction with the length of time you waited to get your appointment today? Excellent Very Good Good Fair Poor 3. Did you see the clinician, or staff member, that you wanted to see today? Yes No Did not matter who I saw today 4. How would you rate your satisfaction with the personal manner of the person you saw today (courtesy, respect, sensitivity, friendliness)? Excellent Very Good Good Fair Poor 5. How would you rate your satisfaction with the time spent with the person you saw today? Excellent Very Good Good Fair Poor Comments: Thank You For Completing This Survey 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005

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41 Patients Primary Care Practice Patient Viewpoint Survey Today s Office Visit Please rate the following questions about the visit you just made to this office. 1. The amount of time you waited to get an appointment. 2. Convenience of the location of the office. 3. Getting through to the office by phone. 4. Length of time waiting at the office. 5. Time spent with the person you saw. 6. Explanation of what was done for you. 7. The technical skills (thoroughness, carefulness, competence) of the person you saw. 8. The personal manner (courtesy, respect, sensitivity, friendliness) of the person you saw. 9. The Clinician s sensitivity to your special needs or concerns. 10. Your satisfaction with getting the help that you needed. 11. Your feeling about the overall quality of the visit. Excellent Very Good Good Fair Poor General Questions Please answer the general questions about your satisfaction with this practice. 12. If you could go anywhere to get health care, would you choose this practice or would you prefer to go someplace else? Would choose this practice Might prefer someplace else Not sure 13. I am delighted with everything about this practice because my expectations for service and quality of care are exceeded. Agree Disagree Not sure 14. In the last 12 months, how many times have you gone to the emergency room for your care? None One time Two times Three or more times 15. In the last 12 months was it always easy to get a referral to a specialist when you felt like you needed one? Yes No Does not apply to me 16. In the last 12 months how often did you have to see someone else when you wanted to see your personal doctor or nurse? Never Sometimes Frequently 17. Are you able to get to your appointments when you choose? Never Sometimes Always 18. Is there anything our practice can do to improve the care and services for you? No, I m satisfied with everything Please specify improvement: Yes, some things can be improved 19. Did you have any good or bad surprises while receiving your care? Yes, many things can be improved Good Bad No surprises Please describe: About You 20. In general, how would you rate your overall health? Excellent Very good Good Fair Poor 21. What is your age? Under 25 years years years 65 years or older 22. What is your gender? Female Male Sources: Medical Outcomes Study (MOS) Visit-Specific Questionnaire (VSQ), 1993 Patient Utilization Questions, Dartmouth Medical School 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005

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43 Patients Gain insight into how your patients experience your practice. One simple way to understand the patient experience is to experience the care. Members of the staff should do a "Walk Through" in your practice. Try to make this experience as real as possible, this form can be used to document the experience. You can also capture the patient experience by making an audio or videotape. Tips for making the "Walk Through" most productive: 1. Determine with your staff where the starting point and ending points should be, taking into consideration making the appointment, the actual office visit process, follow-up and other processes. 2. Two members of the staff should role play with each playing a role: patient and partner/family member. 3. Set aside a reasonable amount of time to experience the patient journey. Consider doing multiple experiences along the patient journey at different times. Through the Eyes of Your Patients 4. Make it real. Include time with registration, lab tests, new patient, follow-up and physicals. Sit where the patient sits. Wear what the patient wears. Make a realistic paper trail including chart, lab reports and follow-up. 5. During the experience note both positive and negative experiences, as well as any surprises. What was frustrating? What was gratifying? What was confusing? Again, an audio or video tape can be helpful. 6. Debrief your staff on what you did and what you learned. Date: Walk Through Begins When: Staff Members: Ends When: Positives Negatives Surprises Frustrating/Confusing Gratifying 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005

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45 Provider Activity Survey Position: Providers MD NP PA Resident (please circle one) Name: Instructions: The purpose of this worksheet is to gather data on the amount of time you spend performing various activities. Please indicate (estimate) the percentage of time spent performing each activity listed below. Keep in mind; we are seeking to obtain data related to a typical period of work. Estimate the average amount of time; over the course of a typical work period (e.g., a week or a month), you spend on the activities listed on the attached table. Try not to represent either a worst-case scenario (i.e., crisis) or a best-case scenario. Estimate the average amount of time (as a percentage of your total time) you typically spend on these activities during a normal period. This is not a detailed time study. If an activity you perform is not included, please add to the list. Make sure that all of your activities are included. The sum of % of your time column should equal 100%. Activity See Patients in Clinic review chart history assess/diagnose patient determine treatment plan See Patients in Hospital Dictate/Document Patient Encounter dictate encounter review transcriptions & sign off Write Prescriptions Complete Forms referrals camp/school physicals Follow-Up Phone Calls answer patient messages & requests Evaluate Test Results review results and determine next actions Manage Charts Miscellaneous CME; attend seminars/attend weekly meeting % of Your Time Total 100% Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

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47 RN Activity Survey Position: RN Name: Instructions: The purpose of this worksheet is to gather data on the amount of time you spend performing various activities. Please indicate (estimate) the percentage of time spent performing each activity listed below. Keep in mind; we are seeking to obtain data related to a typical period of work. Estimate the average amount of time; over the course of a typical work period (e.g., a week or a month), you spend on the activities listed on the attached table. Try not to represent either a worst-case scenario (i.e., crisis) or a best-case scenario. Estimate the average amount of time (as a percentage of your total time) you typically spend on these activities during a normal period. This is not a detailed time study. If an activity you perform is not included, please add to the list. Make sure that all of your activities are included. The sum of % of your time column should equal 100%. Activity Triage Patient Issues/Concerns phone face-to-face Patient Education Direct Patient Care see patients in Clinic injections assist provider with patient visit Follow-up Phone Calls Review and Notify Patients of Lab Results normal and follow-up drug adjustments Complete Forms referrals camp/school physicians Call In Prescriptions Miscellaneous % of Your Time Total 100% Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

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49 MA Activity Survey Position: MA Name: Instructions: The purpose of this worksheet is to gather data on the amount of time you spend performing various activities. Please indicate (estimate) the percentage of time spent performing each activity listed below. Keep in mind; we are seeking to obtain data related to a typical period of work. Estimate the average amount of time; over the course of a typical work period (e.g., a week or a month), you spend on the activities listed on the attached table. Try not to represent either a worst-case scenario (i.e., crisis) or a best-case scenario. Estimate the average amount of time (as a percentage of your total time) you typically spend on these activities during a normal period. This is not a detailed time study. If an activity you perform is not included, please add to the list. Make sure that all of your activities are included. The sum of % of your time column should equal 100%. Activity Patient Flow greet & escort patients to room take vitals Clean/Set up Rooms Between Visits Perform Procedures EKGs Prepare Charts prepare charts for next day appointments Prepare Charts prepare charts for next day appointments Manage Patient Messages & Requests Notify Patients of Lab Results normal mail aways Health Forms Order Supplies and Stock Rooms Miscellaneous % of Your Time Total 100% Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

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51 LPN Activity Survey Position: LPN Name: Instructions: The purpose of this worksheet is to gather data on the amount of time you spend performing various activities. Please indicate (estimate) the percentage of time spent performing each activity listed below. Keep in mind; we are seeking to obtain data related to a typical period of work. Estimate the average amount of time; over the course of a typical work period (e.g., a week or a month), you spend on the activities listed on the attached table. Try not to represent either a worst-case scenario (i.e., crisis) or a best-case scenario. Estimate the average amount of time (as a percentage of your total time) you typically spend on these activities during a normal period. This is not a detailed time study. If an activity you perform is not included, please add to the list. Make sure that all of your activities are included. The sum of % of your time column should equal 100%. Activity Direct Patient Care see patients in clinic injections assist provider with patient visits Patient Flow greet and escort patients to room take vitals Clean/Set up Rooms Between Visits Perform Procedures EKGs Prepare Charts prepare charts for next day appointments Manage Patient Messages & Requests Notify Patients of Lab Results normal mail aways Health Forms Order Supplies and Stock Rooms Miscellaneous % of Your Time Total 100% Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

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53 Receptionist Activity Survey Position: Secretary/Receptionist Name: Instructions: The purpose of this worksheet is to gather data on the amount of time you spend performing various activities. Please indicate (estimate) the percentage of time spent performing each activity listed below. Keep in mind; we are seeking to obtain data related to a typical period of work. Estimate the average amount of time; over the course of a typical work period (e.g., a week or a month), you spend on the activities listed on the attached table. Try not to represent either a worst-case scenario (i.e., crisis) or a best-case scenario. Estimate the average amount of time (as a percentage of your total time) you typically spend on these activities during a normal period. This is not a detailed time study. If an activity you perform is not included, please add to the list. Make sure that all of your activities are included. The sum of % of your time column should equal 100%. Activity Manage Incoming Phone Calls schedule appointments take referral request information transfer to triage take messages for patient requests route calls Reschedule Patient Appointments call bumped and/or no show patients to reschedule Call Confirmation to Patients Manage Front Desk/Patient Requests greet patients; answer questions schedule labs, referrals, etc. after office visit Service Sheets/Paperwork review service sheets prepare batching sheet Miscellaneous % of Your Time Total 100% Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

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55 The Right Care for Every Patient Every Time Activity Survey Position: Name: Instructions: The purpose of this worksheet is to gather data on the amount of time you spend performing various activities. Please indicate (estimate) the percentage of time spent performing each activity listed below. Keep in mind; we are seeking to obtain data related to a typical period of work. Estimate the average amount of time; over the course of a typical work period (e.g., a week or a month), you spend on the activities listed on the attached table. Try not to represent either a worst-case scenario (i.e., crisis) or a best-case scenario. Estimate the average amount of time (as a percentage of your total time) you typically spend on these activities during a normal period. This is not a detailed time study. If an activity you perform is not included, please add to the list. Make sure that all of your activities are included. The sum of % of your time column should equal 100%. Activity % of Your Time Miscellaneous Total 100%

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57 The Right Care for Every Patient Every Time Personal Skills Needs Assessment - Microsystem Resources Development of each member in the practice is key to success. The Personal Skills Assessment tool can help determine education and training needs of each staff member. Each member completes an individual survey and then discusses the action plan with leadership and other staff. A plan is developed to help members achieve goals and be the best they can be. Personal Skills Needs Assessment Skill Needs Assessment Tool Name: Unit: Role: Date: Technical Skills: Work Home Want to Never Use Occasionally Frequently Learn Please rate the following on where and how often you use them CIS* Central Dictation Digital Dictation Link PDA (i.e., Palm Pilot) Word Processing (e.g. Word) Spreadsheet (e.g., Excel) Presentation (e.g., Powerpoint) Database (e.g., Access or File Maker Pro) Patient database/statistics Internet Printer access Fax Copier Telephone system Voice Mail Clinical Information Systems: Want to Never Use Occasionally Frequently Learn What features and functions do you use? Provider Schedule Patient Demographics Lab Results Pathology Problem List Review Reports/Notes Documentation Direct Entry Note Templates Medication Lists Medication Ordering Action Taken on Surgical Pathology *NOTE: CIS (clinical information systems) refers to hospital or clinic-based computers used for such functions as checking in patients, electronic medical records, accessing lab and x-ray information, etc. Customize your list of CIS features to determine skills needed by various staff members to optimize their roles. Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

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59 The Right Care for Every Patient Every Time Case For Improvement The Problem The clinical office and outpatient clinics and other service delivery sites lie at the heart of health care. For most patients, most of the time, these settings are the primary locus of care, trust, coordination, and affection. For most physicians, it is the primary workplace. Despite numerous local innovations in various elements of office-based care, many promising improvements remain unused, fragmented, isolated, and dispersed; their full potential has not yet been tapped. For example, numerous surveys and audits have documented shortcomings of practitioners in complying with well-established guidelines for the clinical aspects of care for patients with chronic disease. Providers feel unprepared and too rushed to meet the educational, clinical, and psychological needs of chronically ill patients and their caregivers. Patients experience care that is uncoordinated, impersonal, and unsupportive, often enduring delays of several weeks for an appointment with a primary care physician or specialist, extended waits when placed on hold, repeated phone calls to obtain a test result or to have a question answered by a provider, and wait times of over an hour to see a physician for a scheduled appointment. Better Models of Care Exist Many innovative practitioners and local managers have made important breakthroughs in the design and performance of office-based practice subsystems as well as outpatient clinics and services over the past several decades. For example, major advances have been reported in improved communication between clinicians and patients; greater levels of self-care by patients and their families; effective use of guidelines, protocols, and evidenced-based medicine; use of office-based computerized patient records; and the development of highly effective scheduling systems. Furthermore, many more such breakthroughs are achievable by adapting innovations from outside health care innovations in information management, performance tracking, physical design, scheduling, communications, and so-called "lean production" to the clinical office and outpatient settings. </P We believe that known innovations can be consolidated into new care delivery designs capable of fundamentally improved performance levels better clinical outcomes, lower costs, higher satisfaction, and improved efficiency. In an ideal office practice, clinicians and staff will be able to say: "We give patients exactly the care they want (and need) exactly when they want (and need) it." Care will be customized to individual preferences, capabilities, and learning styles, and will be coordinated among the clinicians in all health care sites. Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

60 The Right Care for Every Patient Every Time Sample Results By testing and implementing changes to reduce unnecessary visits, increase provider slots, and develop a registry, Iowa Health Systems (Des Moines, Iowa, USA) was able to increase patient visit cycle time to 45 minutes or more. Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

61 Know Your Patients Assessing Your Practice Discoveries and Actions Discoveries 1. Age Distribution 1. 30% of our patients > 65 years old 2. Disease Identification 2. We do not know what percent our patients have diabetes. 3. Health Outcomes 4. Most Frequent Diagnosis 3. We do not know what the range of HgA1C is for out patients with diabetes of if they are receiving appropriate ADA recommended care in a timely fashion. 4. We learned we had a large number of patients with stable hypertension and diabetes, seeing the physician frequently. We also learned that during certain season we had huge volumes of acute diseases such as URI, Pharyngitis and poison ivy. 5. Patient Satisfaction 5. We don t know what patients think unless they complain to us. Know Your Professionals 1. Provider FTE 2. Schedules 3. Regular Meetings 4. Hours of Operation 5. Activity Surveys Know Your Processes 1. Cycle Time 2. Key Supporting Processes 3. Indirect Patient Pulls Know Your Patterns 1. Demand on the Practice 2. Communication Discoveries 1. We were making assumptions about provider time in the clinic without really understanding how much time providers are OUT of the Clinic with hospital rounds, nursing home rounds, etc. 2. Several providers are gone at the same time every week, so one provider is often left and the entire staff works overtime that day. 3. The doctors meet together every other week. The secretaries meet once a month. 4. The beginning and the end of the day are always chaotic. We realized we are on the route for patients between home and work and want to be seen when we are not open. 5. All roles are not being used to their maximum. RNs only room patients and take vital signs, medical assistants doing a great deal of secretarial paperwork and some secretaries are giving out medical advice. Discoveries 1. Patient lengths of visits vary a great deal. There are many delays. 2. None of us could agree on how things get done in out practice. 3. The providers are interrupted in their patient care process frequently. The number one reason is to retrieve missing equipment and supplies from the exam room. Discoveries 1. There are peaks and lows of the practice depending on day of the week, session of the day or season of the year. 2. We do not communicate in a timely way, nor do we have a standard form to communicate. 3. Cultural 3. The doctors don t really spend time with non-doctors. 4. Outcomes 4. We really have not paid attention to our practice outcomes. 5. Finances 5. Only the doctors and the practice managers know about the practice money. 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005 Actions Taken 1. Designated special group visits to review specific needs of this age group including physical limitations, dietary considerations. 2. Staff reviewed coding/ billing data to determine approximate numbers of patients with diabetes. 3. Staff conducted a chart audit with 50 charts during a lunch hour. Using a toll designed to track outcomes; each member of the staff reviewed 5 charts and noted their findings on the audit tool. 4. Designed and tested a new model of care delivery for stable hypertension and diabetes optimizing the RN role in the practice using agreed upon guidelines, protocols and tools. 5. Implemented the point of service patient survey that patients completed and left in a box before leaving the practice. Actions Taken 1. Changed our scheduling processes, utilized RNs to provide care for certain subpopulations. 2. Evaluated the scheduling template to even out each provider s time to provide consistent coverage of the clinic. 3. Entire practice meeting every other week on Wednesdays. 4. Opened one hour earlier and stayed open one house later each day. The heavy demand was managed better and overtime dropped. 5. Roles have been redesigned and matched to individual education, training and licensure. Actions Taken 1. The staff identified actions to eliminate, steps to combine, and learned to prepare the charts for the patient visit before the patient arrives. The staff also holds daily huddles to inform everyone on the plan of the day and any issues to consider throughout the day. 2. Detailed flow charting of our practice to determine how to streamline and do in a consistent manner. 3. The staff agreed on standardization of exam rooms and minimum inventory lists that were posted inside the cabinet doors. A process was also determined on WHO and HOW the exam rooms would be stocked regularly and through the use of an assignment sheet, a person was identified and held accountable. Actions Taken 1. Resources and role are matched to demand volumes. Schedules are created which match resources to variation. 2. Every other week practice meeting to help communication and use of all staff to promote timely communication. 3. The staff meetings heightened awareness of behaviors has helped improve this. 4. Began tracking and posting on a data wall to keep us alter to outcomes. 5. Finances are discussed at the staff meetings and everyone is learning how we make a difference in our financial performance.

