Chart Reviews

Improvement Facilitator TrainingSession 1 Day 2

Chart Review - Overview

• Create a shared understanding of the purpose of the chart review and how it differs from the Model for Improvement

• Describe the timeline and process of the chart review

• Respond to providers concerns about privacy

• Describe measures of success• List next steps and supports related to

chart reviews

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Why Chart Review

• Analyzes current performance• Provides information about

documentation practices• Does not require provider have EMR• Does not require documentation

standards to be in place prior to review• Ability to aggregate results (de-

identified)

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Purpose of Chart Review

• What is the purpose of a chart review?

• A chart review intends to measure current performance against guideline care to identify opportunities for improvement

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The ASaP Intervention

Panel Identificatio

n

Focused Improvemen

t

Build on Success

Document process to ID patient/provider attachment

Generate patient lists for screening

Choose + document screening methods:

opportunistic and/or outreach

Choose + document screening maneuvers

Define & document team roles & responsibilities

Test small change (PDSA)

Standardize processes

Measure reliability of processes

Apply for CME credits

Identify other clinical improvement opportunities

Baseline Chart Review & Current Screening Process Assessment

4-Month Follow Up Chart Review & Screening Process Assessment

Sustainability Chart Review & Continued Follow-up Reviews

30 days

60 days

Ongoing

Process of Chart Review

1. Consent2. Selecting a Bundle3. Agreeing on standards4. Collecting Data5. Analysing Data against standards6. Feeding back results7. Implementing changes8. Allowing time for changes to embed before re-

review9. Collect second set of data10.Analyse second set of data11.Feeding back second set of results12.Repeat 7 – 11 as needed 6

Chart Review - Consent

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Chart Review – Health Information Act

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Privacy and Confidentiality - Implications• Provider Data– Information about the provider is shared

with TOP to support the PCO with the ASaP program

– Collection, Usage, and Reporting of this information is covered in the consent process

– Personally Identifiable Data will be shared between the provider, the PCO, and TOP CPA

– De-identified data will be aggregated for the purposes of PCO reporting

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Privacy and Confidentiality - Implications• Patient Data– Patient consent is not required– No identifiable patient information will

be recorded or shared– Identifiable patient information will be

viewed• Chart reviewers will need to assess their

organizations Privacy Impact Assessment to determine if this activity has been documented• Affiliate Agreement may be necessary if

not addressed in the PIA• Oath of Confidentiality endures beyond

the ASaP initiative10

Chart Review – Selecting Bundle

• Identification of Clinical Maneuvers by provider

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Chart Review – Selecting Bundle

• Table of sampling error by number of maneuvers and charts reviewed

• Key Message: # of charts reviewed and/or # of maneuvers increases precision

• Key Message: Number of chart reviews determined by PCN or other primary care organization

Number of Maneuvers

10 Charts 20 Charts 30 Charts

5 6.0 – 13.8 4.2 – 9.7 3.5 – 7.9

8 4.8 – 10.9 3.4 – 7.7 2.7 – 6.3

10 4.3 – 9.8 3.0 – 6.9 2.4 – 5.6

12 3.0 – 8.9 2.7 – 6.3 2.2 – 5.4

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Agreeing on Standards

• Screening and Prevention of a patient is dependent on three factors– Patient compliance– Ability of health system to perform– Provision of offer

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ASaP – Agreeing on Standards

In Alberta, what are some activities focused on improving screening and prevention for…

– Patient compliance?

– Ability for health system to perform?

– Provision of offer?

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ASaP – Agreeing on Standards

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Maneuver Age (years) Interval

Blood Pressure 18+ Annual Weight 18+ AnnualHeight 18+ Once lifetimeExercise Assessment 18+ AnnualTobacco Use Assessment 18+ AnnualAlcohol Use Assessment 18+ AnnualInfluenza Vaccination/ Screen 18+ AnnualPap Test Females 21 – 69 3 years

Plasma Lipid ProfileMales 40 – 74

Females 50 – 74 3 years

CV Risk CalculationMales 40 – 74

Females 50 – 74 3 years

Diabetes ScreenOne of:- Fasting Glucose- Hgb A1c- Diabetes Risk Calculator

40+ 3 years

Colorectal Cancer ScreenOne of:- FOBT/FIT- Flex Sigmoidoscopy- Colonoscopy

50 – 74

  2 years5 years10 years

Mammography Females 50 - 69 (74*) 2 years

Collecting Data

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Initial Chart Review

• Does the provider have a panel process– YES, then sample entire panel by

creating a list of patients and review records by patient last name starting with the random letter skipping identical last names already reviewed.

– NO, then chart audit must be delayed until a panel process is established for at least 30 days.

– MAYBE, if the provider can generate a partial list of patients that have been confirmed using their new process for a portion of the entire panel sample this list otherwise see NO

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Collecting Data - Bias

• Peter and Mary both work for the Rocky Peaks Primary Care Network as chart reviewers.

• Peter reviews 30 of Dr. Doe’s charts (patients of Dr. Doe aged 18 and older) and finds that all the charts (30/30) have a tobacco use assessment charted in the record.

• Mary reviews the same 30 records and finds that Dr. Doe has a documented assessment for tobacco use on 12 out of the 30 records reviewed.

• What could explain the difference?

BMFC

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Collecting Data - Bias

How could we reduce these sources of error?

