1. Extreme Makeover: Simple Chart Review Transformed into Practice-Based Learning Conference Melissa Jefferis, MD Miriam Chan, PharmD Riverside Methodist Hospital Family Medicine Residency Columbus, Ohio

2. Objectives Review ACGME guidelines, PCMH criteria, and ABFM prerequisites Identify the practice-based learning (PBL) curriculum needs Develop a PBL conference Incorporate patient population management techniques, METRICS, and medication safety management into a PBL curriculum

3. ACGME Competencies Practice-based learning and Improvement – Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

4. NCQA 2011: PCMH Standards and Scoring

5. PCMH “Must Pass” Elements 1A. Access during office hours 2D. Using data for population management 3C. Care management 4A. Self-care process 5B. Referral Tracking and follow-up 6C. Implement continuous quality improvement process

6. ABFM Certification Requirements All residents starting after June 1, 2012 Required to sit for 2015 exam 50 MC-FP points – Must include at least 1 SAM (15 points) – Must include at least 1 Part IV (PPM, METRIC, etc.) (20 points)

7. The Common Elements Evidence-based medicine practice Population management Care management Continuous quality improvement Plan-Do-Study-Act (PDSA) cycle Education of patients, physicians and other medical professionals

8. How Are You Meeting Practice-Based Learning Requirements?

9. Our Previous PBL Curriculum Monthly Journal Club – EBM skills and practice Scholarly activity – Quality and practice improvement projects Weekly Chart Review – Random topic and patients – Obstetric, pediatric and diabetic patients – Checklist focusing on chart completion Our weakest link

10. Chart Review

11. Population Management Outcomes Measurement AAFP METRIC Quality Benchmarks Medication Safety Alerts Enhanced OB Chart Review PBL Conference

12. Resident Educational Objectives Skills to investigate and evaluate the quality of patient care Techniques to mine data from EMR Experiences in engaging in Plan-Do-Study-Act cycles

13. PBL Conference When? Who? Where? 1 hour per week (Monday 1pm) Residents in the office that afternoon with rotating medical and pharmacy students RFPC Conference Room

14. PBL Conference PGY 1 – Unable to attend conference due to patient care time in late afternoon and/or Wednesday afternoon PGY 2 – Attends conference 12 times per year PGY3 – Attends conference 16-20 times per year

15. PBL Conference Week 1 Week 2 Week 3 Week 4 Medication Safety MGO Metric (screening-based) AAFP Metric Enhanced OB Chart Review

16. PBL Conference Schedule of conference – 15 minutes: education from faculty regarding diagnosis, documentation, medication interactions, treatment guidelines and process for data abstraction – 45 minutes: residents complete data abstraction for assigned patients

17. Managing Medication Safety Alerts in Riverside Family Practice Center Week 1

18. Medication Safety Alerts The FDA periodically issues medication safety alerts and warnings that affect prescribing practices – http://www.fda.gov/Safety/MedWatch/default.htm

19. Recent Examples Citalopram related to a potential risk of arrhythmia with doses>40 mg/day Drug interactions, contraindications, dose limitations for lovastatin New restrictions, contraindications, dose limitations for simvastatin Plavix and PPIs potential interactions

20. Medication Safety in Our PBL Curriculum Goal: – Teach residents how to manage medication safety alerts Objectives: – Locate, appraise and assimilate the new evidence-based medication interactions, guidelines, and warnings – Perform population-based approaches to medication safety in the outpatient setting

21. A 3-Step Process Education and planning Intervention Monitor outcomes

22. Step 1: Education and Planning Review FDA alert and recommendations Assess risk to patients and implications for the practice Identify patients who are taking the affected medication Design a coordinated response and patient letter

23. Step 2: Intervention Review chart of affected patients Alert PCPs of their affected patients in the EMR Provide PCPs with relevant information and standard patient letter PCPs take appropriate medication safety measures

24. Step 3: Monitor Outcomes Re-run medication list query to identify patients continuing to have the affected medication Review charts of these patients Assess impact of intervention – Review process and identify practice/ communication gaps

25. Continuous Process Improvement Plan-Do-Study-Act Cycle Step 1: PLAN Plan for a change Step 2: DO Try plan on a small scale Step 3: Study Study the outcomes Step 4: ACT Redefine the Change as necessary

