Newborn Screen Positive Infant ACTion Learning Collaborative Learning Session II All About Children Pediatric Partners, PC February 12, 2011

All About Children Pediatric Partners, PC  Reading, Pennsylvania  Private Practice 80% Medicaid/CHIP Combination of urban and rural, few suburban families ~14,000 active patients, 8 pediatricians, 4 NPs – 9.5 FTEs MacPractice (billing & scheduling), Spring Charts EHR  Team members Eve Kimball, MD David Zobian, MD Deb Degroff, RN

Aim  By November 10, 2010, All About Children Pediatric Partners will have: 1) Written policies covering tracking and management of Newborn Screening Results 2) Educated the entire AACPP staff on how to implement these policies 3) Achieved the result that newborn screening tests of 100% of all newborns who come to our practice or are seen by our practice in the hospital are managed according to these written policies

Office Enthusiasm and Support  10 minute presentation to office staff re NBS project, including the first Excel spreadsheet  Shared Templates  Had physicians review 3 of their own charts and complete the Excel spreadsheet for those patients for the “Prework”, elicited their feedback and changed spreadsheet  Ensuing months: 5 charts reviewed by each clinician Feedback to NBS team given re templates and spreadsheet Templates and spreadsheets changed in accordance with feedback

Changes Implemented  Reliable Systems of Care Need central collection points for all data  Single collecting box for newborn (and hospital) records.  Newborn screen data is placed on the Face Sheet in the PMH / Birth History section of the EHR by the clinician during visit (see screen shots and pop-ups)  Care coordinator calls the families within 48 hours to follow-up  Newborn screens go directly to Deb  Billing information collection point  Finding Hearing Screens – record on Hollister Added “ACT sheet retrieved and suggestions followed, disease information sheet given to parent and explained. Other: ” as a pop-up for use by clinicians if needed. All clinicians have usernames and passwords into the Perkin- Elmer system for data retrieval

Placement of newborn screen info on EHR facesheet:

Final placement for newborn screen info: Office visit templates entry verifies work done: Facesheet index entry:

Spread sheets for data collection:  Study spread sheet (final version):

Spread sheets (continued):  Spread sheet for continued office use:

Changes Implemented (Continued):  Reliable Systems of Care (Continued) Three “incidental” changes:  Installed “back line” extension for clinicians to leave inpatient information for staff to schedule followup appointments when patients are discharged at night or on weekends  Expanded our use of our software/technology!  Put room telephone extensions in our tracker that lists patient name/birthday and staff in room

Changes Implemented (Continued)  Finance Cross-checked the newborn list between the billing software and the EHR software. We have picked up some billing errors (newborn care not billed). PDSA process in progress for ways to eliminate the errors. Nurse Deb documented data entry time needed to support the project:  1 minute per infant when the newborn screen arrives,  one hour per month for ~50 newborns to print the billing software report and check it against the EHR.  Allocating 2-3 hours of staff time per month to maintaining staff support for the project should be adequate. Never assume anything: Deb didn’t know how to bring up the patients by birthdate in the EHR – but she is a fast learner!

Changes implemented: (Continued)  Community-based Care Using one nurse to coordinate the data retrieval has facilitated data collection and increased practice knowledge of community resources Utilized the Perkin-Elmer Website to obtain missing data and data on patients incoming from other physicians/hospitals has been extremely helpful. Abnormal data is transmitted to receiving practices. Perkin-Elmer has never failed to send a newborn report to us! Our password accesses data on infants born elsewhere in PA. PA implemented the “OZ” system with clinician NPI numbers and addresses so that newborn screens go to the clinician designated by the Mother at birth of the infant We have not connected with our regional coordinator – our fault

Changes Implemented (Continued):  Active Well-informed Patients Our documentation of counseling has improved dramatically We give out information on specific diseases when discovered. Our midwives and hospitals give out the newborn screen info pamphlets provided by the state of PA. Patients have expressed appreciation that we mention the newborn screen results Improved data recording and counseling from 0% to 100% (well, maybe 98% - we are human!)

