1. A Systematic Approach to Understanding and Improving Care Delivery and Outcomes Tutorial on the Essential Version of the Health IT-enabled Quality Improvement (CDS/QI) Worksheet * TMIT CONSULTING, LLC www.tmitconsulting.com * Adapted from ONC version posted on healthit.gov: http://bit.ly/oncecqicdshttp://bit.ly/oncecqicds

2. Tutorial Overview Uses fictionalized case example to illustrate CDS/QI Worksheet and related tools in action Worksheet used to analyze current workflow/ information flow for priority improvement target (Blood Pressure [BP] Control) The tool also supports team in brainstorming care enhancements to produce better results for patients, staff, providers and other stakeholders

3. Case Example: Setting Health Center Not all patients read or speak English 10 providers – 6 physicians – 3 nurse practitioners – 1 physician assistant Electronic Health Record (EHR) installed a few years ago

4. Case Example: Project Background BP control metrics below Healthy People 2020 goal triggered BP control quality improvement (QI) project Health Center became aware of strategies and tools for health IT-enabled QI on HRSA/BPHC’s HITEQ CenterHITEQ Center Tried the CDS/QI Worksheet to better understand current BP control activities, and improve them and their results Following are background and details of this work

5. CDS/QI Worksheet Versions The “Health IT-enabled Quality Improvement Worksheet,” or “CDS/QI Worksheet” for short, comes in 2 types: – An ‘Essential’ version designed for initial efforts to understand and improve target-focused care processes – An ‘Enhanced’ version for deeper analysis and change implementation This example covers the use of the outpatient Essential CDS/QI Worksheet to understand and improve hypertension care processes and outcomes – This approach can be applied to many other targets and settings

6. CDS/QI Worksheet Basics The CDS/QI Worksheets help teams consider how to support each care step to ensure better results for targets CDS/QI Worksheet sections answer basic questions: – What are we trying to improve and what is our baseline performance? – What are the categories of activities that determine our performance and provide improvement opportunities? – What are we currently doing (and not doing) to support key decisions, actions, and communication in each category, and how might we improve to get better results? The CDS/QI Worksheet provides a structured approach to documenting and analyzing these key issues – Fosters collaboration among the health center team and with QI partners, e.g., HCCN/PCA, EHR/population management vendors by providing a shared framework for examining and improving workflow

7. CDS/QI Worksheet: First Section of Essential Version Start by documenting details of your improvement target – The clinic included the name of a specific quality measure because reimbursement related to performance on that measure was a driver for their QI efforts - in addition to the primary goal of reducing heart attacks and strokes in their patient population – The clinic listed a specific targeted performance level (75%) and time period over which to achieve the targeted level o They set the target through collaboration among clinical, quality and business teams. Being specific about patient populations, performance level and timeframe details helps to move toward measurable and valuable results – The clinic listed their current performance on controlling blood pressure (65%) right under the targeted levels

8. CDS/QI Worksheet: Second Section of Essential Version Activity categories driving performance on target: 1.Orange Stripe = Interactions with Individual Patients 2.Blue Stripe = Population-oriented activities 3.Green Stripe = Foundational Work; keys for success on 1 and 2

9. Orange Stripe: Individual Patient Supports The flow diagram includes interactions with each patient before, during and after their healthcare encounters It also includes a ‘Not Visit Related’ item that reminds teams to consider decisions and actions that patients make unrelated to any visit. – For example, when they’re in their kitchen, in restaurants, in the grocery store, doing things that have as much to do with whether their blood pressure is controlled as what happens when they’re in the clinic – This item helps teams consider how to best support critical activities and decisions during patient’s daily routine

10. Blue Stripe: Population-oriented Activities This involves looking across all patients to identify and address those individuals needing additional attention to ensure appropriate blood pressure control – For example, generating lists of patients with hypertension whose last office blood pressure wasn’t controlled, or who haven’t returned for timely follow-up, and taking appropriate steps to address these gaps It also includes presenting performance data to teams so they can see how they compare to peers and benchmarks – For example, presenting dashboards with this information, to spur team discussion about how they can reduce care gaps

11. Green Stripe: Foundational Work Practice activities that underpin patient-specific and population management work This includes training staff, developing practice policies and procedures, and configuring the EHR and population management tools – For blood pressure control, these foundational activities include training staff on proper BP measurement techniques and recording results in the EHR, policies for how to handle elevated BP readings taken by medical assistants, and practice protocols for managing hypertensive patients. – It also includes configuration changes to the EHR, such as hypertension-specific order sets, documentation templates, flow sheets, patient education materials, and visual clues such as turning BP red when an elevated value is recorded.

12. Approach Summary Table Third Section of Essential Version

13. Approach Summary Table The Approach Summary Table summarizes the details about target-related information flow and workflow in each of the 3 care activity categories: – Patient-specific – Population management – Foundational The items corresponding to these categories are listed in the table’s header

14. Approach Summary Table (cont.) The top blank row summarizes ‘current state’ – what is currently done at each opportunity to support target- related decisions, actions and communications – Document by discussing these current state details with quality and clinical teams – This structured view highlights strengths and limitations of current care processes and points out opportunities to make the right thing easier to do o For example, pop-up EHR alerts presented to providers about patient’s uncontrolled BP when they were focusing on other tasks were more distracting than useful Summarize these potential enhancements in the second blank row in the summary table – Information to populate this summary table comes from the detail tables in the next CDS/QI Worksheet section

