SNMHI Summit Meaningful EHR Use: Technology Designed to Support the PCMH. Jeff Hummel, MD, MPH

Transcription

1 Summit 2011 LEARN SHARE TRANSFORM Meaningful EHR Use: Technology Designed to Support the PCMH Jeff Hummel, MD, MPH Medical Director for Clinical Informatics, Qualis Health Session 3C March 8, 10:30AM-12:00PM

2 Objectives PCMHs require information management tools. Understand how they fit together Patient Centered Medical Home is the vision Meaningful Use is the tool set Understand that each of these efforts Has multiple steps that require proper sequencing The corresponding steps and their sequencing overlap almost completely The technology (HIT) is always subservient to the human workflows (PCMH) 2

3 Conceptual Framework The Patient Centered Medical Home is the best vision we have for a sustainable model to deliver high value healthcare at an affordable cost An EHR, used correctly (meaningful use) becomes the information management infra-structure for powering the workflows in a PCMH Meaningful use is simply an operational definition of the information management requirements for supporting a PCMH 3

4 Regardless of how you define a PCMH: Every MU element supports many PCMH criteria Every PCMH criterion requires many MU information mgmt tools 4

5 PCMH & MU: A Many-to-Many Relationship PCMH All of the many things that people need to do in order to assure high quality patientcentric care in a manner sustainable for the practice, and at a cost that is affordable to society Meaningful Use All of the many things that computers need to do to store, organize and manage information in a way that supports people in the enterprise of healthcare 5

6 Meaningful Use Core Measures CPOE for medication orders Implement drug-drug and drug-allergy interaction checks eprescribing Record Demographics Maintain a problem list Maintain an active medication list Maintain an allergy list Record Vital Signs Record smoking status Clinical Decision Support Provide patients with an electronic copy of health information Provide an after visit summary Electronically exchange clinical information with other care providers Protect health information via HIPAA privacy and security rules Clinical Quality Measures 6

7 Meaningful Use Menu Measures Drug-formulary checks Incorporate clinical lab data as structured data Generate lists of patients by condition Patient reminders for over 65 and under 5 Provide patients with electronic access (patient portal) Patient specific education Medication reconciliation Summary of care document for care transitions Submit data electronically to immunization information systems Submit surveillance data to public health agencies 7

8 Clinical Quality Measures 3 Core Measures: Hypertension: Blood Pressure measurement Smoking: Tobacco Use & Smoking Cessation Adult Weight Screening: BMI & Weight loss 3 Optional Measures: Child & Adolescent Wt screening & counseling Influenza immunization adults > age 50 Childhood immunization status 3 Additional Measures from a list of 38 8

9 Workflows and Information 9

10 EHRs Control Quality & Cost Don t They? EHRs do not control costs or improve outcomes EHRs make lower costs and better quality possible if they help practices become medical homes Medicine done right requires optimal information use Computers are tools for managing a lot of information Goal: Integrate EHR into medical homes workflows Strategy: get the right information to the right person at the right time to make the right clinical decision Without careful planning computers result in: Providers awash in poorly organized information Providers spending too much time on data entry 10

11 Computers & Humans are Different Technology is a great tool (when it works right) Technology is a terrible master, no matter how well it works Technology processes information completely differently than the human mind when information is configured for one, it makes no sense to the other Let technology do what it does best Let people do what they do best 11

12 What does technology do best? Keep track of large amounts of data Keep track of data over long periods of time Organize data so known patterns are visible Remember complex rules and protocols Maintain check-lists for completeness Prompt humans with decision support Function with constant reliable performance 12

13 What do people do best? Make decisions and be accountable for them Recognition of non-programmed patterns Judge the relative importance of information Put information into the context of the patient Use intuition and experience to give advice Assess emotional valence of information Assess the value of quality of life Establish and maintain relationships with patients 13

14 Format the Information for the User Make sure the data inputs are formatted properly for the EHRs to use in those tasks we rely on technology to do Make the EHR outputs easy for the the human brain to use for those tasks humans do best For information that is already processed by the mind far better than a machine could do, preserve the quality of that information 14

