Transcript Has patient been given Asthma Action Plan?

Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
State Name: Alabama
Practice Name: Pediatric Associates of Alexander City
Team Members: Dr. Arnold Tauro, Melanie Fuller, and
Missy Waldrop
Version 2.0
CQN Asthma Project Practice Key Driver Diagram
Key Drivers
GLOBAL CQN AIM
We will build a sustainable quality
improvement infrastructure within our practice
to achieve measurable improvements in
asthma outcomes
Specific Aim
From fall 2009 to fall 2010, we will achieve
measurable improvements in asthma
outcomes by implementing the NHLBI
guidelines and making CQN’s key practice
changes
Measures/Goals
Outcome Measures:
 >90% of patients well controlled
Process Measures
 >90% of patients have “optimal” asthma care (all
of the following)
 assessment of asthma control using a
validated instrument
 stepwise approach to identify treatment
options and adjust therapy
 written asthma action plan
 patients >6 mos. Of age with flu shot
(or flu shot recommendation)
 >90% of practice’s asthma patients have at least
an annual assessment using a structured encounter
form
Engaging Your QI Team and
Your Practice
*The QI team and practice is active and
engaged in improving practice processes
and patient outcomes
Using a Registry to Manage
Your Asthma Population
*Identify each asthma patient at every visit
*Identify needed services for each patient
*Recall patients for follow-up
Using a Planned Care
Approach to Ensure Reliable
Asthma Care in the Office
* CQN Encounter Form
* Care team is aware of patient needs and
work together to ensure all needed
services are completed
Developing an Approach to
Employing Protocols
* Standardize Care Processes
* Practice wide asthma guidelines
implemented
Providing Self management
Support
* Realized patient and care team
relationship
Interventions
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Form a 3-5 person interdisciplinary QI Team
Formally communicate to entire practice the importance and goal of this
project
Meet regularly to work on improvement
All physicians and team members complete QI Basics on EQIPP
Collect and enter baseline data
Generate performance data monthly
Communicate with the state chapter and leaders within the organization
Turn in all necessary data and forms
Attend all necessary meetings and phone conferences
Select and install a registry tool
Determine staff workflow to support registry use
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care & support population management
Select template tool from registry or create a flow sheet
Determine workflow to support use of encounter form at time of visit
Use encounter form with all asthma patients
Ensure registry updated each time encounter form used
Monitor use of encounter form
Select & customize evidence-based protocols for your office
Determine staff workflow to support protocol, including standing orders
Use protocols with all patients
Monitor use of protocols
Obtain patient education materials
Determine staff workflow to support SMS
Provide training to staff in SMS
Assess and set patient goals and degree of control collaboratively
Document & Monitor patient progress toward goals
Link with community resources
Progress Summary Since
Learning Session 1
Using Registry to manage asthma patients:
•Set up excel asthma registry and registry in EHR system.
•Set up reminders in EHR system with questions to help us monitor each asthma
patient.
Progress Summary Since
Learning Session 1
Engaging the QI team and the practice:
1. QI team is actively functioning
2. Have had regular meetings for clinic staff of our practice
Using a planned care Approach:
1.Using multiple PDSAs asthma questionnaire and asthma
action plan have been chosen and were added to the EHR
system to be electronically produced.
2. Using spirometry on all asthma patients older than 10
years of age.
3. Produced asthma videos with our physicians and others
in the community to be shown in patient room while waiting
on providers and to be available on our website
% of patients with 1 or more asthma-related
hospitalizations within the past 12 months
Insert EQIPP graphs that will help to tell your
improvement story
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paste it into Powerpoint.
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% of patients in which reasons for lack of asthma
control is identified when asthma control is “not
well controlled” or “very poorly controlled”
% of patients with asthma ages 6 months and
older who have received a flu shot or flu shot
recommendation within the past 12 months
% of patients who have a current written asthma
action plan explained to them at this visit
PDSA Cycles
PDSA Title: Pre-Bronchodilator Spirometry Testing
 Plan: Perform spirometry on asthma patients, age 10 and
above, that have an asthma diagnosis.
 Do: Test the changes.
 Study: We are now able to accurately measure and
monitor asthma control. We learned that after testing was
performed many parents seem to be more attentive to
their child’s condition and followed through better with
treatment therapy.