15. Approach Detail Tables Fourth Section of Essential Version (excerpt)

16. Approach Detail Tables The Essential CDS/QI Worksheet “Approach Details” section has tables to flesh out specific details of the target-related current state, and potential enhancements, for each one of the 3 activity categories and their components – The Approach Summary Table summarizes these details – The detail tables are generated by discussion with key stakeholders, such as the QI team, clinicians and clinical and operations staff, and ideally patients – The summary table populated from these detail tables is then used by the QI team in collaboration with others to prioritize and execute high-yield care process changes

17. Approach Detail Tables (cont.) Look at care process from the patient perspective. How can you better help patients understand their conditions and play a more active and effective role in managing them? – Example: When Health Center completed the ‘Not Visit Related’ item in the Patient-specific Activities section, the only support they could think of for supporting critical, daily lifestyle decisions was what patients took away from conversations with their provider, and whatever hypertension brochures in racks they picked up. They realized that this wasn’t adequate to fully engage patients outside of visits, and support their decisions and actions during daily routines related to diet and exercise changes, and medication/care plan adherence. – This triggered productive brainstorming with QI and clinical teams. They documented in the ‘Potential Enhancement’ section how they needed to help patients better track and manage these difficult lifestyle changes, and leverage their portal better to support patient engagement. In addition to putting resources to support meal planning and sodium on the portal, they developed a plan to research online and mobile tools such as Heart360® to use with their patients for tracking BP and exercise outside of visits.Heart360®

18. Clinical Decision Support 5 Rights: A Powerful QI Framework The Clinical Decision Support Five Rights framework asserts that if you want to improve a particular care process or outcome, you need to do a better job of getting: – the right information – to the right people – in the right formats – through the right channels – at the right times to optimize target-related decisions and actions. The next slide gives an example of how this framework was used in the case example setting

19. Clinical Decision Support 5 Rights: A Powerful QI Framework (cont.) Before the clinic started using the CDS/QI Worksheet and CDS 5 Rights framework in their BP QI work, they thought that providing clinical decision support for blood pressure control meant showing EHR pop-up alerts to providers when they opened a patient’s electronic record – They tried alerts, but they weren’t liked or effective The approach embodied in the CDS/QI Worksheet and CDS 5 Rights framework gives a much more powerful mechanism to analyze and improve care delivery processes – It helps teams think through and improve all the who, what, when, where, and how information flow and workflow dimensions that determine whether or not QI targets (such as BP control) are reached – For example, it helped the QI project focus more on patient decisions and needs, and using channels such as mobile applications to meet them better. – The framework similarly emphasized other opportunities and tools to make the right thing easier for the care team – such as EHR-generated huddle sheets to highlight elevated BPs requiring attention during pre-visit planning.

20. Clinical Decision Support 5 Rights: Summary and Examples To improve targeted care processes/outcomes, get: the right information evidence-based, actionable… [what] to the right people clinicians and patients… [who] in the right formats Registry reports, documentation tools, data display, care plans… [how] through the right channels EHR, patient portal, smartphones, home monitoring … [where] at the the right times key decision/action … [when] Recommended as a QI best practice by CMS: bit.ly/cmscdstipsbit.ly/cmscdstips

21. 3 Essential QI Questions Health Center appreciated how the CDS/QI Worksheet helped address ‘What are we currently doing?’ and ‘What changes might we make?’ to BP workflow and information flow What they also wanted was a tool to answer a key question between those: ‘What should we be doing?” to produce better processes and results They were pleased to learn about the CDC/Million Hearts Hypertension Control Change Package (HCCP), designed to answer this question for BP control

22. HCCP: Structure and Use This tool is organized by the same 3 performance drivers as the CDS/QI Worksheet (Individual Patient Supports, Population Management, Foundations) The next 2 slides show more about this change package’s content Health Center found these change concepts, ideas and resources very helpful in identifying powerful BP control strategies and tools The HITEQ Center HIT/QI Guide has information about change packages for other targets

23. HCCP: Screenshots Access this Change Package at: http://millionhearts.hhs.gov/Docs/HTN_Change_Package.pdf http://millionhearts.hhs.gov/Docs/HTN_Change_Package.pdf

24. Change Concepts General notions that are useful in the development of more specific ideas for changes that lead to improvement Change Ideas Actionable, specific ideas for changing a process Tools & Resources Can be adapted by or adopted in a health care setting HCCP: Overview of Contents for Each Performance Driver

25. Example Clinic HIT/QI Results Health Center found the HIT/QI Guide, especially the CDS/QI Worksheet and HCCP, very helpful in their BP QI work, and have begun applying them to other targets After a year, the BP QI project achieved the targeted 75% control rate. The next slide shows an excerpt from an updated version of their CDS/QI Worksheet The CDS/QI Worksheet is used as a ‘living document’ throughout the project to help track current BP-related information flows and workflows Attention to all 3 activity categories in the worksheet and HCCP – individual patient supports, population management, and foundations – together with the broad approach to improving information flow and workflow encouraged by the CDS 5 Rights framework, is key

26. Getting the CDS 5 Rights Right Success Strategy and Plans for Case Example* *This is summary is from a real case study of a practice that achieved a 90% BP control rate. For further details see the Ellsworth Medical Clinic Hypertension QI Case Study.Ellsworth Medical Clinic Hypertension QI Case Study

27. Example Clinic HIT/QI Results (cont.) Another strategy critical to success is to be highly collaborative in your approach to this QI work with providers, staff and patients Rather than looking at improving blood pressure control as something that your QI staff is doing to others providing (and receiving) care, look at the whole effort as working with them to achieve important, shared goals – For example, make care processes more efficient and rewarding for staff and patients, while reducing heart attacks and strokes

28. Conclusion/Next Steps HRSA/BPHC’s HITEQ Center has tools and services to help health centers achieve data-driven, health IT-enabled care process and outcome improvements For additional information see HITEQcenter.org or contact HITEQ here.here