Meaningful Use of Electronic Health Records in Hypertension Management

Transcription

1 Meaningful Use of Electronic Health Records in Hypertension Management Maggie Wanis, DrPh U.S. Department of Health & Human Services, Office of the National Coordinator for Health IT, Office of Programs Beth Schindele Director, Quality Insights of Delaware REC Don Post Program Manager, Delaware Health & Social Services, Division of Public Health, Diabetes and Heart Melanie Rightmyer, MSN, RN Health Systems Program Manager, Alabama Department of Public Health September 10, 2014 National Center for Chronic Disease Prevention and Health Promotion Division for Heart Disease and Stroke Prevention 1

2 CDC Grantee Meeting: State Public Health Actions to Control Chronic Disease Maggie Wanis, DrPH Office of Programs Office of the National Coordinator for Health IT, U.S. Department of Health & Human Services

3 The Big Picture Better Healthcare Better Health Reduced Costs HITECH Act EHR Incentive Program and 62 Regional Extension Centers EHRs & HIE Widespread adoption & meaningful use of EHRs Payment Reform Health IT Enabled Reform Models 9/5/2014 Office of the National Coordinator for Health Information Technology 2

4 Approach: Trusted Advisors via 62 Regional Extension Centers (RECs) Initial Program Goal: 100,000 priority primary care providers achieve meaningful use (MU) by 2014 Every REC: Has a defined service area and specific number of providers Provides unbiased, practical support throughout process Serves as two-way pipeline to federal and local resources Supported by ONC: SME Support EHR Optimization, Practice Transformation National Learning Consortium Partnership with other HHS grantees (HCIA, Beacon, ACO, CPC, HCCNs, QIOs, HIE) Variety of hospital and payer partnerships 9/5/2014 Office of the National Coordinator for Health Information Technology 3

5 Meaningful Use as a Foundation Utilize technology to gather information Improve access to information Care coordination Patient informed Data utilized to improve delivery and outcomes Patient self management Care coordination Evidenced based medicine Use information to transform Improved population health Enhanced access and continuity Data utilized to improve delivery and outcomes Patient engaged, community resources Patient centered care coordination Team based care, case management Basic EHR functionality, structured data Structured data utilized Registries for disease management Registries to manage patient populations Privacy & security protections Privacy & security protections Privacy & security protections Privacy & security protections 9/5/2014 Stage 1 MU Stage 2 MU PCMHs 3-Part Aim ACOs Stage 3 MU 4

6 Network of Support for Every Provider Paper-Based Practice Support Network REC-Provider Partnership Fully Functional EHR Regional Extension Center Community College Workforce Communities of Practice Health Information Technology Research Center (HITRC) Education and Outreach Workforce Vendor Relations Implementation Workflow Redesign Functional Interoperability Privacy and Security Meaningful Use Population Health Health Care Efficiency Patient Health Outcomes 5 5

7 REC Focus: Priority Primary Care Providers While RECs are encouraged to work with all providers, they focus on Priority Settings : Individual/small group primary care practices (<10 PCPs) Public Hospitals and CAHs Community Health Centers and Rural Health Clinics Other settings that serve medically underserved populations Many RECs are also working with specialists and LTPAC, BH providers 6 6

8 Nov-09 Jan-10 Mar-10 May- Jul-10 Sep-10 Nov-10 Jan-11 Mar-11 May- Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May- Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May- Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 REC Performance , , ,254 Enrolled with an REC Live on an EHR Demonstrating MU REC Program Target=100,000 to MU SOURCE: Customer Relationship Management (CRM) Tool, maintained by Health and Human Services, Office of the National Coordinator for Health IT, data as of July 17, /5/2014 Office of the National Coordinator for Health Information Technology 7

9 Stage 2 Builds on Stage 1 Each stage has its own set of requirements for meaningful use. Stage 2 focuses on advanced clinical procedures, including 1 : Measures focused on more rigorous health information exchange (HIE); Additional requirements for e-prescribing and incorporating lab results; Electronic transmission of patient care summaries across multiple settings; and Increased patient and family engagement. 1 The meaningful use of health IT is already leading to widespread quality improvements, but we are just beginning to realize the exciting potential of health IT in tomorrow s health care. 8

10 MU Clinical Quality Measures 2013 Criteria Eligible professionals must meet: 13 required core objectives 5 menu objectives from a list of 10 Total of 18 objectives 6 of a possible 44 clinical quality measures 3 required core or alternate core 3 out of 38 additional measures 2014 Criteria Eligible professionals must meet: 12 required core objectives 5 menu objectives from a list of 10 Total of 17 objectives 9 of a possible 64 clinical quality measures Choose from 3 different NQF domains (3 out of 6 domains) NQF 0018 strongly encouraged NQF 18 and NQF 59 are included in both 2013 and 2014 criteria 9

