Transcript Dr. Pattie Bondurant, Beacon Program Director, HealthBridge

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
Date: Monday, Apr 8, 2013
Time: 9:30 AM - 12:30 PM
Session Objectives
After 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, RN
Gina Carney
Greater Cincinnati Beacon Collaboration
(GCBC)
Beacon Goal
• Provide funding to communities to
strengthen health IT
infrastructure 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
Awarded
September 1, 2010
30 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
Case for Intervention
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
GCBC Adult Diabetes Project
What 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 Project
Clinical 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, RN
Gina Carney
Transformation Equation
What Did We Learn?
Patient Centered Primary Care
Extreme 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 Framework
Standard 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
Meaningful Use & Incentives
• 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.
Stages of Meaningful Use
Stage 1
2011*
Stage 2
2014*
1.
Capturing health information
in a coded format
1.
2.
Using the information to track
key clinical conditions
2.
3.
3.
Communicating captured
information for care
coordination purposes
4.
Reporting of clinical quality
measures and public health
information
Capture information….
4.
5.
6.
7.
Disease management, clinical
decision support
Medication management
Support for patient access to
their health information
Transitions in care
Quality measurement
Research
Bi-directional communication
with public health agencies
Report information…
Stage 3
TBD*
1.
Achieving improvements in
quality, safety and efficiency
2.
Focusing on decision support
for national high priority
conditions
3.
Patient access to selfmanagement 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
Wave 1: Lipid Control
Wave 1: Aspirin
70.0%
100.0%
93.0%
95.0%
91.2%
92.8%
92.9%
87.4%
90.0%
65.7%
63.9%
60.5%
60.0%
78.7%
59.1%
2011 Q4
2012 Q1
50.0%
45.0%
75.0%
40.0%
70.0%
2011 Q2
2011 Q3
2011 Q4
2012 Q1
2012 Q2
2011 Q2
2012 Q3
100.0%
85.0%
95.0%
78.3%
78.3%
75.6%
75.2%
2011 Q3
2012 Q2
2012 Q3
82.4%
81.9%
2012 Q2
2012 Q3
Wave 1: Non-Smokers
Wave 1: BP<140
90.0%
80.0%
59.4%
56.5%
55.0%
85.0%
80.0%
65.0%
78.7%
76.0%
90.0%
85.0%
75.0%
70.0%
80.0%
65.0%
75.0%
82.2%
82.0%
78.7%
76.8%
70.0%
60.0%
2011 Q2
2011 Q3
2011 Q4
2012 Q1
2012 Q2
2011 Q2
2012 Q3
2011 Q3
2011 Q4
2012 Q1
Wave 1: D5 Composite
Wave 1: A1C<8
40.0%
90.0%
34.1%
35.0%
85.0%
30.0%
80.0%
74.0%
75.0%
69.4%
70.8%
70.9%
31.4%
32.2%
2011 Q3
2011 Q4
35.8%
29.7%
27.3%
25.0%
71.5%
20.0%
70.0%
64.9%
15.0%
65.0%
10.0%
60.0%
2011 Q2
2011 Q3
2011 Q4
2012 Q1
2012 Q2
2012 Q3
2011 Q2
2012 Q1
2012 Q2
2012 Q3
HealthBridge
Health 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
Two Remedies for Better Information
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.
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
1
2
Patient Hospital Visit
The patient goes to the
hospital and is admitted to
the ED.
3
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).
HealthBridge
Hospital
Practice receives preferred alert
from HealthBridge and calls
patient for a follow-up visit.
Practice
A
B
ADT
Alert Aggregator
ALERT
C
Admission
D
Clinical Messaging
Practice Follow-up
ED/Admission Technology
Data Elements of ED/Admission Alert
Data Element
HL7 Field
Last Name
First Name
Birth date
Admit Date/Time
PID.5.1
PID.5.2
PID.7.1
PV1.44
Facility
Visit Type
MSH.4
PV1.2
Description
Patient’s last name
Patient’s first name
Date of birth for patient
Date and time patient was admitted to
hospital
Hospital where patient was admitted
Patient class type associated with the
hospital visit
E-Emergency Department visit
Diagnosis Code
Diagnosis Description/Chief
Complaint
MRN
Phone Number
DG1.3
DG1.4
I-Inpatient admission
Diagnosis Code
Diagnosis Description
MSH.10
PID.13
Medical Record Number
Patient’s home phone number
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 Record
 GE Centricity EMR, not integrated with inpatient Lastword
 Transitioned in July 2012 to EPIC outpatient and inpatient
 ED/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
Y
Admit?
Patient
admitted to
the hospital
Patient
discharged
from
hospital
Patient
sets follow
up visit
N
Patient
discharged
from the ED
Patient sets
follow up
visit
Patient
follows up
at MP Clinic
Our process failures
Patient visits
the ED
• Patient visits a
non-UC Health
ED
• ED seen as
primary
provider for
acute illnesses
• No
appointment
available
• Clinic closed
Patient admitted
to the ED
• 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
discharged from
ED
Patient sets
follow up visit
Patient follows
up at MP Clinic
• 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
• Pt’s vague
understanding
of ED visit
• Late follow up
• Incomplete or
delayed ED
visit
information
• Inability to
communicate
with ED
provider
Recognized Barriers
System Created
• > 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
Implications of the System
• 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
Task 2: Create a High Level
Transformation Process Outline
Identify Stakeholders:
• • • -
• • • -
Example: Process Outline:
Action 1
Action 2
Action 3
Aim
Statement
and Charter
Kick Off
Convene
Stakeholders
Develop Your
Process Map
Task 2: Create a High Level
Transformation Process Outline
Tasks
What Will Be
Done?
Elements of the
Transformation
Equation
1: MU of
Health IT
Responsibilities
Who Will Do It?
Timeline
By When?
(Day/Month)
2: Patient
Centric Care
3:Point of Care
Data
4: Value Based
Payment
5: Culture of
Readiness
A.
B.
Resources
Resources Available
Resources Needed
(people, funding,
equipment, supplies, IT,
etc.)
A.
B.
A.
A.
B.
B.
A.
A.
B.
B.
A.
A.
B.
B.
A.
A.
B.
B.
A.
A.
B.
B.
Action 1
Action 2
Action 3
Aim
Statement
Kick Off
Convene
Stakeholders
Develop Your
Process
Outline
Potential Barriers
What individuals or
organizations might
resist?
How?
Communications Plan
Who is involved?
What methods?
How often?
Task 3: List Challenges in Your
Transformation Equation
Transformation
Equation
Elements
Challenges
Meaningful Use
of Health IT





