Continuous Quality Improvement using Centricity EMR

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Carmella Underwood
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1 Continuous Quality Improvement using Centricity EMR Jamie Howard, MD David A. Nelsen, Jr, MD, MS Associate Professors, UAMS Family & Preventive Medicine Sept 22-25, 2004 CLINICAL INFORMATION SYSTEMS 1 Johnny Jones, MD A Is a good citizen C Is learning to share and listen. C Is becoming more dependable during work periods. A Is showing interest & enthusiasm for the things we do. C Is learning to occupy his time constructively. A Is learning to be a better listener. B Is learning to listen to directions more carefully. B Works well with others. 2 1

MD A Is a good citizen C Is learning to share and listen. C Is becoming more dependable during work periods.

2 Environment Major academic medical center 9000 employees 2170 students 650 residents 300,000 outpatient visits per year 3 Logician EMR Family Medicine Project Small team PhD, 2 MD, 1 tech Phased implementation Full implementation Summer

Logician EMR Family Medicine Project Small team 1997 1 PhD, 2

3 Logician EMR Outsourced CIS support 2000 Geriatrics clinic onboard official EMR for UAMS campus Currently in use: Medicine Oncology OB-GYN Most subspecialties 5 Centricity (Logician) Team Julie West, Clinical Systems Director Becky Wolfe Gerald Russell Jean Elwell Xiaolan Liu John Jenkins Sharlene Dean 6 3

subspecialties 5 Centricity (Logician) Team Julie West, Clinical Systems

4 Family & Preventive Medicine 6/6/6 residency program 1 fellow 10 full-time faculty ~4.2 FTE in the clinic ~22,000 MD visits per year 7 Learning Objectives: Understand the process of creating physician clinical practice report cards using the EMR. Understand the use of physician clinical practice report cards as a tool for CQI. Understand the potential effect on provider behavior of these various reporting mechanisms. Implement MEL program code to perform real-time prompting of clinical providers. Evaluate the effectiveness of real-time physician prompting. Summarize the benefits of CQI to a large group medical practice. 8 4

EMR. Understand the use of physician clinical practice report cards as a tool for CQI.

5 Time to Change Speakers Jamie Howard, MD 9 CQI Process Goal of CQI Identify a problem or concern Use a team approach to define and evaluate Gather data, do audit Identify potential changes in the process for improvement Make small incremental changes to see if they work Repeat the process further defining problem and piloting solutions 10 5

potential changes in the process for improvement Make small incremental changes to

6 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Study Plan Do PDSA cycles Problem identified at FMC Wonderful tool available in Logician to prompt for preventive services needed Doctors seemed to be ignoring prompts Simplistic reasons: Doctors didn t believe the prompts were accurate Doctors didn t agree with the recommendations Doctors didn t have time to address the prompts Important to train physicians to incorporate preventive care into practice 12 6

Act Study Plan Do PDSA cycles Problem identified at FMC Wonderful tool available in Logician to prompt for preventive services needed Doctors

7 FMC Preventive medicine project Goal is to increase physicians compliance with offering preventive care interventions to their patients Uses the US Preventive Services Task Force and National Cholesterol Education Program recommendations for health screening with some modifications decided by our group practice Compliance data is derived from entries in to the Logician flowsheet. Entered by doctors, nurses and lab. 13 Data collection plan Gather baseline data that is reliable and easily collected Requires no manual chart audit Displayed and communicated via a physician report card Uses Crystal Reports access the back end of Logician 14 7

Compliance data is derived from entries in to the Logician flowsheet. Entered by doctors, nurses and lab.

8 HEDIS The Health Plan Employer Data and Information Set Parameters or indicators for gathering quality and utilization related data Allows for benchmarking of health care programs, public and private Has become the de facto national standard for measuring health plan performance Usually expressed as rates or percentages Plan members who received a benefit in proportion to those who should have received it 15 HEDIS like reports Pap q 2 years age Colorectal screening >age 50 Colonoscopy q 5 years or hemoccult q 1 year Mammograms q 1 year >age 50 Lipids q 5 years >age

expressed as rates or percentages Plan members who received a benefit in proportion to those who should have received it 15 HEDIS like reports Pap

9 Some interventions planned Individual physician report cards on a regular basis Discussed quarterly at CQI conferences Everyone can view everyone else s report New easier tool for entering interventions in to the flowsheet Nurses can enter some data that doesn t dump directly Respond to feedback for additional interventions (PDSA)

easier tool for entering interventions in to the flowsheet Nurses can enter some

10 Benchmarks How will we know when we re there? Compare our performance to published data from other groups like NCQA, Medicare, Arkansas Foundation for Medical Care (Arkansas Medicaid), other 3 rd party payers 19 Percent 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% colonoscopy women Jul-03 Sep-03 Dec-03 Mar-04 Jun-04 G H Ka Kn Mc N S T Total Faculty 20 10

Arkansas Foundation for Medical Care (Arkansas Medicaid), other 3 rd party payers 19

11 Percent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Mammograms Jul-03 Sep-03 Dec-03 Mar-04 Jun-04 G H Ka Kn Mc N S T Total Faculty

12 Sample of CQI meeting s minutes Physicians attentive to summary page prompts. Ask patients to return for services Attendings attentive to preventive services (PS) during teaching sessions. Nurses enter historical data re PS Nurses close loop on colonoscopies Front desk send letters to patients re PS Letters to focus groups such as htn/dm/no pap Letters to groups in need of preventive care visits 23 Sample workflow Nurse checks in patient and reviews preventive services (PS) due. Nurse removes PS that have been addressed elsewhere or at another time Patient here for acute or chronic care? Doctor sees patient Patient here for preventive care? Many PS due? Doctor addresses current issues and quickly reviews PS due. Minor PS due to address? Cover all PS due and document what has been done in the past. Schedule for return visit to address issues in preventive visit. Address issues during current visit

care visits 23 Sample workflow Nurse checks in patient and reviews preventive services (PS) due.

