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Date: Monday, Apr 8, 2013 Time: 9:30 AM - 12:30 PM. These presenters have nothing to disclose. Using Quality Improvement and Health IT Innovations to Transform Care in the Primary Care Setting The Greater Cincinnati Beacon Collaboration. Session Objectives. - PowerPoint PPT Presentation
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Using Quality Improvement and Health IT Innovations to Transform Care in the Primary Care Setting
The Greater Cincinnati Beacon Collaboration
Date: Monday, Apr 8, 2013
Time: 9:30 AM - 12:30 PM
These presenters have nothing to disclose
Session ObjectivesAfter this session, attendees will be able to:•1.) Learner will understand the use of Health IT tools to catalyze quality improvement work in a primary care setting•2.) Learner will be able to discuss the intersection of quality improvement and Health IT in meeting the requirements of a Patient Centered Medical Home. •3.) Using the Transformation Equation, the participant will be able to identify a component(s) of the equation as a starting point for transforming care in their own setting
An Overview of the Greater Cincinnati Beacon Collaboration
Pattie Bondurant DNP, RNGina Carney
Greater Cincinnati Beacon Collaboration (GCBC)
Beacon Goal •Provide funding to communities to strengthen health ITinfrastructure and exchange capabilities •Achieve measurable improvements in health care quality, safety, efficiency, and population health
Funding
$13.75 million award to Cincinnati
Cincinnati Project Demographic•200+ Adult PCPs•35,000 patients with Diabetes•300+ Pediatricians•30,000 patients with Pediatric Asthma•21 Regional Hospitals
AwardedSeptember 1, 201030 month initiative
Why is technology critical to improving health and health care?
“Information is the lifeblood of medicine. We are only as powerful as the information we have, whether we are a nurse practitioner, a physician, or a respiratory therapist.”
Dr. David Blumenthal, former National Coordinator for Health Information Technology
Patient Care is at Stake
• More than 40 percent of outpatient visits involve a transition of care
• 1 in 5 discharged Medicare enrollees are readmitted within a month – most are preventable
• Referring physicians receive feedback from consultants 55 percent of time
• Physicians make purpose of referral clear 74 percent of time
Incomplete Knowledge of Diabetes and Asthma Care Quality:• Data exists in silos – need more complete data for improvement• No single health system, hospital or practice has complete view of
patient care • Many gaps in information, data sharing only partially electronic
Preventable ED visits: • Patients need appropriate primary care rather than emergency care
Hospital Readmissions:• Hospitals will be challenged on reimbursement for readmissions – big
financial impact• Patients need appropriate primary care to prevent readmission
Transitions in Care: • PCP lacks information from patient’s hospital visit• Specialists lack most current information from PCP
Case for Intervention
GCBC Adult Diabetes ProjectWhat does success look like?
Goals:• 5% improvement in overall
D5 composite score (Registry or EHR-MU Stage 1)
• Reduction of ED/Admissions by 10% (ED/Admit Alerts)
• 80% of Beacon adult PCP practices will achieve at least Level II recognition .
• 10% Improvement in Aggregate Culture Survey Scores
GCBC Adult Diabetes ProjectClinical Transformation
Results/Progress To Date
100% of Beacon adult PCP practices achieved Level III recognition, the highest possible distinction
Achieved 10% Improvement in Aggregate Culture Survey Scores
Interim results (2010- 2011) 7% Increase in Beacon Cohort III teams, 3% Increase in Beacon QID5 teams
Transforming Healthcare
Pattie Bondurant DNP, RNGina Carney
Transformation EquationWhat Did We Learn?
Patient Centered Primary CareExtreme Makeover
• Uncoordinated care
• Over-loaded schedule
• Physician & practice-centric
• Arbitrary quality improvement projects
• Lack of clear leadership & support
• Team-based approach• Open access • Patient engagement & empanelment• Data directed quality improvement
efforts• Engaged leadership
Using the NCQA FrameworkStandard 1: Enhance Access and Continuity of Care
Standard 2: Identify and Manage Patient Populations
Standard 3: Plan and Manage Care
Standard 4: Provide Self-Care Support and Community Resources
Standard 5: Track and Coordinate Care
Standard 6: Measure and Improve Performance
Emphasizing Sustainable Change
HITECH: Policy Framework
Better care for individuals, better health for populations, and lower per-capita costs. IHI-Triple Aim Initiative
• The 2009 ARRA/HITECH Act authorizes incentive funding for health care providers who demonstrate “meaningful use of health information technology.”
