Chronic Care Learning Communities California Association of Public Hospitals Lisa Johnson, M.D. David Ofman, M.D. Oakland, California November 2, 2004 Clinical Information Systems Adapted from Improving Chronic Illness Care

The Care Model Informed, Empowered Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization You are here

If a productive patient-clinician interaction is at the heart of good visit, then information is the life blood flowing throughout that interaction

Currently: Information Available During the Interaction Tends to Be: focused on the paper record disorganized disease/procedure-centered versus patient-centered responsive to the past interaction versus forward looking

What would be more helpful?

Clinical Information System System Change Concepts Provide timely reminders for providers and patients. Identify relevant subpopulations for proactive care. Facilitate individual patient care planning. Share information with patients and providers to coordinate care. Monitor performance of practice team and care system

What is needed in terms of technology? The technology is not the issue! It could be a : shoebox full of 3x5 cards a paper log of patient data spreadsheet simple database web or LAN-based repository electronic medical record

What is the Issue? Functionality! Whatever you use must be able to deliver information that supports the practice team in the delivery of individual and population-based care

For many of us, it will be a registry. A registry is a list of patients and their relevant clinical data that can be sorted by a condition or set of conditions in order to improve and monitor the care of the population

What a Registry Should Be be quick to implement and simple to use be organized by patient; not disease, but responsive to disease populations contain only data relevant to clinical practice make data entry simple and efficient be easy to update from automated data sources assist internal and external performance reporting guide clinical care first, measurement second!

Can I use my EMR for what I need to do? Yes, if… It provides access to lab data, dx test results, and across settings in your system. Guidelines and prompts are included for needed services You can identify populations and subpopulations of patients

Can I…(cont.) If… Allows stratification of patients (complexity, disease severity for case management services) Captures outcomes by provider Captures all critical clinical information

Reminders Timely reminders for providers and patients

Prompts to deliver evidence- based care. They can be delivered : At the time of visit Through population reports Via exception reports

Use of Exception Reports Focus on subgroups: EXAMPLES: Patients not seen in > 6 months: Sort: “not followed at this clinic any longer - delete PCP designation ”, or “needs reminder letter”. Send standardized outreach reminder letter. Patients with HgA1C of > 9.5: Providers and DM Team have focused diabetes case conference on these patients – Goal is to make Care Plan for high risk patients - may need increased multidisciplinary team work

Use of Exception Reports Examples (Diabetic Patients) of Other Exception Reports that can be used to improve care: Patients with no HgA1C within 6 months Patients with no LDL within 12 months Patients with LDL over 130 (or over 100) Patients without documented Pneumovax

Populations and sub- populations Relevant for proactive care.

Populations and sub- populations Relevant for proactive care.

Population-Based Care Goal: Maximize the health outcomes of a defined population (all patients for one clinic, a provider panel, patients at risk) Efforts are made to assure that all relevant members of a population receive needed services Use info systems, planning and outreach

Individual Patient Care Planning

Individual Care Planning Having the right information readily available at the time of the encounter (patient summaries) Having the right tools to create and track treatment plans, both clinical and self- management Ensuring that all routine care is delivered at the appropriate time

Manifestations of care planning Summaries provided to patients Description of patient actions and provider actions Shared care plan

Share information To coordinate care

Avoiding miscommunication Ensure understanding of the care processes across all parties Reduce duplication of effort by care providers Eliminate frustration caused by uncertainty of who is delivering what care when!

Monitoring performance Of the provider and system

Use the CIS to: 1.Create population-specific reports 2.Facilitate external reporting requirements 3.Create dashboard reports of the practice as a whole

CIS: Facts vs. Fears Fear: Why do we have to have a registry? Fact: Planned population-based care cannot be done without knowing your patient population and its key clinical data Fact: Primary care teams that implement registries are more likely to improve processes of care for all chronic conditions Fact: Teams with registries are less likely to lose patients to follow-up, and more likely to improve patient satisfaction as care improves

CIS: Facts vs. Fears Fear: I don’t need anyone telling me how to practice! I’m doing just fine with my patients! Fact: Surveys show that providers consistently under estimate the numbers of patients with chronic disease in their practice Fact: Surveys show that provider consistently over estimate their performance measures on process and clinical outcomes for chronically ill patients. Fact: The two are interdependent. Fact: Knowing you population of patients will help rectify this disparity.