62 Common High Yield Wastes 1. Exam rooms not stocked or standardized missing supplies or equipment 2. Too many appointment types which create chaos in scheduling 3. Poor communication amongst the providers and support staff about clinical sessions and patient needs. 4. Missing information or chart for patient visit. 5. Confusing messaging system 6. High prescription renewal request via phone. Assessing Your Practice Discoveries and Actions Recommended Method to Reduce Waste - Create Standard Inventory supplies for all exam rooms. - Design process for regular stocking of exam rooms with accountable person - Standardize and utilize all exam rooms - Reduce appointment types to Utilize standard building block to create flexibility in schedule. - Conduct daily morning huddles to provide a forum to review the schedule, anticipate needs of patients, plan supplies/ information needed for a highly productive interaction between patient and provider. - Review patient charts BEFORE the patient arrives recommended the day before to ensure information and test results are available to support the patient. - Standardize messaging processes for all providers - Educate/ train messaging content - Utilize a process with prioritizing methods such as a bin system in each provider office. - Anticipate patient needs - Create reminder systems in office, e.g. posters, screensavers - Standardize information that Traps to Avoid - Don t assume rooms are being stocked regularly track and measure. - Providers will only use their own rooms - Providers cannot agree on standard supplies; suggest testing - Frozen schedules of certain types - Use one time (e.g minute building blocks ) - People not showing up for scheduled huddles. Gain support of providers who are interested, test ideas and measure results - Huddles last longer than 15 minutes, use a work sheet to guide huddle - Don t sit down - Avoid doing chart review when patient is present - If you have computerized test results, don t print the results - Providers want their own way adding to confusion to support staff and decreases ability for cross coverage - Content of message can t be agreed upon test something - Doesn t need to be the RN Medical assistants can obtain this information 7. Staff frustrated in roles and unable to see new ways to function. 8. Appointment schedules have limited same day appointment slots. 9. Missed diseasespecific/ preventive interventions and tracking. 10. Poor communication and interactions between members. 11. High no-show rate 12. Patient expectations of visit not met, resulting in phone calls and repeat visits. - Review current roles and functions using activity survey sheets - Match talent, education, training, licensure to function - Optimize every role - Eliminate functions - Evaluate follow-up appointments and return visit necessity. - Extend intervals of standard follow-up visits - Consider RN visits - Evaluate the use of protocols and guidelines to provide advice for homecare- - Consider phone care - Utilize the flow sheets to track preventative activities and diseasespecific interventions. - Utilize stickers on charts to alert staff to preventative/ disease specific needs - Review charts before patient visits - Create registries to track subpopulation needs. - Hold weekly staff meetings to review practice outcomes, staff concerns, improvement opportunities. - Education and Development - Consider improving same day access - Reminder systems - CARE vital sign sheet- - Evaluating patient at time of visit if their needs were met - Be sure to focus on talent, training and scope of practice not individual people. - Don t set a certain number of same day appointments without matching variations throughout the year. - Be alert to creating a system for multiple diseases and not have many stickers and many registries. - Hold weekly meetings on a regular day, time and place - Do not cancel make the meeting a new habit - Automated reminder telephone calls are not always well received by patients - Use reminders to question patient about needs being met - New habits not easily made. 2003, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005

63 The Right Care for Every Patient Every Time MEASURE 3 rd NEXT AVAILABLE APPOINTMENT Measure this once a week over the next month, always on the same day of the week. Do all providers on the same day. Day Time of day To get the 3rd available appointment, pretend a patient calls and the first 2 chronological appointments with a clinician do not work for the patient. Record the next chronologically available appointment. Count the days between today and the date of 3rd available for each physician. Count calendar days, which includes weekends, holidays, and days off. Do not count any saved appointments for urgent visits since they are blocked off the schedule. For more information please review the information on the IHI website. Week 1 Urgent New Patient (# calendar days) Established Patient (# calendar days) Routine Physicals Week 2 Urgent New Patient (# calendar days) Established Patient (# calendar days) Routine Physicals

64 The Right Care for Every Patient Every Time Week 3 Urgent New Patient (# calendar days) Established Patient (# calendar days) Routine Physicals Week 4 Urgent New Patient (# calendar days) Established Patient (# calendar days) Routine Physicals Week 5 Urgent New Patient (# calendar days) Established Patient (# calendar days) Routine Physicals

65 The Right Care for Every Patient Every Time MEASURE DAILY DEMAND This is the daily number of patient requests for appointments, no matter when the appointment is actually scheduled. This includes phone calls, walk-ins, fax and requests or patients sent to Urgent care on that day or any other referral request. Just make a tick mark for each request in the appropriate box. Need to determine if to be done by provider, department or total office. MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

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67 The Right Care for Every Patient Every Time MEASURE NO SHOW RATE Measure daily for a 2-week period. Include the patients that call to tell you they will not show up with less than a 24-hour notice. Monday Tuesday Wednesday Thursday Friday AM PM Monday Tuesday Wednesday Thursday Friday AM PM

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69 The Right Care for Every Patient Every Time New Patient Panel Size New patient numbers seen per month (over the next month) m ******************************************************************************************* ** Panel size The number of unique patients seen during the last 18 months. (Each patient is only counted one time even though they may have been seen 10 times.) This can usually be documented by your Practice Management (PM) system for you.

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71 Plan Phase Checklist The Right Care for Every Patient Every Time TASK DATE STARTED DATE COMPLETED SENT TO FMQAI INITIALS Establish the EHR Team Prioritization of Ideas/Recommendations Next Steps In Your Practice Implementation Timeline Template Change Management and Quality Improvement Processes (with color process flow) Electronic Health Record Implementation in Physician Offices: Critical Success Factors How To Improve Shape demand Match Supply and Demand Redesign the System Shortening Waiting Times: Six Principles for Improved Access Checklist for Implementing Open Access Scheduling Reduce Appointment Types Reduce Scheduling Restrictions Reduce Appointment Times By Using Building Blocks To Create Short And Long Appointment Times Maintain Truth In Scheduling Minutes Behind Graph Start On Time Agreement Office Visit Cycle Time Unplanned Activity Card DOQ-IT Current Return on Investment (ROI) Literature for EHRs in Small to Medium Sized Physician Offices Document Review

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73 The Right Care for Every Patient Every Time Establish the EHR Team It is critical to determine the level of interest and support for an EHR initiative among your colleagues and staff. If you can identify and empower champions, you increase the likelihood of success. You must also uncover potential resistance. Address individuals' concerns directly and invite them to be involved in the process. One of the best approaches is to identify the team early and assign roles. When each office staff becomes the member of the team, it becomes their project. See recommendation below. Team Members: Position Areas of Responsibility Person/Name Executive Sponsor Project Manager Project Director to play the leadership role. Manage and oversee all aspects of the EHR project including project administration and resource management. Clinical Leader Oversee the clinical impact of the project and make decisions about how clinical processes are redesigned. Business Leader Technical Leader Oversee the financial and legal concerns during the project. Responsible for the technical aspects of the project as well as the technical advisor to the project. Builder 1 Define and build the database and rules and procedures. Trainer 1 Develop procedures and curriculum and teaching the end users. No matter how these roles are filled, they must be filled. You may want to consider a consultant to fill the role of technical leader and/or project manager. Many EHR vendors can provide consultative services. If a consultant is used, a person in the practice serving in one of the other roles must provide oversight of the consultant.

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75 Prioritization of Ideas/Recommendations TEAM NAME: DATE: Use the following scale to prioritize ideas: 1 = Positive/High/Easy; 2 = Moderate/Medium; 3 = Negative/Low/Most Difficult Write down key resources needed for action, service and stakeholder issues, potential dollar savings, and implementation start date Idea/Recommendation (Please print each idea) Outcomes patient & clinical impact (1=Positive 3=Negative) Cost savings opportunity (1=High 3=Low) Buy-in ease (e.g., MDs, Nurses) (1=Easy 3=Difficult) Ease of implement ation (1=Easy 3=Difficult) Total Resources needed & estimated cost for each Issues: clinical, service & stakeholder Saving potential ($) Date of implementation Page 1 of 2 Prioritization of Ideas/Recommendations

76 Idea/Recommendation (Please print each idea) Outcomes patient & clinical impact (1=Positive 3=Negative) Cost savings opportunity (1=High 3=Low) Buy-in ease (e.g., MDs, Nurses) (1=Easy 3=Difficult) Ease of implement ation (1=Easy 3=Difficult) Total Resources needed & estimated cost for each Issues: clinical, service & stakeholder Saving potential ($) Date of implementation Page 2 of 2 Prioritization of Ideas/Recommendations

77 Next Steps In your Practice Implementation Timeline Template [Team Name] Team Project: Who Resp Key Stake-holders Date Complete Major Deliverable WK 1 WK 2 WK 3 WK 4 WK 1 WK 2 WK 3 WK 4 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Page of

78 [Team Name] Team Project: Who Resp Key Stake-holders Date Complete WK 1 WK 2 WK 3 WK 4 WK 1 WK 2 WK 3 WK 4 Page of

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81 Change Management and Quality Improvement Processes Role of Executives Show active and visible support, both privately and professionally Ensure that the change remains a priority demonstrate their commitment as a role model of change Provide compelling justification for why the change is happening Communicate a clear understanding of the goals and objectives of the change Provide sufficient resources for the team and project to be successful Change Management Methodology/Strategy Change readiness assessments (assessing employees and managers in areas such as culture and values, past changes, employee readiness and resistance) Communications (includes communication planning and communication activities) Training (education and training programs to build skills and knowledge) Executive sponsorship (the visible actions by business leaders) Incentive and reward programs (ranging from small incentive programs to compensation changes) Employee feedback (enabling employees to openly share their thoughts and feelings about the change) Supervisor's direct coaching to employees (helping individual employees through the change process) Resistance management (tactics for systematically managing resistance) Sacrificial lamb (visibly removing a key manager that is an obstacle to change) Employee participation (involving employees in the design of the change) Key Components of Managing Change See chart following this page Quality Improvement Process and Measuring Success It is useful to consider how you are going to tell whether you were successful in your transition to an EHR. Is it that you use the EHR? Is it that you increased revenue? Is it higher job satisfaction? Or is it some combination of these? It would benefit the practice, if you can develop a detailed framework with pre- and post-measures to determine whether your EHR implementation succeeded. This is the time to develop those criterions and begin measurement. This should be a team effort as Quality Improvement never ends and it involves everyone in a practice.

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83 Skills Incentives Resources Action Plan Lack of Direction Vision Incentives Resources Action Plan Off Target Vision Skills Resources Action Plan Lack of Buy-In Vision Skills Incentives Action Plan Frustration Vision Skills Incentives Resources Incorrect Focus Vision Skills Incentives Resources Action Plan

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85 The Right Care for Every Patient Every Time Electronic Health Record Implementation in Physician Offices: Critical Success Factors Overview Implementation refers to the process of introducing an EHR into a physician office. The effort of designing, implementing, and using an information system involves numerous considerations and a series of processes that change the organization, the people and the information system involved. Successful implementation of an electronic health record in the physician office involves application of technical, project management, and organizational skills, and embodies much more than mere installation of appropriate hardware and software. As Wager et al succinctly states, Technical success alone does not ensure the EMR will be accepted and used by physicians The success of EMR implementation and utilization depends on the integration of the system into an often complex organizational setting. Additional research supports this conclusion. In a case study of five community-based practices, all of which implemented the same EHR system, the authors found that the same EHR in comparable settings was viewed very differently. They conclude that within the practices analyzed, perceived success or failure of the EMR system appeared to be related to organizational factors that were present before or during system implementation. Literature describing implementation of EHRs into physician offices emphasizes the importance of broader organizational context and the effects that EHR introduction has on office workflow and culture. Given the importance of these factors in the implementation process, evaluation of medical informatics projects is increasingly taking into account the social, organizational, political, and other non-technical factors surrounding an information systems project. vi In a report titled Successful Computerization in Small Primary Care Practices: A Report on Three Years of Implementation Experience, Keshavjee et al state, initial success of EMR implementation is largely dependant on managing the stress of the major change in the practice and depends on a perception that sufficient value is gained from the change to justify the costs vii Proper planning, training, and organizational mobilization are critical success factors to EHR implementation. EHR Implementation: Phases and Benchmarks of Successful Implementation As the framework below reflects, a large proportion of the effort associated with implementation should occur before the actual system is installed. Critical to project success is the up-front investment of time and energy. viii To illustrate this, in an eight-phase IT project framework outlined by Worthley in his textbook, Managing Information in Healthcare, system installation is the seventh step in the process. ix The majority of the implementation process precedes installation, and involves problem identification, system design, and testing. Various implementation and IT project management processes have been put forth in the literature. The outline below highlights dominant themes and factors identified with successful EHR implementation, but is not intended to serve as a comprehensive checklist or sequential timeline to successful implementation. Rather, it is intended as a broad framework to identify many of the key broad and widely cited critical success factors for EHR implementation. It is broken down into three major phases: Pre-Installation, Installation, and Post-Implementation. As the literature suggests, the majority of critical success factors fall into the preinstallation phase.

86 The Right Care for Every Patient Every Time Pre-Installation Identify Physician Champion In a study of solo/small physician practices in California, the authors state, identify an EMR Champion- or don t implement x. The importance of strong physician leadership is underscored in the literature. The literature broadly emphasizes the importance of a physician champion to drive EHR implementation. The following characteristics are associated with this lead: Formal or informal authority to lead change: A well-respected leader who is powerful enough to make things happen. Commitment to EHR implementation and ability to sell benefits to other physicians and office staff. To be successful, physicians and office staff must buy-in to the project. This leader must be careful to set realistic expectations. Prepare Organization for Change Change management is critical to successful EHR implementation. Prior to implementing and installing an EHR, a leader must prepare the organization for change by identifying core values, understating broader organizational context and stakeholder concerns, understanding end-user needs, creating a vision for change, and being sensitive and responsive to organizational stress resulting from change. Identify Strategic Objectives A critical element in preparing an organization for the change that will result from implementation of an informatics project is identifying key core values and focusing efforts on those. Clarifying areas for practice improvement in quality and efficiency helps to focus IT solutions on these areas. Strategic alignment of IT investments with the practice s clinical and business strategies is one important critical success factor for organizations that wish to assess the ROI of IT investments. Gain Support of Organizational Leadership/Secure Management Commitment The importance of organizational support is one of the most dominant factors associated with successful implementation of EHR. Support from management and/or senior leadership helps ensure adequate resource commitment, critical to successful implementation. Such resources are needed to build an infrastructure to support the system and its users over time and include not only up-front investment in hardware and software, but also time and staff allocation. In one study of EMR implementation in an ambulatory care setting, the authors found an association between perceived usefulness of an EMR and organizational support. The authors explain, By providing strong support for the redesign effort, management can communicate its commitment to the EMR investment. xx

87 The Right Care for Every Patient Every Time Involve Multiple Stakeholders Involve the entire staff including upper management and administrative staff in implementation and training activities. Being able to meet the needs of conflicting stakeholders, including physicians, nurses, office staff and administrators, as well as vendors and patients requires a strong project manager who can ascertain broad needs, build support, and effectively negotiate solutions. Good Project Management Establish project infrastructure (i.e. project team, including project manager, physician champion) to support proper planning and ongoing support of the project. Consider Workflow Redesign To be successful, health informatics systems need to support- or at least not be in conflict with- the organizational structures of the organization in which the systems are implemented. In one case study of EHR implementation in a solo pediatric practice, one critical success factor identified was the minimal amount of reengineering that occurred in re-designing workflow: automated processes reflected, and sometimes simplified the physician s manual workflow. Conduct Research The process of choosing software is an important time to learn about the strengths and weaknesses of the EMR, the vendor who is selling it and the type of support that is likely to be required for the EMR product Site visits and speaking to experts helps establish realistic expectations for physicians looking to implement systems. Offer Hands-On Training and Testing of Software Hands-on training, geared at appropriate computer skill levels is critical. Hands-on training with a software demonstration program, or a simulated demonstration model should occur early and often, and be tailored to the needs and work schedules of the physicians. Go Live Go live date should be boring because all staff has had experience testing and using software. Application/installation of hardware/software: Computer hardware should be selected and ordered well before installation. Staff should already be familiar with the hardware from training activities Cable high volume work areas and exam rooms

88 The Right Care for Every Patient Every Time Post-Installation Ongoing EMR Quality Improvement and Management One EHR Implementation methodology suggests that after the EHR software is installed, the ongoing management should be handed over to an office support team. As software, technology and medicine change, practices will continually have to adapt. Building flexible systems and continuous improvement of management processes are among the critical issues to consider in analyzing the success of health informatics projects. Ensure Ongoing IT Support: Vendor and/or In-House Vendor support: The importance of proper technical support cannot be understated. Various authors cite the importance of vendor support On-site technical support: It is important to have on-site support to make adjustments to the system, and address technical issues that arise. In one literature review, the authors report many successful implementation efforts involve physician super-users who assist in training of others. Super-users are those physicians who rapidly become expert users such that other physicians can call upon them for assistance. Customizing EMR: Some reports suggest that the ability to customize an EHR to physician and practice needs is related to the success of EHR implementation. However, opinions in the literature regarding the importance of EHR customization are mixed. In a literature review of best practices in EHR implementation, Keshavjee et al found the ability to customize software was cited in the literature much less frequently than many other critical success factors. Many authors neglected to mention whether their software was customizable, whether they did any customization work or whether they thought customization of EMR software was important to achieve success in their implementation Most implementers mentioned that special problem-solving teams involving technical people, trainers, nurses and physicians were an important tool to help achieve course corrections when problems start arising after go-live. Problems were considered inevitable and having dedicated staff to help users resolve their problems and achieve productivity goals is an important tool for implementers as they computerize practices. This material was prepared by Florida Medical Quality Assurance, Inc., the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