11 Comprehensive Support Beyond EHR Implementation Improve Care Quality: Assess ACO, PCMH models 5 1 Plan: Conduct readiness assessment Prepare for future pay for performance Empower patients in their own health care Operate & Maintain: 4 Primary goal: Give providers as much support as possible 2 Identify tools needed for change (i.e. EHR system, workflow changes, etc) Transition: Continuous quality improvement Redesign practice workflow MU Stages 1, 2, 3 Implement: Provide technical assistance 3 Perform HIT education & training 9/5/2014 Partner with local stakeholders, HIEs Office of the National Coordinator for Health Information Technology 10

12 REC Program: Foundational Strategies Responsiveness to the marketplace using adaptive business intelligence Developing infrastructure for rapid cycle improvement and diffusion of innovative practices and lessons from early adopters Partnerships and collaboration 9/5/2014 Office of the National Coordinator for Health Information Technology 11

13 Ways that Health IT can be Meaningfully Optimized to Improve Patient Health Health Information Technology New Payment Models New/ Improved Ways of Delivering Care Population Health Awareness Improved Care 9/5/2014 Office of the National Coordinator for Health Information Technology 12

14 Public-Private Alignment for Care Delivery Transformation Care Delivery Improvement through Medical Home New Payment Model through Accountable Care Accreditation Bodies Commercial Payer Medicare and Medicaid Pilots Population Health Awareness Million Hearts Medicaid Medicare Commercial ACOs Medicare and Medicaid EHR Incentive Programs State Innovation Models 9/5/2014 Office of the National Coordinator for Health Information Technology 13

15 RECs Engaged in Practice Transformation and Enabling the Three-Part Aim The national network of RECs are currently working on over 300 different programs to help providers transform their practices and demonstrate meet Three-Part Aim goals * As reported by 56 out of 62 RECs. Many REC are working on several initiatives within each category. 9/5/2014 Office of the National Coordinator for Health Information Technology 14

16 ONC Million Hearts Call to Action Key Strategy #1- ONC goal of assisting 5,000 providers on achieving improved outcomes on the Blood Pressure Control and Smoking Cessation measures through support from the Regional Extension Center Program. Key Strategy #2- Engage and enlist the Million Hearts Health IT Fellows to serve as SME in sharing and reviewing tools/resources and provide recommendations to ONC. 9/5/2014 Office of the National Coordinator for Health Information Technology 15

17 ONC Million Hearts Call to Action Key Strategy #3- Coordinate a Million Hearts Community of Practice (CoP) of RECs, federal partners and other stakeholders to provide support and resources on leveraging Health IT to assist providers on the ABCS. Key Strategy #4- Develop tools and resources to assist RECs and Providers in making progress on the ABCS. Tools/Resources reviewed and rated by Million Hearts Health IT Fellows. 9/5/2014 Office of the National Coordinator for Health Information Technology 16

18 Thank You Questions? Maggie Wanis

19 Comprehensive Support Beyond the EHR Implementation Process Beth Schindele Director, Quality Insights of Delaware REC

20 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health Improve Care Quality: Assess ACO, PCMH Million Hearts models Prepare for future pay for performance Empower patients in their own health care Operate & Maintain: Continuous quality improvement MU Stages 1,2,3 4 5 Implement: Provide technical assistance 1 Primary goal: Support providers throughout the process 2 3 Partner with local stakeholders, HIEs Plan: Conduct readiness assessment Identify tools needed for change (i.e. EHR system, workflow changes, etc) Transition: Redesign practice workflow Perform HIT education & training

21 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health 1 Primary goal: Support providers throughout the process Plan: Conduct Readiness Assessment: A complete analysis of the EHR functionalities, and organizational workflow Demming PDSA model Identify the tools, protocols and processes that need change: EHR system Workflow Changes Optimization of the EHR Clinical Documentation Patient Recall & Reminder Clinical data sets templates to capture Million Hearts data Patient engagement and participation Data monitoring processes for rapid change

22 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health Primary goal: Support providers throughout the process Transition: 2 Redesign practice workflow: Identify Best Practices for the organization Streamline workflow Improve efficiency Improve clinical documentation Increase patient satisfaction Perform HIT education & training: Staff education for utilization of EHR Provide in-depth EHR education to increase utilization Plan weekly huddles and Train the Trainer sessions with staff Importance of HIE, Blue Button, Mobile Health and Registries

