Using EHR Information to Support Workflows for Medical Homes: Get the right tool for the job

Transcription

1 Using EHR Information to Support Workflows for Medical Homes: Get the right tool for the job Jeff Hummel, MD, MPH Medical Director for Clinical Informatics Qualis Health January 26, 2010

2 Objectives Introduction: Which comes first, accurate reporting, or getting the workflow right? Workflows necessary for medical homes and the reporting functionality to support them Attribution Care Management Test and Referral Tracking Population Management Performance Reporting

3 Why is this so important PCMH effort is the only strategy out there for saving primary care Every system is perfectly designed to give you exactly the outcome you get Our system is broken: we are getting mediocre outcomes despite best effort We can t improve what we re doing without: Better organized information Measuring what we re doing

4 Which comes first? Outcomes measures and workflow are interdependent and inseparable Workflows depend on information Reports, dashboards & rules engines are all ways to organize information effectively Outcomes reporting is completely dependent on workflow: To deliver the care being measured To generate useable data for reporting, through standardized data entry

5 Information is inseparable from workflow Population outcomes report reflects current information Chart opened by clinical team during encounter Rules engine calculates if immunizations are indicated Reporting Database Immunization Table Clinical team updates chart information Pop Mgr contacts Pt, creates action plan & updates EHR information Hepatitis A Hepatitis B Varicella Zoster Diphtheria Tetanus TDAP Pneumocoocus Date Date 1 2 Date 3 Date 4 Date 5 Clinical team orders needed immunization Pop Mgr uses action report to identify Pts needing immunization Clinical team documents immunization given Clinical team gives Target immunization

6 The report as change catalyst Reports expose unstable workflows & performance variation Start with mapping current workflow and creating a future state to: Standardize workflow & reduce waste Standardize how data are captured Only by problem-solving reporting issues can the workflow be fixed Only by problem-solving unstable workflows can the reporting problems be fixed

7 4 levels of reporting tools Excel spreadsheet: Not scalable Internal EHR features: Often not very robust Usually require programming Business Intelligence Query Engines: Complex reporting tools for DB analysts; costly May be hard wired to a specific EHR Result is canned reports Custom QI aftermarket products: Agile dashboards designed for QI end-user Often a service agreement

8 The Key Workflows for PCMH Attribution: who is the PCP? Care Management: Dashboards Prevention Chronic illness care Referral and Test Tracking: Overdue results Abnormal results Population Management: Generating action reports: Pts needing services Measuring performance: across practices

9 Attribution: Foundation for Empanelment

10 Attribution: Defining the goals Data definition: designate the PCP field Create a report for initial attribution: Define criteria for attribution, e.g. Provider seen most often Provider seen most recently Define mechanism for entering the decision into the PMS/EHR Define a workflow for Pt to validate & update attribution with each visit

11 Workflow for Attribution Report writer creates attribution report Attribution report is run Report output populates PCP field in PMS PMS updates PCP field in EHR Reporting Database PMS EHR Patient makes appt Scheduler asks Pt to validate PCP PMS has correct PCP? Yes Scheduler proceeds to appoint Pt Pt has office visit No Scheduler corrects the PCP field entry in PMS

12 What IT Tools Did We Use? Report from Reporting Data Base (or PMS) For each active Pt For each office visit in past x months OV Date Encounter Provider Apply agreed upon rules Programming to auto load output into designated field Maintenance: Workflow only

13 Care Management: Goals No one leaves the clinic without it being addressed The power of physician recommendation If we can t deal reliably with patients who are already in the clinic, it makes little sense to ask people to come in for preventive care Strategy: standardized workflows, integrated with information, that involve the entire team, to guarantee results

14 The Care Mgmt Workflow Patient makes appointment Day of visit team huddle to review charts & plan Pt arrives at clinic and is given Previsit summary MA rooms Pt and updates HM data from PVS Pt leaves with HM issues addressed & info updated Provider sees Pt and signs pended orders MA discusses with Pt, orders and pends HM interventions

15 The clinical decision-making information assembly line

16 Care Mgmt: Chronic Illness Identical workflow strategy for gathering the information during a visit: Plan for today s patients in the Huddle Pre-visit summary to help activate Pt Gather and organize as much info as possible before provider enters room

17 What IT Tools Did We Use? Prevention and Chronic Illness Care Rules Engines Dashboards Flow Sheets Workflow designed to gather and organize the information so the correct clinical decision was obvious

18 Test and Referral Tracking Workflow goal: Have a process to detect when Pts are lost to follow-up What is the workflow? Whose job is it to track down overdue results? How do they do it, and when? What tools support the workflow Overdue results rules engine Report showing name & date of orders that need attention

19 Overdue results workflow Test is ordered Pt given instructions on how to get test done Pt calls and is scheduled for test Pt goes to the facility and has the test performed Results sent to ordering provider Ordering provider uses information to make clinical decision High priority test activates pre-set ODR timer Option 1: Nonresulted test triggers alert to ODR in-basket ODR Mgr contacts Pt to see what happened Option 2: Weekly report: Denominator is all Pts who have had the test ordered > set interval; Numerator is all of the denominator Pts with tests not resulted Process is un-stuck and timer reset

20 Don t over-do over-due results Don t overload the workflow Pick only high priority tests to track Don t over-build it: Automate the tedious tasks Leave clinical decision-making to humans Keep the action burden low Set up standardized responses to ODRs Use automated messaging where it makes sense

21 Abnormal results Workflow goal: Abnormal results won t slip through the cracks What is the workflow? Who does it? When? What tools do they need to do it? Example: All women with abnormal paps

22 A workflow for abnormal paps Pap smear done Result returns to provider Normal? No Provider selects abnl tracking interval Provider makes clinical decision(s) Usual care including follow-up Yes Patient notified After tracking interval is elapsed, chart is reviewed Yes Pt on track? No Pt contacted to assure not lost to f/u Abnl Paps Reporting Database Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Var 1 Var 2 Var 3 Var 4 Var 5

23 What does the report need? Patient name, ID Date of last pap The f/u interval Some way to resolve or turn it off when Pt no longer needs tracking Reset f/u interval to a new value Delete f/u interval

24 Population Management What is the workflow? Goals: Automate monitoring Early recognition of complications Assure systematic interventions Risk factor reduction Empowering patients Self-management support Patient education Whose job is it?

25 Workflow steps Chronic Disease Manager runs & reviews action report Chronic Disease Manager contacts Pt Orders tests Adjusts treatment Assesses patient self-management needs Coordinates with PCP for Information flow Clinic visits Group visits

26 Information flow in Population Mmgt

27 Anatomy of an action report Denominators Careful definition of the population Accurate attribution is essential Numerators: All the patients needing action Orders & results Custom data entry fields All the Population Manager needs to see is the patients in the numerator

28 Outcomes Reports Same principle as action reports except the numerator is reversed Denominator: entire population Numerator: Those meeting criteria Must be able to drill down to clinic & provider but not to patient level Attribution must be reliable Trending to monitor progress External and external for incentives All you may need is percents

29 Getting Started Identify a topic where success is likely A clear plan Widely shared motivation for change Organizational capability Redesigning the workflow (another whole topic for discussion) Creating and maintaining the report Whose job is it? Do they have the right tools? Do they have the right skills?

30 Conclusion: Reports/Dashboards & workflow are inseparable, so build them together Medical Homes requires new workflows and new information management Empanelment Care management Results tracking Population management Outcomes reporting Get the right tool for the job

31 Questions?