 Act: Adopt
PDSA Ramps
P D
P D
P D
S A
S A
S A
TEST 4
What: CQN EHR form
Who: All asthma patients
Who :Providers with help of nurses
Where: Both offices
When: February 2010
TEST 4
What: Action plan in EHR
Who :All asthma patients
Who: providers and nurses
Where: Both offices
When: February
TEST 4
What: Spirometry pre & post aerosol
Who :Asthmatic 10 years older
Who: NPs and nurses
Where: Both offices
When: At present
P D
P D
P D
S A
S A
S A
TEST 3
What: EHR form
Who : Asthma patients
Who : Dr. Tyler and Kristal
Where: Alex city office
When: January 2010
TEST 3
What: Final paper action plan
Who: All asthma patients
Who : Providers and nurses
Where: Both offices
When: January
TEST 3
What: Spirometry
Who: New asthma patient
Who :Melanie, Courtney
Where: Kellyton office
When: February
P D
P D
P D
S A
S A
S A
TEST 2
What: CQN paper form
Who: Known asthmatics
Who: Physician, NP and Kristal
Where: Both pediatric offices
When: October 2009
TEST 2
What: Different action plans
Who : 5 patients
Who : Providers
Where: Both offices
When: October
TEST 2
What: Spirometry
Who: New asthmatic 10 years old
Who :Dr. Tyler, Kara
Where: Main office
When: January
P D
P D
P D
S A
S A
S A
TEST 1
What: CQN paper form
Who : Known asthmatics
Who : Dr. Tauro and Melanie
Where: Kellyton office
When: Sept 2009
CQN asthma form
TEST 1
What: AAP version
Who: 3 patients per week
Who : Dr Tauro and Tyler:
Where: Both offices
When: September end
Asthma action plan
TEST 1
What: Demonstration of spirometry
Who : Providers, NPs and nurses
Who : Spirometry rep
Where: Main office
When: December
Spirometry
Office Flow Document
Post Visit Activities
During Office Visit
Office Visit Prework
Pediatric Associates of Alexander City -- Flow Diagram
Patient with new diagnosis
of Asthma, an asthma form
is created and filled out
concurrently
Asthma
patients
identified at
time of
appointment by
front desk or
nurse.
After patient is checked in,
nurse will complete parent
section of encounter form.
After parent
section
complete send
task to provider
Provider
completes
asthma form
NO
Review
spirometry
results
with
patient
and/or
family
YES
Provider completes
form immediately
after the visit
Proviider has informed
clinical discussions
about asthma and form.
Provides education and
assesses need for
spirometry.
Nurse provides
additional asthma
education as
needed
Asthma videos
viewed while pt is
waiting on provider
Post
spirometry
testing to
be
performed
after
breathing
treatment
if ordered
by
provider
Perform spirometry on
newly dx patients to
confirm diagnosis
Provider updates
Asthma Action
Plan and reviews
with patient
and/or family
Completed form printed and
put in folder with the asthma
encounters
Copy printed by provider
and given to patient at end of visit
Enter atleast 5
encounter forms into
EQIPP before deadline
Provider may
initiatebronchodilator
treatments
Perform spirometry on
established asthma
patients to have baseline to
monitor control.
Provider informs patient
when to schedule followup appointment
Nurse assures
that a follow-up
appointment was
made, if not call and
set up appointment
Asthma patients targeted for
proactive communication, such as
reminder cards for flu shots, recall flu
appointments and asthma action plans
updated.
Pediatric Associates - Office flow document weaknesses
Office visit: Pre work:
* No consistency in communication between the check in person
and the nurse while using EHR
During the office visit:
* Completing the EHR CQN form is time consuming as nurse has to
complete the section and send the task to the provider.
* During the busy days, it slows down the patient flow.
* Spirometry is time consuming during the busy office days.
* We are not sure when and where to show the asthma education videos.
* Time constraints with asthma education when the child is brought in
by the relatives and not the parents.
Post visit activities:
* With the EHR it is difficult to keep a tab on the patients that were
entered into the EQIPP.
Asthma Questionaire in EHR
PEDIATRIC ASSOCIATES
ASTHMA QUESTIONAIRE
Patient:Chester T Tester
Tauro MD
DOB:05/31/2005
Provider:Arnold J.
Physician Section (using NIH categories and tables)
1.
Asthma severity level:
Intermittent
2.
Is the patient on a controller medication?
Yes
No
If yes, does the patient/parent report using controller medications daily?
Started this visit
Severe Persistent
Moderate Persistent
Mild Persistent
Parent Section
1. How many days of school/daycare has your child missed due to cough or wheezing in the
past 6 months?
1
2
3
4
5
6
7
8
9
10
Other
Yes
No
3.
For patients who use rescue/controller inhalers, is a spacer utilized? (Maxair and dry powder
inhalers do not require spacer)
Yes
No
N/A
4.