89 The Right Care for Every Patient Every Time HOW TO IMPROVE Primary Care Access Three strategies for improving patient access are: 1. Shape Demand: Improving access is all about increasing the ability of the system to predict and absorb demand (patients requests for care). Reducing the amount of demand makes it easier for the system to absorb current or future levels of demand. 2. Match Supply and Demand: To improve access, clinics should balance supply and demand. If the demand is greater than supply, there is a delay in providing care. If the supply is greater than demand, then resources are being wasted. When supply and demand are matched, there is no delay in providing care. 3. Redesign the System: One way to increase a clinic s ability to absorb more demand is to make the clinic more efficient. If an appointment now takes 45 minutes, but can be redesigned to take 20 minutes, then more patients can be seen on a given day. This doesn t necessarily mean working faster, but working smarter. It doesn t mean less time with patients; it means more quality time with patients. Although the strategies are not arranged in a sequential order, most clinics find it useful to do the following: Know the extent of access delays Begin working down the backlog of appointments Match supply and demand by reducing or shaping demand and redesigning the system to increase supply Many health care organizations have used the Model for Improvement* very successfully to test and implement changes. Using the key elements of the model, especially testing changes on a small scale with Plan-Do-Study-Act (PDSA) cycles,** has helped organizations improve patient access. Including the right people on a process improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs. Improvement Methods The Model for Improvement,* developed by Associates in Process Improvement, is a simple yet powerful tool for accelerating improvement. The model is not meant to replace change models that organizations may already be using, but rather to accelerate improvement. This model has been used very successfully by hundreds of health care organizations in many countries to improve many different health care processes and outcomes. The model has two parts: Three fundamental questions, which can be addressed in any order. The Plan-Do-Study-Act (PDSA) cycle** to test and implement changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement. Page 1 of 8

90 The Right Care for Every Patient Every Time Including the right people on a process improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs. Forming the Team Including the right people on a process improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs. First, review the aim. Second, consider the system that relates to that aim: What processes will be affected by the improvement efforts? Third, be sure that the team includes members familiar with all the different parts of the process managers and administrators as well as those who work in the process, including physicians, pharmacists, nurses, and front-line workers. Examples of Effective Teams Effective teams include members representing three different kinds of expertise within the organization: system leadership, technical expertise, and day-to-day leadership. There may be one or more individuals on the team with each kind of expertise, or one individual may have expertise in more than one area, but all three areas should be represented in order to drive improvement successfully. System Leadership Teams need someone with enough authority in the organization to institute a change that has been suggested and to overcome barriers that arise. The team's system leader understands both the implications of the proposed change for various parts of the system and the more remote consequences such a change might trigger. It is important that this person have authority in all of the areas that are affected by the change. This person must have the authority to allocate the time and resources the team needs to achieve its aim. Clinical Technical Expertise A technical expert is someone who knows the subject intimately and who understands the processes of care. An expert on improvement methods can provide additional technical support by helping the team determine what to measure, assisting in design of simple, effective measurement tools, and providing guidance on collection, interpretation, and display of data. Day-to-Day Leadership A day-to-day leader is the driver of the project, assuring that tests are implemented and overseeing data collection. It is important that this person understands not only the details of the system, but also the various effects of making change(s) in the system. This person also needs to be able to work effectively with the physician champion(s). Page 2 of 8

91 The Right Care for Every Patient Every Time Example: Improving Care in Office Practices Aim: We will improve care for all our patients with chronic disease by making improvements in our clinic that impact the six dimensions of quality, as outlined in the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century. Team: Team Leader:, MD, Medical Director for primary care clinics Technical Expert:, MD, Physician at downtown clinic Day-to-Day Leader:, RN, Manager of downtown primary care clinic Additional Team Members: Patient educator, medical assistant, clerk/scheduler, laboratory manager, quality expert Setting Aims Improvement requires setting aims. An organization will not improve without a clear and firm intention to do so. The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected. Agreeing on the aim is crucial; so is allocating the people and resources necessary to accomplish the aim. In 1999, the Institute of Medicine (IOM) in Washington, DC, USA, released To Err Is Human: Building a Safer Health System, a report that brought much public attention to the crisis of patient safety in the United States. In 2001, the IOM issued a second report, Crossing the Quality Chasm: A New Health System for the 21st Century, which outlines six overarching "Aims for Improvement" for health care: Safe: Avoid injuries to patients from the care that is intended to help them. Effective: Match care to science; avoid overuse of ineffective care and under use of effective care. Patient-Centered: Honor the individual and respect choice. Timely: Reduce waiting for both patients and those who give care. Efficient: Reduce waste. Equitable: Close racial and ethnic gaps in health status. Many organizations use the six IOM aims to help them develop their aims. Example For Clinic Access Reduce waiting time to see a urologist by 50 percent within 9 months. Offer all patients same-day access to their primary care physician within 9 months. Reduce waiting time to see a physician to less than 15 minutes within 9 months. Page 3 of 8

92 The Right Care for Every Patient Every Time Establishing Measures Measurement is a critical part of testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement. Measurement for improvement should not be confused with measurement for research. This difference is outlined in this chart: Measurement for Research Purpose To discover new knowledge Measurement for Learning and Process Improvement To bring new knowledge into daily practice Tests One large "blind" test Many sequential, observable tests Biases Control for as many biases as possible Stabilize the biases from test to test Data Gather as much data as possible, "just in case" Gather "just enough" data to learn and complete another cycle Duration Can take long periods of time to obtain results "Small tests of significant changes" accelerates the rate of improvement Three Types of Measures Use a balanced set of measures for all improvement efforts: Outcome Measures (voice of the customer or patient): How is the system performing? What is the result? For diabetes: Average hemoglobin A1c level for population of patients with diabetes For access: Number of days to appointment For critical care: Intensive Care Unit (ICU) mortality For medication systems: Adverse drug events per 1,000 doses Process Measures (voice of the workings of the system): Are the parts/steps in the system performing as planned? For diabetes: Percentage of patients with hemoglobin A1c level measured twice in the past year For access: Average daily clinician hours available for appointments For critical care: Use of adverse drug event chart review Page 4 of 8

93 The Right Care for Every Patient Every Time Balancing Measures (looking at a system from different directions/dimensions): Are changes designed to improve one part of the system causing new problems in other parts of the system? For reducing time patients spend on a ventilator after surgery: Make sure reintubation rates are not increasing For reducing patients' length of stay in the hospital: Make sure readmission rates are not increasing Sample Measures For Access Time to third next available appointment Delay from time of appointment to time to see clinician Percentage of "good" or "very good" answers on selected patient satisfaction survey questions Average daily clinician hours available for appointments Average daily demand for appointments For Diabetes Percentage of patients with HbA1c (blood sugar) level measured twice in the past year Percentage of patients with documented self-management goals Average HbA1c level for population of patients with diabetes Percentage of patients with documented foot exam in the past year Percentage of patients with fasting LDL cholesterol level less than 100 in the past year Selecting Changes This model uses three key strategies to eliminate waiting times. Although the strategies are not arranged in a sequential order, most clinics find it useful to: (1) Know the extent of access delays; (2) Begin working down the backlog of appointments; and (3) Match supply and demand by reducing or shaping demand and redesigning the system to increase supply. In contrast to traditional methods of dealing with access, this model seeks not to control the daily patient demand for care, but rather to predict it and respond to it. This model is based on the principle that when supply and demand are in balance (or equilibrium) there is no need for waits in the system. In traditional systems, demand is divided into urgent and routine. This division creates a delay by creating separate lines (or queues) for different types of patients. Removing the queues removes the delay. Page 5 of 8

94 The Right Care for Every Patient Every Time Three strategies for building a sustainable system for improved patient access are: 1. Shape Demand: Improving access is all about increasing the ability of the system to predict and absorb demand (patients requests for care). Reducing the amount of demand makes it easier for the system to absorb current or future levels of demand. 2. Match Supply and Demand: A clinic with improved access is one where supply and demand are in alignment. If the demand is greater than supply, there is a delay in providing care. If the supply is greater than demand, then resources are being wasted. When supply and demand are matched, there is no delay in providing care. 3. Redesign the System: One way to increase a clinic s ability to absorb more demand is to make the clinic more efficient. If an appointment now takes 45 minutes, but can be redesigned to take 20 minutes, then more patients can be seen on a given day. This doesn t necessarily mean working faster, but working smarter. It doesn t mean less time with patients; it means more quality time with patients. Match Supply and Demand: Understand Supply and Demand in Primary Care Improving access is all about getting supply and demand in equilibrium. Match Supply and Demand: Understand Supply and Demand in Specialty Care Improving access is all about getting supply and demand in equilibrium. Shape the Demand: Reduce the Backlog "Backlog" consists of all of the appointments that are on the future schedule for a particular clinic. Match Supply and Demand: Reduce Appointment Types Having a lot of appointment types actually increases total delay in the system because each appointment type creates its own differential delay and queue. Match Supply and Demand: Plan for Contingencies For clinics with Advanced Access, contingency plans shift the variation from the demand (patient) side to the supply (provider) side. Shape the Demand: Reduce Demand in Primary Care Reducing the amount of demand makes it easier for the system to absorb current or future levels of demand. Shape the Demand: Reduce Demand in Specialty Care Improving access is all about increasing the ability of the system to predict and absorb demand (patients requests for care). Redesign the System: Understand Supply and Demand Improving access is all about getting supply and demand in equilibrium. Redesign the System: Synchronize Patient, Provider, and Information The production of goods and services in any system usually involves multiple stages operating at different times and different speeds. Redesign the System: Predict and Anticipate Patient Needs at Time of Appointment To ensure that patient needs are met and that patients flow smoothly through the clinic process, staff look ahead on the schedule to identify patient needs for a given day or week. Page 6 of 8

95 The Right Care for Every Patient Every Time Redesign the System: Optimize the Environment Fully utilizing rooms and equipment increases the number of patients that can be seen each day. Redesign the System: Optimize the Care Team Staff mix is key to maximizing the capacity of the clinic. Redesign the System: Manage the Constraint One characteristic of systems is that there is always a constraint on the flow. TESTING CHANGES Once a team has set an aim, established its membership, and developed measures to determine whether a change leads to an improvement, the next step is to test a change in the real work setting. The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for actionoriented learning. Reasons to Test Changes To increase your belief that the change will result in improvement. To decide which of several proposed changes will lead to the desired improvement. To evaluate how much improvement can be expected from the change. To decide whether the proposed change will work in the actual environment of interest. To decide which combinations of changes will have the desired effects on the important measures of quality. To evaluate costs, social impact, and side effects from a proposed change. Page 7 of 8

96 The Right Care for Every Patient Every Time Steps in the PDSA Cycle Step 1: Plan Plan the test or observation, including a plan for collecting data. State the objective of the test. Make predictions about what will happen and why. Develop a plan to test the change. (Who? What? When? Where? What data need to be collected?) Step 2: Do Try it out the test on a small scale. Carry out the test. Document problems and unexpected observations. Begin analysis of the data. Step 3: Study Set aside time to analyze the data and study the results. Complete the analysis of the data. Compare the data to your predictions. Summarize and reflect on what was learned. Step 4: Act Refine the change, based on what was learned from the test. Determine what modifications should be made. Prepare a plan for the next test. Page 8 of 8

97 The Right Care for Every Patient Every Time Shortening Waiting Times: Six Principles for Improved Access Thinking about delivering health care like UPS delivers boxes might make some people uneasy. But Mark Murray, MD, MPA, says health care providers can learn a lot from the successful companies that track packages, assemble cars, and serve food quickly. Adding a bit of understanding of economic supply and demand theory can t hurt either. The work that corporations have put into streamlining processes should be harnessed by health care to reduce the bane of many health systems existences: waiting times, everything from the extra hour in a doctor s office to an extra six months waiting for a procedure that is in limited supply. Murray points to six principles for improving access: understanding the balance between supply and demand, recalibrating the system, applying queuing theory, creating contingency plans, influencing the demand, and managing the constraints. Understanding the Balance Between Supply and Demand "If we can get a balance between the demand for appointments and the supply of appointments if we can get, understand, and measure that balance then we can eliminate waiting times," says Murray. "That involves basically doing today s work today, rather than using the old paradigm of stratifying urgent and non-urgent work. This does not prevent us from being able to see those patients with urgencies; changing the way that we see priority allows us to do the work that needs to be done today, as well as the work that could be done today." But hardly anyone is doing things that way. "We just don t see it that way in health care," says Murray. Working in systems that are always behind or late, "there is a strong imperative to take care of those patients who are sick," he says. "So what we do is find mechanisms to get those patients who can t wait in immediately. So, instead of thinking about how the whole system works dynamically, we only try to solve one part of the equation, which is, how do I take care of those patients with so-called urgent care needs? " What results is a fairly even flow of work, but three months late. One way to change that is to consider how external demand and internal demand contribute to the whole picture. Primary care physicians don t have much control over external demand, says Murray when patients decide they are sick or need to be seen. Internal demand, however, is far more controllable; it is created by doctors who bring patients back for repeat visits or checkups. "You use the internal demand to load-level," he says. "You bring patients back at times during the day when demand is predictably lower early mornings or late in the week." The second way is to measure the supply and "recognize that it s the supply variation that causes the waiting times," Murray says. The number of doctors working any particular day should fit the demand as well as possible "making sure we have enough supply each day, each half-day, each hour, each minute," he says. Recalibrating the System "Once we understand the balance between demand and supply and we understand the system s dynamics, the second step is to recalibrate our system," says Murray. That means getting rid of the backlog like "draining a lake or emptying a warehouse." There s nothing magical about clearing out the warehouse; practices need to figure out how much work is coming in each day, and "do more stuff for a period of time to catch up." Applying Queuing Theory Health care providers must apply queuing theory to appointment scheduling. "If we can reduce the number of queues or lines, we can actually reduce the time it takes in total wait time inside the system," says Murray. Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

98 Shortening Waiting Times - Page 2 The Right Care for Every Patient Every Time Compare a grocery store and a bank, he says. At a grocery store, you pick a particular line. There are multiple lines, each with a specific clerk, and each with a short or long wait time. At a bank, however, one line feeds any one of a number of universal tellers. There s less waiting time at a bank, says Murray, and the reason is that you re "load-leveling." In health care, practices tend to have several different appointment types some for Pap smears, some for physical exams, and some for procedures. Where the increased waiting times occur is when there s an open slot for a physical exam, but no one is using it. "That s where we end up creating variation," says Murray, and that means longer waits. Reducing the number of appointment types which frees appointment clerks and receptionists from trying to figure out what patients want or putting them into a particular pigeonhole is probably one of the more dramatic ways to reduce demand." It s not always possible to do it completely variables such as needing a particular room for a sigmoidoscopy or accommodating a patient s choice of clinician can make it difficult but most of the time it can be done. Creating Contingency Plans This is where systems can accommodate the variations inherent in health care delivery. "There s demand variation and there s supply variation, and the contingency plans deal with or address, how do we manage those predicted variations in a predetermined manner? We re prepared to deal with the variation rather than react to it." Practices should ask, "What are we going to do when there s variation in supply or variation in demand?" says Murray. Despite what many doctors think, seasonal demand involving the flu, for example, is the result of not only some increase in demand, but is just as likely due to a decrease in supply, he notes. The January and February flu season follows the holiday season, during which many doctors take vacations. That means they re catching up on work from the holiday as well as handling increased demand; both must be taken into account when creating a contingency plan. Influencing the Demand "In primary care, the best way that we can influence demand is to cement that doctor- or clinician-patient relationship and to make sure that patients get to see their own providers every time and that providers get their patients every time," says Murray. When patients see their own providers, there are less visits and there is less time with each visit, explains Murray. "That relationship results in not only reduced visits, but better clinical outcomes and lower system costs," he says. "So continuity is really the key." Specialists already have continuity, Murray notes. "On the other hand, when we look at the specialists in terms of the constraints in the system [see below], what we often see is specialists are asked to do work that actually could be done by somebody else in the system. The development of service agreements between primary care and specialty care is a strong way to reduce the demand for specialty care." Such service agreements define which work is done by each of the entities, and defines the packaging in which the work is sent from one to the other, says Murray. "In addition, the service agreement helps clarify the referral process, both for those patients that are known and those patients that are unknown," he says. Managing the Constraints The constraints in a system are the rate-limiting step, Murray explains, and they ought to be the providers. In a private practice, things can only move as fast as the doctor-patient relationship. The trick here is to take the unnecessary work from the constraints, or elevate the care team so that work can be properly allocated to them, he says: "This frees up the providers to do the work they are unique and essential for." That means taking away any work that can be done by someone else. All of these approaches, he says, will result in doctors being able to "do the work sooner not quicker, but sooner." Clinical Microsystems, The Place Where Patients, Families and Clinical Teams Meet : Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement. Adapted from the original version, Dartmouth-Hitchcock, version 2, February 2005.