23 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health Primary goal: Support providers throughout the process 3 Implement: Provide hands-on technical assistance: Local, trusted advocate Implement Health Information Technology including: EHRs Patient Portal Mobile Technology Blue Button Configuration of EHR Customization of EHR templates Build data reports and monitor Million Hearts measures for improvement Perform Root Cause Analysis to identify risk Measure outcomes Partnerships with stakeholders: Local stakeholders Public Health Hospitals Pharmacies HIEs National stakeholders: ONC CMS CDC QIN-QIOs

24 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health 4 Primary goal: Support providers throughout the process Operate & Maintain: Continuous quality improvement Rapid Change Cycle PDSA Public awareness campaign Alignment of incentives and initiatives at organization and patient level: Million Hearts PCMH Meaningful Use All stages ACO HEDIS P4P programs Payor initiatives Clinical Integration Network Health Information Exchange

25 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health 5 Primary goal: Support providers throughout the process Improve Care Quality: Assess, Implement and Facilitate: Million Hearts PCMH Meaningful Use All stages ACO HEDIS P4P programs Payor initiatives Clinical Integration Network Health Information Exchange Prepare organizations for value based payment model Empower Patients in their own health care Empower Caregivers with tools and resources Share success stories on National platforms

26 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health Continuous Quality Improvement Patient & Family Engagement Pre-Visit Registration Patient Intake Provider Visit Check-Out Post Visit Privacy & Security Continuous Process Improvement Using EHR optimization and QI/PI models to perform tasks to meet MU objectives, while working to increase awareness and improve preventable cardiovascular disease outcomes.

27 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health Continuous Quality Improvement Regional Extension Centers Provide National Regional Community & Family PCP & Specialist Acute Care & CAH LTPAC Health Information Technology & Population Health Technical Assistance Continuous Process Improvement Using EHR optimization and QI/PI models to perform tasks to meet MU objectives, while working to increase awareness and improve preventable cardiovascular disease outcomes.

28 Comprehensive Support Beyond the EHR Implementation Process: Million Hearts and Public Health Thank you! Beth Schindele Quality Insights of Delaware REC

29 Meaningful Use of Electronic Health Records in Hypertension Management September 10, 2014

30 Four chronic diseases cardiovascular disease, cancer, chronic lower respiratory diseases and diabetes account for over 50% of all deaths among Delaware residents Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

31 According to Delaware s 2013 Behavior Risk Factor Survey (BRFS), 35.6% of Delawareans have been told by a health care professional that they had high blood pressure at some point during their lifetime. That means more than 257,000 adult Delawareans have been told that they have high blood pressure during their lifetime. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

32 Prevalence (%) 100.0% Self- Reported High Blood Pressure by Sex and County, % 80.0% 70.0% 60.0% 50.0% Male Female 40.0% 30.0% 20.0% 10.0% 0.0% State Kent New Castle Sussex Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

33 Prevalence (%) 100.0% Self-Reported High Blood Pressure by Race and County, % 80.0% 70.0% 60.0% 50.0% 40.0% White Black Other 30.0% 20.0% 10.0% 0.0% State Kent New Castle Sussex Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

34 100.0% Self-Reported Prevalence by Age Group, % 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

35 Delaware s Hypertension Prevention and Control Initiative Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

36 Project Purpose: The strategy of the work is to promote reporting of blood pressure measures (NQF#0018) and, as able, initiate activities that promote awareness, clinical innovations, team based care, and self monitoring of high blood pressure among patients. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

37 Partnership Development: Quality Insights of Delaware (QID), the state's Medicare Quality Improvement Organization (QIO) The Regional Extension Center (REC) Delaware Division of Public Health Participating Provider Practices and Health Systems Medical Society of Delaware Million Hearts Delaware Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

38 What is NQF 0018: Controlling High Blood Pressure: Percentage of members/patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (less than 140/90 - early stage 1 hypertension) during the measurement year. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

39 Clinical Measures Meaningful Use Domain: Clinical Process/Effectiveness Clinical Quality Measure Clinical Quality Measure Measure Type with Associated ID National Quality Forum Center for Medicaid and Medicare Services 0018 PQRS 236 GPRO HTN PQRS 1 GPRO DM-2 Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

40 Data Collection Sources: Provider Practices/Health Systems Electronic Health Records Dashboards Regional Extension Center Customer Relationship Management (CRM) system CRM Dashboard Reports for Quality Measures Portal Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