Has the patient received oral steroids for bronchospasm within the past 12 months?
Yes
No
5.
Were one or more key asthma indicators present in considering the diagnosis? EQIPP 3
Yes
No
6.
Were lung function measures by PFT used to establish diagnosis? EQIPP 4
No
7.
Was a validated instrument used to determine the current level of asthma control? EQIPP 5
Yes
No
5. How comfortable are you in your ability to manage your child's asthma, rated on a scale of 110?
Not comfortable =
1
2
3
4
5
6
7
8
9
10 = Very
comfortable
8.
What is the patient's current level of control during the past month? EQIPP 6
Well controlled
Not well controlled
Very poorly controlled
Did you review reasons for lack of control? (allergens, smoking, non adherence) EQIPP 6b
Yes
No
6. During the past week, how often has your child used a rescue medicine? (albuterol, proventil,
ventolin, maxair, xopenex)
Not at all
less than 1 time per day
1-3 per day
4 or more per day
9.
Are PFTs scheduled, or results obtained within last 1-2 years? EQIPP 7
No
Age Inappropriate
2. How many workdays have you or another caregiver missed due to your child's cough or
wheezing in the past 6 months?
1
2
3
4
5
6
7
8
9
10
Other
3. Has your child visited the ER or another clinic due to cough or wheezing in the last 12
months?
Yes
No
If yes, how many times?
1
2
3
4
5
6
Other
EQIPP 1
4. Has your child been admitted to the hospital for coughing or wheezing/asthma in the past 12
months?
Yes
No
If yes, how many times?
1
2
3
4
5
6
Other EQIPP 2
7. When are your child's symptoms worse?
Exercise
Winter
8. How often does coughing limit your child's activities?
None
a little of the time
some of the time
all of the time
Spring
Summer
Fall
Yes
Yes
10. Did you use age appropriate NIH stepwise tables to identify treatment options or adjust
therapy based on control of asthma symptoms? EQIPP 8
Yes
No
11. Has a flu shot been given, or recommendation made within last 12 months? EQIPP 9
Yes
No
Patient younger than 6 months, contraindications, vaccine unavailable
most of the time
9. Over the past 2-4 weeks, how frequently has your child had cough, shortness of breath,
wheezing or reduced activity?
During the day?
< or equal to 2 days/week
> 2 days/week but not daily
Daily
Throughout the day
During the night?
< 2 nights/month
3-4 times/month
1 time/week but not
nightly
Often7 times/week
10. How would your rate your child's asthma control during the past month?
not controlled at all
poorly controlled
somewhat controlled
completely controlled
well controlled
12. Does the patient have a written Asthma Action Plan? EQIPP 10
Yes
No
If yes, was the plan updated and reviewed with the family at this visit? EQIPP 10b
Yes
No
13. Were self management techniques or materials provided to the family at this visit? (inhaler
instruction, smoking cessation help, avoiding triggers) EQIPP 11
Yes
No
14. Has the patient been seen by an allergist or pulmonologist during the last 12 months for
assistance with asthma management due to severity of illness? Specialist:
Yes
No
Referred this visit
15. Was a follow up appointment scheduled? EQIPP 12
Yes
No
Asthma Action Plan in EHR
Asthma Registry started in Excel
• First we identified all those patients that were diagnosed
with a code of 493 (including 493.00, 493.01, 493.02,
493.10, 493.11, 493.12, 493.81, 493.90, 493.91, and
493.92) during a given time period (we started with
October – December 2009) using a report from our Intergy
system entitled Diagnosis Visits Analysis Detail by Provider.
• Next we put each of these patients into an excel
spreadsheet, only listing them once even though they may
have come in many times during this time period. In this
file, we included patient name, dob, sex, diagnosis code,
status in EHR (whether we had asthma listed as a problem
on patient or not), and provider. Tried to make it as simple
as possible for the providers to be able to go back into EHR
and find these patients so that they could add asthma as
one of their problems.
