Transcript Dr. Peter Muir, Family Practice Physician, Collaborating

Peter Muir MD
Springfield Center for Family Medicine
Collaborating Communities
Health Information Exchange
HealthBridge Tri-State Regional Extension Center
June 2010
Introduction
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Family doc
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In practice 30 years
Office 4 days a week, hospital rounds, 24x7 call
SCFM 6 doc FP group
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Computers since 1980
EMR since 2003 w transcription since 2000
Quick survey
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How many on:
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Paper charts?
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EMR?
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eRx?
 Meet all 25
(swap seats)?
meaningful use criteria
Meaningful use for PCPs
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Initial read of the criteria is overwhelming
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Any practicing PCPs on the steering committee?
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80% computerized physician order entry?!? (1)
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BPs on 2 yr olds?!? (8)
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How do we communicate between offices?
We need a Health Information Exchange
Complicated and Expensive Issues
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drug-formulary checks (2)
eg RxHub, multiple drug plans, locations, etc
checking insurance eligibility electronically
on 80% patients (15)
timely electronic access to health information
lab results, problem list, medications, allergies
on 10% of all unique patients (18).
How to quantify and report?
initial cost and sustainable cost considerations
Final rule still pending
Narrow line between meaningful
use and useless meaning
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Rx compliance by pharmacy or claims data
- does not include samples, half tabs, etc
- interferes with work flow,
- pharmacy timing rather than at pt intervention,
- use lab results and medication reconciliation
Narrow line between meaningful
use and useless meaning
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Email
- patient becomes diagnostician
- security concerns
- time consuming
- not recognized under fee for service plans
Narrow line between meaningful
use and useless meaning
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Timely electronic access 10% unique patients
(18)
- some patients still on rotary dial phones
- doc, what does this mean???
- glucose meter automated reporting vs
manually recording
- not recognized under fee for service plans
Signal to Noise Ratio
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In the old days, a fax was important.
Now, it is spam due to the flood of info.
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Electronic records can make it too easy to
overwhelm the most critical interface the clinician.
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Need to filter out less important info
and amplify any important info
(format, duplication, reports)
How to get started?
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Start somewhere
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Look at work flow
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Follow the information
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Make it work for you and your office
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You are the expert for your office
Who
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Office leadership:
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clinical & clerical teams
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authority to make it happen
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be consistent & persistent
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Seek assistance from REC
What
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Look at work flow:
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reduce repetitive effort
eg allergies, date/time
(caution re MMSE, lose orientation x2)
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reduce errors
eg record ht as ft/in vs in from tape
PQRI opportunities
Why
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Hurts the first year,
but then life gets better
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Have access to your own data
Compliance and outcome analysis
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ARRA
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REC
Where
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Many items easier with an
'annual' risk assessment checklist approach
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Practice and disease management
- graphing vitals makes impact
- tracking microalbumins, colonoscopy, etc
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Medication management & reporting (recalls)
When
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If on paper,
start with pt summary forms, flow sheets
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Save transcription files by patient to import
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Timeline, need to implement 2010 or 2011 for
maximum benefit
[1] Use CPOE
Computer Physician Order Entry
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Measure:
CPOE is used for at least 80 percent of all orders.
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Response:
Placing orders by LabMaster, Radiology and
Rx covers >80% of orders.
[2] Implement drug-drug, drugallergy, drug-formulary checks
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Measure:
The EP has enabled this functionality.
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Response:
RxModule has drug-drug, drug-allergy checks.
Drug-formulary via Epocrates,
Add formularies with new servers.
[3] Up-to-date problem list current
& active Dx ICD-9 or SNOMED
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Measure:
At least 80 percent of all unique patients seen by
the EP have at least one entry or an indication of
none recorded as structured data.
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Response:
Dx list (ICD-9) maintained by IM Assessment.
Problem list and PHx provide more detail.
[4] Generate & transmit permissible
prescriptions electronically (eRx)
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Measure:
At least 75 percent of all permissible
prescriptions written by the EP are transmitted
electronically using certified EHR technology.
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Response:
eRx targets require extra effort by MD & billing.
Recommend print weekly totals for MD.
[5] Maintain active medication list
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Measure:
At least 80 percent of all unique patients seen by
the EP have at least one entry (or an indication of
“none” if the patient is not currently prescribed
any medication) recorded as structured data.
Response:
Rx module maintains active list. All users
should set preferences for active list.
Use stop dates for temporary Rx.
MDs need to delete inactive Rx. SEE 21
[6] Maintain active medication
allergy list
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Measure:
At least 80 percent of all unique patients seen by
the EP have at least one entry (or an indication of
“none” if the patient has no medication allergies)
recorded as structured data.
Response:
Allergy module maintains active allergy list.
Nurses must check appt slip against pt chart &
verify with patient.
[7] Record demographics
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Measure:
At least 80 percent of all unique patients seen by
the EP or admitted to the eligible hospital have
demographics recorded as structured data.
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Response:
NextGen does at patient registration.
[8] Record and chart changes
in vital signs
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Measure:
For at least 80 percent of all unique patients age
2 and over seen by the EP, record blood pressure
and BMI; additionally, plot growth chart for
children age 2 to 20.