41 Reports for Quality - Measures Portal As of June 23 rd, 2014, of the 385 providers reporting quality measures in the portal, 136 (35.3%) are reporting data on NQF 0018 Controlling High Blood Pressure. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

42 Final Data and Dashboard Yr-1 (data obtained from Reports4Quality - Measures Portal) Raw Data Report Numerator Denominator Percent Measured Providers NQF 18: Blood Pressure Management % 385 NQF 59: DM HbA1c Control (<9%) % 385 Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

43 Getting Started: Through our state Regional Extension Center: Developed a methodology for collecting, identifying and tracking physicians/health systems that utilize and report measure 0018 Created/designed reports to identify primary care practices currently addressing and reporting on quality improvement measures/core Objectives /National Quality Forum (NQF) measure 0018 Promoted the use of a web-based service (Reports for Quality) that requires the provider to register and agree to provide the numerators and denominators of the targeted quality improvement measures Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

44 Getting Started Continued: Incorporated the promotion of the Million Hearts campaign and messaging among providers and their patients. Developed a "Best Practice Survey" Developed a report showing "Best Practice" tools written protocols utilization of treatment guidelines defined procedures or policies, prompts, referrals Established comparatives of "Best Practice" and "Best Outcomes" Developed a "Best Practice Plan" Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

45 Components of a Best Practice Plan: Incorporate Million Hearts Evidence-Based Practice Protocol into the practice s EHR Lifestyle Modifications: Medication Therapy: Self-Monitoring Devices: Patient Referral to an HTN Specialist: Patient Referral to Community Support Groups Set up Hypertension Clinical Decision Support alerts into their EHR system. Based on the patient s blood pressure being entered into the system, have the system alert the provider of this significant finding and to implement a protocol. Set up monthly recall reports to remind staff to call patients who have Hypertension and have not been in to see their provider over the last 3 6 months. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

46 Best Practice Plan Continued: Outside of routine office visits, send a secure message to the patient between visits to monitor their blood pressure and to schedule a visit when Blood Pressure is not in acceptable range. Encourage the provider to track NQF-0018 Controlling High Blood Pressure in the Measures Portal on a monthly basis. This will allow the provider to track his/her performance and to benchmark their outcomes against other providers in the State of Delaware. Encourage the provider to collaborate with the MH campaign of DE. Encourage the provider to refer their patients to the Engaged Delaware website which has many tools and resources to help and educate their patient on their disease. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

47 Beyond the EHR Educating the Physician Practices: An educational flyer (see attachment) about Controlling High Blood Pressure was developed and faxed by the Medical Society of Delaware to 600 providers ed to 1,084 contacts with an open rate of 19% handed out to 40 physician practices and discussed with the office personnel when visits were made to the practices. 5 EHR user group meetings were conducted. At these meetings, the flyer was incorporated into a packet of information handed to them and if was discussed with participants on ways to assist practices in controlling high blood pressure. There were approximately 60 practices represented at these users group meetings. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

48 Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

49 Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

50 Lessons Learned and Barriers: Distributing Educational Information: ing flyers to practices has an average of 18 19% open rate. Direct distribution of flyers and speaking to the practice personnel during office visits or meetings has a significant higher level of interest. Practices seem to be more inclined to integrate the referrals into their EHRs when this information is discussed with them instead of just reading a flyer sent to them through the mail. Customizing Reports in the Practices EHRs: With the limitation of the functionalities of the different vendors EHRs, very few of them allow practices to pull standard measure reports. If measures data is required, it is important that the practice utilizes their report writer where they are required to customize their reports. Very few practices know how to pull customized reports. This requires time on the REC staff to assist the practices in customizing these reports. This is both time and resource intensive. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

51 Lessons Learned and Barriers Continued: EHR Functions: Most providers have an EHR but they are not using the maximum functionality to incorporate protocols, alerts, referrals, reminders and other tools to engage their patients. EHR Integration: The inclusion of hypertension and diabetes control protocols would assist the provider in practicing consistent best practice medicine which would improve their measures and patient outcomes. Reporting: Limitations of the data depository source (CRM) to extract raw data for NQF 59 and standardized NQF reports are not included in most EHR systems Surveys: Due to the resource limitations of the contract, ing surveys to providers do not result in a high return rate so your results cannot be statistically valid. In the future, surveys need to be accomplished by having staff visit the office or through telephone calls which is very resource intensive. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

