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6/17/2019
1
Digitizing Peer Review
Using the EHR for Chart Review
Charles Kitzman, MS/MBA
Chief Information Officer – Shasta Community Health Center
Redding CA
Background Information
History/Vitals
Problems/Goals
Implementation
Lessons Learned/Process Improvements
Current State/Feedback/Analysis
Questions and Answers
Agenda
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Located in Redding, CA Shasta County Est. 1992
ACGME Teaching Health Center
Primary Care Residency/NP/PA Fellowship
40K Unduplicated Patients/Year ¼ of Shasta County
93% of Patients live below Federal Poverty level
Homeless, Behavioral Health, Dental, Pediatrics, Ryan
White, Specialty Care, Maternity, ISAP, MAT.
Innovation Hub – Center of Care Innovations
PCMH Level 3 Certified in All Sites
2015 HRSA OSV 19/19 score
Vitals – About SCHC
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Mission and Staff
Shasta Community Health Center’s mission is to provide quality
health care services to the medically underserved populations we serve and to improve the overall health of our community.
The Paper Process
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Lack of engagement
Time consuming
Low volume
Infrequent results
Often difficult to assess care with just one note
Goals Stay in line with Quarterly
schedule
Improve data collection
Increase engagement
Decrease “burden”
Provide “longitudinal” look [use this space to place an image that best
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Some Considerations
Sharing more data than ever
Our data has “legs” (ED, PH, Pharmacy, HIE)
Coordination of care increasingly important
Process becomes transparent
Implied bias?
Regional HIE efforts
SacValley MedShare
19+ Live Data Contributors
750K/2.2M lives in Service Area
EDIE/VA/Public Health
The Survey Itself
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Questions
Identify the Correct Encounter
Identify the Correct Type of Visit
The System highlights/selects the
encounter for the end-user to make
things easier
Questions (Continued)
Evaluate the Chronic Problem List
Evaluate the Completeness and
accuracy of the Medication List
Questions
Assess Functional Status
Evaluate Physical Exam
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Questions
Lab selection and timing
Diagnosis, Integration of
Clinical Information
Questions
Development/Execution of
Treatment plans
Questions
Communication, Education and
Access to Care
Clinician/Patient
Clinician/Consultants
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Questions
Overall Quality/Coordination
Dental? Integrated Behavioral
Health? Specialty Consults?
Some early changes….
Eliminated a question that asked “Would
you recommend this provider for a family
member?”
Added comment boxes to all questions
Added rubrics for several questions
Force comment if a score of poor is given
Other than that, no substantive changes
to the process.
The Process/Tools
NextGen EHR platform
System Practice Templates for Configuration
SQL Server Reporting Services (Enterprise)
SQL Jobs
Survey Monkey (Premier Plan)
STATA analysis tool
Chart Review M&M Committee
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System Practice Templates
Designed to give clients real-time control
over template features and processes
Part of the core software design
System allows for creative additional
functionality
Benefits/Liabilities
We have vigorously exploited this
tremendous opportunity
Manage Peer Review Template
3 Panels for 3 Processes to
control:
Who will be reviewed?
Which charts should be
selected/Removed?
Who will do the reviewing?
Who will review?
We cannot expect all providers in our practice to participate.
Telemedicine, Specialists, Moonlighters, Per Diem etc.
Most of the reviewing is done by FT/PT staff.
Requires Coordination/Process with HR to add/remove users.
Employee Number Field/Sys Admin is leveraged for categorization.
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What charts should we use?
Used to remove
confidential charts
VIP – Board Members,
Senior Leadership, etc
Can use this to also
evaluate scribes to a
degree
Schedule
Each provider/reviewer gets one task sent
every Monday.
They can open it and complete it whenever
they like so long as all Peer Review tasks are
done prior to the end of each quarter.
We track for compliance and the CMO
receives a quarterly report.
Reports are usually emailed to providers and
medical directors within two weeks after the
end of the quarter.
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Early Lessons Learned
74% Completion Rate
AVG time to complete 6 minutes
This has helped us identify systemic
issues in our processes. (Ex. “Not
taking” med reconciliation)
Dental integration means even
more eyes on the chart than usual
– mutual professional grace
Rubrics help – changes are
coming
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Med Reconciliation
Poor Scripting by MA staff
MA’s can’t stop meds
Document Not taking
No follow-up reason
Difficult to erase
Identified as a systemic issue
Resolved by new workflow
Informatics built new tools
Results
The Road ahead…
Change is hard – questions and weighting can be
compromised
Aggregate reporting for administrative purposes/trending
More emphasis on coordination of care
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Breakout Activity 1
Review the existing questions in the SCHC Chart Review.
Work together to find a suitable replacement question for the “Communication between
providers” question.
The question must have the same 6 options for response. Excellent, Good, Adequate, Poor, Very
poor and N/A.
Create a rubric for the question. What does excellent look like? Poor? Etc.
Anecdotes
“It definitely saves time as far as the reviews. Knowing who did the encounter does
influence my review a bit, even though I try not to be biased. I could usually figure out
when it was redacted though anyway.”
“I think the digital chart review is an excellent system. Once I learned the system, I can
quickly scan the chart looking for the pertinent information and then fill out the
questionnaire. It has tremendously increased my efficiency and I think it has helped us to
obtain good information in the most efficient and “pain free” way possible. I’m very
thankful for it.”
“Easy and fairly efficient way to incorporate into my weekly workflow.”
