Menu Item: Dashboards and Analytics/Business Informatics

Transcription

1 Cover Page Menu Item: Dashboards and Analytics/Business Informatics Name of Applicant Organization: Fremont Family Care Organization s Address: 2540 N Healthy Way, Fremont, NE Submitter s Name: Elizabeth Belmont Submitter s Title: Advanced Practice Registered Nurse, Director Primary Care Clinics Submitter s bbelmont@famc.org Executive Summary Fremont Family Care is part of Health Care Professionals which is a wholly owned 501(c) -3 subsidiary of Fremont Area Medical Center. The mission of our organization is to improve the health and wellness of the people in the communities we serve. Fremont Family Care implemented eclinicalworks electronic medical record in October of 2010 and shortly after the initial implementation and go live began tracking and improving population health in our communities. This case study will describe the steps we took as a clinic to implement the electronic medical record, utilize dashboards and analytics within the EMR to improve the health and wellness of the patients we serve. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 1

2 Background Knowledge In October of 2010 Fremont Family Care implemented eclinicalworks electronic medical record with the help of an EMR support team and Curas our support/vendor. The goal was to improve the care of the patients in the population we served. With the innovative forward thinking leadership team we embarked on EMR implementation to achieve this goal. The team began to develop population management and quality improvement goals. Within a year of implementation of the EMR we felt that we had enough data entered in to the EMR to begin this process. Prior to the implementation of the EMR Fremont Family Care used a paper medical record to store data and treat patients. The front sheet was the sheet on the left hand side of the chart contained information including immunizations, social history, family history, medications, allergies, and problem list. This list however was frequently out of date, illegible, and inaccurate. The front sheet was something that we tried to maintain but despite our best efforts it was still less than perfect. Providers were frequently frustrated with the inaccuracy of the data and if you were seeing a patient for another provider it was difficult to read or determine the plan. Transcription of dictated progress notes was inefficient and frequently behind by 1-2 weeks. These issues left the providers, staff, and patients frequently frustrated with the inefficient paper system. Local Problem and Intended Improvement The biggest and most urgent problem was inaccurate, out of date paper charts. The information in the chart was frequently out of date by 1-2 weeks and this information was what we were basing our medical decisions on. This left a lot to be desired. Immunizations, social history, family history, medications, allergies, and problem list on the front sheet was frequently out of date, inaccurate, or illegible. There was a great potential for medication errors as providers would adjust medications and fail to update the front sheet. The nursing staff would refill medications based on the front sheet. Also if allergies were not listed accurately there was a potential for patient harm. We had no way of tracking quality of care given to our patients as our problem lists were frequently out of date and the immunization list was also frequently lacking accurate data. Laboratory and radiology reports being missed, misplaced, or filed incorrectly in the chart leading to delay of care. Implementation of eclinicalworks electronic medical record was the way we were going to solve all of these issues. With the EMR the front sheet would now be electronic and updated automatically. We would now have structured data problem lists that would always be legible and searchable from the registry. If there were medical problems that did not get placed on the problem list we could look back at the past diagnoses to see if that was in fact a problem for the patient. Immunizations would be entered into the EMR and this information would always be found in the same place. We would also be able to track if the patient was up to date on immunizations and be reminded to provide immunizations to patients who were due. Medication lists would be accurate as the data would flow directly from our EMR to the pharmacy and vice versa. Allergies would be entered as structured data, cross referenced with the medication list and against any new prescriptions to prevent patient harm. The ultimate goal was to establish an interface with the local hospital that provided the services for most of our laboratory and Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 2