CIS: Facts vs. Fears Fear: It’s just more work during our already hectic day! Fact: Using a patient summary form from a Registry will actually reduce charting time and make the visit run more smoothly Fact: The form gives a snapshot of past care, reminders of needed care and planning for future care all at the time of the visit Fact: Teams with registries feel better prepared for visits since they have the patient information when and where they need it.

CIS: Facts vs. Fears Fear: This will cost me a fortune and there’s no return on investment! Fact: Implementing a registry is simple, and there are economies of scale as you add more patients. Fact: Registries facilitate populations-based care which improves outcomes and patient satisfaction Fact: Planned care via the registry generates visits that are typically of higher intensity while reducing unexpected visits for acute exacerbations

Making Clinical Information Work for You in Clinical Practice

The Software Assess available software for appropriate functionality Install the software. Identify training resources. Highlight CIS importance to rest of team for buy-in

The Chronic Illness Data Manager Identify best person on team to manage the disease management information. Choose person with computer skills and interest. Define roles and responsibilities for manager. Secure training for manager as needed. Train a back-up.

Populating a Registry Use billing data and ICD9 codes to identify specific populations or build prospectively. Download names and contact information into registry. Establish process for regular population updates.

Getting Clinical Data into the Registry Define the relevant clinical data needs. Use the visit for collecting non- automated data. Develop and test data capture process. Use chart audits judiciously. Develop and test data entry process

Using Data at Point of Care Establish process for producing patient summary data for use at time of visit (acute or planned) Make sure summary is replacing other data capture processes to avoid double entry. Ensure summary is on chart or in exam room. Ensure new data is captured on the summary. Develop process for new summary data to be entered into registry.

Using Data for Care Reminders Establish what you want “reminding” about. Determine how you want to be reminded. (i.e, exception reports or individual patient prompts) Identify team member responsible for monitoring reminders. Create process for responding to reminders. (i.e., who calls patient, when. for what purpose) Create process for updating/modifying reminders.

Using Data to Monitor Performance Determine what types of population reports are needed, and at what reporting intervals. Establish process for creating customized reports. Who will generate reports? Who receives reports? Do the reports facilitate continued improvement?

Keys to Success from Those that have Implemented Registries Everyone understands the clinical utility and supports the time involved in registry upkeep. Care management using registry data is a team approach Dedicated time each week for primary team to use data Data forms are clear, roles are assigned. Data are clinically relevant, used for patient care first, and measurement second. Data can be shared with patient to improve understanding of treatment plan.

Barriers to CIS use Lack of perceived value Competing business and productivity demands Lack of office flow expertise Lack of information support Lack of leadership support

For More Information: Please visit Improving Chronic Illness Care’s web site at

Target Areas for Improvement Problem: Low levels of Lipid Profile documentation AND low levels of self-mgt goal setting. Idea: Actively find patients without lipid profile and get them into the clinic. Combine visit for free lipid profile with SM Goal setting. Purpose of a test cycle: Test use of free lipid profiles to improve performance on the key measures. Set SM Goals at time of lipid visit Query run Free lipid profiles offered

Monitor Impact of Test Cycles of Change All care teams setting SM goals with pts

Implemented foot stamp Monitor Impact of Implemented Changes RN’s doing foot exams

Stuck at 53% for LDL < 100 Brainstorm Decision Support? Documentation? Test not ordered (no buy-in to guideline) Tests not ordered (missing prompt) Test ordered (but not treating to target) Data verification – comparison of registry to chart and lab records Identify Reasons for Lack of Improvement: Ocean Park Health Center