99 Checklist for Implementing Open Access Scheduling Task Date started Date completed Date sent to FMQAI Initials Determine backlog Separate good/bad backlog Create plan for Backlog Reduction Complete worksheet Set date for starting open access scheduling Educate staff Educate patients Create plan to address variations in supply and demand

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101 The Right Care for Every Patient Every Time Reduce Scheduling Complexity: Reduce Appointment Types Practices with improved access make no distinction between urgent and routine appointments. Remember, if the goal is to do today's work today, the distinction between urgent and routine is no longer necessary. For primary care, the only distinctions between appointment types needed are: Provider is present vs. provider is absent A short appointment type for return visits A long appointment type for physicals and new patients When the provider is present the patient is seen, and when the provider is absent the patient is offered the choice of an appointment the next time the provider is present or today with another care team member. All other special appointment types, such as those for disease entity or physicals by age groups, can be eliminated. Reducing appointment types simplifies telephone appointment triage, allows more flexibility for patients, and reduces queues. Adapted from IHI.org A resource from the Institute for Healthcare Improvement

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103 The Right Care for Every Patient Every Time Reduce Scheduling Complexity: Reduce Scheduling Restrictions In addition to reducing appointment types and times, practices can create more flexibility in their schedules by reducing other constraints such as only offering physicals on certain days of the week or times of the day. While some providers may initially fear that this change will create days with multiple back-to-back physicals, natural variation in demand means that the requests for physicals or other types of complex appointments are actually fairly evenly distributed across the appointment calendar. Adapted from IHI.org A resource from the Institute for Healthcare Improvement

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105 The Right Care for Every Patient Every Time Reduce Scheduling Complexity: Reduce Appointment Times by Using "Building Blocks" to Create Short and Long Appointment Times First decide on the scheduling increment or building block. For example, the increment may be 15 minutes and is used for the length of a short appointment. The long appointment is usually a multiple of the short appointment, for example, 30 or 45 minutes. The scheduler simply combines two or three short appointments to make a long appointment. Some practices standardize on a single appointment type and length so that a pace or cadence for the day can be set and maintained (e.g., a 20-minute appointment). The appointment length must be long enough to accommodate many different types of services and patient needs, and to allow providers to stay on time. For example, one patient visit may only require 10 to 15 minutes, leaving extra time for the next appointment should it take longer than the allotted 20 minutes. Adapted from IHI.org A resource from the Institute for Healthcare Improvement

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107 The Right Care for Every Patient Every Time Minutes Behind Graph Mark Murray & Associates, LLC Sacramento, California, USA A "Minutes Behind" graph is a very helpful way to show graphically the effect of providers starting late/staying late, starting late/catching up, and starting on time/getting late. The x (horizontal) axis is the time of day in appointment increments (ie -8:45, 9:00, 9:15, etc. if in 15- minute increments). The y (vertical) axis is the number of minutes behind, so would start at a negative number (in case they are ahead), come up to 0 (right on time), and proceed upwards from 0 (for # of minutes behind). So it might start with -20, -15, -10, -5, 0, 5, 10, 15, 20, etc. Background Case Study: One practice noticed that they were at 0 (on time) every day until about 10:30, and then got about 15 minutes behind. When they thought about what happened around 10:30, they discovered that a bolus of lab results arrived every day, and the MD took about minutes to review. Once they understood, they were able to flex and adapt. Directions Calibrate your axes with the appropriate start/end time and intervals. For every appointment time on the x axis, graph the number of minutes behind or ahead by provider. Whatever time the MD actually starts, graph the "minutes behind" or ahead. For example, if the provider gets in the room at 9:00 AM for the 8:45 AM patient, then at the 9:00 AM time, they are 15 minutes behind. Do that every 15 minutes, and watch the MD individual patterns emerge. If the providers starts on time at 8:45 AM, put a 0 in at that time. Show the providers the data, and analyze the patterns with them for insights and opportunities to improve. Adapted from IHI.org A resource from the Institute for Healthcare Improvement

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109 The Right Care for Every Patient Every Time Start on Time Agreement The providers and staff of are aware of the importance of starting each appointment session on time. We are committed to provide our patients with the most timely care possible. Therefore, we have signed this agreement to formalize our commitment to redesign our practice to make possible on time delivery of appointed care. This will include: Staff beginning work at such a time that they can prepare the first patient for the session before the time of the appointment with the provider. (This many necessitate moving to two appointments MA and provider) * Providers and staff committing to being at the work place ready to work at the appointed time. Pre-appointment chart review for completeness and presence. Changing registration for new patients to time of making appointment or during confirmation call. * See information on synchronize patient, information and provider. Signatures: Date Date Date Date Date Date Date Date Date

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111 The Right Care for Every Patient Every Time Office Visit Cycle Time Definition The office visit cycle time is the amount of time in minutes that a patient spends at an office visit. The cycle begins at the time of arrival and ends when the patient leaves the office. (Note: The cycle time does not include time spent in laboratories or radiology during primary care visits. Specialty clinics may opt to include testing and procedure time in total cycle time since these activities are an integral part of the planned specialty care visit.) Both primary care and specialty teams clinics may wish to distinguish between the time the patient spends with the physician or other members of the care team ("value-added" time) and the time spent waiting ("non-value-added time"). The goal is not to reduce total cycle time but to maximize the time the patient spends with the physician or other members of the care team. Office visit cycle time serves as a balancing measure for Time to Third Next Available Appointment. Balancing measures ensure that improvements in one area do not have negative consequences in another. For example, a clinic may improve its access but require patients to wait longer in the waiting room unless they are also working on ways to improve efficiency and patient flow. Goal Decrease the office visit cycle time to 30 minutes or 1.5 times the actual time spent with clinician. For example, if the average patient spends 20 minutes with a clinician during the office visit, then the goal for the office visit cycle time would be 30 minutes (1.5 x 20 minutes = 30 minutes). Data Collection Plan Sample a minimum of 15 patients per week on a pre-selected day and time. Use the same day and time of day each week. Selecting a time during the day that is often the busiest in the office (e.g., mid-morning Adapted from IHI.org A resource from the Institute for Healthcare Improvement

112 The Right Care for Every Patient Every Time for adult clinics, late afternoon for pediatric clinics) is a good method to ensure that the data captures the true capability of the system. At the agreed-upon start time, begin recording the time each patient checks in to clinic registration and the time the patient checks out. Stop collection when the data from 15 patients has been recorded. The clerk in the registration and/or check-out areas can record each person s name (or identifier) and time. If patient arrives early, time starts at scheduled time of appointment. One method for measuring the amount of time for each step in the patient visit (value and nonvalue added time) is to use a patient cycle tool. The patient takes the cycle form with them throughout the visit and records the time that each part of the visit begins (e.g., time the staff member left in the waiting room, time the provider came into the room, etc.). The Patient Cycle Tool is a simple, one-page data collection sheet for this measure. Patients or staff can fill out the sheet. Sample Graph Use Improvement Tracker to enter, save, and graph your team's data Adapted from IHI.org A resource from the Institute for Healthcare Improvement

113 The Right Care for Every Patient Every Time Unplanned Activity Card Trustees of Dartmouth College, Batalden, Godfrey, Nelson Hanover, New Hampshire, USA One way to understand inefficient processes and interrupted flow is by using the Unplanned Activity Card. The Unplanned Activity Card assists the team in identifying waits and delays in the process of providing smooth and uninterrupted patient care. Once the interruptions or delays are uncovered, teams can generate and test improvement ideas. Directions Download the file and have each provider carry the card during a patient session and document when and why patient care is delayed or interrupted. Put a "tic" mark for each incident of unplanned activity or Indirect Patient Care "Pulls." This tool can be adapted for any role in the practice to discover interruptions in workflow. Adapted from IHI.org A resource from the Institute for Healthcare Improvement

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115 Current Return on Investment (ROI) Literature for EHRs in Small- to Medium-Sized Physician Offices What is the current state of EHR ROI in Small- to Medium-Sized Physician Offices? Given the relatively new state of EHR implementation in small- to medium-sized practices and lack of current widespread adoption, only office-specific case studies of EHR implementations currently exist (see below), but fail to provide meaningful average estimated ROI that can be generalized to a state or national population of physician offices 1. The following reasons have been offered to explain why generalizing the findings of current case studies would not offer meaningful ROI 2. Smaller physician offices that have implemented EHRs have realized considerably different EHR ROI due to the variations in the determinate variables for ROI 3. Smaller physician offices have just recently begun implementing EHRs and exploring issues that directly affect ROI 8. Variations in physician support of EHR implementation Variations in EHR implementation support Variation in office activities and expenditures (i.e., office square footage, staffing hours, patient volume, and physician numbers) 4,5,6 Variation in EHR software and data management 7 Variation in EHR component selection, implementation and use (the wide menu of EHR components offer varied ROI when selected in different combinations by the physician offices) Patient privacy issues Private and government insurance reimbursement systems that are not compatible with EHR systems Lack of current, national interoperability of EHR applications 9 Clinical office workflow design is generally not yet compatible with EHR needs How long is it taking to see a ROI and how much is being realized? Though case studies have presented conflicting ROI results 10,11,12, the most comprehensive case study to date 13 has made the following findings: EHR ROI Per Physician Per Year over a 5-year Implementation Period ROI Year 1 Year 2 Year 3 Year 4 Year 5 Average -$21,700 $21,200 $14,600 $47,200 $47,200 Minimum -$11,900 $8,000 $4,700 $20,100 $20,100 Maximum -$26,600 $41,300 $31,400 $85,100 $85,100 5-Year EHR ROI Per Physician based on range of EHR Features Implemented Feature Light EHR Medium EHR Full EHR Online Patient Charts Electronic Prescribing Laboratory Ordering Radiology Ordering Electronic Charge Capturing Average ROI -$18,200* $44,600* $86,400* *Assumes a 5% discount rate

116 What is working? By reviewing a wide range of case studies that have been conducted to study small- to medium-sized physician office implementation of EHRs, the general findings are that ROI can be maximized if common barriers and benefits are addressed at implementation onset 14,15,16,17. Attributes of physician offices that have realized qualitative and quantitative ROI from EHR implementation. EHR office champion identified at onset Office physicians committed to EHR implementation at onset Electronic data exchange with labs and vendors is maximized Comprehensive EHR support is established at onset Office identified specific opportunities for improvement that the EHR system would address this led EHR vendor selection and focused EHR implementation efforts Complete conversion to a paperless system from onset 1 Podichetty V, Penn D. (2004). The progressive roles of electronic medicine: benefits, concerns, and costs. Am J Med Sci. 328(2): Miller R, Sim I, Newman J. (2003). Electronic medical records: lessons from small physician practices. University of California, San Francisco. Oakland, CA: California Healthcare Foundation. 3 Wager, K. A., Lee, F. W., White, A. W., (2000). Life after a disastrous electronic medical record implementation: one clinic s experience. Idea Group Publishing. 4 Erstad, T., (2003). Analyzing computer-based Patient Records: A Review of Literature. Journal of Healthcare Information Management, 17(4), Bingham, A., (1997). Computerized patient records benefit physician offices. Healthcare Financial Management, 51(9), Wang, A., Middleton, B., et al., (2003). A cost-benefit analysis of electronic medical records in primary care. The American Journal of Medicine, 114(5), MacDonald K, Metzger J. (2002). Achieving tangible benefits in small physician practices. First Consulting Group. Oakland, CA: California Healthcare Foundation. 8 Bodenheimer T, Grumbach, K. (2003). Electronic technology. A spark to revitalize primary care? JAMA 290: Hammond WE. (2004). Perspective: The Role Of Standards In Electronic Prescribing. Health Aff (Millwood) May Miller et al (2003). 11 MacDonald K, Metzger J. (2002). 12 Cooper JD. (2004). Organization, management, implementation and value of ehr implementation in a solo pediatric practice. Healthc Inf Manag. 18(3): Tables and data adapted from Wang, S. J. et al (2003). 14 MacDonald K, Metzger J. (2002). 15 Miller et al (2003). 16 Wager et al (2000). 17 Wang et al (2003). DOQ IT: Current Return on Investment (ROI) Literature for EHRs in Page 2 of 2 Small- to Medium-Sized Physician Offices

117 The Right Care for Every Patient Every Time Select Phase Checklist TASK Vendor Evaluation Matrix Evaluate and compare systems DATE STARTED DATE COMPLETED SENT TO FMQAI INITIALS DOQ-IT Vendor List Contracting Guidelines with EHR Vendors Glossary Red Flags and FAQ s Document Review

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119 Vendor Evaluation Matrix Instructions: Score each vendor on a scale from 1 (poor) to 5 (excellent) on each of your prioritized items. Total up your ratings for each vendor to help make your comparisons. Write the names of the vendors you are comparing in the watermark space provided in vendor columns. Use the blank rows at the end of the worksheet to ask your own questions. Functionality/Usability Priority Vendor A Vendor B Vendor C Vendor D Vendor E Charting Can the system accommodate (and potentially improve) my workflow? Can I easily build and/or customize off-the-shelf templates? Does the system offer a variety of data entry options, e.g., dictation, voice recognition, structured notes, etc.? Can I make subsequent edits and addendums to clinical documentation? Does the system alert me about unfinished portions of the clinical documentation and can I bypass it if necessary? Can I access other such clinical information as previous labs, progress notes, etc. from a patient s electronic chart while charting? Does the system allow me to multi-task, e.g., create task, order lab, etc. while charting? Does the system allow me to forward patient information to staff, other physicians, etc. via , electronic faxing, messaging, etc.? Does the system ensure that only authorized clinicians can sign clinical documentation? Prescriptions Can I complete a prescription within a few clicks? Can I look up medication information and is this information valuable?

120 Functionality/Usability Priority Vendor A Vendor B Vendor C Vendor D Vendor E How extensive (and how sensitive) is the system s interactions checking capability, e.g., drug-drug, drug-allergy, drug-food? How accurate is the system in identifying drug-condition warnings, e.g., pregnancy? Can I refill a medication within a few clicks? Can previous sigs be viewed from the refill screen? Can the system handle multiple drug formularies? Can the system send prescriptions electronically to pharmacies in my local market? Lab and Results Management Can I complete a lab order within a few clicks? Can the system send lab orders electronically to laboratories, hospitals, etc. in my local market? Can I pull up and review lab results within a few clicks? Can the system receive lab results electronically from laboratories, hospitals, etc. in my local market? Does the system notify me of abnormal lab results and provide normal ranges? Can the system show me trending of results over time? Can I create and/or customize off-the-shelf order sets? Decision Support Does the system utilize clinical information from all parts of the chart to provide decision support? Does the system alert me when patient data indicates intervention is recommended? Can I access medical literature, clinical guidelines, etc.? DOQ-IT: Vendor Evaluation Matrix Page 2 of 4

121 Functionality/Usability Priority Vendor A Vendor B Vendor C Vendor D Vendor E Disease and Population Management Assuming good data entry for all patients, can I query the system and identify patients that have a particular condition, are on a certain medication, etc.? Does the system track patients for follow-up and send out reminders? Can I create ad-hoc reports or am I limited to ones provided off-the-shelf? Can I customize these reports? Does reporting module handle and/or queries together? Health Record Management Can I look up a patient by a number of different criteria, e.g., name, MRN, SSN, etc.? Does the system provide a summary view of a patient s health status? Does the system handle other such clinical documents as x- rays, reports, etc.? Does the system allow me to maintain patient lists, e.g., problems, allergies, medications, etc.? Can I organize patient information within the system in a similar way to my paper charts? Clinical Tasking & Messaging Can I access and manage various tasks, e.g., sign progress notes, review labs, etc. within a few clicks? Can I task or message someone else in the practice and do it with a few clicks? Does system alert me of overdue tasks and urgent lab results? How disruptive are the alerts, are they customizable and can they be overridden? Can I manage tasks and messages from a computer other than my own? DOQ-IT: Vendor Evaluation Matrix Page 3 of 4

122 Functionality/Usability Priority Vendor A Vendor B Vendor C Vendor D Vendor E Financial considerations Roughly how much could the system cost my clinic? Can you offer an Application Service Provider (ASP) option, purchase option, or monthly subscription option? Roughly how much do the software licenses cost? About how much will on-going maintenance and upgrades cost? How often will a support person(s) be available once the system goes LIVE in case of any system difficulty? How are the licenses issued? Concurrent user versus per practitioner? TOTAL SCORE DOQ-IT: Vendor Evaluation Matrix Page 4 of 4

123 Vendor List The companies listed below are Electronic Health Record (EHR) and Health Information Technology (HIT) vendors, which have declared their support for the DOQ-IT program. These vendors have agreed to sign a DOQ-IT letter of intent to declare their intention to meet program expectations regarding the capture and output of clinical quality data. Note to members of the American Academy of Family Physicians (AAFP): The AAFP has signed agreements with select software, hardware, and network services companies, enabling them to purchase products and services at significantly reduced prices, and in some cases, obtain additional assistance at no charge. An AAFP discount is offered to AAFP members through the organization s Partners for Patients program. Other vendors may have joined that are not known as of this date. Current as of December 22nd, 2005 A4 Health Systems 5501 Dillard Dr. Cary, NC AAFP Discount: Yes ABELSoft 3310 South Service Road Burlington, Ontario CANADA L7N 3M AAFP Discount: No AcerMed, Inc Fitch, Ste. 100 Irvine, CA AAFP Discount: Yes Advanced Filing Systems 1561 S.W. 68th Ave. Fort Lauderdale, FL AAFP Discount: No Aimset Corporation 50 Woodside Plaza Ste. 511 Redwood City, CA AAFP Discount: No Allscripts Healthcare Solutions 2401 Commerce Dr. Libertyville, IL AAFP Discount: Yes AmazingCharts.com, Inc Main St. Hope Valley, RI AAFP Discount: Yes Amicore, Inc. 200 Minuteman Rd. Andover, MA AAFP Discount: Yes Aristos Group P.O. Box Austin, TX AAFP Discount: No ArcSys, Inc Sage Hollow Dr. Draper, UT AAFP Discount: No Axolotl 800 El Camino Real West Suite 270 Mountain View, CA AAFP Discount: Yes Blue Ox Medical Solutions 701 Foulk Rd. Ste. 1G Wilmington, DE AAFP Discount: No Bond Technologies 3903 Northdale Blvd. Ste. 100W Tampa, FL AAFP Discount: No CaduRx, Inc. Farmington, UT AAFP Discount: No Catalis Health 9050 Capital of Texas Highway North, Ste. 360 Austin, TX AAFP Discount: No Lumetra: DOQ-IT Vendor List, 1/20/2006, Page 1 of 6