3 radiology testing. With the interface results would flow electronically directly into the patient s chart real time. This would provide more accurate and timely patient care. Design and Implementation After our initial go live in October of 2010 the data from the front sheet was hand keyed in by a transcriptionist. The front office staff asked all patients to bring their prescription bottles with them to the appointment when making appointment reminder calls. The medications were then corrected or entered from the prescription pill bottle at their appointment by a clinical staff member. This process was implemented to help reduce the possibility of medication errors. The patients were also asked to fill out new demographic information and health history information at the time of their first appointment after go live. This information was then keyed in by clinical staff members. The health history form listed medications, allergies, past medical history, family history, and social history. The clinical staff members would have to verify this with the patient and correct or key in new information that was not already entered into the patient s electronic medical record. Immunization history was keyed in by the transcriptionist based on the information found on the front sheet of the paper record. The providers at Fremont Family Care decided as a group what laboratory and radiology reports were important and needed to be scanned into the medical record. The transcriptionist would scan into the patient documents section of the electronic medical record the last year of laboratory reports and the last year of radiology reports. The providers also recommended certain important reports be scanned in such as last colonoscopy and associated pathology report, last mammogram, and last DEXA scan. Once the transcriptionist had scanned in all of these documents a black line was drawn across the front of the paper chart indicating it had been converted to the electronic medical record. The paper record was brought back with the patient as was the workflow prior to implementing EMR. This record was then reviewed by the provider and data was entered into the EMR. The provider would then go through the paper chart and determine if any important documents were missing from the electronic medical record. These documents were then flagged and scanned in by the transcriptionist. The transcriptionist would then draw a second line across the front of the paper chart indicating that it had been completed. This process was a simple way for providers and staff to know the chart had been fully converted without opening the record or looking in the electronic medical record. Fremont Family Care following the initial go live period began to track and implement quality care metrics around preventive and chronic care of our patients. Initially we tracked and reported on blood pressure control in diabetics as well as colonoscopy, pneumonia vaccine, and screening mammogram. The practice implemented a workflow for clinical staff to access the Clinical Decision Support System (CDSS) tool within the EMR to identify patients who were in need of screening tests. We implemented standing orders where clinical staff could order screening mammogram, screening colonoscopy, and administer pneumonia vaccine if the patient was due according to the CDSS alert functionality within the EMR. Fremont Family Care as part of Fremont Area Medical Center develops two quality initiatives each fiscal year to be placed on the Organizational Excellence Initiative Scorecard. These initiatives are chosen with input from the providers at Fremont Family Care. After the quality Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 3

4 goals are developed a rating scale to determine our performance is developed based on National guidelines. Fremont Family Care s performance on the goals is then monitored throughout the fiscal year. The providers and staff at Fremont Family Care are given a scorecard monthly with the individual provider s performance in relationship to these goals. The clinical teams are given a graph that includes all providers in order to determine outliers and also create a team building experience. The outliers are identified and there is a discussion with individual clinical teams to determine any barriers or need for additional education. At the end of the fiscal year the staff are financially rewarded based on the outcomes of these quality measures. The staff are given a monetary bonus based on where the clinic as a whole fell on the rating scale. The financial bonus is calculated solely on the outcome of the goal. This process has helped improve staff buy in and gives them a incentive for improved performance. Fremont Family Care has seen an improvement in goal performance using this model Utilization of Health IT Following the establishment of quality care metrics and implementing the MAQ Dashboard, FFC established a quarterly review process of metrics. These results are shared with each clinical team and across the practice (See figure below). The providers/clinical teams who are outliers are identified. The director has a discussion with the clinical staff and the provider to determine what barriers the staff are facing or if further education is necessary. This discussion typically leads to improved performance as new individualized workflows by provider are developed. These workflows are developed with input from the clinical team members which helps them to buy in to the process and improve performance. This evaluation is done on at least a quarterly basis, monthly for some quality metrics. The performance improvement is then determined and improvements or workflow changes/updates occur on an as needed basis based on the outcomes of the quality metrics. The clinical team members are then able to develop a process for addressing any barriers or care gaps that are identified during this process. The process of evaluating outcomes and reporting performance across the clinic has helped with staff and physician engagement in the goals and their respective outcomes. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 4

5 The development of clinical decision support best practice alerts provided reminders to busy providers and medical assistants to make sure that diabetic patients were receiving the appropriate interventions at the correct time to foster improvement in outcomes. Improved documentation improved accountability and helped to foster friendly competitiveness to achieve outcomes improvement throughout the practice. Figure 2 shows an example of the CDSS window which is accessible from the top of the progress note and also from the patient s hub. The Clinical Decision Support System identifies appropriate screening and chronic care items based on patient s gender, age, and diagnoses. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 5

6 The items in red indicate that the patient is due for these tests. The EMR leadership team linked the CDSS alerts to orders so that clinical staff and providers are able to easily click on the arrow next to the order to order the appropriate screening test and this will also link it to the appropriate screening diagnosis. This process streamlined identifying testing needs and ordering the appropriate tests. In the paper record identifying last screening tests, immunizations, etc was a labor intensive inefficient process that was frequently overlooked by providers and staff. Fremont Family Care also worked with Fremont Area Medical Center to implement a laboratory and imaging interface. This process has been greatly successful and results now stream directly into the EMR in a structured format which is searchable. The results are also back to the provider typically the same day the test is ordered. Figure 3 shows laboratory tests that came across the interface. This process allowed the practice to now track the patient s progress as the results are all visible from the most recent order, allowing for real time intervention in response to abnormal results. The laboratory coming directly into the EMR in a structured format also allows the practice to track quality metrics as this is now searchable through the registry and reporting features within the EMR. Figure 3: Interfaced laboratory results. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 6