Excel Registry
Asthma Patients from 10/01/09 through 12/31/09
(To be given to each of the providers to add as a problem in the EHR system so that reminders will appear)
Patient Name
DOB
M/F
Diagnosis
Status in HER
PatientName
12/9/1997
M
493.00
Added as problem by EOT
PatientName
7/30/2009
M
493.90
Not listed as problem
PatientName
3/18/1998
F
493.92
Not listed as problem
PatientName
1/31/2006
F
493.92
Not listed as problem
PatientName
4/9/2003
M
493.92
Not listed as problem
PatientName
11/14/2007
M
493.92
Not listed as problem
PatientName
11/7/2008
M
493.90
Not listed as problem
PatientName
11/18/2008
M
493.90
Not listed as problem
PatientName
12/30/2005
M
493.92
Not listed as problem
PatientName
7/3/1996
F
493.90
Not listed as problem
PatientName
1/18/2003
F
493.02
Yes, already listed as problem
PatientName
12/25/1998
F
493.90
Not listed as problem
PatientName
8/13/2004
M
493.90
Yes, already listed as problem
PatientName
10/29/2003
M
493.02
Added as problem by EOT
PatientName
8/2/2007
Provider
EOT
MR
MR
AJT
AJT
KL
KL
MR
AJT
KL
EOT
KBT
KBT
EOT
Onset Date
9/1/2009
M
493.90
Added as problem by CS
CS
PatientName
7/9/2000
F
493.90
Not listed as problem
MR
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
PatientName
10/27/2003
6/29/2008
11/22/1997
9/17/2008
6/16/2006
9/25/1999
12/8/2004
6/17/2005
6/18/2007
7/3/2001
10/15/1988
3/15/2006
11/11/2008
3/24/2004
8/1/2007
M
F
M
F
M
F
F
F
M
F
F
M
M
F
M
493.92
493.92
493.90
493.90
493.92
493.92
493.00
493.90
493.92
493.90
493.00
493.90
493.92
493.92
493.92
Not listed as problem
Not listed as problem
Added as problem by EOT
Added as problem by CS
Not listed as problem
Not listed as problem
Yes, already listed as problem
Not listed as problem
Not listed as problem
Added as problem by CS
Added as problem by EOT
Added as problem by CS
Not listed as problem
Not listed as problem
Not listed as problem
KL
AJT
EOT
AJT
AJT
AJT
EOT
KBT
KL
AJT
EOT
CS
AJT
AJT
AJT
11/9/2007
2/17/2010
2/11/2009
12/14/2006
11/21/2006
6/1/2006
Excel Registry then used to make
EHR Registry
• The Excel Registry was sorted by provider and
then each provider was given a copy of their
listing.
• The providers were asked to review their listings
and for those patients that did not have asthma
listed as a problem (but they had been given a
diagnosis code of asthma), they were asked to
add the problem of asthma to their patient
charts so that the reminder questions would pull
to their Health tab.
Asthma added to problem listing
in EHR on patient chart
Note that patient Chester Tester has a problem with asthma and diabetes.
EHR Registry
• So now that each of the patients that we pulled from our
billing as having been diagnosed with asthma also have
it listed as a problem in EHR, the patient’s Health tab in
their chart will contain reminder questions that will
appear when they are due based on guidelines we have
set up in the system.
• These reminders will direct the providers to complete
their asthma questionaire and asthma action plan, to
show them the asthma videos, perform spirometry, or
verify that the patient has been given their flu vaccine.
• As the providers complete these tasks, they are to mark
the reminder as satisfied so that it will then go away and
reappear when due again.
Reminder questions for registry patients
in EHR
Has Asthma Questionaire been completed on patient?
Has patient been given Asthma Action Plan?
Has patient watched Asthma Educational Videos?
Has patient performed spirometry test yet?
Has patient received flu vaccine (if applicable)?
Note that you can use the same idea with
diabetes patients
Patient needs Thyroid function
Managed by Children’s Hospital Endocrinology
Review insulin dosing and blood sugar diary
Monitor insulin scripts filled
Patient’s physical exam is due – including foot exam
Patient needs labwork for Hemoglobin A1C completed
Patient needs semi-annual Urine microalbumin
Refer patient to opthalmologist for yearly visit
Patient needs Lipid profile
Key Learnings
 Learned how to use spirometry on asthma patients
 Learned to categorize asthma as a chronic disease
in EHR in order to track progress
 Learned to have more consistent and more frequent
follow-up
 Learned to have better patient education through
asthma action plans and videos
Barriers and Successes
• Time constraint is the main obstacle in
implementing this project – which we have over
come.
• Completed the production of two asthma
educational videos that will be played in patient
rooms and will be available on our website
• Identified our asthma patients based on billing
and have established our registry
• Began using spirometry on asthma patients
Future Plans
• Continue doing spirometry on as many asthma
patients as possible
• Continue updating our registry in both excel and
EHR
• Continue educating our asthma patients as
much as possible with our educational videos in
patient rooms and posted on our website
• Use Facebook to point our patients to our
website for updates or other notifications