Asthma Encounter Form Development Eastern Maine Medical Center’s Outpatient Pediatric Practice (Husson Pediatrics) Michael A. Ross, MD FAAP American Academy of Pediatrics CAQI: Asthma Quality Improvement Program

The Issues Multiple metrics need to be tracked in order to improve asthma quality and report data for the AAP’s Asthma Quality program (and for the Maine PCMH pilot) Multiple metrics need to be tracked in order to improve asthma quality and report data for the AAP’s Asthma Quality program (and for the Maine PCMH pilot) Physicians need to use an encounter form that promotes implementation of 2007 asthma guidelines. Physicians need to use an encounter form that promotes implementation of 2007 asthma guidelines. The form needs to be user friendly towards a variety of individual documentation styles. The form needs to be user friendly towards a variety of individual documentation styles. The form needs to be linked to online reference for up-to-the- minute evidence-based practice The form needs to be linked to online reference for up-to-the- minute evidence-based practice Data collection needs to be exported to existing Registry (Meridios) - Current metrics are limited to manual EQUIP entry Data collection needs to be exported to existing Registry (Meridios) - Current metrics are limited to manual EQUIP entry The form needs to be plastic, to reflect medicine’s evolutionary nature The form needs to be plastic, to reflect medicine’s evolutionary nature The form needs to work with our existing QA structure at Husson Pediatrics The form needs to work with our existing QA structure at Husson Pediatrics

Current system at Husson Pediatrics: GE-Centricity EMR, Based Largely on CCC-forms GE-Centricity EMR, Based Largely on CCC-forms Protocols: Reminder system that promotes delivery of care by non- provider staff (MA, RN, receptionist) for physician review. Protocols: Reminder system that promotes delivery of care by non- provider staff (MA, RN, receptionist) for physician review. Current Protocols: Current Protocols: Flu Shots Flu Shots Smoking Status Smoking Status Asthma Management Plans Asthma Management Plans Populated from medication list Populated from medication list Asthma Control Test Asthma Control Test No asthma-specific encounter form exists: most provider documentation is entered via an open “HPI” field (and thus untrackable) No asthma-specific encounter form exists: most provider documentation is entered via an open “HPI” field (and thus untrackable)

Could we use an existing encounter form? Multiple Asthma forms are available: Multiple Asthma forms are available: Maine’s Ah!Asthma Form Maine’s Ah!Asthma Form Cincinnati Children’s asthma management form Cincinnati Children’s asthma management form AAP’s CQN-encounter form AAP’s CQN-encounter form GE-Centricity “CCC” asthma management form GE-Centricity “CCC” asthma management form Each form was analyzed – could they work with our current setup? Each form was analyzed – could they work with our current setup?

AAP’s CAQI Asthma Encounter form: What worked: What worked: Promoted use of 2007 guidelines Promoted use of 2007 guidelines Captured all AAP’s metrics Captured all AAP’s metrics What didn’t: What didn’t: Paper based Paper based ACT was “built in” ACT was “built in” Some PCMH Metrics were missing Some PCMH Metrics were missing

Ah!Asthma form: : What worked: What worked: Promoted use of 2007 guidelines Promoted use of 2007 guidelines Allowed for “external” ACT administration Allowed for “external” ACT administration Captures other metrics not available as part of AAP’s current program, but part of PCMH Captures other metrics not available as part of AAP’s current program, but part of PCMH What didn’t: What didn’t: Paper based Paper based

GE/CCC-Asthma Form v (cutting edge version) What worked: What worked: Promoted use of 2007 Asthma guidelines Promoted use of 2007 Asthma guidelines Obs terms for registry capture Obs terms for registry capture Auto-Populated Management Plans Auto-Populated Management Plans Linked to online/onboard asthma resources Linked to online/onboard asthma resources Incorporated data into Asthma Management handout Incorporated data into Asthma Management handout What didn’t: What didn’t: Interface did not allow for addition of AAP/PCMH metrics Interface did not allow for addition of AAP/PCMH metrics Could not incorporate Asthma Control Test or other tools into clinical decision making Could not incorporate Asthma Control Test or other tools into clinical decision making Interface was confusing to physicians - resistant to use Interface was confusing to physicians - resistant to use No area for Asthma past history No area for Asthma past history Needed to re-assign an new obs term to every asthmatic in practice (“severity” term) Needed to re-assign an new obs term to every asthmatic in practice (“severity” term) Unable to alter/add to existing form for future. Unable to alter/add to existing form for future.