7 Fremont Family Care also implemented a patient portal which allows patients secure online access to their medical record. The patient portal allows secure messing to the practice. Patients are able to communicate with their care team using the patient portal. The portal is an integral part of our population management initiatives. Patients are able to see their lab results as soon as they are reviewed by their health care provider. This allows patients to track their results over time. The vital signs are also available on the patient portal so patients are able to track their weight and blood pressure. The portal has allowed us to communicate more effectively with patients. Fremont Family Care makes the CDSS alerts available on the patient portal. This gives the patient real time information on which preventive health care items they are due for and which have been completed. The Clinical Decision Support tool the patient sees on their secure patient portal is the same screen the providers use in the practice. Using the patient portal we are also able to send letters to patients letting them know that they are due for certain preventive care items. This is done by letter for those who are not web enabled but using the patient portal gives the patient real time access to this information and the ability to communicate with the practice in a secure environment at their convenience. The popularity of our patient portal feature continues to grow over time. This figure shows the secure messaging feature using our patient portal. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 7

8 Preventive care letter screenshot from the patient portal. Value Derived Implementation of eclinicalworks EMR has allowed our practice to have instant access to the patient s record from any location. This has streamlined patient care, decreased repeating testing unnecessarily, and improved the management of the patient s in the population we serve. The data in the EMR is now accurate and up to date. We are able to track and demonstrate quality patient care across our practice and by provider. The ability to track and benchmark the quality of care our clinics provide has allowed us to implement quality care goals and strive to improve upon those goals. We have been able to run registry reports to identify patients who are due for screening testing, send registry letters to these patients through the mail or electronically through our secure patient portal. This process has prompted patients to contact our office and schedule screening examinations, appointments, or receive the pneumonia vaccine. We believe that this proactive process of identifying and contacting patients due for preventive testing and/or immunizations has allowed us to reach patients who otherwise may have been lost to follow up in the paper record. Our effort to analyze care outcomes for our diabetic patients and the resulting changes to workflow to ensure that the appropriate coordinated preventative care is delivered has seen immediate and significant results. Since the implementation of the FFC diabetic workflow and tracking in 2013, we have seen a significant increase in the number of diabetic patients who have maintained hemoglobin A1C levels under 7. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 8

9 Lessons Learned Implementation of an EMR system is a challenge across the practice however it is a much better way to care for our patients. Starting from paper charts and converting to electronic medical record is a challenge for staff and providers. It is essential to have a strong EMR leadership team with clinical background. Developing a process of converting charts from the paper record to the electronic medical record was key to our practice. Input from the providers and clinical staff regarding what information was important to transfer to the electronic chart was also very helpful. Our practice had a dedicated person to scan and enter information into the electronic medical record from the paper chart. This was helpful to us this person became familiar with the data that needed to be converted which streamlined the process. The medication list was a challenge for our practice as the medication list on the front sheet of the paper chart was typically not updated. The workflow of having patients bring their prescription bottles with them to their first appointment was very beneficial so that the data could be entered into the EMR accurately and then would be updated with any change made to the medication within the EMR. This helped us to reduce medication errors. The ability to set, monitor, and improve upon quality goals has been an asset to our practice. Quality goals were not monitored in the paper record and this data was very beneficial to our practice. We were able to track and report these goals across our practice by provider. This process allowed us to identify gaps in care and improve patient care. Detailed data identifying improvement in quality goals is identified in the menu case study on population management. Financial Considerations Fremont Family Care s initial investment in the EMR has been detailed in the ROI core case study. The additional costs include staff training including paying wages outside of patient care hours. This time has not been significant as training is typically added in to our monthly staff meetings. Our nurse practitioner has been the clinical quality leader for our practice. There has been additional overhead for using her as a resource outside of patient care hours to develop, Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 9

10 implement, train staff, and report on the quality measures. Seeing real time data demonstrating improvement in clinical measures and population management is something that is invaluable to the practice and the population we serve. The financial return on investment for these measures has been in additional revenue from increasing the number of pneumonia vaccines administered. We also realized a return in investment by increasing the number of colonoscopies performed by the two physicians within our practice who perform colonoscopies which has been detailed in the menu case study on population management. As result of improvements in morbidity of our diabetic patients, FFC has demonstrated a cost savings for our diabetic population. Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics Page 10