“I like it, it’s easier than looking at the paper charts and less wasteful.“
“Accessible, Fits into the provider’s workflow, Need two screens for convenience, Great
addition to our process, So glad to be rid of paper in this process
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Assessing Quality from Review
of Medical Records
Robert Moore MD MPH MBA
Chief Medical Officer, Partnership HealthPlan of California
Objectives
Understand the underlying causes of diagnostic error
Identify ways electronic Peer Review Tools can detect these errors
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Six Domains of Quality
Safe
Effective
Patient Centered
Timely
Efficient
Equitable
Crossing the Quality Chasm, 1999,
Institute of MedicineWhat is missing?
Diagnostic Accuracy
Up to 50% of clinical diagnoses are inaccurate, depending on the
type/prevalence of the problem, the degree of workup, the time
since initial presentation.
Autopsy series of patients with serious conditions and secret
shopper visits to primary care clinicians both find fundamental errors
10-20% of the time
Source: Mark Graber: “The Incidence of
Diagnostic Error in Medicine,” BMJ Oct 2013
Cause of Misdiagnosis
The human brain, dealing
with uncertainty!
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Intuition vs. Data in decision making
The other side of the coin: over-ordering diagnostic tests
Choosing Wisely campaign
Most Common Errors in Health Records
1. Inadequate history and physical examination (Fast thinking)
2. Prematurely anchoring on a common diagnosis, ignoring data not
consistent with this
3. Missing key findings generated by support staff
4. Illogical electronic medical record notes
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Common Errors I: Inadequate history and physical exam
Reason for Visit: Back Pain
History: 28 year old former construction worker on disability with a history of chronic lower back pain for the past 10 years, here to establish care with a new doctor. Pain is present constantly, worse with activity, helped by taking hydrocodone.
Review of systems: No cough, headaches, chest pain
Vitals: BP 130/90 Pulse: 80 Weight 240 lb.
Chest: clear to auscultation
CV: regular rate
Abd: Soft
Assessment: Back Pain
Plan: CT Scan of Lumbar Spine
Common Errors II: Premature Anchoring
Reason for Visit: Painful urination
History: Othewise healthy 26 year old woman with 1 week history of burning with urination. Denies frequency, urgency, abdominal pain. Had UTI diagnosed 1 month ago.
ROS: No nausea, vomiting, diarrhea, fever, no history of kidney stones
Exam: BP 130/90 P: 80 Wt. 170 lb
Chest: clear to auscultation
CV: Regular rate, no murmur
Abd: Soft, non-tender, no hepatomegaly. Flank: No pain.
Urinalysis: Neg WBC, RBC: 1+, Ketones 1+, Urobilinogen negative, Nitrite negative
Assessment: Urinary tract infection
Plan: Ciprofloxacin 400mg PO qday for 3 days
Drink plenty of fluids
Common Errors III: Ignoring Data Collected by Medical Assistants
Reason for Visit: Chronic Pain
History: 30 year old man with history of chronic pain, taking MS ER 15 mg twice a day, here to get his quarterly visit to pick up a prescription for his medication. Taking Medication on schedule, uses acetaminophen for breakthrough pain. No tobacco, drinks 1-2 glasses of wine per day. Depression under control with SSRI. CURES report shows only MS ER prescribed by PCP
Exam: BP: 210/130 P: 100 Weight: 180
PHQ9 (done by medical assistant): 20
Exam: No acute distress, ambulates well, normal affect
Chest: CTA CV: Regular rate
Back: mild paraspinous muscle tenderness
Lab: Urine toxicology screen positive for morphine only
Assessment: Chronic Pain, Depression
Plan: Refill MSER 15mg #56, x 3 months (3 triplicates given). Refill 25 mg Sertraline #90, refill x3
Medication use agreement updated.
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Quality of Documentation: Worse with Electronic Health Records
Human Decision Making: Heuristics and Biases
Heuristics (Mental rules of thumb):
1. Affect heuristic
2. Anchoring heuristic
3. Availability heuristic
4. Representativeness heuristic
5. Commitment heuristic
1. Belief bias
2. Confirmation bias
3. Optimism bias
4. Hindsight bias
5. Framing effect
6. Loss aversion
7. Narrative fallacy
8. Regression fallacy
9. Planning Fallacy
10. Halo Effect
11. The law of small
numbers
12. “What you see is all
there is” bias
Biases
Breakout Activity II
Four groups
Each assigned one of the 4 most common problems encountered in medical records
Discuss what your health centers have done to address the issue (if anything)
How can an automated peer review process be leveraged to address this:
Chart selection
What question asked of the reviewer; how is question phrased?
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Disease Focused Peer Review
Example:
Diagnosis: Acute Bronchitis (with no history of COPD or immune compromise)
Standard of Care: No antibiotics prescribed if no COPD or other co-morbidity.
Screen for: Incorrect Diagnosis used (should have use COPD exacerbation or pneumonia, for example)
If diagnosis correct, and no co-morbidities: screen for prescription of antibiotics
Breakout Activity III: Disease Specific Peer Review
Same exercise for all tables
Work together to answer the following:
1. List conditions in which there is clear evidence that a specific action should be done or should not be done. (Hint: consider both the most common reasons
for outpatient visits and rarer conditions where failure to perform an action could have catastrophic consequences.)
2. For each condition, list one or more parameters that could be objectively evaluated by a peer reviewer.
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