Changes implemented (Continued):  Active Well Informed Patients (Continued) Nurse puts Alert in chart that newborn screen is normal for clinician to inform parent – saves clinician looking through chart Placed website for retrieval of ACT sheets in the EHR website list Placed sources of disease specific patient information on our website

Cycles of Improvement  Most important changes: Defined how to collect data for the study and how to involve clinicians.  Involved EHR, Billing Software and meeting with clinicians for their input re how best to collect data “Accidental” changes  Changes in tracking system – now able to call clinicians instead of paging them  Addition of “after hours extension” to leave messages for front desk staff to schedule follow-up appointments  Improved our use of our EHR

Cycles of Improvement  Data collection/clinician involvement PLAN  “Dump” list of newborns for the month from billing software  Brief the clinicians on the project and solicit their input (David)  Newborn screening reports sometimes omitted the child’s final name DO  MacPractice – “marketing”- entered birthdate parameters.  Retrieved names from Spring Charts using birthdate and compared the lists – not always the same.  Presented project to clinicians – they suggested putting the data under Past Medical History  Called doctors and nurses at hospitals involved with newborn screens and called Perkin-Elmer

Cycles of Improvement (continued):  Data collection/clinician involvement (continued) STUDY  Found that we needed to double-check billing software against EHR information  Improved clinician compliance with the study  Discovered that hospital nurses were not putting the final names on newborn screen sheets ACT  Entered names from Billing Software onto our spreadsheet then checked against EHR names by birthdate  Involved clinicians in data gathering  Hospital nurses now instructed to put “final names” on the newborn screening filter paper

Cycles of Improvement  “ Accidental” Improvements “Aha” moments from staff while discussing the project in our weekly Kare Improvement Team meetings. The following questions/answers arose:  We need to see our hospitalized and newborn patients within two days of discharge – how can we set them up if they go home at night or weekend? First implementation of the nighttime phone extension had a system glitch – once that was fixed it is working well.  How can we decrease the number of overhead pages? Placing extensions in the tracker was done immediately – works when people use it!!!  Expanded use of our EHR abilities

Results We had no refusals of screens by parents during the study period! All infants were screened Most screens are received from Perkin-Elmer by 2 weeks of age

Results (Continued): Our only abnormals were sickle, hemoglobin C, and BARTS hemoglobin traits and G-6-PD. They are so common that our staff knows what the recommendations are and does them! We had NO false positives during the period of the study – very unusual but that’s what happened! These were two patients with BARTS hemoglobin – their charts were annotated that they may have microcytic anemia later due to “alpha thalassemia minor”

Results (Continued): We had only one positive result other than BARTS and S, C trait and G-6-PD deficiency during the study period!!

What You Have Learned  Single collection points for data and tasks  Involving all clinicians early with hands-on tasks is critical to their being willing to help with implementing change  Making the excel spread sheet work for data collection is initially time intensive but a huge savings of time and paper during the project and worth the extra time at the beginning.  Deb RN recording alert in patient record for the clinicians facilitated achievement of our goal to counsel 100% of parents about newborn screen results.

Include challenges and setbacks  Dr. Zobian and I remain the primary resource for our clinicians when they have positive findings other than the “ordinary” ones, despite our attempts to encourage them to use the ACT sheets as their guide. Our clinicians are not yet facile with use of the ACT sheets because we have not had large numbers of diseases to trigger use. However as they have opportunity to use them, the ACT sheets have become a helpful resource  Communication of changes to staff members and getting them to use the system changes!

General Lessons Learned  What contributed to your progress so far Continued reminders from Drs. Zobian and Kimball to the clinicians Involvement of physicians and nurse practitioners in data collection resulted in their “buy in” with the project Feedback to physicians and NPs on their performance Deb RN placing alerts in the EHR to remind clinicians when screens arrive in charts.  Anticipated issues Maintaining our progress! Streamlining Deb’s role to meet our needs.