26. For Example Simvastatin Label Change (6/8/11)

27. Educate About The Alert FDA alert – Use of simvastatin when taken at high doses or in combination with several interacting medications FDA recommendations – New contraindications – Dose limitations for simvastatin when taken with certain other medications Risk to patients – Simvastatin (80 mg) is associated with increased risk of myopathy

28. Develop an Action Plan

29. Evaluate The Alert Impact to practice – Simvastatin is a common prescribed medication for hyperlipidemia Generate a listing of patients taking simvastatin 80 mg as well as patients taking simvastatin in combination with other contraindicated medications

30. Our Results: General Information 53 patients taking simvastatin 80 mg or Vytorin 10/80 – 83% (44 patients) taking simvastatin 80 mg >12 m – 49% (26 patients) not at LDL goal – 100% with no documentation of assessing myopathy

31. Our Results: PCPs Actions PCPs response occurred in 68% (36 patients)

32. Our Results: Type of Actions

33. How To Improve PCP Response? “Take cover now” VS “unsurvivable” “mass devastation” “catastrophic” 32% (17 patients) did not have any action taken

34. Implementing AAFP and MGO METRICs Weeks 2 and 3

35. METRIC Measuring, Evaluating and Translating Research Into Care

36. Available AAFP METRICs Asthma Chronic Obstructive Pulmonary Disease Coronary Artery Disease Depression Diabetes Geriatrics Hypertension Immunizations for Adolescents Immunizations for High-Risk Adults

37. AAFP METRICs Goal: Teach residents performance improvement Objectives: Residents will be able to: Use EMR to create patient registry Assess current practice patterns Develop performance improvement plan Study effectiveness of performance improvement plan

38. A 3-Step Process Learning from current practice Application of PI plan Evaluation of PI effort

39. Step 1: Learning from current practice Use EMR to develop patient registry for each physician participating Chart review to determine baseline performance data

40. Step 2: Application of PI Plan Review baseline data to find poor performance areas Determine performance improvement plan Education to physicians and staff regarding plan Implement the plan

41. Step 3: Evaluation of PI Effort Create updated patient registries for participating physicians Repeat chart review to determine performance Compare post-intervention to pre-intervention performance

42. AAFP METRIC Depression

43. Develop an Action Plan

44. Step 2: Application of PI Plan Review with physicians DSM-IV criteria for Major Depressive Disorder Education to staff regarding depression and PHQ-9 Medical assistants to hand out PHQ-9 to patients being seen for depression

45. Severity Assessed for New or Recurrent Episode Symptoms Actively Monitored Suicide Risk Assessed at Each Visit Evaluation of Depression Metric Performance 42.9% 40.8% 57.1%

46. RFPC Data Interns do not have the patient numbers required for participation Staff participation varied with handing out PHQ-9

47. Week 4 Enhanced OB Chart Review

48. OB Chart Review Previously – Monthly chart review of OB patients at 36 weeks gestation. – Used a paper form to review a paper chart for completeness. Currently – Monthly chart review using a paper form to review an EMR chart for completeness.

49. NCQA PCPI Guidelines Prenatal Measures – Establishment of Gestational Age – Prenatal Care Screening – Behavioral Health Risk Assessment – BMI Assessment and recommended weight gain Doing very well at #1 and #2. Need to revise forms to gather more applicable data for the rest

50. OB Chart Review Data

52. Future Projects: Medication Safety Citalopram (Celexa) Dosing Considerations in Geriatric Patients Aliskiren (Tekturna) Containing Medications in Chronic Renal Disease and Diabetic Patients New FDA Medication Alerts

53. Future Projects: Performance Improvement Preventative Care Measures (MGO) – Colorectal Cancer Screening – Partnership with Ohio Academy of Family Physicians AAFP Metrics – Hypertension – Core disease state for PCMH Application – Workgroup across OhioHealth addressing documentation issues

54. Future Projects: OB Labor and Delivery Measures – Elective Delivery Before 39 Weeks – Cesarean Delivery for Low-Risk Nulliparous – Episiotomy – Spontaneous Labor and Birth – Care Coordination: prenatal record present at delivery Postpartum Measures – Breastfeeding rate – Postpartum Follow-up Rate

55. Conclusions We hope that our experience has helped you: – Evaluate your current practice-based learning curriculum – Find your educational need – Create your own customized PBL curriculum

56. Questions?