52 Lessons Learned and Barriers Continued: EHR s Upgrades: With Stage 2 Meaningful Use requirements occurring, all of the vendors are requiring practices to upgrade their systems. These upgrades may mean hardware upgrades, major functionality upgrades in the software and changes in how data is being produced on reports. So, in the project plan, time and resources need to be allocated to respond to these changes. Practices Utilizing the Measures Portal: Several large practices are resistant to use the Measure Portal due to the amount of data to input. These practices are looking for interfaces or electronic ways of uploading the data from their EHR into the Measures Portal to eliminate the need to manually input the data. Data Collection: CRM database did not have the capacity to extract raw data for Meaningful Use Alternate Clinical Quality Measure, such as the National Quality Forum (NQF) measures, this is a limitation of the system as it was designed only for Meaningful Use. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

53 Next Steps: Implement the "Best Practice Plan" with participating current and new providers to effectively impact system changes for addressing both diagnosed and undiagnosed patients with high blood pressure for the purpose of increasing action steps to early identification and control of hypertension Develop a strategy to increase the number of physicians/health systems participating in the Regional Extension Center Develop a strategy to increase the number of physicians/health systems reporting on NQF 0018 and 0059 Develop data portal abilities to collect additional specific reportable objectives identified in the 1305 grant. Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

54 Next Steps Continued: Spread and promote Best Practice to other state initiatives and Quality Improvement Projects (i.e. Medical Society of Delaware s Patient Centered Medical Home initiative, State Medicaid program and Medicaid Manage Care Organizations). Identify pilot practices to develop systemic interventions workflow changes, clinical decision support, patient notifications and HIT alerts/reminders, in particular those that contain a high proportion of high risk patients, etc. Build custom reports for practices by REC HIT staff. Continue to enter data directly into Measures Portal for NQF Delaware Division of Public Health s Diabetes & Heart Disease Prevention and Control Program

55 Delaware Division of Public Health Bureau of Chronic Disease Diabetes & Heart Disease Prevention and Control Program Thomas Collins Building Suite 10 Dover, DE Phone: Fax:

56

57 ALABAMA... Meaningful Use of Electronic Health Records in Hypertension Management 9/10/2014

58 Building Collaborative Partnerships

59 Ground-Breaking Partnerships Developing partnerships Identifying who is missing SWOT Invitations Listening skills perfected The power of Alabama Medicaid partnerships Medicare Blue Cross Blue Shield of Alabama Giving back

60 Percentage of Total Blue Cross and Blue Shield of Alabama, Alabama Medicaid, and Medicare Hypertensive Populations Combined

61 Alabama Density of Hypertension by County Blue Cross and Blue Shield of Alabama Claims data In-state members age July June 2013

62 Hypertension Only Diabetes Only

63 Successes

64 Successes Mobile County Health Department

65 Population Health Management Implementation at Mobile County Health Department Measure Outcomes Define Population Manage Care Ongoing.... Data Integration Analysis Reporting Communications Identify Care Gaps Engage Patients Stratify Risks

66 Changing the Approach of Patient Care in Mobile Population panels Days and times of clinics Mobile clinics Recruiting help from medical student interns Team approach using non-physician team members WISEWOMAN

67 Millimeters of Mercury 1/27/14 Successes Innovative methods to analyze present data. 2/10/14 2/24/14 3/10/14 3/24/14 4/7/14 4/21/14 5/5/14 5/19/14 6/2/14 6/16/14 6/30/14 7/14/ Participant #WW-AHA3LV with Follow-up Data Systolic Diastolic Date of BP Reading & 3 Month Follow-Up

68 Millimeters of Mercury Successes Blood Pressure Decreases 73.8% of all participants decreased their Systolic BP 63.8% of all participants decreased their Diastolic BP Overall BP Changes 9.35% 11.98% Baseline Last Reading Baseline Last Reading Systolic Diastolic

69 Maxwell Air Force Base Be Well Classes Check Change Control Case Management Non-Physician Teams A1C Query Identifying Gaps or Problems

70 Challenges Getting patient data back in a consistent format Access to collated data Red tape vaporizer Patient compliance with recording multiple readings and learning proper technique Blood pressure measurement proper technique Developing working relationships with the Regional Extension Center and the Alabama Primary Health Care Association of Federally Qualified Health Centers

71 Where Do We Go From Here? Public Health Areas Regional Care Organizations

72 Alabama Battles Blood Pressure Control Through Population Health Management Whether you THINK You CAN or Think You CAN T, You are RIGHT! Henry Ford

73 Questions? Melanie Rightmyer, DNP, RN Health Systems Program Manager (334) Sondra Reese Chronic Disease Epidemiologist (334)