1. Increasing screening for osteoporosis Team 1 - 10/2013 Thanks to Georgia Carlson and N Topeka staff

2. Increasing screening for osteoporosis Increase parsable documentation of fulfillment of patient choice for screening by USPSTF osteoporosis guidelines by 25% within 3 months This is your operationalized version The elevator version is the project title

3. Baseline data Made by QI Tools at OpenCPU Sometimes only a single baseline measurement is available

4. Baseline: Fishbone or Ishikawa diagram (cause and effect diagram) Made by QI Tools at OpenCPU

5. Baseline flow chart Made by LucidCharts PNG file downloaded from Lucid

6. Process map: baseline (optional) Made by QI Tools at OpenCPU

7. Stakeholder analysis Stakeholder’s impression of barriers – Doctor.: Clarity of evidence-based guidelines for f/u – Nurse: Hassle to input dx of tobaccoism in EHR=multiple clicks Reluctance to persistently ask about smoking cessation Lack of knowledge regarding billing for counseling Stakeholder’s impression of benefits from improvement – Doctor: Better cessation rates/counseling=more $$ – Nurse: More likely to ask and document if aware of $$ Stakeholder’s impression of solutions – Doctor: All interventions seem reasonable and appropriate. – Nurse: Willing to try new EHR documentation, concern that “not willing to quit, not counseled” will not be used

8. Chart review We manually reviewed 50 charts for – Presence of asthma in promoted Problem lists Criterion: ICD9 Criterion: Excluded free text – Parsable documentation in Health Maintenance of PFTs/spiro with pre/post testing or methacholine challenge – Criterion: Excluded free-text entries – Scanned documents PFTs/spiro Presence of hyper-reactivity by pre/post testing or methacholine challenge

9. Pareto chart Made by QI Tools at OpenCPU Sometimes sorted bar-chart is better

10. Interventions March 2011 – All anticoag patients cared for by residents Single provider receives all results – Cypress patients Nurses verify doses when pt arrives for lab draw May 15, 2011 – All anticoag patients cared for by residents Registry for identified late patients June 8, 2011 – Cypress patients Point of care testing

11. Flow chart: revised Result is sent to Cypress Clinic PA contacts the patient Patient reports warfarin use and factors such as diet, medications, etc Warfarin dose adjusted INR f/u scheduled Blood is drawn POC for INR by lab or home health or other EHR queried weekly for pts without INR > 30d Patient contacted > 30 d Result entered into EHR Clinician & patient make decisions: Use Warfarin by Wichita nomogram Nurse enters results into EHR Nurse forwards results to PA

12. Lit search: Clinical Evidence USPSTF Guidelines (http://www.uspreventiveservicestaskforce.org/uspstf/uspsos te.htm) Comparison of different screening tools (FRAX®, OST, ORAI, OSIRIS, SCORE and age alone) to identify women with increased risk of fracture. A population-based prospective study (PMID: 23669650) Bone-Density Testing Interval and Transition to Osteoporosis in Older Women (PMID: 22256806) Better would be to include a quantitative estimate of benefit

13. Lit search: Implementation Evidence Mailed intervention and self-scheduling improves osteoporosis screening compliance Control group: 5% Mailed letters: 17% o J Bone Miner Res. 2013. PMID: 2283681222836812 Electronic Standing Orders Highlight Care Gaps and Allow Nonphysicians to Address Them o DEXA rose from 45% to 52% o http://innovations.ahrq.gov/content.aspx?id=3140 http://innovations.ahrq.gov/content.aspx?id=3140 Try to quantify benefit

14. Intervention 1: Improved Documentation 4 main categories Concise RN-approved Star: automatic drop-down to A/P ICD-9 code and G-billing code for appropriate counseling Bill code every time, but will not be billed after max allowable

15. Intervention #2: Patient Information Information to be sent by PCP Resident

16. Results: projected monthly income Unit priceBefore intervention @ 100 Pts/month After intervention @ 100 Pts/month Revenue264.90829.20 INR8.83264.90 Encounter billing18.810.00564.30 Expense0.00212.19 Staff time (who, how much) $0.3/minute0.00 Supplies for machine 207.18 per box which provides 48 tests ($4.32 per test) 0.00129.49 Machine496.200.0082.70* Net income per month 617.01

17. Results: Made by QI Tools at OpenCPU Unusual to have this slide

18. Summary Initial results suggest an improvement occurred Revenue positive

19. Recommendations for future teams Can G-code be used for quarterly billing for anticoagulation?