Cincinnati Children's asthma encounter form What worked: What worked: Excellent overall template for asthma care Excellent overall template for asthma care Promoted use of 2007 guidelines Promoted use of 2007 guidelines Past Asthma history documentation Past Asthma history documentation Lots of educational opportunities (Mask-Mouthpiece add-on) Lots of educational opportunities (Mask-Mouthpiece add-on) What didn’t: What didn’t: “On-board” ACT did not work with our existing system “On-board” ACT did not work with our existing system “On-Board” Asthma Management handout did not work with our system “On-Board” Asthma Management handout did not work with our system Minimal room for free-typing was bothersome to some providers Minimal room for free-typing was bothersome to some providers Entire form is an encounter: cannot be used with our hospital’s current “CCC- CPOE” system. Entire form is an encounter: cannot be used with our hospital’s current “CCC- CPOE” system. Some obs terms not in our system, or already used in other areas (Custom made for Cincinnati) Some obs terms not in our system, or already used in other areas (Custom made for Cincinnati)

Solution? “Steal Shamelessly” – Peter Margolis, MD, PhD Professor of Pediatrics, Cincinnati Children’s

Choose what worked from each to make our own Used Cincinnati Children’s for a physical template Used Cincinnati Children’s for a physical template Added aspects from Ah!Asthma form, CAQI encounter form, and GE-CCC-asthma. Added aspects from Ah!Asthma form, CAQI encounter form, and GE-CCC-asthma. Added specific obs terms to interface with our registry Added specific obs terms to interface with our registry 2-tabbed form: 2-tabbed form: Asthma follow-up Asthma follow-up Asthma diagnosis. Asthma diagnosis.

The First Tab: Emphasizing the Acute history

Moving down the First Tab: Decision support  Questions shift based on age of patient  Prompts provider to assign a category based on 2007 guidelines of control  Auto-Populates the Asthma Control Test scored from the last visit and from Today’s visit  Encourages the Provider to assign a level of baseline control  Brief reference material directly on form  Tracks step-wise approach, and provides quick access to Maine’s Ah!Asthma online asthma management resource

Online Resource:

Bottom of First Tab: More Metrics Prompts provider to investigate other aspects of control (ER visits, school days missed, hospitalizations, spirometry) Investigates family’s degree of comfort with asthma Encourages provider to provide further patient education Quick-link to asthma-related patient educational materials/handouts

Second Tab: New diagnosis/New patient with Asthma

Moving down the Second Tab: Diagnosing Initial Degree of Severity  Questions shift automatically based on age of patient  Severity Assessment based on 2007 guidelines  Allows for a diagnosis to be assigned directly from the form  Utilizes Cincinnati Children’s mask/mouthpiece educational checklist

Current Form Status Some minor tweaks still pending (typos, links to order spirometry and asthma education referrals from form, etc). Some minor tweaks still pending (typos, links to order spirometry and asthma education referrals from form, etc). Rolled out to Providers at Husson Pediatrics of 12/23/2009. Rolled out to Providers at Husson Pediatrics of 12/23/2009. To be incorporated into Pediatric Encounter Documents in the near future. To be incorporated into Pediatric Encounter Documents in the near future. Meridios (Registry) terms assigned, registry programming in near future. Meridios (Registry) terms assigned, registry programming in near future.

Sharing In the Spirit of the Collaborative, we are happy to share this encounter form with any who would benefit from it’s use. Please contact me at for details: Michael Ross, MD FAAP Husson Pediatrics, EMMC