Transcript Using an EHR to Improve Diabetes Care: A Practical Approach

Using an EHR to
Improve Diabetes Care:
A Practical Approach
By
Donald T. Stewart, MD
[email protected]
My Background
• Family Practice, started solo from scratch in 1983
after residency
• Grew to 6 provider practice which was sold to
Swedish Hospital in 2003
• Now Medical Director of 7-provider clinic in 12clinic system
• First EMR 1997 on Newton Message Pad
Migrated to Practice Partner in 2001. Paperless
since 2003
What do we need to do improve
the quality of diabetes care?
• Most of us do just fine with the patients
who come in for a scheduled visit and
follow-up when we tell them to.
• The problem is with the patients who do not
follow-up for scheduled care
• We need to educate them
• And, we need to keep track of them, and get
them into the office when they need it.
The Registry, a Necessity
• Database of patients with problems you are
interested in following
• Useful for identifying the patients you never see
because they fail to come in
• Tracks specific outcomes measures
• Reports that give you feedback on which of your
goals you need to work harder to meet
• A way to compare performance of physicians and
practices to each other
Examples of Registries
• CDEMS: Chronic Disease Electronic
Management System
http://www.cdems.com/
• For an excellent review of 16 registry
products by the California HealthCare
Foundation, try this:
http://www.chcf.org/documents/chronicdi
sease/ChronicDiseaseRegistryReview.pdf
How an EMR Can Help:
Data at Your Fingertips
• No time wasted looking for charts or lab reports or
in doing double data entry
• You should chose an EMR with built-in registry
capabilities, or at least ease of generating the data
you want
• The EMR can remind you at the time of care what
services are overdue for the patient whose own
agenda was an urgent care visit.
How an EMR Can Help:
During the Visit
• Remind the provider of what needs to be
done
• Reminding the provider when not to goal
• Formulary compliance
• Presenting data to patients
• Patient education materials
How an EMR Can Help:
When There is No Visit
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Scheduling patients
Documenting phone contacts and Rx refills
Lab letters, patient reminders
Messaging and workflow
Information access when on call
How an EMR Can Help:
Financial Incentives
• More reimbursement through better
documentation
• Greatly increased operating efficiency of
the office
• Documenting quality for better patient
acceptance
• Pay for Performance
The Visit Note:
Basic Issues
• Templates vs free-form data entry
– Templates for data you want to analyze or
remember
– Free-form to personalize the note.
• Voice recognition vs typing
– Learn to type
• Pen based systems
– Slick, but slow
Diabetic Data You Care About
(that you want to automagically go into your
visit note)
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Diagnosis Date
Diabetes Educator
Endocrinologist
Frequency of glucose
monitoring
• Frequency of blood
pressure testing
• Frequency of exercise
• Diet
• Symptom Status
– Painful Neuropathy
– Numbness
– Hypoglycemic
episodes
– Sexual function
• Patient Concerns
– Amputation
– Blindness
– Renal failure
Lab Data to Follow
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FBS
HgbA1c
LDL
HDL
Trigs
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VLDL
AST
ALT
Microalbumin
Creatinine
Treatment Data to Follow
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Aspirin
Metformin
ACE/ARB
Statins
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Thiazoladinediones
Fibrates
Sulfonureas
Niacin
Patient-Centered Data
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Fears about diabetes
Exercise behaviors
Smoking Status
Diet behaviors
Self-management
goals
The Practical Part--Examples: MA Check-in
• (These examples are with Practice Partner)
• Patients who have diabetes are flagged in the
system, so when our MA’s put them in the room,
the template that they enter the vitals on reminds
the MA to take the patient’s shoes off, check the
HgbA1c, lipids, and microalbumin if not up to
date, and give pneumovax and flu shots if not up
to date.
• The MA’s have standing orders to do this no
matter what the supposed reason for the visit was.