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Collecting Data – Reducing Bias

• Reviewer Bias– Preferably the same reviewer for initial and

follow up chart reviews– Preferably one or few reviewers for the

primary care organization (e.g. PCN)– Availability of realistic examples and

indications of documented offers or exemptions

– Single point of contact for questions not addressed

• Outcome Bias– Record only documented actions– Record only actions which have occurred

(not intended future actions)20

Collecting Data – Bias

• Peter and Mary both work for the Rocky Peaks Primary Care Network as chart reviewers. Dr. Doe from the Blue Meadow Family Clinic has agreed to participate in ASaP. Peter has reviewed the charts of Dr. Green already but Peter will be on vacation for 3 weeks during the planned follow up chart review time for Dr. Doe.

• Who should review Dr. Doe’s charts?

BMFC

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Collecting Data – Bias

• Peter reviews 30 patients of Dr. Doe who presented to the clinic for a complete medical exam between January and February of 2013.

• Dr. Doe wants to know about his performance in screening for his entire panel.

• What types of bias are present in Peter’s method?

BMFC

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Collecting Data – Reducing Bias

How could we reduce the sources of error in Peter’s approach?

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Collecting Data – Reducing Bias

• Selection Bias– Sample drawn from the whole– Randomization of selection– Familial Bias

http://www.randomlettergenerator.com

• Selection Bias– Sample drawn from the whole– Randomization of selection– Familial Bias

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Collecting Data

• Doctor Doe at Blue Meadows clinic has 2238 patients according to his EMR. He started a Panel Process 30 days ago as prework for the ASaP initiative. He has 345 patients on his panel since starting this new process.

• Peter reviewed patients from the panel listing of 2238 and found a screening rate of 22% and then reviewed only patients on the shorter 345 patient list and found a screening rate of 38%.

• What would account for the differences in screening rates and which panel list should he use?

BMFC

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Collecting Data

• You are reviewing the chart of Sally a 55 year old patient of Dr. Doe for Mammography. There is no notation in the encounter notes that she was offered mammography in the past 2 years. The scanned documents does not have a requisition for ‘mammo’ either. Though you note a surgical report for bilateral mastectomy 5 years ago.

• How do you record this information?• Would the answer be different if this

information was recorded in surgical history?

BMFC

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Chart Review – What does an ‘Offer’ look like?

• Completion

• Decline

• Exclusion/Exemption

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Data Collection – Evidence of Offer

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Screening Offers Documentation

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BMFC

Chart Review – Data Collection & Analysis

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Chart Review Report

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Chart Review Report

• Dr. Doe calls you and wants to know what the 38% screening rate means.

• What is the denominator?– We randomly selected 30 patient records

from your list of patients who were between 18 and 79 and reviewed their record for the 11 maneuvers you selected.

• What is the numerator?– We looked for documented evidence that

the screening and prevention for all maneuvers were addressed which included: results, patient declines, and exclusion/exemptions within the appropriate time frame.

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Chart Review Report – Key Messages

• How can I improve?– Goal is not 100%– Based on ‘GUIDELINE’ care which has

exceptions– Records ‘DOCUMENTED’ actions not

‘actual’ actions– What do you (provider/team) think can

be improved?– Comment on what was observed• E.g. It was difficult to find exclusions• E.g. Patients with chronic disease were

not screened33

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The ASaP Intervention

Panel Identificatio

n

Focused Improvemen

t

Build on Success

Document process to ID patient/provider attachment

Generate patient lists for screening

Choose + document screening methods:

opportunistic and/or outreach

Choose + document screening maneuvers

Define & document team roles & responsibilities

Test small change (PDSA)

Standardize processes

Measure reliability of processes

Apply for CME credits

Identify other clinical improvement opportunities

Baseline Chart Review & Current Screening Process Assessment

4-Month Follow Up Chart Review & Screening Process Assessment

Sustainability Chart Review & Continued Follow-up Reviews

30 days

60 days

Ongoing

60 day wait

Chart Review – Follow up Sampling

• Opportunistic Method• If the provider used an opportunistic

approach to offer screening:– Identify the patients who could have

been offered screening by selecting panel patients who were seen between chart review (follow up) and completion of the changes.

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Chart Review – Follow up

• Dr. Green has a panel of 2153 patients. The team implemented an opportunistic approach to screening and finished implementing changes on May 18th. How would we create a list of patients to sample for follow up chart review?

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BMFC

Chart Review – Follow up

• Outreach Method• If the provider used an outreach

method to offer screening:– Identify the group of patients that

outreach was attempted with by having the provider or team recreate the list of patients who were planned for contact

• If both methods (Outreach and Opportunistic) were used then select half the sample size from each method (e.g. 10 Opportunistic and 10 Outreach records reviewed) 37

Chart Review – Outreach Sampling

• Dr. Smith has selected 5 maneuvers (Blood Pressure, Height/Weight, Tobacco Use, Colorectal Cancer, and Cardiac Risk) but due his large panel size he has chosen to generate a list of patients who are 50 years old and last name begins with A, B, C, or D.

• You are preparing for the chart review by generating the list of patients to sample. What is the criteria you would use/ask the superuser to create the list?

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Chart Review – Next Steps

• Confirm who is conducting chart reviews in your organization

• Determine if your organization has a Privacy Impact Assessment which contemplates chart reviews

• Confirm number of charts to be reviewed• Complete Maneuvers Checklist• Complete Screening Offers Documentation

in Clinic for each provider/clinic

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Chart Review Summary

• Chart reviews provide an objective measure of how the providers system for screening is performing

• The follow up chart review will occur approximately 4 months after the initial chart review and include patients which the new process could have affected

• Success is described as an offer of screening, completed result, documented decline, or documented exclusion within the appropriate timeframe

• Identifiable provider data will be shared with the IF +/- CPA and de-identified data will be aggregated

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