1. UNIVERSITY OF MISSOURI Family & Community Medicine EMR Dashboards & Registries Helping the Team Take Action in the Patient-Centered Medical Home

2. UNIVERSITY OF MISSOURI Family & Community Medicine Presenters Jeffery Belden, MD Rhonda Polly, APRN Sarah Swofford, MD Karl Kochendorfer, MD

3. UNIVERSITY OF MISSOURI Family & Community Medicine Objectives 1.Recognize how the clinical dashboard (patient summary screen) can be used for improved efficiency, effectiveness, and coordination of care for patients with chronic diseases. 2.Identify how evidence-based decision support can be integrated into EMR, using patient’s live data. 3.Identify how to select quality measures and manage cohort data to coordinate care outside the office visit using a team approach.

4. UNIVERSITY OF MISSOURI Family & Community Medicine Overview  Dashboards & Algorithms Jeff Belden MD  Nurse Role & Registry Tool Rhonda Polly APRN  Quality Measures & Performance Sarah Swofford MD  Outcomes & Future Directions Karl Kochendorfer MD

5. UNIVERSITY OF MISSOURI Family & Community Medicine The Medical Home - MU style 1. A medical home, relationship based 2. Care across settings 3. Team care 4. Nurse partner/Care Coordinator 5. Self-management support 6. Community resources 7. Focus on improvement 8. Information technology enabled

6. UNIVERSITY OF MISSOURI Family & Community Medicine Medical Home Features 1.Access and Communication 2.Patient Self-Management Support 3.Electronic Prescribing 4.Test Tracking 5.Referral Tracking 6.Advanced Electronic Communication 7.Pt Tracking and Registry Functions 8.Care Management (with EBM) 9.Performance Reporting and Improvement NCQA - Patient-Centered Medical Home Certification Standards

7. UNIVERSITY OF MISSOURI Family & Community Medicine Medical Home Features 1.Access and Communication 2.Patient Self-Management Support 3.Electronic Prescribing 4.Test Tracking 5.Referral Tracking 6.Advanced Electronic Communication 7.Pt Tracking and Registry Functions 8.Care Management (with EBM) 9.Performance Reporting and Improvement NCQA - Patient-Centered Medical Home Certification Standards

8. UNIVERSITY OF MISSOURI Family & Community Medicine Our EMR needed help We needed some new features & usability We offered to help vendor develop them

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10. UNIVERSITY OF MISSOURI Family & Community Medicine Jeff Belden MD Main Points  Dashboard page (Patient Summary Screen) allows efficient preparation for chronic disease visits  Dashboard page makes a handy summary for the patient to take home

11. UNIVERSITY OF MISSOURI Family & Community Medicine WORKFLOW In advance

12. UNIVERSITY OF MISSOURI Family & Community Medicine Review schedule Overview Find hot spots Find missing pieces Trigger memories

13. UNIVERSITY OF MISSOURI Family & Community Medicine On doctor’s arrival

14. UNIVERSITY OF MISSOURI Family & Community Medicine Huddle Make notes together Gather missing pieces Gird loins

15. UNIVERSITY OF MISSOURI Family & Community Medicine On patient’s arrival

16. UNIVERSITY OF MISSOURI Family & Community Medicine Nurse greets & prepares patient VS, smoking Med list review. Refills? Foot exam Eye exam date Immunization review, administration Update EMR Print “Patient Summary” page  & DM page

17. UNIVERSITY OF MISSOURI Family & Community Medicine DASHBOARD Patient Summary

18. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Summary

19. UNIVERSITY OF MISSOURI Family & Community Medicine Problem List

20. UNIVERSITY OF MISSOURI Family & Community Medicine Medication List

21. UNIVERSITY OF MISSOURI Family & Community Medicine Vital signs, Pain, Smoking…

22. UNIVERSITY OF MISSOURI Family & Community Medicine Lab

23. UNIVERSITY OF MISSOURI Family & Community Medicine Sparklines | Word-sized graphs

24. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Summary (scrolled down)