MA Check-In Example– Non-Diabetic
.D: 04/04/06 : 12:19am
.T: «*»Visit & Vitals
MA: «req» «&Cindi» «&Anita» «&Barbara» «*Corey» «&Monika» «&Virginia» «*Marilyn»
Type of Visit: «*OV» «*BP» «*UA» «*AllerShot» «*Immu» «*FluShot» «*OtherShot»
«*EKG» «*Weight»
Treating provider today: «REQ» «*DTS» «*CML» «*LLC» «*GHP» «*DYP» «*CCL» «*SPF»
.V1: Syst. BP «*» : Diast. BP «*» : P. «*» :
.V2: T «*» : Ht. «*» : Wt. «*» :
.V3: OFC «*» : Resp. «*» :
.L: Visual Acuity OD: «del» «*WithCorr» «*NoCorr»
.L: Visual Acuity OS: «del» «*WithCorr» «*NoCorr»
MA Check-In Example – Diabetic Patient
MA: «req» «&Cindi» «&Anita» «&Barbara» «*Corey» «&Monika» «&Virginia» «*Marilyn»
DiabetesDxDate: 12/2001 on 07/16/2002
«***************POSSIBLE DIABETIC PATIENT***************...»
«del»Influenza: X on 09/29/2005
«del»To Update Influenza, Click the following: «del» «*LastFlu»
«del»Pneumovax: 06/03/02 on 06/03/2002
«del»To Update Pneumovax, Click the following: «del» «LastPneumo»
LastEyeExam: 8/04 on 10/21/2004
.L: LastEyeExam: «del»
.L: *Ophthalmologist: «del»
.L: *Optometrist: «del»
«del»HEMOGLOBIN A1C: 6.2 on 03/06/2006
«del»GLUCOSE, FASTING: 111 on 03/06/2006
«del»CHOLESTEROL: 123 on 03/06/2006
«del»HDL CHOLESTEROL: 47 on 03/06/2006
«del»LDL CHOLESTEROL: 68 on 03/06/2006
«del»TRIGLYCERIDES: 123 on 03/06/2006
«del»ALT: 34 on 09/26/2003
«del»MICROALBUMIN, UR: 20 on 08/03/2001
«del» «*****No MICROALBUMIN/CREATININE Recorded -- Please get one per standing orders*****...»
«**** Please Have Patient Remove Shoes*****...»
The Practical Part:
Physician Note
• We use the same master template for all
visits, which gives us a basic structure to the
notes.
• We can add any number of problems to a
given note, which enables us to update
diabetes status no matter why the patient
scheduled the visit.
Physician Template Examples . .
• For my practice are included at the end of this
slide set. These are too busy for new users.
• They give you an idea of the richness of
information on chronic disease management that
can be included in your note
• Do not show what the note looks like when saved
• NOT for an urgent care practice
• Just one person’s way of doing it.
Physician Note: Subjective(1)
Subjective:
- ID: «*PCP» «*New Pt» «*MA»
This 56 yr old male «*Accomp_By»
has the following major problems:
Major Problem List:
BACKACHES ( )
HYPERTENSION 401.9 ESSENTIAL BENIGN
DIABETES 250.00 INSULIN DEPENDENT
HYPERLIPIDEMIA 272.4
takes the following medications:
Allergies:
PENICILLIN
Current Medications:
Rx: LEVITRA 20mg 1 prn - days, 12, Ref: 12
Rx: PROZAC 20MG 1 CAP QD - days, 90, Ref: 3
Rx: LISINOPRIL 10mg 1/2 qd - days, 45, Ref: 41
Rx: EXERCISE 20 min tiw - days, , Ref: 0
Rx: METFORMIN HCL 1,000mg 1 bid - days, 180, Ref: 12
«DEL» «*SeesTheseSpecialists»
and presents today with the following issues or concerns:
«DEL» «*NeedRefil» «f/u» «cc...» «cc:system...» C1.
«*NextProblem»
Physician Note: Subjective(2)
and presents today with the following issues or concerns:
«DEL» «*NeedRefil» «f/u» «cc...» «cc:system...» C1.
Problem: «*FUof...» «S-...»
«*NextProblem»
«*ROS»
«Insert Past Medical History»
«Insert Social History»
«Insert Family History»
«DEL» «*HabitEntr»
«DEL» «*HCMEntry»
Physician Note: Problem Menu
Physician Note: Diabetes(1)
Physician Note: Diabetes(2)
Physician Note: CV Labs
Physician Note: Diabetic ROS
Physician Note: Exam(1)
Physician Note: Exam(2)
Physician Note: Assessment
Physician Note: Plan
Once you get the data into your
system, then what do you do
about it?