124 Cerner Corporation 2800 Rockcreek Pkwy. Kansas City, MO AAFP Discount: Yes ChartConnect, Inc. 104 S. 6 th Ave. Yakima, WA AAFP Discount: No ChartLogic, Inc S. 700 East, Ste. 200 Salt Lake City, UT AAFP Discount: Yes ChartWare, Inc. 101 Golf Course Drive Ste. A220 Rohnert Park, CA AAFP Discount: No Clinical Integration Networks of America, Inc. 705 West Ave. B, Ste. 600 Garland, TX AAFP Discount: No ComChart Medical Software 275 Varnum Ave., Ste. 102 Lowell, MA , ext AAFP Discount: No MEDENT - Community Computer Service 15 Hulbert St. Auburn, NY AAFP Discount: No Companion Technologies 8901 Farrow Rd. Columbia, SC om AAFP Discount: Yes Delphi Health Systems 360 Bloomfield Ave. Windsor, CT AAFP Discount: No DocSite 48 Mount Vernon St. Ste. 100 Winchester, MA AAFP Discount: Yes DOCS, Inc West Sunset Springdale, AR AAFP Discount: Yes DSS, Inc U.S. Hwy 1, Suite 200 Juno Beach, FL AAFP Discount: No eclinicalworks Westborough Executive Park 114 Turnpike Rd. Westborough, MA AAFP Discount: Yes Electronic Healthcare Systems, Inc. 100 Brookwood Place Ste. 410 Birmingham, AL AAFP Discount: Yes e-mds, Inc. e-mds Campus, Building One 500 West Whitestone Blvd. Cedar Park, TX AAFP Discount: No Emdeon 2202 N. West Shore Blvd. Ste. 300 Tampa, FL , ext AAFP Discount: Yes Encite, Inc. 969 Eisenhower Blvd. Johnston, PA AAFP Discount: No Ethidium Health Systems 3993 Huntingdon Pike Ste. 108 Huntingdon Valley, PA AAFP Discount: No Flexis, Inc Alma Street Palo Alto, CA AAFP Discount: No GE Healthcare Technologies 540 West Northwest Highway Barrington, IL AAFP Discount: Yes Greenway Medical Technologies 121 Greenway Blvd. Carrollton, GA AAFP Discount: Yes Lumetra: DOQ-IT Vendor List, 1/20/2006, Page 2 of 6

125 gscribe, Inc Lexington Ave. North Suite 100 Shoreview, MN AAFP Discount: No Health Probe 5693 S. Bear Wallow Road Suite 100 Morgantown, IN AAFP Discount: Yes Healthcare Informatics Technology Services, Inc Kitsap Way, Ste. 390 Bremerton, WA AAFP Discount: No HealthcareWare 755 Waverly Ave, Ste. 407 Holtsville, NY AAFP Discount: No IAtroware 2706 Louanna Street Midland, MI AAFP Discount: No ImageMarkIT, Inc. 907 Centerbrook Dr. Brandon, FL AAFP Discount: No imed Software 2014 West Pinhook Rd. Ste. 704 Lafayette, LA AAFP Discount: No imedica Corporation 2250 Charleston Rd. Mountain View, CA AAFP Discount: Yes Infor-Med, Inc Canoga Ave. Ste. 1500, #195 Woodland Hills, CA AAFP Discount: Yes InteGreat Concepts, Inc North 78 th Way Ste. 100 Scottsdale, AZ AAFP Discount: No Integrated Healthware 101 Billerica Ave., Bldg. 5 North Billerica, MA AAFP Discount: Yes Intermountain Health Care e- Business 36 South State St. 18 th Floor Salt Lake City, UT AAFP Discount: Yes Isprit P.O. Box Indianapolis, IN AAFP Discount: No JMJ Technologies, Inc Cumberland Blvd., Ste Atlanta, GA AAFP Discount: Yes KMS Computer Services, Inc. 121 West Walnut St. Kokomo, IN AAFP Discount: No MDAnywhere Technologies, Inc. 401 E. Pratt St., Ste Baltimore, MD AAFP Discount: No MDsync LLC Aiea Height Dr. Room 105 Aiea, HI AAFP Discount: No M.D. Web Solutions Cory Lake Drive, Ste. 1 Tampa, FL AAFP Discount: No MDTablet, LLC 1836 Lackland Hill Pkwy. St. Louis, MO AAFP Discount: Yes Medappz, LLC 3350 NW 2nd Ave. Suite A30 Boca Raton, FL AAFP Discount: No MedcomSoft, Inc Eglinton Ave., East, Ste. 900 Toronto, Ontario M3C 1H AAFP Discount: Yes Lumetra: DOQ-IT Vendor List, 1/20/2006, Page 3 of 6

126 Medical Communication Systems, Inc. 800 West Cummings Park, Ste Woburn, MA AAFP Discount: No Medical Informatics Engineering, Inc W. Jefferson Blvd. Fort Wayne, IN AAFP Discount: No Meditech Medical Information Technology, Inc. and LSS Data Systems Meditech Circle Westwood, MA AAFP Discount: No MedicWare, Inc N. Irwindale Ave., Ste. 215 Irwindale, CA AAFP Discount: Yes MediNotes Corporation 1025 Ashworth Rd., Ste. 222 West Des Moines, IA AAFP Discount: Yes MedNet Systems, Inc. 72 Cudworth Rd. Webster, MA AAFP Discount: No MedPlexus, Inc De La Cruz Blvd., Ste. 200 Santa Clara, CA AAFP Discount: Yes Medsphere Systems 120 Vantis, Suite 405 Aliso Viejo, CA AAFP Discount: No Medstar Systems 3115 NW 10 Terrace, Ste. 104 Fort Lauderdale, FL AAFP Discount: No Misys Healthcare Systems 8529 Six Forks Rd. Raleigh, NC AAFP Discount: Yes NCG Medical Systems 140 North Westmore Drive Suite 100 Altamonte Springs, FL AAFP Discount: No NeoDeck Software Calle Sol #22 Ponce, PR AAFP Discount: No NewCrop, LLC 6402 Mercer St. Houston, TX AAFP Discount: No NextGen Healthcare Information Systems, Inc. 795 Horsham Rd., 2 nd Floor Horsham, PA AAFP Discount: Yes NorthBase, Inc Vesta Dr. Raleigh, NC AAFP Discount: No NoteWorthy Medical Systems 6001 Landerhaven Dr. Cleveland, OH AAFP Discount: Yes OmniMD 303 South Broadway, Ste. 101 Tarrytown, NY AAFP Discount: Yes Outcome 201 Broadway, 5 th Floor Cambridge, MA AAFP Discount: No Physician Micro Systems, Inc Sixth Ave. Seattle, WA AAFP Discount: Yes PhysBiz Inc. 641 Braddock Ave. East Pittsburgh, PA AAFP Discount: No Pulse Systems, Inc North Cypress Wichita, KS AAFP Discount: Yes QuickMed, Inc W. Okanogan Ave. Kennewick, WA AAFP Discount: Yes Sapphire Enterprises 2445 Alexander Lake Drive SW Marietta, GA AAFP Discount: No Lumetra: DOQ-IT Vendor List, 1/20/2006, Page 4 of 6

127 Solventus, LLC 625 Oaks Dr., Ste. 305 Pompano Beach, FL AAFP Discount: Yes Spring Medical Systems 9005 Louetta Rd. Spring, TX AAFP Discount: Yes Stat! Systems, Inc Ninth St., Ste. 317 Berkeley, CA AAFP Discount: No STI Computer Services, Inc. Valley Forge Corporate Center 2550 Eisenhower Ave., Bldg. C Norristown, PA AAFP Discount: No Symmetry Information Systems 9724 Kingston Pike, Ste. 504 Knoxville, TN AAFP Discount: No SynaMed, LLC Queens Blvd. Kew Gardens, NY AAFP Discount: Yes Visionary Medical Systems, Inc Mariner Street Suite 227 Tampa, FL AAFP Discount: No Wellinx Baur Blvd. St. Louis, MO AAFP Discount: Yes Wellogic 222 Third St. Cambridge, MA AAFP Discount: No WhiTech Medical Solutions 1575 Chattanooga Ave. Dalton, GA AAFP Discount: No WiFiMed, Inc. 2 Clock Tower Place Ste. 250 Maynard, MA AAFP Discount: No WLJ Consulting P.O. Box Roswell, GA AAFP Discount: No Vericle, Inc. One Austen Court Marlboro, NJ AAFP Discount: No VersaForm Systems Corp. 591 W. Hamilton Ave., Ste. 201 Campbell, CA AAFP Discount: No Lumetra: DOQ-IT Vendor List, 1/20/2006, Page 5 of 6

128 Disclaimer Please note that the HIT vendors referenced in this document have expressed an interest in developing their products and services to comply with the reporting and interoperability standards advanced by the Centers for Medicare & Medicaid (CMS). The listing of these vendors does not constitute an endorsement by Lumetra. The U.S. Department of Health and Human Services, CMS, and Lumetra do not endorse or recommend any product or service to the exclusion of others. Questions Questions regarding this list should be directed to: Glen Moy Lumetra One Sansome Street, Suite 600 San Francisco, CA Sources AAFP Partners for Patients Web site: and Accessed March 10, Anderson, Mark R. AC Group s 2004 Annual Report: Computer Systems for the Physician s Office, AC Group, May

129 Contracting Guidelines with EHR Vendors In general, if a contract is presented to your group from a software company, it will be written from the perspective of the software company. You can request language changes to make the intent of the contract more equal, although many companies may not be flexible about language changes. Do not be afraid to ask. Specifics to consider: General: 1. The contract should have bi-lateral termination clauses without penalty given within a certain notice period. 2. The contract should stipulate that it shall not be transferred by one party without written approval of the other party. 3. The contract should have a definition section for anything that is not readily understandable. Don t be afraid to require the vendor to spell out clauses in acceptable language. 4. The contract should spell out what happens in the event of default by either party and should be as evenly weighted as you can possibly negotiate. 5. The contract should clearly outline how the product is to be delivered. Is it run as an on-site application or delivered in an Application Service Provider (ASP) model through Internet connectivity. Software: 1. The contract should spell out or explicitly address that you should own the data and that the data will be returned should the agreement between the two parties be terminated for any reason. 2. Contract should outline the minimum hardware required to sufficiently run application as demonstrated. Contract should have provisions for hardware support if sold with system. 3. Contract should describe process on how upgrades to hardware are handled and notifications when upgrades are required for future releases.

130 4. The contract should also include language about the vendor turning over source code, data models, etc. should it for whatever reason cease to exist. This is usually handled through a process of escrowing the source code with a third party. 5. The contract should spell out whether the cost of the system includes upgrades, patches, etc. and, if so, how many, who is responsible for applying them, at what cost, and what happens if an upgrade negatively impacts the system. 6. The contract should spell out how non-vendor upgrades, patches, etc. (such as for the OS or DBMS) are handled, who is responsible, etc., similar to above. 7. If the system includes third party software and/or content, the contract should spell out the associated costs, who is responsible for those costs, who is responsible for support, and how updates are handled. 8. The contract should include language regarding the vendor ensuring the confidentiality of patient and practice information. The vendor should be required to execute a separate HIPAA Business Partner Agreement. 9. The contract should state that the vendor agrees to comply with HIPAA requirements and to make the necessary government-required modifications to ensure this compliance is at no additional cost to the practice. The vendor should provide changes that are required to sell or certify software in the current environment. 10. Access to system through dial-up or internet for the purpose of support should be clearly documented and list who will have access to data during on-line support fixes. This data should be a part of the HIPAA access record. 11. Access to system for updates should be defined. Clearly spell out procedures for changes and updates and when they can occur. 12. The contract should include delineation of test environments and whether there is one included within the system. 13. The contract should provide provisions for the ability of data to be separated if multiple practices will be using the same database. The application should allow for some data export in the case of a doctor that splits from the practice. Likewise, how is data combined if practices merge? 14. The contract should be structured to include a progressive payment schedule based on the achievement of certain implementation milestones. 15. The contract should specify the conditions under which a breach of contract has occurred, such as the system not performing as specified, consistent poor performance, etc. and at what point money is refunded, or payments may cease. Page 2 of 5

131 Support: 1. The contract should outline what support hours will be available (including time zone) and what level of support is included. 2. Costs for additional support should be itemized on the contract. 3. The contract should clearly outline the term of the support agreement. 4. The contract should have a clearly delineated escalation path for those issues, which are not resolved by first-line support. 5. The contract should outline when a resolution has been achieved. 6. The contract should outline where support is delivered and that vendor support staff should speak clear English. Many vendors have outsourced support to other countries. Interfaces: For each interface to another system, e.g., laboratory, billing, scheduling, etc., the contract should indicate whether the cost of the interface includes interface-programming time and, if so, how many hours are included. It should detail what happens if and when those hours and the associated costs are exceeded. 2. The contract should also identify what is included with the interface, for example interface specifications or programming. 3. The contract should state what happens if subsequent programming is needed either because of initial errors or if additional modifications are needed. 4. The contract should stipulate who owns the interface and who will troubleshoot it when it goes down. 5. Each interface should have terms outlined regarding which party is responsible for upgrading it, and which party will assure that it functions with new upgrades of main products. Training: 1. The contract should identify how many training hours are included, who is covered, and what is included with the training, e.g., training material, customized cheat sheets, etc. 2. The contract should explain what happens if additional training is needed and what the billing rate is for additional time. 3. The contract should spell out what are acceptable and non-acceptable costs and establish a per diem rate for trainers (if there are on-site sessions). 4. The contract should stipulate what (if any) follow-up training is provided, and at what cost. Implementation: Page 3 of 5

132 1. The contract should spell out what is and is not included in the implementation costs: what services will you receive, how many hours, who the resources will be, what sort of materials will be provided (e.g., project plan, implementation guides, specs), etc. 2. The contract should spell out what are acceptable and non-acceptable costs and establish a per diem rate for implementation staff. 3. The contract should have liability clauses for who is responsible during building of on-site applications and templates. 4. The contract should include who will be responsible for implementation of hardware if not provided by software vendor. Disaster Recovery and Planning: 1. The contract should spell out how product is delivered either via ASP or installed on-site application. The contract should detail ownership of data through either system. 2. If ASP or remote operations model is selected: a. The contract should include guarantees for uptime and service level agreements (SLA). b. The contract should provide guarantees on data availability, when service is performed, and notification of scheduled downtime. c. The contract should provide a detailed plan of how data is secured, back up and restored along with a testing methodology utilized. d. The contract should provide for contingency planning if ASP is down for a significant time. 3. If the Owned and installed model is selected: a. The contract should outline when service should be performed, how often, and how long it should take b. The contract should clearly delineate what hardware is required for backup and how frequently that should be run. This includes tape backup, battery or UPS devices required, workstations and server protections required, and a defined environment in which servers should operate. c. The contract should outline expected times for backup and processes for testing backups. d. The contract should offer a model for escalating support for failures and downtime and include a priority list of who should be contacted for catastrophic events. 4. The contract should include definitions of support and recovery of physical and/or wireless networks and how passwords are recovered. Page 4 of 5

133 5. The contract should clearly outline what network security is required for supporting connectivity to the Internet. This is usually listed as firewalls, virus protection, spyware protection, password security, and other security devices to limit access to networks and applications. Caveats: Look at the warranty, disclaimer and limitation of liability sections very carefully. Usually these are written all in caps, and they severely limit the software company s liability. They are not likely to change either section substantively (if at all), even if you request it, so read and understand this part and what it means for you. 2. Check carefully to see what the software company warrants to you and what your responsibilities are with regard to it. 3. Look to see if they specify minimum hardware requirements and be prepared to meet them. If you use what they consider to be substandard equipment (to try to save some money), it may invalidate the agreement. 4. Read the indemnification section carefully as well. This is another section that they are not likely to change for you, so understand what it is stipulating. 5. Check the duration and termination clauses again, you should be able to free yourself from this with relatively little organizational pain. (No handcuffs or shackles.) 6. Understand the different ways in which the vendor can terminate the agreement and make a contingency plan for this. This material was prepared by the Arkansas Foundation for Medical Care and distributed by Florida Medical Quality Assurance, Inc., the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Page 5 of 5

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135 Glossary, Red Flags, and Frequently Asked Questions (FAQ s) Vendor Software Licenses License cost of various modules. Typically, modules will be licensed on concurrent or named user basis. For example, with a concurrent license, if there were 4 providers and 8 employees, a minimum of 12 concurrent licenses would be needed. However, if the providers were halftime [meaning, they only used the system half time] (and all 4 never used the system at any one time, only 10 licenses would be needed). If using a named user license under the same circumstances, 12 licenses would always be needed as licenses are not shared among different people. There can be a provision though for active and inactive providers (which means they could look at information, but not enter it in the system). Under an ASP (monthly rental agreement), software licenses are not being purchased, but rented. However, the same issues exist for determining the number of ASP licenses as with a license purchase. Red Flags or Things to Look Out For: 1. Vendor doesn t specify type of license in quote. 2. Functionality is not specified. 3. Not specified for what period of time license is in force. FAQ s What is the best type of license? Perpetual concurrent What is the definition of provider for the license? Depends on quote can be physician, NP, PA or others What is the difference between perpetual and term license? Perpetual is a one-time license fee. Term is a renewable license fee. Interfaces Software programs that allow data from the EHR system to flow back and forth between external applications. These applications can either reside outside the practice, such as lab applications or can be another system within the practice, such as a billing system.