25. UNIVERSITY OF MISSOURI Family & Community Medicine Health Maintenance

26. UNIVERSITY OF MISSOURI Family & Community Medicine Visits

27. UNIVERSITY OF MISSOURI Family & Community Medicine CAD Risk Calculator

28. UNIVERSITY OF MISSOURI Family & Community Medicine Framingham Risk Score

29. UNIVERSITY OF MISSOURI Family & Community Medicine Go to Diabetes Summary

30. UNIVERSITY OF MISSOURI Family & Community Medicine Diabetes Summary

31. UNIVERSITY OF MISSOURI Family & Community Medicine Quality Performance

32. UNIVERSITY OF MISSOURI Family & Community Medicine Link to Treatment Algorithm Clinical Decision Support

33. UNIVERSITY OF MISSOURI Family & Community Medicine DM2 Treatment Algorithm

34. UNIVERSITY OF MISSOURI Family & Community Medicine Ready to Enter Exam Room

35. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Summary Uses

36. UNIVERSITY OF MISSOURI Family & Community Medicine Uses Dashboard Chalkboard Report card Carrot & stick Take home

37. UNIVERSITY OF MISSOURI Family & Community Medicine Chalkboard

38. UNIVERSITY OF MISSOURI Family & Community Medicine Report Card For me  Quality dashboard For patients  BP  Weight  Lab results: A1C, Lipids

39. UNIVERSITY OF MISSOURI Family & Community Medicine Carrot & Stick Framingham Risk  Persuasion Make red dots go away

40. UNIVERSITY OF MISSOURI Family & Community Medicine Take Home Send with patient  BP  Weight  Lab results  Updated med list

41. UNIVERSITY OF MISSOURI Family & Community Medicine Take Home Wallet-size list

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43. UNIVERSITY OF MISSOURI Family & Community Medicine Rhonda Polly APRN  Nurse Role  Registry Tool

44. UNIVERSITY OF MISSOURI Family & Community Medicine Collaborative Team Effect APRN Role in MO Scope of Practice in MO Collaborative Practice Agreements See patient’s during clinic visits  With physician 7 Faculty 1 Fellow 9 Residents  Some billable individual appointments with APRN

45. UNIVERSITY OF MISSOURI Family & Community Medicine Collaborative Team Effort 1.Face-to-face intro in clinic  patient & nurse partner 2.Nurse partner shares exam room  starts visit  sees with physician or  afterwards

46. UNIVERSITY OF MISSOURI Family & Community Medicine Collaborative Team Effort 3.Reinforcement - sometimes repetitive information 4.On visit day - communicate findings with physician 5.Encourage self-management goals

47. UNIVERSITY OF MISSOURI Family & Community Medicine Care Coordinator Evidence 15 randomized controlled trials of care coordination Only 2 showed enough promise to continue funding Four trends that emerged: – In-person contact was better than mostly phone contact – Target patients with moderate to severe illness – Assist with transitions of care (i.e. hospital discharge) – Assist with medication education\compliance Peikes. Effects of care coord: 15 randomized trials. JAMA. 2009

48. UNIVERSITY OF MISSOURI Family & Community Medicine Tracking Patients

49. UNIVERSITY OF MISSOURI Family & Community Medicine Chronic Care Coordinator Patient List

50. UNIVERSITY OF MISSOURI Family & Community Medicine Filter for DM

51. UNIVERSITY OF MISSOURI Family & Community Medicine Quality Measures Met by %

52. UNIVERSITY OF MISSOURI Family & Community Medicine Patient Summary Screen 8 Quality Measures

53. UNIVERSITY OF MISSOURI Family & Community Medicine Diabetes Type II Algorithm

54. UNIVERSITY OF MISSOURI Family & Community Medicine Collaborative Efforts To Meet Measures Contact phone nurse through EMR by message  call patient  schedule A1C, Urine-Microalbumin, & FLP  schedule eye exam with Ophthalmology CCN calls patient  discuss home BG and BP’s  educate and/or adjust medications as needed in collaboration with physician. Can bill for some visits

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56. UNIVERSITY OF MISSOURI Family & Community Medicine Sarah Swofford MD  Quality Measures  Performance

57. UNIVERSITY OF MISSOURI Family & Community Medicine Quality measures How to select quality measures Use of EMR in measuring quality of care

58. UNIVERSITY OF MISSOURI Family & Community Medicine Quality measure selection Specific Measurable Achievable Relevant Timely Easily exported from EMR

59. UNIVERSITY OF MISSOURI Family & Community Medicine Quality measure selection Where to start? Potential list of quality measures is large (DOQ-IT, NQF, AMA-PCPI, NCQA, DPRP, etc.) We compiled a list of 200

60. UNIVERSITY OF MISSOURI Family & Community Medicine Quality measures abound

61. UNIVERSITY OF MISSOURI Family & Community Medicine Diabetes quality measures

62. UNIVERSITY OF MISSOURI Family & Community Medicine Quality measures We picked DOQ-IT quality measures to start with Focused on Diabetes Mellitus DOQ-IT quality measures had specific patient inclusion criteria, most detailed, thought out