• The federal government will pay eligible professionals that meet meaningful use (MU): o Up to $44K under Medicare or o Up to $63,750 under Medicaid
• Eligible hospitals can receive millions.• Payments come in 3 Stages – with increasing
requirements.
Meaningful Use & Incentives
Stages of Meaningful Use
Stage 12011*
Stage 22014*
Stage 3TBD*
1. Capturing health information in a coded format
2. Using the information to track key clinical conditions
3. Communicating captured information for care coordination purposes
4. Reporting of clinical quality measures and public health information
Capture information….
1. Disease management, clinical decision support
2. Medication management3. Support for patient access to
their health information4. Transitions in care 5. Quality measurement 6. Research7. Bi-directional communication
with public health agencies
Report information…
1. Achieving improvements in quality, safety and efficiency
2. Focusing on decision support for national high priority conditions
3. Patient access to self-management tools
4. Access to comprehensive patient data
5. Improving population health outcomes
Leverage information to improve outcomes…*Indicates “payment year” in which each Stage is first introduced.
Actual compliance timeframe depends on an EP’s first payment year.
Quality Reporting: Monitoring Progress
HealthBridgeHealth Information Exchange
In operation since 1997 as a 501c3 Not for Profit
One of the nation’s largest, most advanced and successful health information exchanges
One of only a handful of HIEs nationwide with a sustainable business model
Provide HIE services for Greater Cincinnati and four other HIEs – Dayton HIN, CCHIE, HealthLINC, NEKY RHIO, Quality Health Network • What Does an HIE Do?
• Delivers 3-6 million clinical messages PER MONTH;
• 2011- more than 60 million messages;
• 3+ million unique patients, 50 total hospitals, 7500 physicians
Like any good transportation system, our health information system must have two parts to work well: HIT = health information technology (e.g., EHR)
+HIE = health information exchange and interoperability
But the business case for HIT and HIE in health care is challenging.
Two Remedies for Better Information
ED/Admission Alerts • Goal: reduce readmissions and prevent subsequent ED visits by enhancing the delivery of better coordinated, preventive care in the primary care setting• Process
• Electronic Alerts triggered on registration at ED or hospitalization•Alert sent through HealthBridge to Primary Care Physician (PCP)•Alerts are Patient Centric-alerting PCP where the patient presents for care, anywhere in the region• Practice intervenes – schedules follow up appt. w/patient, informs of same day/open scheduling for future, get copy of discharge
HealthBridge ED Alert Architecture
Hospital
Admission
ADT
1 Patient Hospital Visit
The patient goes to the hospital and is admitted to the ED.
HealthBridge
Alert Aggregator
2
Clinical Messaging
A
D
C
B
Practice
HealthBridge Integration
HealthBridge receives the ADT and matches on the patient. If the patient is part of a subject group, an alert will be created from one of the four options (A, B, C, D).
ALERT
3 Practice Follow-up
Practice receives preferred alert from HealthBridge and calls patient for a follow-up visit.
ED/Admission Technology
Data Element HL7 Field Description
Last Name PID.5.1 Patient’s last nameFirst Name PID.5.2 Patient’s first name
Birth date PID.7.1 Date of birth for patientAdmit Date/Time PV1.44 Date and time patient was admitted to
hospital
Facility MSH.4 Hospital where patient was admittedVisit Type PV1.2 Patient class type associated with the
hospital visit
E-Emergency Department visit
I-Inpatient admission
Diagnosis Code DG1.3 Diagnosis CodeDiagnosis Description/Chief Complaint
DG1.4 Diagnosis Description
MRN MSH.10 Medical Record NumberPhone Number PID.13 Patient’s home phone number
Data Elements of ED/Admission Alert
Direct with PDF Attached ED/Admission Alerts
ED Alerts Project
University Internal Medicine - Pediatrics Experience
Jonathan “JT” Tolentino, MD
Assistant Professor of Internal Medicine and Pediatrics
University of Cincinnati
UC Internal Medicine-Pediatrics Clinic at Hoxworth
• Hospital-Based Clinic• Combined faculty-resident
teaching and private practice• NCQA Level III-Certified Patient
Centered Medical Home.• Many unique challenges
associated with combined practice.