136 Red Flags or Things to Look Out For: 1. One-way or two-way interface is not specified. 2. Data format not specified (structured or non-structured). 3. Additional license costs, if any, not specified 4. Interface promised, but not available. FAQ s Does cost cover third party updates? Typically, you would pay for third party updates, but depends on the vendor. Does every interface need some customization? Not necessarily, but make sure the vendor demonstrates the functionality. What if the vendor says they will have the interface soon? Ask for a development plan and timeline to verify claims. Third Party: EHR Specific These are applications that are essential to the basic infrastructure of the system. They are the building blocks, such as the technical platform upon which the EHR system is built (e.g., Windows, Linux, or MacIntosh, etc.) Also, what kind of database structure controls the system (e.g., SQL, Oracle, etc.)? When Comparing license costs, note if there are separate general system license costs or if these are rolled into the main cost. Also, ask whether there will be additional costs when the vendor upgrades their software and it becomes necessary to install a new version of the database or operating system. Make sure your infrastructure software will support any features you wish to add later on. Red Flags or Things to Look Out For: 1. Extra cost is not specified in quote. 2. Customer is responsible for learning about updates. 3. The database is proprietary; not standard. FAQ s How often should a third party database be updated? Depends on the content (e.g., Drug interactions should have more frequency than patient education) Should updates cost extra? Should be part of support and maintenance. Third Party: General System These are applications that are essential to the basic infrastructure of the system. They are the building blocks such as the technical platform the EHR system is built on such as, Windows, Linux, or MacIntosh, etc. Also what kind of database structure controls the system SQL, Oracle, etc.

137 When comparing license costs note if there are separate general system license costs or if these are rolled into the main cost. Also, will there be additional costs when the vendor upgrades their software and it is necessary to install a new version of the database or operating system. Make sure your infrastructure software will support any features you wish to add later on. Red Flags or Things to Look Out For: 1. Extra cost is not specified in quote. 2. Customer is responsible to be aware of updates. 3. The database is not standard, but proprietary. FAQ s What is the best technology to use as a platform? There are various operating systems and databases. However, make sure that the technology is not proprietary. Should you always update to the latest database and operating system? Not necessarily right away. Find out if this will impact your EHR system. Who should be responsible for updating the general system software? Typically the customer is responsible for installing general system updates. Conversion Services These are consulting services offered by the vendor. These services will take your original data, either in paper or electronic form, and transfer the data into the HER system database. Red Flags or Things to Look Out For: 1. No time estimates given. 2. Costs don t include any guarantees. FAQ S How long does a conversion typically take? Depends upon complexity. Make sure that a detailed plan is presented with timelines. How do I know everything was converted correctly? Develop a robust test plan with the vendor. Is there a chance that my information can t be converted? If it is in electronic format, as long as you have the underlying database structure, there shouldn t be a problem.

138 Implementation Services These are consulting services offered by the vendor. These services will provide planning and actual implementation of an EHR system. It is important when comparing quoted implementation costs that physicians understand which detailed cost line items a particular vendor will be supply. Also, make sure and take a look at their project plans. Red Flags or Things to Look Out For: 1. Vendor can t commit to a project plan with milestones. 2. Only vendor can customize templates. 3. Implementation is not broken into small enough tasks. FAQ s Do I need to be involved? Absolutely. Designate a point person who is responsible to interface with the vendor on a regular bases. How do I know the vendor is completing all the tasks? Review the vendor s detailed project plan and have regular status meetings. Why do implementations fail? Not enough involvement, communication, and regular status review. Who should be involved in a needs assessment? Both the vendor and members of your staff who will use the system. Training Services These are consulting services offered by the vendor. They provide hands on training for all aspects of the system. Red Flags or Things to Look Out For: 1. There is no cost listed for future training. 2. There is no formal training plan. 3. There is no definition of what expenses will be reimbursed along with limits. FAQ s Is it better to ask the vendor to train the whole staff or train the trainer? Depends on the size of the staff How do I know if my staff has been trained adequately? You should develop real life scenarios and test them. How much time will training take? It depends on many factors, but make sure the vendor gives you a training plan outlining this.

139 Data Recovery Services A mechanism and process to safely store duplicate databases and recreate the data should a disaster occur. Red Flags or Things to Look Out For: 1. Back ups not made on regular schedule. 2. Off site storage not as secure as it should be. 3. No process documented for recovery. FAQ s What do you look for in off site storage? Scrutinize the security and environment of the location in which the backups are being held. Ask about the regularity of the backup process. Find out about accessibility to your data. Should I just backup on my own? As long as you have a safe and secure location to store backups and you will backup regularly. Annual Support & Maintenance Support and maintenance costs are typically 15-20% of the software license costs. Where the actual license is normally a one-time fee, the support and maintenance costs are renewed on a yearly basis. This yearly fee basically covers two areas: 1)any upgrades or new releases; and 2)customer service and support. It should be noted that both vendor EHR software and third party software will need support, so it is important to determine which components the support costs cover. Also, some vendors might have more than one service level agreement representing different support options at different costs. Red Flags or Things to Look Out For: 1. No support agreement. 2. No guarantees of service. 3. No cap on renewal percentage increases. 4. No software escrow costs offered. 5. Extra costs for database schema. 6. Added maintenance costs for third party products. 7. No support for third party products. 8. No support for previous version or release. 9. Cut off of support services if payment is in dispute. FAQ s What type of guarantees of service should I expect? Depending on your service agreement there should be guaranteed response times and escalation processes What recourse do I have if I do not receive adequate support? This is negotiable. You can ask or a discount or partial refund of support fees Can I change service level agreements? Yes, service level agreements should follow your needs.

140 Financing Alternatives A vendor should offer you the option of either leasing or financing your system. Red Flags or Things to Look Out For: Vendor just passes you on and is not involved in this process. FAQ s What happens if I lease or finance and the system is not acceptable? You are dealing with the finance company, so you still need to honor your contract. What are the benefits of leasing or financing? Lower start up costs Terms EHR implementation typically involves a number of phases and takes time. And, things can go wrong. Therefore, the payment terms should reflect milestone-based payments. This means should pay the vendor percentages of the total as major parts of the project plan are successfully completed. Red Flags or Things to Look Out For: 1. Vendor wants most of the payment up front. 2. Vendor is not willing to agree to final payment when system is accepted. 3. There is not policy or process for payment refund or reduction. FAQ s How should I break up payments? Best done by specifying major milestones in an implementation plan. Who determines when a payment milestone has been successfully reached? Criteria should be determined and agreed to ahead of time by the vendor and yourself. Service Level Agreement: Hours of Support The methods that will be used for communicating and resolving issues. Typical methods are , phone, and online chat. Ask whether remote diagnostics and/or on site visits by support analysts are available. Red Flags or Things to Look Out For: 1. Normal business hours are specified instead of detailed days and hours. 2. No after hours support available.

141 FAQ s What is the standard for hours of support? No set standard, but expect something like 8-6, Monday through Friday How do I know if I will need after hours support? Experience using the system will dictate this. Service Level Agreement: Methods of Support The methods that will be used for communicating and resolving issues. Typical methods are , phone, and online chat. Remote diagnostics can be available and, in some instances, it might be necessary to have a support analyst come on site. Red Flags or Things to Look Out For: 1. Customer needs to use or other indirect methods before getting phone or live support. 2. Only or online chat available. FAQ s How do remote diagnostics work? The vendor can take control of your system and look at problems remotely. What is the best method to use for problem resolution? , phone and in-person can all help resolve problems depending on complexity and vendor responsiveness. All should be offered. Service Level Agreement: Severity/Priority Classification Different types of problems have different levels or urgency and importance. The severity level of a problem is usually noted when a support ticked is opened up. Resolution guarantees are based on severity levels. For example, CPOE down would be a high severity level while a patient education database not working might be a lower level of severity. Red Flags or Things to Look Out For: 1. There is no severity level classification. 2. Severity level is not tied into resolution. FAQ s How do I determine severity levels? Discuss this with your vendor. Can you change the level of severity? Yes. Why do you need different severity levels? It is not reasonable to expect that every problem will be taken care of immediately.

142 Service Level Agreement: Response Times Different functions of the system might warrant different response times based on severity level. There should be a schedule of response times for different types of problems, and the service level agreement should define this accountability. Red Flags or Things to Look Out For: 1. Vendor not willing to make a commitment to a resolution schedule. 2. Response is dependent on how busy the vendor is. FAQ s What kicks off an escalation? If a problem can be resolved by present means within a specified period of time. What levels of escalation should there be? Will depend on the size of the vendor s support organization. Service Level Agreement: Customer Responsibilities and Duties These are the steps that the customer needs to take in order to ensure that the vendor has all the information they need to resolve an issue. Red Flags or Things to Look Out For: 1. Customer doesn t document and can t recreate the problem. 2. Customer waits too long to report and issue. FAQ s How do you know if it s really an issue or a glitch? Try to recreate it a few times. How should you report the problem? This depends on the vendor s escalation process. What should I do if I can t recreate the problem? Make sure the initial occurrence is reported and keep track of it. Make sure the vendor is aware. Service Level Agreement: Compliance A documented track record of how well the vendor is meeting its customer support commitments. Red Flags or Things to Look Out For: 1. A vendor is not required to track its compliance. 2. There is no mechanism in place for a vendor to use its compliance program to improve support. FAQ s What happens if statistics show that a vendor is not meeting its obligations? You can use this track record as criteria to kick in penalties should be necessary. This material was prepared by the Arkansas Foundation for Medical Care and distributed by Florida Medical Quality Assurance, Inc., the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.

143 The Right Care for Every Patient Every Time Implementation Phase Checklist TASK Common Implementation Problems EHR Implementation Options Incremental vs. Big Bang; comparing Approaches DATE STARTED DATE COMPLETED SENT TO FMQAI INITIALS Redesign the System Re-identify Project Team Physician Champion Project Manager Additional Dept Champions Subject matter experts Develop Project Plan Implementation schedule/timeline Assign roles and Responsibilities Discuss change management process. Develop tracking and management processes Communication Schedule regular meetings with vendor s implementation staff Provide staff regular updates Post implementation timeline in break room and document progress Utilize newsletters, , etc. to address specific issues Mapping Of Critical Practice Workflow Document Review

144 The Right Care for Every Patient Every Time TASK Identify problem areas and bottlenecks Re-map workflow based on EHR incorporation DATE STARTED DATE COMPLETED SENT TO FMQAI INITIALS Existing Data Incorporation Identify key data and documents that must be in system Develop plan to enter this data and documents into system Develop and plan to handle new, outside documents and information Training Review staff PC skills Assessments/keyboarding Develop a plan to address Staff skills training prior to EHR training General overview of system by vendor for all staff Conduct multi hands-on, task oriented training sessions tailored to staff responsibilities (remember cross training) ID super users and give them extra training Allow staff on the job learning time Develop cheat sheet, quick reference cards, diagrams of new workflow System Testing Conduct test of single module Conduct test of interaction between two or more modules Conduct test of interfaces (other systems) Document Review

145 The Right Care for Every Patient Every Time TASK Conduct system stress or load testing Ensure testing covers multiple Scenarios and situations Contingency Plans Develop disaster recovery plan Test ability to restore system before go live Ensure backup plan is in place and running Arrange for regular storage of Backups at an offsite location GO LIVE PLANNING Determine if providers schedules will be reduced and how much Determine go live approach DATE STARTED DATE COMPLETED Schedule catch up time in the schedule Schedule sufficient support staff Identify vendor staff to give staff assistance Notify third parties and other vendors of go-live date Plan for things going really wrong and when to stop and what will happen then Schedule mid-day huddle to evaluate progress Hold end of day debriefing to ID problems and address issues BE PATIENT BRING FOOD AND HAVE A GOOD TIME! CELEBRATE!!!!!! SENT TO FMQAI INITIALS Document Review

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147 Common Implementation Problems Problem Staff Resistance Training Project Management Interfaces Solutions Establish project team that consists of physician champions and other motivated practice staff Communicate the value the system will bring to staff on an individual level Identify staff s concerns and develop plans for addressing them Involve staff throughout the implementation process Manage expectations by establishing realistic goals, providing quick wins, and demonstrating progress Tailor sessions to the roles and responsibilities of staff Ensure sessions are task oriented and hands-on Provide staff with time to play with system outside of formal sessions Create super users and ensure they receive additional training Develop aids such as cheat sheets, quick reference guides, etc. to support staff learning Define scope of before completion of contract Develop detailed project plan Establish roles & responsibilities Ensure sufficient resources allocated on both practice and vendor side Identify project risks and develop plans to mitigate them Ensure project plan allows sufficient time for installation and testing Make sure test plans cover different scenarios and situations Evaluate effect of typical message loads or cycles on system

148 Problem Workflow Automation Solutions Map out workflows and identify problem areas or bottlenecks Determine how system can be utilized within processes and address identified problems Re-map processes Determine key information and documents that need to be entered into system Handling of Paper-based Information Establish process for entering information into system Determine process for handling new outside documents Ensure allocated resources (hardware and staff) appropriate to information input volume Ensure hardware meets minimum requirements System Performance Load test system to evaluate effect of typical number of users Evaluate ability of network to handle increased traffic and utilization Ensure system maintenance procedures are in place and working Contingency Planning Ensure that disaster recovery plan is in place Test ability to restore system from backups prior to golive Determine amount physicians are willing to reduce productivity levels Implementation Approach Evaluate staff receptiveness to system and strength of project leadership Develop rollout schedule of system modules or functions based on desired productivity and receptiveness levels Ensure amount of training provided matches implementation approach DOQ-IT: Common Implementation Problems Page 2 of 2

149 EHR Implementation Options Incremental vs. Big Bang: Comparing Approaches 1 Incremental Approach -Reduces shock to staff and physicians -Spreads out costs of software and implementation over longer period -Project less likely to blow up -Total training, implementation costs may be higher -ROI is not achieved as quickly -Risk getting stuck at midpoint Big Bang Approach -Shortens painful parallel paper/emr operation period -Achieves ROI more quickly -Less likely to get stuck partway to the goal -Higher risk of blow up -Significant productivity hit at go-live and some time afterward -Staff or physicians unable to cope with change may rebel Adapted from the presentation, EHR in the Small Practice, Mark Leavitt, MD, PhD, October 14, 2004

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151 The Right Care for Every Patient Every Time Redesign the System Ensure that Patient, Provider, and Information are All Available at Start of Visit Use a "chart check" as an inspection step prior to the synchronization point (physician entering exam room) to reduce the chances that physicians (a scarce resource) and patients (the key customer) will have to wait for necessary information (e.g., lab results or diagnostic tests, etc.) at the time of the visit. Use Health Prompts to Anticipate the Full Potential of Today's Preventive medicine and chronic care guidelines are examples of prompts that can be imbedded electronically or used manually to generate information that the care team needs on the day of the clinic visit. The prompt tells the care team that the patient may be due for a sigmoidoscopy, flu shot and pneumococcal vaccine, or an HbA1c test for diabetes, for example. Limit Interruptions Interruptions create unnecessary variation in the flow of tasks, disrupt the coordination of work among staff, and contribute to patient s waits for services or treatment. For example, a provider interrupted during a patient visits for a phone call, or because patient information or exam room supplies and equipment are missing. To decrease these common types of interruptions, have physicians track the number of times and reasons why they leave the exam room for missing items to identify what equipment is needed in the room at all times. Clinics can also establish telephone call policies to mitigate interruptions by phone. Use Continuous Flow to Avoid Batching Doing work as it occurs during the course of an office visit (e.g., doing documentation at the end of each visit) reduces the bottlenecks created by holding similar types of work to be done at a future time (batching). For example, some practices save all telephone calls, documentation, refills, etc., for the end of the day or session. This is referred to as batching. With continuous flow, all work is accomplished as it presents itself and completed in one continuous action. Appointment times may need to be lengthened, or pauses placed in the schedule, to accommodate continuous flow and reflect a certain truth in scheduling. Continuous flow does not mean that time is added to the day, but that it is reallocated throughout the day. Use Rooming Criteria to Ensure that Patients are Prepared for Visit Rooming criteria check sheets help ensure that the patient is ready for the physician. Check sheets typically include such items as "shoes off" for a diabetes patient. This not only helps fully prepare the patient for the visit, but also aids float or cross-trained personnel when they come in to assist, assuring a standardized preparation for each visit. Adapted from the Institute for Healthcare Improvement, Redesigning the System.

