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

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 Follow the instructions to take a picture of your graph and paste it into Powerpoint. 1. Along the top of the PDF document, click on 'Tools' 2. Click on 'Select and Zoom' 3. Click on 'Snap Shot Tool' 4. Your mouse arrow becomes a cross, and you will click on one corner of the graph and drag it to the other corner of the graph. When you unclick, you have just taken a picture of the graph. 5. You can then copy it in Powerpoint by clicking 'copy'.

% 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

TEST 1 What: CQN paper form Who : Known asthmatics Who : Dr. Tauro and Melanie Where: Kellyton office When: Sept 2009 PD SA TEST 2 What: CQN paper form Who: Known asthmatics Who: Physician, NP and Kristal Where: Both pediatric offices When: October 2009 PD SA TEST 3 What: EHR form Who : Asthma patients Who : Dr. Tyler and Kristal Where: Alex city office When: January 2010 PD SA TEST 4 What: CQN EHR form Who: All asthma patients Who :Providers with help of nurses Where: Both offices When: February 2010 PD SA TEST 1 What: AAP version Who: 3 patients per week Who : Dr Tauro and Tyler: Where: Both offices When: September end PD SA TEST 2 What: Different action plans Who : 5 patients Who : Providers Where: Both offices When: October PD SA TEST 3 What: Final paper action plan Who: All asthma patients Who : Providers and nurses Where: Both offices When: January PD SA TEST 4 What: Action plan in EHR Who :All asthma patients Who: providers and nurses Where: Both offices When: February PD SA TEST 1 What: Demonstration of spirometry Who : Providers, NPs and nurses Who : Spirometry rep Where: Main office When: December PD SA TEST 2 What: Spirometry Who: New asthmatic 10 years old Who :Dr. Tyler, Kara Where: Main office When: January PD SA TEST 3 What: Spirometry Who: New asthma patient Who :Melanie, Courtney Where: Kellyton office When: February PD SA TEST 4 What: Spirometry pre & post aerosol Who :Asthmatic 10 years older Who: NPs and nurses Where: Both offices When: At present PD SA CQN asthma formAsthma action planSpirometry PDSA Ramps

Office Flow Document

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

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 , , , , , , , , , and ) 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

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 functionPatient needs semi-annual Urine microalbumin Managed by Children’s Hospital EndocrinologyRefer patient to opthalmologist for yearly visit Review insulin dosing and blood sugar diaryPatient needs Lipid profile Monitor insulin scripts filled Patient’s physical exam is due – including foot exam Patient needs labwork for Hemoglobin A1C completed

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