.
.
.
.
.
Readiness for
Change
Challenges





.
.
.
.
.
Patient-Centered
Care
+





.
.
.
.
.
X
Point of Care
Information





.
.
.
.
.
Value- Based
Payment
X





.
.
.
.
.
=
Transformed
Care
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
Our Approach using the
Transformation Equation
Data
Empanelment
Empanelment
Team Development
Empanelment
Meaningful Tools
Data
Team Development
Empanelment
Meaningful Tools
Data
Team
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 diabetesrelated 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
“Scope of training” vs.
“Scope of ability”
System developed to empower
support staff and MAs to become
the key drivers to the success for
care coordination.
Who is your
“keystone?”
University Internal Medicine/Pediatrics
Med/Peds ED/IP Alert
Process Map
Developing Tools for Success
Patient in Emergency Department
ED Alert Triggered
Patient Status
High Risk
Low Risk
Follow-up Appointment
Within 3 days of ED Visit
Diabetes Related
ED Visit?
No
Notification via Clinical
Update to provider
Yes
Appointment
set up
automatically
F/u
No F/u
Diabetes-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
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
04/01/12
04/08/12
04/15/12
04/22/12
04/29/12
05/06/12
05/13/12
05/20/12
05/27/12
06/03/12
06/10/12
06/17/12
06/24/12
07/01/12
07/08/12
07/15/12
07/22/12
07/29/12
08/05/12
08/12/12
08/19/12
08/26/12
09/02/12
09/09/12
09/16/12
09/23/12
09/30/12
10/07/12
10/14/12
10/21/12
10/28/12
11/04/12
11/11/12
11/18/12
11/25/12
12/02/12
12/09/12
12/16/12
12/23/12
12/30/12
01/06/13
01/13/13
01/20/13
01/27/13
02/03/13
02/10/13
02/17/13
02/24/13
03/03/13
Weekly Total of ED visits
Number of ED visits per week
30
PDSA #3 6/30/2012 Risk Stratification
Tool Includes DM vs.
non-DM related visits
25
20
15
10 PDSA #1 4/30/2012
- Risk Stratification
PDSA #2 6/18/2012
- New CSC Trained
in ED Alerts
5
0
Week
Weekly ED visits
Median
Goals
Reasons for Emergency Department Use
96.7%
100%
100.0%
90.0%
90%
83.3%
76.7%
80%
Percentage
70.0%
70%
60%
50%
40%
46.7%
14
30%
20%
7
10%
2
2
2
2
0%
Reason
Individual Quantities & Percentages
Cumulative Percentages
1
Feedback
MD 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 nonUC 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/CincinnatiOH/HealthBridge/128672340540952
LinkedIn: http://www.linkedin.com/company/healthbridge_3
YouTube: http://www.youtube.com/user/HealthBridgeHIE
Thank You……….