Quality Measures/ Population Health Lauren Veicht, MBA March 11, 2015

Agenda About Us Background Information Approach Quality Measures & Workflow Patient Engagement Q & A

About Us Headquarters in Springfield, IL Second largest private multi-specialty clinic in Illinois Nearly 400 providers Practicing in nearly 80 medical specialties and sub-specialties Serving 20+ locations, and a population of nearly 1 million patients Went live on Allscripts TouchWorks EHR in 2006 using all modules

Background Information Identify patients that can benefit from a disease management program. Target patients with specific high risk needs or chronic conditions to help manage them more closely and effectively. Promotes consistency and continuity of care, thereby improving quality of care and reduce costs.

Approach Segment the population into categories for prioritization. Prioritize prevention and interventions for patients at highest risk and subsequently highest cost. Shifting from a defensive approach, to an offensive approach to patient care by utilizing clinical quality measures.

Capturing Measures We are currently utilizing primary care measures, in order to accommodate both Meaningful Use and our MSSP/ACO programs. Some of these quality measures are: Preventative Care and Screening: Influenza Immunization Pneumonia Vaccination Status for Older Adults Falls: Screening for Future Fall Risk Tobacco use: Screening and Cessation Intervention Diabetes Mellitus: Hemoglobin A1c Poor Control Colorectal Cancer Screening Hypertension (HTN): Controlling High Blood Pressure Depression Remission at Twelve Months

Influenza Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. Workflow: We have QIS hosted by EHR Integration For this measure, we document vaccine administration via the Immunization tab. Historical data is documented via Immun Hx tab and flows to QIS.

Pneumonia Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. Workflow: Same as for Influenza – active medication administration is documented via the Immunization tab Historical information is documented under Immun Hx tab in TW. This information then flows to QIS.

Falls Screening Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. Workflow: We plan to use a series of questions to determine whether the patient is high risk for falls. We will assess whether the patient has: A history of falling in the previous year; Four or more medications per day (dizziness); Balance and gait problems; Low blood pressure Data will be captured via the vitals panel

Tobacco Screening Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user Workflow: We utilize an order group to meet this measure, which includes our individual education orders and instructions. The patient also receives a pamphlet from the provider.

Diabetes Mellitus Description: Hemoglobin A1c Poor Control: Percentage of aged 18—75 years with diabetes mellitus who had most recent HgbA1c greater than 9.0% Workflow: We have an order/result interface - This is data is captured once the electronic lab result is finalized with an HgbA1c is greater than 9%.

Colorectal Screening Description: Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening. Workflow: Fecal occult blood test (FOBT) lab test flows automatically into QIS; Flex sig and colonoscopy are a document, enter into the order that you received the result, or manual entry into QIS.

Hypertension Description: Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (< 140/90 mmHg) Workflow: Data captured during intake process via vitals panel

Depression Remission Description: Adult patients age 18 and older with major depression and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. Workflow: We are reviewing two possibilities; Implementing a paper form for patients to fill-out, scan in, and pull a query on the scanned documents. Or, we are also reviewing an upgraded version of QIS, which will allow us to build “Depression Remission” and input the date we had the patient fill out the form.

Patient Engagement 90% prefer web-based access to health information and education 72% want to book, change or cancel physician appointments online 88% want to receive email reminders for preventative or follow-up care 76% want the option of email consultations with doctors

Patient Engagement at Springfield Clinic FollowMyHealth: -FMH Achieve -Utilizing online forms -Recently implemented online registration Photos in TouchWorks: - Capturing before and after photos of patient surgeries - Will provide patients a visual aid in detailing their progress dbMotion: -Planning to interface with 1 MSO, and 3 local hospitals -Lincoln Land HIE has decided to use dbMotion solution as the EHR agent for the local hospitals SC Calcs: - Providing patients electronic forms that can be completed in the office on an iPad - Forms file directly into TW after approval mySC Mobile App: -Symptom Checker - Disease Prevention Program - New Patient Appt. Requests - Library of health articles and apps QIS Upgrade: Allow providers to enter information in QIS, and have it flow to appropriate place in TW. Assist with MSSP/ACO workflows.

Questions?