Beyond Meaningful Use -- Multi- disciplinary Team Integration of Customized Smoking Cessation Patient Education Into EMR Clinical Decision Support

Transcription

1 Beyond Meaningful Use -- Multi- disciplinary Team Integration of Customized Smoking Cessation Patient Education Into EMR Clinical Decision Support Wendy Angelo, MD Capital Region Healthcare

2 Learning Objectives By the end of the hour, you will be able to: Give examples of how an EMR can educate both providers and patients. Identify strategic steps that increase the chances for success of a community-wide education program. Describe at least two advantages of a team approach to patient education.

3 My Background Wendy Angelo, MD Family physician for 15 years Physician advisor and clinical Informatician for Capital Region Healthcare / Concord Hospital Proponent of using technology to make it easy for providers do the right thing

4 Located in Central NH Hot Bed of Medical informatics

5 Second busiest acute care hospital in NH 205 beds Regional referral area 275,000 15,000+ admissions annually Concord Hospital

6 170 Providers Accessing >125,000 Electronic Patient Records 95% of Primary Care Breast Care Center 100% Pulmonary Lipid Management 100% Surgery Diabetes Education 100% Wound Healing Center Gastroenterology 66% Dermatology Nutrition Counseling 60% OB/Gyn Sleep Center 75% Pediatrics Family Dental Center

7 For a Rural Community We Are Fortunate to Have a Depth of EMR Penetration and a Culture of Collaborative Practice That Enhances Our Ability to Take on Quality Improvement at a Community Level.

8 Triennial Community Needs Survey 2004 Identified smoking cessation support as one of the most pressing needs of communities served by the hospital.

9 Why Focus on Smoking Cessation The human cost of tobacco use is devastating The financial burden of tobacco use is staggering Systematizing the identification and treatment of every tobacco user in a health care setting leads to substantial improvements in cessation rates Treating tobacco use and dependence a systems approach. US public health service

10 Our Smoking Cessation Program Traditional methods such as smoking cessation Concord Hospital s Center for Health Promotion Experienced steadily declining enrollment figures over the last several years Had no enrollees for a period of 15 months prior to the start of this project

11 We Were Not Meeting Our Patient s s Needs We Needed to Do Some Quality Improvement

12 First Principles of Quality Improvement Quality is a system property Institute of medicine Every system is perfectly designed to get exactly the results it gets Dr. Berwick s s 1 st law of improvement Let s s collaborate to design systems that get our patients the services they need

13 Our System Needed a Redesign!

14 System Approach Form a multi disciplinary team Review current evidence around smoking cessation Create an EMR based tool incorporating the best evidence Create metrics to monitor success

15 Formation of a Multi-disciplinary Team Enlistment of representative members Health educator PCP champion EMR champions IT specialists Administrator Weekly meetings

16 Job #1 Review the Evidence

17

18 The Evidence Behind the PHS Recommendations Systems that increase the documentation and assessment of tobacco use markedly increase which clinicians counsel smokers to quit Clinician counseling markedly increases rates of successful smoking cessation Smoking cessation treatment is cost-effective: average cost per smoker for effective cessation treatment is ~ $166 Treating tobacco use and dependence a systems approach. US public health service

19 The Evidence (Cont.) Systematic reviews showed that brief counseling by a provider improves the rate of patients who quit smoking and don t relapse for 1 year. 4 RCT s found that antismoking advice improves smoking cessation for people at high risk of smoking-related disease.

20 Smoking Cessation Clinical Decision Support Tool A New Centricity Form Is Born

21 Rule #1 When We Create New Tools in the EMR

22 How Can We Use Our EHR to Make It Easy to Do the Right Thing? Dramatically improve those aspects of quality we can measure And Preserve and protect the time we need to talk with our patients

23 Principles of Effective Decision Support Speed is everything. Anticipate needs and deliver in real time. Fit into the user s workflow. Simple interventions work best. Little things can make a big difference (changing counseled to quit prompt to red) Monitor impact, get feedback, and respond From ten commandments for effective decision support Bates et al, JAMIA Dec 2003

24 Old EMR Smoking Documentation Mainly Unstructured Data Consistent With Paper Documentation Styles

25 Unstructured data

26 Step 1 in EMR Form Development What information do we want the form to capture as structured (vs. Unstructured) data? What s the difference?