15 HEALTH INFORMATION EXCHANGE 1. Transmit key data set externally 2. Care transition summary BEGIN DATA/INFO SHARING 1. Pt access to health information 2. Pt copy of health information 3. Pt specific education material 4. Feed immunization registry 5. Submit data for syndromic surveillance to Publ Hlth 6. Report quality data to CMS 7. Med-formulary checks INSTALL INTERFACE 1. Clinical laboratory results TURN ON DATA USE TOOLS 1. Decision support tools 2. Medication reconciliation 3. Lists of Pts by condition 4. Pt clinical visit summaries 5. Send clinical reminders to Pts INSTALL CATEGORICAL DATA CAPTURE 1. Computerized provider order entry 2. eprescribing 3. Med-med/allergychecks 4. Active medication list 5. Active medication allergy list 6. Problem List in ICD-9/SNOMED 7. Vital Signs 8. Smoking Status INSTALL PRACTICE MGMT SYSTEM 1. Record demographics 2. Protect health information privacy 15 15

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17 Base Camp: Essential Skills & Equipment Meaningful Use Patient Demographics Privacy & Security Medical Home Leadership to lead change Empanelment Set up Care Teams Define Roles and Tasks Pt Centered Scheduling Appt Supply & Demand Measure Pt Experience Help Pts with Insurance 17 17

18 Empanelment 18

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20 Team-based Care & Role Definition Step 1 Step 2 Step 3 Step 4 What do I do? Gather the right information Organize the information correctly Make the decsion Carry out the decision Teams are defined by how they handle this sequence If the team is defined as people standing around waiting to do what I tell them... This process doesn t start until the doctor walks into the exam room Only the 4 th step is delegated In a PCMH care team: Many What do I do? questions can be decided in the team huddle Gathering the right information is delegated to other team members The provider-lead educates and supports team members in what information to gather and how to gather it Organizing the information can be greatly enhanced with HIT 20

21 Camp I: Essential Skills & Equipment Meaningful Use Install Interfaces for Lab & Imaging Medical Home Establish QI team to lead Assure Pts able to see own care team when possible Cross train team members for flexibility Respect Pts & Families Values & Expressed Needs Communicate with Pts at 21 21

22 Getting lab results to patients Lab Test Ordered Lab Test Run Lab result crosses Interface Result Arrives in Ordering Provider s Inbox Provider Reviews Lab Result Provider sends lab results to Pt Provider documents lab reviewed No Result requires action? Yes Team set plan into action/ contacts Pt Provider creates plan & orders intervention 22

23 Telephone Visits Arrange for follow-up from clinic visits to be done as scheduled telephone visits Schedule 5 minutes per call Put the call on the provider s clinic schedule Have the chart at the provider s desk Provider has paper chart and any electronic information open before calling patient Provider documents care in record Telephone care as a substitute for routine clinic follow-up.wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. JAMA Apr 1;267(13):

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25 Camp II: Essential Skills & Equipment Meaningful Use Vital Signs Smoking Status Problem List Medication List Allergy List CPOE eprescribing Set up Med- Med/Allergy alerts Medical Homes Establish Metrics for Improvement Adopt formal QI process Involve Care Teams & Pts in QI Build PCMH into hiring & training process 25 25

26 Gathering Med Info before the Provider walks in the room Pt makes Appt Reminder Call from Clinic remember med list Care team reviews chart in AM huddle Pt arrives at clinic Pt given Pre- Visit Summary (PVS) with med & allergy list Pt corrects meds & allergies in waiting room Nurse/MA greets Pt and gets VS in hallway Nurse/MA rooms Pt Demographics Demographics Med List Med List Nurse/MA opens Med List EHR Nurse/MA places check mark beside medications on Med List that Pt is taking MA secures chart, lets pt know provider will be in shortly, and leaves room If new allergies are reported, type of reaction is entered Allergy List MA opens allergy tab, reviews allergies and asks Pt about new allergies MA marks Medications as reviewed Medication Reconciliation MA ask patient about any medications taken that are not on Med List and enters them as Historical Meds Med-Med/ Allergy/Alerts Nurse/MA discontinues meds no longer taken Medication Reconciliation 26 26

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28 Camp III: Essential Skills & Equipment Meaningful Use Decision Support Med Reconciliation Lists of Pts by condition After-visit summaries Send clinical reminders to Pts Medical Homes Point-of-care reminders Reporting for Pop Mgmt Data for Pt mgmt by need Track sub-populations Set up visit summaries, Pt info & care reminders Shared decision-making Time for indirect Pt care 28 28