• Diverse payer mix – 60% Medicare/Medicaid, 25% private, 15% indigent care
Clinic Characteristic
• Team: • 35 Attending providers and resident providers assigned to one of
five nurses for care management/coordination• 10 additional faculty preceptors present one half-day per week for
teaching• Medical Assistants – Clinic triage and immunization• Clinical Support staff - patient scheduling and referrals
Electronic Medical RecordGE Centricity EMR, not integrated with inpatient LastwordTransitioned in July 2012 to EPIC outpatient and inpatientED/inpatient notification available for those admitted to UC Health
facilities
Problem Definition
• Lack of meaningful data• No process to systematically identify patients visiting
the emergency room• Inconsistent process
Understanding our problem:Patient Visits to the ED
Patient visits the
ED
Patient admitted to the ED
Patient admitted to the hospital
Patient discharged
from hospital
Patient discharged from the ED
Admit?
Patient follows up
at MP Clinic
Patient sets follow up
visit
Patient sets follow
up visit
Y
N
Our process failures
Patient visits the ED
Patient admitted to the ED
Patient discharged from
ED
Patient sets follow up visit
• Incorrect PCP identified by ED or patient
• PCP not notified of the ED visit
• ED visit occurs during non-clinic hours
• PCP contact “non-critical” to the ED visit
• Patient visits a non-UC Health ED
• ED seen as primary provider for acute illnesses
• No appointment available
• Clinic closed
• No notification to the PCP’s office
• Vague discharge instructions
• Despite PCP notification, support staff/nurse not instructed to set follow up
• Information overload • Delayed notification of
ED visit to PCP
• Patient/family does not call
• Office unaware of need for follow up
• Home care services unaware of need for follow up
Patient follows up at MP Clinic
• Pt’s vague understanding of ED visit
• Late follow up • Incomplete or
delayed ED visit information
• Inability to communicate with ED provider
Recognized Barriers
• > 45 providers • Multiple hospitals and hospital
systems• Incomplete or missing medical
records• Teaching practice – trainees at
different levels of experience and understanding
• Diverse payer group • Provider-centered decision
making model
• Inconsistent practices and processes
• Lack of reliable information • Lack of coordination • Ineffective follow up
appointments • No tools or processes to
coordinate care and uncover gaps
System Created Implications of the System
Task 2: Create a High Level Transformation Process Outline
Identify Stakeholders:•-•-•-
Example: Process Outline:
•-•-•-
Aim Statement
and Charter
Kick OffConvene
Stakeholders
Action 1 Action 2 Action 3
Develop Your Process Map
Task 2: Create a High Level Transformation Process Outline
Aim Statement
Kick OffConvene
Stakeholders
Action 1 Action 2
Develop Your Process Outline
Action 3
TasksWhat Will Be
Done? Elements of theTransformation
Equation
ResponsibilitiesWho Will Do It?
TimelineBy When?
(Day/Month)
ResourcesA.Resources AvailableB.Resources Needed (people, funding, equipment, supplies, IT, etc.)
Potential BarriersA.What individuals or organizations might resist?B.How?
Communications PlanWho is involved?
What methods?How often?
1: MU of Health IT
A.
B.
A. B.
2: Patient Centric Care
A.
B.
A. B.
3:Point of CareData
A.
B.
A. B.
4: Value BasedPayment
A.
B.
A. B.
5: Culture ofReadiness
A.
B.
A. B.
Task 3: List Challenges in Your Transformation Equation
Transformation
Equation Elements
Meaningful Use of Health IT
+Patient-Centered
CareX
Point of Care Information
XValue- Based
Payment=
Transformed Care
Challenges
. . . . .