152 The Right Care for Every Patient Every Time Start the First Morning and Afternoon Appointments on Time Agree on a common definition of a specific clinic appointment time. If the registration desk doesn t open until 8:00 AM, there is no way the patient can be placed in a room, have his or her history taken, and be ready to see the physician at 8:00 AM. If all agree that an "8:00 AM appointment" means "physician sees the patient at 8:00 AM," then tasks can be synchronized around that point and waiting times can be reduced. While the concept is simple, the implementation is difficult. It means that the patient must be registered, roomed, and prepped by the point of synchronization (8:00 AM) so the provider can enter the room on time and have all the necessary information to begin the encounter. Some clinics successfully use the strategy of communicating two times to the patient: Arrival time for the important registration and rooming process, and appointment time for the actual encounter with the provider Develop Mechanisms to Smooth Scheduled Appointments Alternating appointments of different lengths throughout the day may help to smooth the provider's work by creating natural breaks or pauses. For example, spacing two long appointments at different times in the afternoon (rather than back-to-back) may create time for providers to return phone calls or huddle with a staff member between shorter appointments. Occasionally, when back-to-back long appointments occur, the care team may decide to reverse the order of events needed for the appointment, or quickly use their cross-trained skills to assist each other to smooth the flow. Do Patient Registration on the Phone when Confirming the Patient Appointment Obtain patient information prior to the day of an appointment whenever possible. This removes work on the day of the appointment and allows for advance planning for special resources required to meet the patient's needs. Manage the Constraint Identify the Constraint (Person or Process) It is often difficult to identify a constraint by evaluating the demand and the capacity for each resource because they can be masked by constraints in other parts of the system. To identify the constraint, observe where the work is piling up, or where the queues are forming. Look for certain signals within the system, such as places where material or information is in short supply, or where patients or staff is waiting, to help identify constraints. Clinics usually expect that the physician is the constraint, but there may be other factors. Drive Unnecessary Work Away from the Constraint Every system has a constraint called "the rate-limiting step" (i.e., the step that determines the rate at which work passes through the system). This constraint usually has the most valuable and scarcest resources. The focus should be on optimizing the capacity of the rate-limiting step, not on optimizing every resource in the system. The rate-limiting step should never be idle, ensuring that work flows smoothly through it. Adapted from the Institute for Healthcare Improvement, Redesigning the System.

153 The Right Care for Every Patient Every Time In a clinic setting, the primary provider is often the rate-limiting step because he or she does a number of things that uniquely add value to the system. Any work that the provider is doing that is not related specifically to his or her unique skills and expertise as a provider should be assigned to other members of the care team. Develop Flexible, Multi-Skilled Staff Cross-training is an important way to prepare for the unexpected because it enables staff to assume different duties as needed. The ability of a clinic to respond to expected or unexpected surges in demand or unexpected, yet predictable events depends to a large extent on the flexibility of the staff to adjust their responsibilities during these periods. Examples of Tests of this Change Some clinics have a float team that is trained to cover responsibilities throughout the clinic when needed. Other clinics have trained their scheduling staff to clean instruments and set up rooms for procedures. Anticipate Unusual but Expected Events The natural variation that occurs as part of the everyday functioning of a practice often creates problems. Reducing the variation in supply and demand for appointments might eventually reduce the problems, but how does staff cope in the meantime? One way is to prepare back-up plans to deal with unexpected situations. A number of situations occur relatively infrequently but not completely unexpectedly, such as the need for a patient to be admitted directly from the clinic to the hospital, or a parent who brings three children to an appointment scheduled for one child. The practice knows these events happen with some frequency they just don't know exactly when they will occur. To avoid disrupting the normal flow of clinic practice, clinics agree upon a standard protocol to follow for each event, including clear responsibilities for each staff member (e.g., the clinic manager notifies the Emergency Department of a probable admission as soon as a patient arrives in the clinic). This preplanning helps the clinic to continue functioning as smoothly as possible, and allows for some adjustments in the supply to meet the unanticipated demand. Adapted from the Institute for Healthcare Improvement, Redesigning the System.

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155 The Right Care for Every Patient Every Time Evaluation/Improvement Phase Checklist TASK DATE STARTED DATE COMPLETED SENT TO FMQAI INITIALS Measures Overview Data Submission Process Reliability The Model for Chronic Disease Management Patients Assessment Of Care for Chronic Conditions Assessment of Chronic Illness Care (version 3.5) Evaluate Implementation Process Assess impact of EHR on office processes Measure changes as able Assess for comprehensiveness of training for staff Assess satisfaction with vendor Assess for use of Evidence Based Medicine (EBM) features Assure DOQ-IT data is being captured/ ask for report Improvement processes Identify additional areas for improvement using EHR Assure that data transmission has been tested and is enabled Identify person responsible for data transmission Document Review

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157 Measures Overview The Right Care for Every Patient Every Time The set of healthcare quality measures that will be used to track progress in achieving the goals of the Physician Practice: DOQ-IT project are: Coronary Artery Disease (CAD) Antiplatelet Therapy Drug Therapy for Lowering LDL Cholesterol Beta-Blocker Therapy-Prior MI Blood Pressure Diabetes Mellitus (DM) HbA1c management HbA1c management control Blood Pressure Management Eye exam Heart Failure (HF) Left Ventricular Function (LVF) Assessment Left Ventricular Function (LVF) Testing Weight Measurement Blood Pressure Screening Hypertension (HTN) Blood Pressure Screening Plan of Care Lipid Profile LDL Cholesterol Level ACE Inhibitor Therapy Lipid Measurement LDL Cholesterol Level Urine protein testing Foot exam Patient Education Beta-Blocker Therapy ACE Inhibitor Therapy Warfarin Therapy for Patients with Atrial Fibrillation Blood Pressure Control Preventive Care (PC) Blood Pressure Measurement Pneumonia Vaccination Tobacco Use Colorectal Cancer Screening Lipid Measurement Tobacco Cessation Influenza Vaccination LDL Cholesterol Level Breast Cancer Screening

158 The Right Care for Every Patient Every Time Quality measures were developed by the Centers for Medicare and Medicaid Services (CMS) and several partners including: American Medical Association (AMA) Physician Consortium for Performance Improvement The Consortium includes methodological experts, clinical experts representing more than 60 national medical specialty and state societies, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services. National Diabetes Quality Improvement Alliance (Alliance) The National Diabetes Quality Improvement Alliance is a "project by project" partnership of independent diabetes organizations throughout America who govern themselves independent of higher governance. National Committee for Quality Assurance (NCQA) NCQA is a national non-profit organization that evaluates health care through accreditation, the Health Plan Employer Data and Information Set (HEDIS) and through a comprehensive member satisfaction survey. CMS and their partners discussed the measures with representatives from various electronic health record (EHR) vendor companies at a meeting in Chicago in October At this meeting it was determined that technical specifications would be defined so that vendors could enable their systems to provide QIOs with the data necessary to calculate these measures. Using the data collected in this way, QIOs will assist physician practices in identifying areas where the management of patients and specific diseases, in particular chronic care conditions and preventive measures, can be improved through more effective use of the systems and practice redesign techniques to enhance healthcare quality and practice efficiency. Physicians participating in the DOQ-IT project will be required to submit data about all of their relevant adult patient visits by appropriate condition over the Internet to the QIO Clinical Warehouse. Please see the Data Submission for more information.

159 The Right Care for Every Patient Every Time Data Submission Process Under the direction of the Centers for Medicare & Medicaid Services (CMS), the DOQ-IT project will offer physician offices a process for submitting data related to quality measures implemented by the Doctor's Office Quality (DOQ) project to a central repository. Physician Office participants will implement an electronic health record (EHR) system in their office and upload data no less than once per month through an Internet site called QualityNet Exchange (QNet Exchange) at Through QNet Exchange, the data will be loaded into the Quality Improvement Organization (QIO) Clinical Warehouse, where they will be stored for reporting purposes. After uploading data, participants will have the ability to access feedback reports through the QNet Exchange on quality measures. These reports will allow them to monitor their performance and receive comparison data (state and national) on the DOQ quality measures. What is QNet Exchange? A 2003 egov Pioneer Award winner, QNet Exchange is an Internet site that provides secure, real-time communications and data exchange between two or more organizations, including hospitals, QIOs, End Stage Renal Disease (ESRD) facilities and networks, Performance Measurement Systems (PMS)/vendors, and Clinical Data Abstraction Centers (CDAC). QNet Exchange does not store files transmitted through it but acts only as a secure transport mechanism. QNet Exchange also provides a framework for running data checks on files before they are uploaded, thereby reducing network traffic and user feedback time. Go to for more information. What are the steps for submitting DOQ-IT data to the QIO Clinical Warehouse? Step1: Implement an EHR system developed by a vendor on the DOQ-IT list of potential vendor companies. This list is currently in development. Step 2: Determine if your technical system meets the minimum requirements necessary to participate in this project. Step 3: Determine who will serve as the DOQ-IT Data Manager and Security Administrator in your organization. The Data Manager will be responsible for monthly uploads of data from the office EHR to the QIO Clinical Warehouse through an Internet connection to QNet Exchange. The Security Administrator will be responsible for controlling access to the submitted data and the submission and feedback reports. It is possible for one person to serve in both capacities. In addition, a commercial vendor can be hired to cover the Data Manager role. Step 4: Register on QNet Exchange. In order to upload data and/or receive submission and feedback reports, Data Managers will be required to register as users on QNet Exchange. Go to for more information. How much will it cost to submit DOQ-IT data to the QIO Clinical Warehouse? There is no cost involved in registering on QNet Exchange, uploading data or downloading submission and feedback reports related to your data.

160 The Right Care for Every Patient Every Time How will the QIO Clinical Warehouse keep my data secure? QNet Exchange provides a secure means for data exchange. Access to QNet Exchange requires the use of a personal username and password. Built on current data encryption standards, QNet Exchange utilizes a 3-tier architecture based on 128-bit FIPS 140 approved SSL encryption and 256 Nist approved AES session keys to encrypt and protect data. QNet Exchange is easy to use and requires no special software. How does the data get from the EHR to the QIO Clinical Warehouse? Step 1: Physician office personnel or EHR vendor staff use the EHR system to export data, which the system converts to the proper HL7 format, to a local file system. Step 2: The Data Manager then accesses the Internet and navigates to Step 3: The Data Manager logs onto QNet Exchange using the log-on and password received during the QNet Exchange registration process. The Data Manager will then select one or more files to be uploaded. Step 4: If multiple files are selected QNet Exchange will automatically compress and encrypt the files. Step 5: As the files are being read and uploaded by QNet Exchange, each file is run against a set of DOQ-IT data checks to determine if accurate data are being uploaded and to certify the source of the data. These data checks are performed before the data are allowed into the system. This process will be completed almost instantaneously. Step 6: If the file passes the first set of DOQ-IT data checks, the file is uploaded to QNet Exchange. If the file(s) does not pass the first set of checks, it is not uploaded. A submission report is delivered to the Data Manager (via QNet Exchange) that contains the following information: A list of each file that was processed and whether or not the file was successfully uploaded to the DOQ-IT database. If the file was not successfully uploaded, the reason(s) for failing the set of data checks (e.g., some of the required data are missing) is recorded. This report is available immediately to the Data Manager to give them an understanding of the level of success achieved in uploading the data file. This report will also provide the information they will need to correct files within the EHR, if needed but will not contain copies of the files. Step 7: As the files are being read from QNet Exchange and uploaded to the DOQ-IT system, each file is checked against a second set of DOQ-IT data checks to determine if accurate data are being uploaded and to certify the source of the data. Step 8: As detailed in Step #6, a submission report is generated and available to the Data Manager (via QNet Exchange) to inform them of the success or failure of the data upload. If the file passes the second set of data checks, it is loaded into the QIO Clinical Warehouse. If the file(s) was not successfully uploaded, the reason(s) for failing the set of data checks is recorded and included in the submission report so that corrections can be made.

161 The Right Care for Every Patient Every Time RELIABILITY Reliability theory a scientific method of evaluating, calculating, and improving the overall reliability of a complex system has been embraced by and used effectively in industries such as manufacturing, nuclear power, and aircraft carriers to improve the rate at which a system consistently produces appropriate outcomes and prevents adverse events. Clearly, health care is not like manufacturing. In its 1999 report on medical errors, To Err Is Human, the Institute of Medicine (IOM) notes that health care differs from a systematic production process mostly because of huge variability in patients and circumstances, the need to adapt processes quickly, the rapidly changing knowledge base, and the importance of highly trained professionals who must use expert judgment in dynamic settings. But the IOM also notes that other endeavors that are as complex, fluid, and high-risk as providing health care benefit from the application of reliability principles. The report cites nuclear aircraft carriers as an example of organizational performance requiring nearly continuous operational reliability despite complex interrelated patterns among many people. Applying reliability theory to health care has the potential to help reduce defects in care or care processes, increase the consistency with which appropriate care is delivered, and improve patient outcomes. Recent studies published by The RAND Corporation report that for many clinical conditions with known best practices for quality care, only about 50 percent of patients receive care consistent with the recommendations. The inconsistent application of evidence-based care leads to variation sometimes significant variation in the quality of care Americans receive. Put another way, the American health care system is unreliable at providing high quality care. What would a reliable health care system look like? A reliable health care system is one that is designed to ensure that every patient consistently receives evidence-based, effective care every time he or she needs it. In a reliable health care system, there would be no variation in the kind or quality of care due to the time or place of care, or because of geography, gender, ethnicity, or socioeconomic status. Assessment of Chronic Illness Care Survey Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation Seattle, Washington, USA Improving Chronic Illness Care (ICIC), a national program of The Robert Wood Johnson Foundation, developed the Assessment of Chronic Illness Care (ACIC) survey to assist health care organizations in assessing current levels of care based upon the six components of the Chronic Care Model (community resources, health organization, self-management support, delivery system design, decision support, and clinical information systems). The survey allows organizations to identify areas for improvement in chronic illness care before beginning quality improvement work and to periodically evaluate the impact of the changes made on improving chronic illness care. Adapted from the Institute for Healthcare Improvement website,

162 The Right Care for Every Patient Every Time Use the ACIC in two ways: To identify areas for improvement in chronic illness care before beginning quality improvement work. To periodically evaluate the impact of the changes your organization is making to improve chronic illness care. Background The ACIC is modeled after an instrument developed by the Indian Health Service for evaluating diabetes care (Acton et al., 1993, 1995). This survey is designed to help systems and provider practices move toward the "state-of-the-art" in managing chronic illness. The results can be used to help your team identify areas for improvement. This tool has been used in multiple Institute for Healthcare Improvement Breakthrough Series Collaboratives focused on improving chronic illness care to guide improvement teams in making changes to their organizations. CHRONIC CARE MODEL There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers who have the necessary resources and expertise. Learn more about the changes that focus on the six components of the model and can be applied to a variety of chronic illnesses, health care settings, and target populations. Adapted from the Institute for Healthcare Improvement website,

163 The Right Care for Every Patient Every Time There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers backed up by resources and expertise. The changes described here can be applied to a variety of chronic illnesses, health care settings, and target populations. *The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues with support from The Robert Wood Johnson Foundation. Self-Management Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health. Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Delivery System Design The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient s status; and making follow-up a part of standard procedure. Clinical Information System A registry an information system that can track individual patients as well as populations of patients is a necessity when managing. Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs. Adapted from the Institute for Healthcare Improvement website,

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165 The Right Care for Every Patient Every Time The Model for Chronic Disease Management There are six fundamental areas identified by the Chronic Care Model making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients who take an active part in their care and providers backed up by resources and expertise. The changes described here can be applied to a variety of chronic illnesses, health care settings, and target populations. *The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues with support from The Robert Wood Johnson Foundation. For more information and general tips on selecting changes, see Improvement Methods. Self-Management Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health. Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.

166 Delivery System Design The Right Care for Every Patient Every Time The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient s status; and making follow-up a part of standard procedure. Clinical Information System A registry an information system that can track individual patients as well as populations of patients is a necessity when managing chronic illness or preventive care. Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.