Practice Partner Research
Network
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Quality Research Network coordinated by
Medical University of South Carolina
Agency for Healthcare Research and Quality
funding – Future funding guaranteed by PP
10+ years experience, over 25 peer-reviewed
articles
960,000 patients --- 7,700,000 patient contacts
Quality Reports available to all Practice Partner
users
How PPRNet Works
• See patients using Practice Partner
• Enter your data any way you want to
• Send in a data extract every quarter
– (5 minutes of operator time to do this)
• Receive Quality Report and Patient Level
Reports a month later
• Meet with your group and decide what to
change
Quarterly PPRNet Reports
65 pages
• Diabetes
• Heart Disease &
Stroke
• Cancer Screening
• Immunizations
• Infectious Disease
• Mental Health
• Substance Abuse
• Alcohol Abuse
• Nutrition and Obesity
• Inappropriate
Prescribing for Elderly
• Summary
Performance
Indicators
Diabetes Reports
• % HgbA1c measure in
last 6 months
• % HgbA1c < 7.0
• % BP Measure in 6
months
• % BP < 130/80
• % LDL meas. Last
year
• % LDL < 100
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% HDL meas last year
% HDL > 45
% Trig meas. last year
% Trig < 150
% >=40 yrs on asa
% microalbumin meas
last year
• % on ACE/ARB
Patient Level Reports
• In addition to the Quarterly report, you get a
Excel Spreadsheet that enables you to sort
your data on any number of variables, and
get the list of patients meeting the criteria.
• This enables you to pull out the patients
who, for example, haven’t been seen in > 6
months and had last HgbA1c > 6.5
• You can use the list for recall letters
Patient Level Reports
• The Patient Level Report spreadsheet is
basically a Registry that enables you to
focus on whichever patient group you want
to for quality improvement
• Also enables you to generate any custom
reports you want to generate for P4P,
insurance contracting, or other purposes
Thank You . . .
Questions?
A Template Example
• Practice Partner is incredibly customizable,
and comes with a set of basic and easy-touse templates
• The following is an example of the variety
of prompts and reminders that can be put
into a template by someone who is perhaps
too compulsive in his documentation
Physician Note: Subjective(1)
Subjective:
- ID: «*PCP» «*New Pt» «*MA»
This 56 yr old male «*Accomp_By»
has the following major problems:
Major Problem List:
BACKACHES ( )
HYPERTENSION 401.9 ESSENTIAL BENIGN
DIABETES 250.00 INSULIN DEPENDENT
HYPERLIPIDEMIA 272.4
takes the following medications:
Allergies:
PENICILLIN
Current Medications:
Rx: LEVITRA 20mg 1 prn - days, 12, Ref: 12
Rx: PROZAC 20MG 1 CAP QD - days, 90, Ref: 3
Rx: LISINOPRIL 10mg 1/2 qd - days, 45, Ref: 41
Rx: EXERCISE 20 min tiw - days, , Ref: 0
Rx: METFORMIN HCL 1,000mg 1 bid - days, 180, Ref: 12
«DEL» «*SeesTheseSpecialists»
and presents today with the following issues or concerns:
«DEL» «*NeedRefil» «f/u» «cc...» «cc:system...» C1.
«*NextProblem»
Physician Note: Subjective(2)
and presents today with the following issues or concerns:
«DEL» «*NeedRefil» «f/u» «cc...» «cc:system...» C1.
Problem: «*FUof...» «S-...»
«*NextProblem»
«*ROS»
«Insert Past Medical History»
«Insert Social History»
«Insert Family History»
«DEL» «*HabitEntr»
«DEL» «*HCMEntry»
Physician Note: Problem Menu
Physician Note: Diabetes(1)
Physician Note: Diabetes(2)
Physician Note: CV Labs
Physician Note: Diabetic ROS
Physician Note: Exam(1)
Physician Note: Exam(2)
Physician Note: Assessment
Physician Note: Plan