29 Population Management 29

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31 Camp IV: Essential Skills & Equipment Meaningful Use Pt-specific health info Pt access to & copy of own info via portal Direct data link to Immunization Registry Med formulary checks Report Quality to CMS Syndromic Surveillance Medical Homes Web-based access for Pts Support PHRs Enable remote monitoring 24/7 access to care with health technology Referral Tracking 31 31

32 Referral Tracking PCP decides to refer Decision Support PCP checks decision support and orders any additional tests CPOE PCP orders referral and additional tests Pt goes to Referral Coordinator in clinic Demographic Data Referral Coordinator logs into Referral Exchange & fills out appt request & admin data Clinical Summary Patient leaves clinic with instructions that specialist will contact them Communication between Pt s PCP & Consultant includes: Initial clinical information for specialist Consultant s management suggestions to PCP Dictated consult report Health Information Exchange Message sent to PCP re: suggested next steps Triage Consultant receives referral request Triage Consultant reviews clinical criteria No Decision Support Referral meets clinical criteria Yes Referral sent to Specialty Scheduler Scheduler contacts pt & schedules appt Pt has consultation visit with specialist HIE Specialist dictates consult note 32

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34 Summit: Essential Skills & Equipment Meaningful Use Transmit key data set externally Continuity of Care Record Medical Homes Follow-up with ED or hospital D/C within hours Planned interactions using complete, up-todate information 34 34

35 Health Information Exchange 35 35

36 Gartner Hype-Cycle: The Default EHR Implementation Experience EMR implementation EMR selection Using information to drive improvement Standardizing care processes Integrating IT into patient centered workflow Grappling with information overload Figuring out how the technology works 1 year later 36

37 Where is Meaningful Use Headed? Stage 2 MU: 2013 Menu items become core Add physician notes Record Pt preferences for communication EBM for decision support Pt entered data visible List care-team members Increase percent of MU measures required to mid-point for Stage 3 Stage 3 MU: 2015 Most MU measures require 80-90% of Pts Exchange data with PHRs Pts report experience Pts can upload data into EHR Self-mgmt tools for Pts 2-way HIE with imm registries Reportable condition button Pt-generated data to Public Health 37

38 PCMH: Re Cap Step 1 Make the organizational commitment Tackle empanelment and match capacity to demand Figure out the team structure HIT: Use the practice management system to support empanelment Get everyone up to speed on the brave new world of privacy & security in an EHR world 38

39 PCMH: Re Cap Step 2 Work on team function through role definition and standardized workflows Institutionalize the culture quality improvement Use getting lab results to patients as the content for these activities HIT: Set up two-way interfaces for lab and imaging Standardize workflows for CPOE and results reporting for lab and imaging 39

40 PCMH: Re Cap Step 3 Focus team activities on gathering information for clinical decision making Focus QI initiatives correct data entry Perfect the AM huddle to plan strategy for each patient HIT: EHR Go-Live with emphasis on entering categorical data, including VS, preventive measures, Problem List, Med List & Allergy List 40

41 PCMH: Re Cap Step 4 Integrate information into workflows Referral and lab tracking Use patient lists to build registry functionality Design Pt Visit Summaries for greatest impact HIT: Turn on decision support for care teams Reporting for internal information consumers Build reports for patients 41

42 PCMH: Re Cap Step 5 Let patients see records for self-mgnt support & shared decision-making Use e-visits to make time for longer office visits of greater value to the patient Share EHR data with state & national entities HIT: Patient portal Quality reporting Public Health Reporting 42

43 PCMH: Re Cap Step 6 Focus team activities on care transitions Medication reconciliation HIT: Strategies for HIE with key trading partners: ED & Hospital Specialists HIE Key data set for HIE Continuity of Care Document and PHR 43

44 Conclusion HIT is necessary, but insufficient for a PCMH Without HIT, the work-arounds for getting right information to the right person at the right time become the limiting factor Without the becoming a PCMH, HIT becomes just one more expensive not-so-magic bullet that won t fix our broken healthcare system The optimal HIT implementation strategy is ideally suited for simultaneous conversion to a PCMH 44

45 Questions? 45