Response:
Nurses must record BP starting at age 2.
Print Ht/Wt/BMI pediatric growth charts
at well checks/annually. SEE 23
[9] Record smoking status for
patients 13 years old or older
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Measure:
At least 80 percent of all unique patients 13 years
old or older seen by the EP “smoking status”
recorded.
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Response:
MDs need to have smoking status recorded on
social hx or cold template for all patients.
Add to float nurse protocol
[10] Incorporate clinical lab-test
results into EHR as structured data
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Measure:
At least 50 percent of all clinical lab tests results
ordered by the EP or by an authorized provider of
the eligible hospital during the EHR reporting
period whose results are in either in a positive /
negative or numerical format are incorporated in
certified EHR technology as structured data.
Response:
Have lab/rad results as structured data from 2009
Implement results interface via Rosetta or Mirth
on new servers - MUIR.
[11] Generate lists of patients
by specific conditions
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Measure:
Generate at least one report listing patients of
the EP with a specific condition.
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Response:
Need to modify diabetes selection Crystal Report
(select by ICD9 range) - MUIR
[12] Report ambulatory quality
measures to CMS or the states
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Measure:
For 2011, an EP would provide the aggregate
numerator and denominator through attestation as
discussed in section II.A.3 of this proposed rule.
For 2012, an EP would electronically submit the
measures are discussed in section II.A.3. of this
proposed rule.
Response:
Select criteria (HTN, DM, lipids, CHF).
Review II.A.3 for reporting PQRI - MUIR.
[13] Send reminders per patient
preference for preventive/follow-up
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Measure:
Reminder sent to at least 50 percent of all unique
patients seen by the EP that are 50 and over.
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Response:
Could create report on active pts >50 without
annual exam in past 12 months. - MUIR
MDs need to flag annual assessment. COST
[14] Implement 5 clinical decision
rules, orders, & track compliance
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Measure:
Implement five clinical decision support rules
relevant to the clinical quality metrics the EP is
responsible for as described further in section
II.A.3.
Response:
Select 5 support rules
(Hba1c, microalbumin, lipids, etc)
Need to review II.A.3 reporting PQRI - MUIR.
[15] Check insurance eligibility
electronically public private payers
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Measure:
Insurance eligibility checked electronically for at
least 80 percent of all unique patients seen by the
EP.
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Response:
Check via CCHIE? GBS?
How to automate? COST
[16] Submit claims electronically to
public and private payers
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Measure:
At least 80 percent of all unique patients seen by
the EP or admitted to the eligible hospital have
demographics recorded as structured data.
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Response:
NextGen does.
[17] Provide electronic copy of
health info: Dx, Rx, allergy, results
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Measure:
At least 80 percent of all patients who request an
electronic copy of their health information are
provided it within 48 hours.
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Response:
Could comply by print to pdf and burning CD.
Anticipate low volume (pt request).
Minimal cost.
[18] Timely electronic access to
health info: Dx, Rx, allergy, results
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Measure:
At least 10 percent of all unique patients seen by
the EP are provided timely electronic access to
their health information.
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Response:
Could do via NextGen Next MD.
Any potential for CCHIE?
This one is problematic
(10% of all active patients) COST +++
[19] Provide clinical summaries to
patients for each office visit
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Measure:
Clinical summaries provided to patients for at
least 80 percent of all office visits.
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Response:
Could print office visit note on all patients
(could auto-print each time generated)
PAPER COST
[20] Exchange key clinical info
with providers electronically
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Measure:
Performed at least one test of certified EHR
technology's capacity to electronically exchange
key clinical information.
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Response:
CCHIE can do this by sending visit note/exam.
Most offices can not receive other formats
except pdf. SEE 22.
[21] Perform Rx reconciliation
at relevant encounters
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Measure:
Perform medication reconciliation for at least 80
percent of relevant encounters and transitions of
care.
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Response:
Rx module maintains active list.
All users should set preferences for active list.
Use stop dates for temporary Rx.
MDs need to delete inactive Rx. SEE 5.
[22] Provide summary care record
for transition of care & referrals
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Measure:
Provide summary of care record for at least 80
percent of transitions of care and referrals.
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Response:
CCHIE can do this by sending visit note/exam.
Most offices can not receive other formats
except pdf. SEE 20.
[23] Submit electronic data
to immunization registries
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Measure:
Performed at least one test of certified EHR
technology's capacity to submit electronic data
to immunization registries.
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Response:
OHIO does not have capability of electronic
submission/transmission.
Might meet
criteria by checking OH vaccine website for all
pediatric well checks. SEE 8.
[24] Provide electronic syndromic
surveillance data to public health
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Measure:
Performed at least one test of certified EHR
technology's capacity to provide electronic
syndromic surveillance data to public health
agencies (unless none of the public health
agencies to which an EP or eligible hospital
submits such information have the capacity to
receive the information electronically).
Response:
OHIO does not have capability of electronic
submission/transmission. CCHIE?
[25] Protect electronic health info
by certified EHR technology
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Measure:
Conduct or review a security risk analysis in
accordance with the requirements under 45 CFR
164.308 (a)(1) and implement security updates
as necessary.
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Response:
New edge security server threat management
gateway and domain restructuring is part of
server upgrade. - MUIR