63. UNIVERSITY OF MISSOURI Family & Community Medicine DOQ-IT Doctors Office Quality – Information Technology National initiative of the Centers for Medicare and Medicaid services that promotes the adoption of EHR Set of healthcare quality measures used to track progress in achieving the goals of the DOQ-IT project

64. UNIVERSITY OF MISSOURI Family & Community Medicine Diabetes quality measures All patients with diabetes >18 and ≤75 years of age Annual HbA1C HbA1C >9.0% (poor control) Most recent BP <140/90 Annual LDL

65. UNIVERSITY OF MISSOURI Family & Community Medicine Diabetes quality measures All patients with diabetes >18 and ≤75 years of age LDL <130 Annual urine microalbumin Dilated eye exam (q1-2yrs) Annual diabetic foot exam

66. UNIVERSITY OF MISSOURI Family & Community Medicine Quality measure reporting Dashboard/summary screen Individual report to provider Interactive analytics report

67. UNIVERSITY OF MISSOURI Family & Community Medicine Diabetes Summary

68. UNIVERSITY OF MISSOURI Family & Community Medicine Patient summary screen

69. UNIVERSITY OF MISSOURI Family & Community Medicine Monthly report Monthly e-mail report with graph of my performance over time

70. UNIVERSITY OF MISSOURI Family & Community Medicine Ability to “drill down” on my performance Analytics software available through our EMR to “drill down” to various levels  Clinic wide performance  Provider specific performance  Patient specific information

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74. UNIVERSITY OF MISSOURI Family & Community Medicine Drill down to patient level

75. UNIVERSITY OF MISSOURI Family & Community Medicine Export to Excel

76. UNIVERSITY OF MISSOURI Family & Community Medicine Submitting to PQRI EMR electronically pulls 3 DM quality measures and submitted to PQRI on my behalf Percentage of patients aged 18 to 75 years with diabetes mellitus

77. UNIVERSITY OF MISSOURI Family & Community Medicine Submitting to PQRI HbA1C >9.0% LDL <100 BP <140/80

78. UNIVERSITY OF MISSOURI Family & Community Medicine Submitting to PQRI Potential $ from CMS? Still waiting……

79. UNIVERSITY OF MISSOURI Family & Community Medicine Lessons learned Some quality measures easier to capture than others Hard data (A1C) vs. subjective (diabetic foot exam) Lots of opinions about what to measure Where to set the bar But my patients shouldn’t be included

80. UNIVERSITY OF MISSOURI Family & Community Medicine Lessons learned Need a starting point for quality measures Strive for improvement, not perfection Need buy-in from your providers, so accuracy is important

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82. UNIVERSITY OF MISSOURI Family & Community Medicine Karl Kochendorfer MD  Outcomes  Future Directions

83. UNIVERSITY OF MISSOURI Family & Community Medicine Broken healthcare system “Good Luck with the American Health-Care System” cards

84. UNIVERSITY OF MISSOURI Family & Community Medicine Medical Home Features 1.Access and Communication 2.Patient Self-Management Support 3.Electronic Prescribing 4.Test Tracking 5.Referral Tracking 6.Advanced Electronic Communication 7.Pt Tracking and Registry Functions 8.Care Management (with EBM) 9.Performance Reporting and Improvement NCQA - Patient-Centered Medical Home Certification Standards

85. UNIVERSITY OF MISSOURI Family & Community Medicine Does Measuring Improve Quality? From: Healthcare IT News. Sep 2008

87. UNIVERSITY OF MISSOURI Family & Community Medicine GM Green Team Perfect Care

88. UNIVERSITY OF MISSOURI Family & Community Medicine DM Patient Workflow

90. UNIVERSITY OF MISSOURI Family & Community Medicine My data over the past 7 months

91. UNIVERSITY OF MISSOURI Family & Community Medicine Lessons Learned Just having the data doesn’t mean improvement Integrate the data into your workflow Start by focusing on a select few quality measures Be prepared to get many new requests for specialized summary screens  ID, surgery, peds

92. UNIVERSITY OF MISSOURI Family & Community Medicine Future Steps Build a consolidated summary screen Go beyond the current PCMH definition and measure  Overall health  Coordination of care  Person-focused care over time Link faculty incentive to improvement Rollout CPOE, Patient web portal Assist our docs with their Board certification

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94. Questions ? UNIVERSITY OF MISSOURI Family & Community Medicine