167 Patients Staying healthy can be difficult when you have a chronic condition. We would like to learn about the type of help you get from your health care team regarding your condition. This might include your regular doctor, the nurse, or the physician s assistant who treats your illness. Assessment of Care for Chronic Conditions Copyright 2004 MacColl Institute for Healthcare Innovation, Group Health Cooperative. Used with permission, Judith Schaefer, MPH. Version 8/13/03 Over the past 6 months, when I received care for my chronic conditions, I was: None of the Time A Little of the Time Some of the Time Most of the Time Always 1. Asked for my ideas when we made a treatment plan Given choices about treatment to think about Asked to talk about any problems with my medicines or their effects Given a written list of things I should do to improve my health Satisfied that my care was well organized Shown how what I did to take care of myself influenced my condition Asked to talk about my goals in caring for my condition Helped to set specific goals to improve my eating or exercise Given a copy of my treatment plan Encouraged to go to a specific group or class to help me cope with my chronic condition. 11. Asked questions, either directly or on a survey, about my health habits. 12. Sure that my doctor or nurse thought about my values, beliefs, and traditions when they recommended treatments to me. 13. Helped to make a treatment plan that I could carry out in my daily life. 14. Helped to plan ahead so I could take care of my condition even in hard times. Cont d 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February

168 Patients Over the past 6 months, when I received care for my chronic conditions, I was: None of the Time A Little of the Time Some of the Time Most of the Time Always 15. Asked how my chronic condition affects my life Contacted after a visit to see how things were going Encouraged to attend programs in the community that could help me Referred to a dietitian, health educator, or counselor Told how my visits with other types of doctors, like an eye doctor or surgeon, helped my treatment Asked how my visits with other doctors were going Obtaining deeper information about your patients can be difficult. One method is to use the HowsYourHealth web site A beginning step is to have all the practice staff complete the survey to gain insight into the process for patients and for the practice to see how aggregate data about a group can help develop plans of care. Go to the website for more information. On the front page choose, For Health Professionals. This will tell you about the features of the program and how to customize the survey for your setting. Getting Good Medical Care and Improving Your Health Many Things to Do! Our Proven WEB SITE will help you! 1. What matters to you: fun, easy, brief, for ages Instant, personalized information 3. Completely confidential with no advertising 4. Gets patient and doctor on the same page 5. And much more May Seem Confusing Lots of Information! How do you use the web site? Go to On the front page choose For Health Professionals to get information on the features of the program and how to customize it for your setting. 2001, Trustees of Dartmouth College, Godfrey, Nelson, Batalden, Institute for Healthcare Improvement Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005

169 Assessment of Chronic Illness Care Version 3.5 Please complete the following information about you and your organization. This information will not be disclosed to anyone besides the ICIC/IHI team. We would like to get your phone number and address in the event that we need to contact you/your team in the future. Please also indicate the names of persons (e.g., team members) who complete the survey with you. Later on in the survey, you will be asked to describe the process by which you complete the survey. Your name: Date: / / Month Day Year Organization & Address: Names of other persons completing the survey with you: Your phone number: ( ) - Your address: Directions for Completing the Survey This survey is designed to help systems and provider practices move toward the state-of-the-art in managing chronic illness. The results can be used to help your team identify areas for improvement. Instructions are as follows: 1. Answer each question from the perspective of one physical site (e.g., a practice, clinic, hospital, health plan) that supports care for chronic illness. Please provide name and type of site (e.g., Group Health Cooperative/Plan) 2. Answer each question regarding how your organization is doing with respect to one disease or condition. Please specify condition 3. For each row, circle the point value that best describes the level of care that currently exists in the site and condition you chose. The rows in this form present key aspects of chronic illness care. Each aspect is divided into levels showing various stages in improving chronic illness care. The stages are represented by points that range from 0 to 11. The higher point values indicate that the actions described in that box are more fully implemented. 4. Sum the points in each section (e.g., total part 1 score), calculate the average score (e.g., total part 1 score / # of questions), and enter these scores in the space provided at the end of each section. Then sum all of the section scores and complete the average score for the program as a whole by dividing this by 6. For more information about how to complete the survey, please contact: Judith Schaefer, MPH tel ; [email protected] Improving Chronic Illness Care A National Program of the Robert Wood Johnson Foundation Group Health Cooperative of Puget Sound 1730 Minor Avenue, Suite 1290 Seattle, WA Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

170 Assessment of Chronic Illness Care, Version 3.5 Part 1: Organization of the Healthcare Delivery System. Chronic illness management programs can be more effective if the overall system (organization) in which care is provided is oriented and led in a manner that allows for a focus on chronic illness care. Components Level D Level C Level B Level A Overall Organizational Leadership in does not exist or there is a little interest. is reflected by senior leadership and specific dedicated resources (dollars and personnel). Chronic Illness Care Score Organizational Goals for Chronic Care Score Improvement Strategy for Chronic Illness Care Score Incentives and Regulations for Chronic Illness Care Senior Leaders Benefits Score Score Score do not exist or are limited to one condition is ad hoc and not organized or supported consistently are not used to influence clinical performance goals discourage enrollment of the chronically ill discourage patient selfmanagement or system changes is reflected in vision statements and business plans, but no resources are specifically earmarked to execute the work exist but are not actively reviewed utilizes ad hoc approaches for targeted problems as they emerge are used to influence utilization and costs of chronic illness care do not make improvements to chronic illness care a priority neither encourage nor discourage patient selfmanagement or system changes are measurable and reviewed utilizes a proven improvement strategy for targeted problems are used to support patient care goals encourage improvement efforts in chronic care encourage patient selfmanagement or system changes is part of the system s long term planning strategy, receive necessary resources, and specific people are held accountable are measurable, reviewed routinely, and are incorporated into plans for improvement includes a proven improvement strategy and uses it proactively in meeting organizational goals are used to motivate and empower providers to support patient care goals visibly participate in improvement efforts in chronic care are specifically designed to promote better chronic illness care Total Health Care Organization Score Average Score (Health Care Org. Score / 6) Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

171 Part 2: Community Linkages. Linkages between the health delivery system (or provider practice) and community resources play important roles in the management of chronic illness. Components Level D Level C Level B Level A Linking Patients to is not done systematically. Outside Resources Partnerships with Community Organizations Score Score Regional Health Plans Score do not exist do not coordinate chronic illness guidelines, measures or care resources at the practice level is limited to a list of identified community resources in an accessible format are being considered but have not yet been implemented would consider some degree of coordination of guidelines, measures or care resources at the practice level but have not yet implemented changes is accomplished through a designated staff person or resource responsible for ensuring providers and patients make maximum use of community resources are formed to develop supportive programs and policies currently coordinate guidelines, measures or care resources in one or two chronic illness areas is accomplished through active coordination between the health system, community service agencies and patients are actively sought to develop formal supportive programs and policies across the entire system currently coordinate chronic illness guidelines, measures and resources at the practice level for most chronic illnesses Total Community Linkages Score Average Score (Community Linkages Score / 3) Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

172 Part 3: Practice Level. Several components that manifest themselves at the level of the individual provider practice (e.g. individual clinic) have been shown to improve chronic illness care. These characteristics fall into general areas of self-management support, delivery system design issues that directly affect the practice, decision support, and clinical information systems Part 3a: Self-Management Support. Effective self-management support can help patients and families cope with the challenges of living with and treating chronic illness and reduce complications and symptoms. Components Level D Level C Level B Level A Assessment and Documentation of Self-Management are not done. are expected. are completed in a standardized manner. Needs and Activities Score Self-Management Support Score Addressing Concerns of Patients and Families Score Effective Behavior Change Interventions and Peer Support Score is limited to the distribution of information (pamphlets, booklets) is not consistently done are not available is available by referral to selfmanagement classes or educators is provided for specific patients and families through referral are limited to the distribution of pamphlets, booklets or other written information is provided by trained clinical educators who are designated to do self-management support, affiliated with each practice, and see patients on referral is encouraged, and peer support, groups, and mentoring programs are available are available only by referral to specialized centers staffed by trained personnel are regularly assessed and recorded in standardized form linked to a treatment plan available to practice and patients is provided by clinical educators affiliated with each practice, trained in patient empowerment and problem-solving methodologies, and see most patients with chronic illness is an integral part of care and includes systematic assessment and routine involvement in peer support, groups or mentoring programs are readily available and an integral part of routine care Total Self-Management Score Average Score (Self Management Score / 4) Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

173 Part 3b: Decision Support. Effective chronic illness management programs assure that providers have access to evidence-based information necessary to care for patients--decision support. This includes evidence-based practice guidelines or protocols, specialty consultation, provider education, and activating patients to make provider teams aware of effective therapies. Components Level D Level C Level B Level A Evidence-Based Guidelines are not available. are available but are not integrated into care delivery. are available and supported by provider education. are available, supported by provider education and integrated into care through reminders and other proven provider behavior change methods. Score Involvement of Specialists in Improving Primary Care is primarily through traditional referral. is achieved through specialist leadership to enhance the capacity of the overall system to routinely implement guidelines. includes specialist leadership and designated specialists who provide primary care team training. includes specialist leadership and specialist involvement in improving the care of primary care patients. Score Provider Education for Chronic Illness Care is provided sporadically. is provided systematically through traditional methods. is provided using optimal methods (e.g. academic detailing). includes training all practice teams in chronic illness care methods such as population-based management, and selfmanagement support. Score Informing Patients about Guidelines is not done. happens on request or through system publications. is done through specific patient education materials for each guideline. includes specific materials developed for patients which describe their role in achieving guideline adherence. Score Total Decision Support Score Average Score (Decision Support Score / 4) Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

174 Part 3c: Delivery System Design. Evidence suggests that effective chronic illness management involves more than simply adding additional interventions to a current system focused on acute care. It may necessitate changes to the organization of practice that impact provision of care. Components Level D Level C Level B Level A is not addressed. Practice Team Functioning Practice Team Leadership Score is not recognized locally or by the system. is addressed by assuring the availability of individuals with appropriate training in key elements of chronic illness care is assumed by the organization to reside in specific organizational roles. is assured by regular team meetings to address guidelines, roles and accountability, and problems in chronic illness care is assured by the appointment of a team leader but the role in chronic illness is not defined. is assured by teams who meet regularly and have clearly defined roles including patient selfmanagement education, proactive follow-up, and resource coordination and other skills in chronic illness care is guaranteed by the appointment of a team leader who assures that roles and responsibilities for chronic illness care are clearly defined. Score Appointment System can be used to schedule acute assures scheduled follow-up are flexible and can includes organization of care care visits, follow-up and with chronically ill patients. accommodate innovations such as that facilitates the patient seeing preventive visits. customized visit length or group multiple providers in a single visit. visits. Score Follow-up is scheduled by patients or is scheduled by the practice in is assured by the practice team is customized to patient needs, providers in an ad hoc fashion. accordance with guidelines. by monitoring patient utilization. varies in intensity and methodology (phone, in person, ) and assures guideline follow-up. Score Planned Visits for are not used. are occasionally used for are an option for interested are used for all patients and Chronic Illness Care complicated patients. patients. include regular assessment, preventive interventions and attention to self-management support. Score Continuity of Care is not a priority. depends on written between primary care providers is a high priority and all chronic Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

175 Components Level D Level C Level B Level A Score (From Previous Page) communication between primary care providers and specialists, case managers or disease management companies and specialists and other relevant providers is a priority but not implemented systematically disease interventions include active coordination between primary care, specialists and other relevant groups Total Delivery System Design Score Average Score (Delivery System Design Score / 6) Part 3d: Clinical Information Systems. Timely, useful information about individual patients and populations of patients with chronic conditions is a critical feature of effective programs, especially those that employ population-based approaches. 7, 8 Components Level D Level C Level B Level A Registry (list of patients with specific conditions) Reminders to Providers Feedback Score Score Score Information about Relevant Subgroups of Patients Needing Services Patient Treatment Plans Score is not available are not available is not available or is nonspecific to the team is not available. includes name, diagnosis, contact information and date of last contact either on paper or in a computer database include general notification of the existence of a chronic illness, but does not describe needed services at time of encounter is provided at infrequent intervals and is delivered impersonally can only be obtained with special efforts or additional programming are not expected. are achieved through a standardized approach. allows queries to sort subpopulations by clinical priorities includes indications of needed service for populations of patients through periodic reporting occurs at frequent enough intervals to monitor performance and is specific to the team s population can be obtained upon request but is not routinely available are established collaboratively and include self management as well as clinical goals. is tied to guidelines which provide prompts and reminders about needed services includes specific information for the team about guideline adherence at the time of individual patient encounters is timely, specific to the team, routine and personally delivered by a respected opinion leader to improve team performance is provided routinely to providers to help them deliver planned care are established collaborative an include self management as well as clinical management. Follow-up occurs and guides care at every Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

176 Components Level D Level C Level B Level A Score point of service Total Clinical Information System Score Average Score (Clinical Information System Score / 5) Integration of Chronic Care Model Components. Effective systems of care integrate and combine all elements of the Chronic Care Model; e.g., linking patients self-management goals to information systems/registries. Components Little support Basic support Good support Full support Informing Patients is not done. about Guidelines Score Information Systems/Registries Community Programs Score do not include patient selfmanagement goals do not provide feedback to the health care system/clinic about patients progress in their programs. happens on request or through system publications include results of patient assessments (e.g., functional status rating; readiness to engage in self-management activities), but no goals provide sporadic feedback at joint meetings between the community and health care system about patients progress in their programs. is done through specific patient education materials for each guideline include results of patient assessments, as well as selfmanagement goals that are developed using input from the practice team/provider and patient provide regular feedback to the health care system/clinic using formal mechanisms (e.g., Internet progress report) about patients progress. includes specific materials developed for patients which describe their role in achieving guideline adherence include results of patient assessments, as well as selfmanagement goals that are developed using input from the practice team and patient; and prompt reminders to the patient and/or provider about follow-up and periodic re-evaluation of goals provide regular feedback to the health care system about patients progress that requires input from patients that is then used to modify programs to better meet the needs of patients. Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

177 Components Little support Basic support Good support Full support Organizational Planning for Chronic Illness Care Score Score Routine follow-up for appointments, patient assessments and goal planning Guidelines for chronic illness care does not involve a population-based approach is not ensured are not shared with patients uses data from information systems to plan care is sporadically done, usually for appointments only are given to patients who express a specific interest in self-management of their condition uses data from information systems to proactively plan population-based care, including the development of self-management programs and partnerships with community resources is ensured by assigning responsibilities to specific staff (e.g., nurse case manager) are provided for all patients to help them develop effective selfmanagement or behavior modification programs, and identify when they should see a provider. uses systematic data and input from practice teams to proactively plan populationbased care, including the development of selfmanagement programs and community partnerships, that include a built-in evaluation plan to determine success over time is ensured by assigning responsibilities to specific staff (e.g., nurse case manager) who uses the registry and other prompts to coordinate with patients and the entire practice team are reviewed by the practice team with the patient to devise a self-management or behavior modification program consistent with the guidelines that takes into account patient s goals and readiness to change Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

178 Total Integration Score (SUM items): Average Score (Integration Score/6) = Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

179 Briefly describe the process you used to fill out the form (e.g., reached consensus in a face-to-face meeting; filled out by the team leader in consultation with other team members as needed; each team member filled out a separate form and the responses were averaged). Description: Scoring Summary (bring forward scoring at end of each section to this page) Total Org. of Health Care System Score Total Community Linkages Score Total Self-Management Score Total Decision Support Score Total Delivery System Design Score Total Clinical Information System Score Total Integration Score Overall Total Program Score (Sum of all scores) Average Program Score (Total Program /7) Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

180 What does it mean? The ACIC is organized such that the highest score (an 11 ) on any individual item, subscale, or the overall score (an average of the six ACIC subscale scores) indicates optimal support for chronic illness. The lowest possible score on any given item or subscale is a 0, which corresponds to limited support for chronic illness care. The interpretation guidelines are as follows: Between 0 and 2 = limited support for chronic illness care Between 3 and 5 = basic support for chronic illness care Between 6 and 8 = reasonably good support for chronic illness care Between 9 and 11 = fully developed chronic illness care It is fairly typical for teams to begin a collaborative with average scores below 5 on some (or all) areas the ACIC. After all, if everyone was providing optimal care for chronic illness, there would be no need for a chronic illness collaborative or other quality improvement programs. It is also common for teams to initially believe they are providing better care for chronic illness than they actually are. As you progress in the Collaborative, you will become more familiar with what an effective system of care involves. You may even notice your ACIC scores declining even though you have made improvements; this is most likely the result of your better understanding of what a good system of care looks like. Over time, as your understanding of good care increases and you continue to implement effective practice changes, you should see overall improvement on your ACIC scores. Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

181 WEB SITE LINKS The Right Care for Every Patient Every Time General Florida Medical Quality Assurance, Inc. DOQ-IT Institute for Healthcare Improvement Dartmouth Greenbook Clinical Microsystems Assess Measurements to assess access to your practice Staff Satisfaction Tools and More Clinical Practice Survey Staff Meeting Skills and Agenda Template Patient Survey Online Tools to Gather Information Plan 10 Step Journey Through Change the Journey 10 Step Journey Through Change Interventions Personal Reaction to Change Tool Project Team Role and Responsibility Matrix Tools to Redesign the Processes Tools to Redesign the System Select Key Questions for EHR Vendor References Samples of: Master License, System and Maintenance Agreement Customer Agreement Service Level Agreement Business Associate Agreement Addendum Request for Proposal: Electronic Health Record Guideline EHR Selection Tools Implement EHR Implementation Checklist EHR Implementation in Physicians Offices: Critical Success Factors Implementation Planning Strategies

182 The Right Care for Every Patient Every Time Evaluate/ Improve Data Submission Register to Submit Direction to Submit Population Management Chronic Care Model This area includes measurements and tools to redesign the care of your patients with chronic illnesses. Group Visit 101 Diabetes Care Redesign Asthma Care Redesign

183 The Right Care for Every Patient Every Time Articles Online Introduction Access Plan E-Health Terms in Plain English Frank Rhie, MD, MBA, Alteer Corporation Technology Consult EMR or EHR?, Medical Economics, November What It Takes to Be a Physician I.T. Champion, Health Data Management Justify Before Your Buy, Healthcare Informatics Online, August Work Smarter, Not Harder to Save Your Practice Money, Family Practice Management, May Answers to your Questions About Same-Day Scheduling, Family Practice Management, March Electronic Medical Records: Lessons Learned from Small Physician Practices, University of California, San Francisco, Making Every Minute Count: Tools to Improve Office Efficiency, Family Practice Management, April The New Model of Family Medicine: What s in it for You?, Family Practice Management, may

184 The Right Care for Every Patient Every Time Articles Page 2 Select Implement Technology Consult Tips From an EMR Pioneer, Medical Economics, October How to Select an Electronic Health Record System, Family Practice Management, February Electronic Medical Records: A Buyer s Guide for Small Physician Practices, Forrester Research, October 2003 (This report contains a link to an interactive evaluation tool.0 EMR Success: Training is the Key, Medical Economics, May What to Pack for the EHR Journey, For The Record, December Evaluate/Improve CLINICAL Getting Rewards for Your Results: Pay for Performance Programs, Family Practice Management, March Pre-Planning the Office Visit, Physicians Practice, March Building a Patient Registry From the Ground Up, Family Practice Management, Nov/Dec SERVICE Phones Driving You Crazy? Try Clinical Messaging, Medical Economics, March Starting a Revolution in Office-Based Care, Family Practice Management, October Strategies for Better Patient Flow and Cycle Time, Family Practice Management, June