. . . . .
. . . . .
. . . . .
Readiness for Change
Challenges
. . . . .
ED Alerts Post Intervention
University Internal Medicine- Pediatrics Experience
Jonathan Tolentino, MD
Assistant Professor of Internal Medicine and Pediatrics
University of Cincinnati
Objectives for the UC Med-Peds ED/Admit Alert Project
1. Characterize the use of emergency services by patients with diabetes
2. Develop a system that coordinates care after an emergency department visits in an environment with multiple providers
3. Develop clinic infrastructure to divert emergency department visits for non-emergent illnesses
EmpanelmentMeaningful ToolsDataTeam
Our Approach using the Transformation Equation
DataEmpanelment
EmpanelmentTeam Development
EmpanelmentMeaningful ToolsData
Team Development
Empanelment
Our patients with type II diabetes that are at high risk for complications will need close follow up after a visit to the emergency room for a diabetes-related visit. This risk stratification strategy will not include patients who are in the emergency room and admitted to the inpatient unit for a diabetes-related issue.
N=125 (out of 435 total)
Team
Clinical Support Staff
Medical Assistant
Nurse
Physician
Clinic Manager
System developed to empower support staff and MAs to become the key drivers to the success for care coordination.
Who is your “keystone?”
“Scope of training” vs. “Scope of ability”
Developing Tools for SuccessDiabetes-related ED visit is defined as a patient whose diagnosis description/chief complaint transmitted through the ED alerts system includes any of the following:
•Hyperglycemia, Elevated Blood Sugar, or High Blood Sugar
•Out of medications or in need of medication refills
•Infected foot or lower extremity
•Hypoglycemia or low blood sugar
University Internal Medicine/Pediatrics
Med/Peds ED/IP Alert Process Map
Patient in Emergency Department
ED Alert Triggered
Notification via Clinical
Update to provider
No F/u F/u Appointment
set up automatically
Low Risk
Follow-up Appointment
Within 3 days of ED Visit
Patient Status
High Risk
Diabetes Related ED Visit?
Yes
No
Our Johari Window*
“Ignorance is bliss”:
Moving out of the unknown.
* Luft, J.; Ingham, H. (1955). "The Johari window, a graphic model of interpersonal awareness". Proceedings of the western training laboratory in group development (Los Angeles: UCLA).
One Patient’s Story
FeedbackMD experience
• Positive, noted opportunity to reach out to patients who have not been seen in a while
• Notification of patients admitted helpful, especially when admitted to non-UC Health hospital
MA and CSC experience• Easy to use algorithm, no issues with determining which patients need to
be called• Highest volumes on Mondays• Difficulty getting records from some health systems
RN team• Positive – able to help manage patient team• Some difficulty getting records from health system with multiple hospitals • Uncertainty of follow up needed for patient who have been admitted• Late adopters – CSC and MAs were our earliest adopters
Our Lessons
• ED alerts coupled with a simplified algorithm empowers our nursing, MA, and CSC staff to assist MD/providers in decision making
• Coupling point of care information, meaningful use, and a simplified algorithm is easily adaptable to chronic care management of many diseases
• Limitations with current point of care information – ED visits vs. inpatient visit.
• Adding decision support for with risk stratification allows for additional empowerment of decision making.
• Some elements may not be in our control - Not all patients are willing to make a follow up appointment, even after reaching out to them.
Our Lessons
• Practice transformation is possible if all aspects of the transformation equation is addressed.
• We just now beginning to understand the process and our patients• Backing into optimized system of care – cannot always go in
without the data. • Only 16% of our diabetic patients use emergency care
services for diabetes-related reasons• Over 30% of our diabetic patients were going to other health
systems – what are we missing, what didn’t we know before.
Questions
Beacon web page • www.healthbridge.org/beacon
Social Media • Twitter: http://twitter.com/healthbridgehio • Facebook:
http://www.facebook.com/pages/Cincinnati-OH/HealthBridge/128672340540952
• LinkedIn: http://www.linkedin.com/company/healthbridge_3 • YouTube: http://www.youtube.com/user/HealthBridgeHIE
Thank You……….