13 Problem areas Database incomplete E.g. hysterectomy, colonoscopy not recorded Clinicians too busy Clinicians not understanding protocols Patients no show for appointments like mammograms and colonoscopies. Data collection problems PCP may change from one year to the next PS recommendations changed 25 Time to Change Speakers David A. Nelsen, Jr., MD, MS 26 13

protocols Patients no show for appointments like mammograms and colonoscopies.

14 Real-Time Quality Assurance Problem Physicians, particularly resident physicians often fail to monitor clinical care according to current guidelines. Examples Transaminase checked every 6-12 months on statin therapy HgbA1C checked every year in diabetes 27 EMR attributes Current medication list Current problem list Lab values as discrete data (obsterm) List of services due (protocols) Programming language (MEL) End-user customizability 28 14

Examples Transaminase checked every 6-12 months on statin therapy HgbA1C checked every year in diabetes 27 EMR

15 Our Implementation Intake form used for every office visit Vital signs BMI w interpretation Enter important obsterms View services due Orders, follow-up stuff 29 Intake form 30 15

16 Intake form Reminders embedded as MEL code which fires pop-ups Reminders are different for nurses please enter weight please enter responsible provider Physicians see the reminders only once but can fire them again from the form 31 Reminder

weight please enter responsible provider Physicians see the

17 Reminder2 33 reminder

18 How does this work? {fn dn_check_for_recommendations() { if document.recs_viewed=="yes" then return "" else "" endif if (find("user","jobtitle")== or find("user","jobtitle")== ) then "" else return "" endif add_text_comp('enterprise\function Libraries','dn_recommendations1','at_beginning') check_recs() return ""}} 35 {fn check_recs(){local a= b= The function if (val(obsany('bp systolic'))> 160 or val(obsany('bp diastolic'))>92) and match(d,"401")==0 then a=useryesno("this patient has an elevated blood pressure of " + obsany('bp systolic') + "/" + obsany('bp diastolic') + " but no diagnosis of hypertension on the chart." + hret + hret +"Would you like to add this diagnosis to the problem list?" + hret + hret + "Click yes if you would like to add it otherwise click no.") else "" endif if a=="yes" then MEL_ADD_PROBLEM("DX OF", "Hypertension", "ICD-401.9",str(._TODAYSDATE),"","") else "" endif 36 18

$00) then "" else return "" endif add_text_comp('enterprise\function Libraries','dn_recommendations1','at_beginning') check_recs() return ""}} 35 {fn check_recs(){local a= b= The function if$

19 The function.. if ((val(obsany('creatinine'))> 1.5 and match(e,"metformin")<>0 and PATIENT.SEX=="M") or (val(obsany('creatinine'))> 1.4 and match(e,"metformin")<>0 and PATIENT.SEX<>"M")) then userok("this patient has an elevated creatinine of " + obsany('creatinine') + " and is on Metformin." + hret + "Metformin should not be used if the creatinine is above 1.5 in males or 1.4 in females." + hret + hret + "Please correct this on the patient's current medication list. ") else "" endif//creat 1.4 in females, 1.5 in males.. 37 The Function if ((durationdays(str(last_signed_obs_date('sgot (AST)')),str(._todaysdate))>180 or durationdays(str(last_signed_obs_date('sgpt (ALT)')),str(._todaysdate))>180 or (str(last_signed_obs_date('sgpt (ALT)')) =="" and str(last_signed_obs_date('sgot (AST)')) =="")) and match(e,"astatin")<>0) then userok("this patient is on a statin-type lipid lowering medication and it has been greater than 6 months since an AST or ALT has been checked." + hret + hret + "Please consider this issue today. ") else "" endif//statin and no ast or alt

5 in males or 1.4 in females." + hret + hret + "Please correct this on the patient's current medication list. ") else "" endif//creat 1.4 in females, 1.5 in males.. 37 The Function if ((durationdays(str(last_signed_obs_date('sgot (AST)')),str(.

20 Impact on Practice Wow, these are really neat. ( wow, these are really easy to ignore ) Objective data 39 Total AST count Total AST obs Jan 2002 Mar 2002 May 2002 Jul 2002 count Sep 2002 Nov 2002 Jan 2003 Mar 2003 May 2003 Jul 2003 Sep 2003 Nov 2003 Jan 2004 Mar 2004 May 2004 month 40 20

AST obs 400 350 300 250 200 150 100 50 0 Jan 2002 Mar 2002 May 2002 Jul 2002

21 SGOT vs visits AST as percent of visits Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 41 Total A1C Count HgbA1C count count Jan-03 Mar-03 May-03 Jul-03 Sep-03 Nov-03 Jan-04 Mar-04 May-04 Jul-04 Month 42 21

22 A1C corrected for visits A1C per visit corrected % visits w A1C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 43 Summary Difficult to gauge improvement in care Need to focus my report patients on statins patients with DM It s difficult to mine data from Logician 44 22

23 The End 45 23

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