27 Structured data

28 UNSTRUCTURED DATA

29 Step # 2 Embed Dynamic Reminders to Collect the Data Structured For Both Providers and Staff

30 providers FIRST PAGE OF ENCOUNTER

31 STAFF

32 Next, Embed the 5 A s of Tobacco Counseling Ask Advise Assess Assist Arrange follow-up

33 Ask Advise Assess Arrange follow-up Assist

34 Then, Individualize Educational Material to Stage of Readiness Create patient education materials that can be customized to the patient s stage of change Make it easy to use Incorporate it into the normal workflow of the provider

35 Handout Types Developed Smoke free living: thinking about quitting? Smoking cessation: contemplation Smoke free living: preparing to quit Smoking cessation: action Smoke free living: congratulations! Smoking cessation: relapse Smoking cessation: prenatal patient information

36 Next, Show Providers How to Use the Tool Health educator trains providers to: Utilize Prochaska / DiClemente model to assess stage of readiness to quit Employ motivational interviewing Invoke 5 R s for those not ready to quit Relevance Risk Rewards Roadblocks Repetition

37 What to Do When 3 Minutes Is Too Long

38 Assist

39 What to Do When 3 Minutes Is Too Long Give healthy plan form as homework Reasons to quit: reasons not to quit: My goal for stopping smoking is: The steps I will take to achieve my goal are: The things that could make it difficult to achieve my goal include: My plan for overcoming these difficulties includes: Support/resources I will need to achieve my goal include: My confidence that I can achieve my goal: (Scale of 1-10 with 1 being not confident at all, 10 being extremely confident)

40 What to Do When 1 Minute Is Too Long NH Smoker's Help Line enrollment form Prints out with patient demographics and the patient signs it Faxed to the state program Program contacts patient by phone 2 times prior to quit date 2 times after quit date

41

42 Framing and Measuring Our Accomplishments Communicating framework for measuring success What is the clinical case for our goals What metrics do we need to measure? How we will report to providers their success?

43 Clinical Framework an Obtainable Goal Target high-risk populations by incorporating into the NCQA s Certification as part of the project DPRP HSRP

44 Metrics Create crystal report to measure number of patients >18 whose smoking status has been identified, and smokers who have been counseled to quit within the last year.

45 Create Baseline Metrics Where Is the Starting Line?

46 What Would You Estimate the Smoking Rates in Your Practices? Less than 20 % % % Over 70 % Don t know

47 Concord Baseline Smoking Data /1/2004 % smoking status complete % of smokers counseled % smokers

48 Communicating to Providers 1. Distribute reports to PCPs, illustrating each PCP s scores in comparison to colleagues scores and to DPRP AND HSRP benchmarks.

49

50 Our Results Did It Work?

51 2 year trend graph 100% 90% 80% 70% 60% % with known smoking status % smokers counseled <1y % non-smokers (known status) % smokers (known status) % previous smokers (known status) 50% 40% 30% 20% 10% 0% Sep-04 Mar-05 Sep-05 Mar-06 Sep-06 Mar-07 Sep-07 Mar-08 Sep-08 Mar-09 Sep-09 Mar-10

52 Ongoing Challenges (Remember the Big AND ) Encouraging physicians to shift to a teambased approach to smoking cessation. Aligning incentives with non-clinical staff. Balancing measurable quality with nonmeasurable quality. Expanding the metrics down to 13 years old for meaningful use

53 What Cessation Strategies Have Worked for You?

54 Question and Answers Thank You