1. Clinical Information Systems
Presenter name
Presenter Organization
Location and date
Adapted from Improving Chronic Illness Care

2. Clinical Information Systems Self- Management Support
The Care Model
Community
Health System
Resources and Policies
Health Care Organization
Clinical Information Systems
Self- Management Support
Delivery System
Design
Decision
Support
Prepared,
Proactive
Practice Team
You are
here
Informed,
Empowered
Patient
Productive
Interactions
Open with reminding audience of where they are in the Chronic Care Model. Mention that information systems are the glue that holds all of the system redesign work together because without it you can never be sure who your patients are, what care they are receiving and how the changes you make in other areas of the model are actually impacting outcomes.
Improved Outcomes

3. is the life blood flowing throughout
If a productive patient-clinician interaction is at the heart of good visit, then information
is the life blood flowing throughout
that interaction
The Holy Grail of system redesign is creating productive interactions between patients and provider. Timely clinically relevant Information is used to facilitate that interaction.

4. 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
Describe how information is either for billing purposes or focused on the paper record.
The chart is disorganized, oversized and is a nightmare when dropped accidentally!
Chart is procedure focused on labs, routine exams, processes, and does not see the patient as the center of care….the patient is something things happen to.
Chart is not a forward looking tool for practitioners since its orientation is to past interactions and procedures…therefore it does not facilitate care planning

5. What would be more helpful?
Use this to set up an overview of the system change concepts involved in redesigning clinical information systems.

6. 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
Care reminders and feedback for providers and patients are built into the information system. (Systems will prompt reminders to perform needed labs or exams and let them know how they are doing with process and outcome measures.)
See: Stroebel et al. A Randomized Trial of Three Diabetes Registry Implementation Strategies in a Community Internal Medicine Practice. Journal of Quality Improvement v28, n8 Aug 2002
Relevant patient subgroups can be identified for proactive care. (Such as to notify all the smokers of a new cessation program, invite patients to a group meeting, or alter medications if some new therapy is shown to be beneficial.)
See D.K. McCulloch, M.J. Price, M. Hindmarsh and E.H. Wagner, "A population-based approach to diabetes management in a primary care setting: early results and lessons learned," Effective Clinical Practice 1 (1998):12-22
Individual patient care planning is facilitated by the information system. (Care plan is stored by the system and can be adjusted as patient changes their routine and care is adjusted.) The emerging literature of the impact of Order Entry systems demonstrates that clinically relevant prompts and reminders at the point of care significantly reduce medication errors, overuse of labs and other tests and ensure increased rates of preventive measures.
See Kuperman et al. Computer Physician order Entry: Benefits, Costs and Issues. Ann of Intern Med v139, n1 July 2003
Sharing information as feedback to patient on how they are managing their condition as well as insuring that all providers on care team are aware of patient’s treatment plans.
Use data from the info system to produce performance reports that facilitate improvements in population management.
This part of the discussion needs to focus on information systems that can fulfill all of the functions above. It may be a registry, EMR or other system available to the health system. Ultimately EMRs will have this functionality, but until then the health system needs to ensure that their info system can do the above tasks.The functionality is the key
(I.e., querying populations of patients and their outcomes, identify important subgroups whether within a condition or sub groupings of co-morbid patients)
This is emphasized in the next slides.

7. 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
Use this slide to remind people that technology is not a barrier to getting better information into practice. Nurses have used shoebox full of 3x5 cards for decades (the original registries).
Oldham et al Managed Care quarterly 1999;7(3):35-44
Technology is more efficient, but is not necessary to setting up a good clinical information system.

8. 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
Focus on functionality as the issue…..you want information that supports the care team to proactively deliver care to populations of patients as well as individuals.
See following citations for more information on Population-based care:
M.R. Greenlick, "The emergence of population-based medicine," HMO Practice 9 (1995): E.H. Wagner, "Population-based management of diabetes care," Patient Education and Counseling 16 (1995):
For a good overview of population-based care and how information fits into the redesign process refer to:
McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. Improvement in Diabetes Care Using an Integrated Population-Based Approach in a primary Care setting. Disease Management. 2000; 3(2):

9. 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
Some may view a registry as an intermediate step between the paper chart and an EMR. It is a necessary step. Waiting for the perfect EMR is not the solution.
D.K. McCulloch, M.J. Price, M. Hindmarsh and E.H. Wagner, "A population-based approach to diabetes management in a primary care setting: early results and lessons learned," Effective Clinical Practice 1 (1998):12-22

10. What a Registry Should Be
be quick to implement
be simple to use
be organized by patient; not disease, but responsive to disease populations
contain only data relevant to clinical practice
when necessary, make data entry simple and efficient
be easy to update from other automated data sources
assist with internal and external performance reporting
guide clinical care first, measurement second!
Highlight ease of implementation and use.
Point out that disease registries are not the way to go since many patients have multiple chronic conditions. The registry is organized by patient that can have one or more conditions associated with their care.
While data for registries should be used to assist in performance reporting, emphasize that their main function is to drive clinical care in an organized fashion by sorting population of patients and their common needs and delivering services proactively to meet multiple population needs.

11. What a Registry Should Not Be
try to emulate data load & functionality of an EMR
require an advanced training operate and maintain
not become the “obsession” of practice activity
Distinguish the registry from a Electronic medical record which contains more information than is needed, typically cannot monitor populations of patients and is really an electronic version of the old paper record….useful without the population functionality listed in earlier slides.
By “obsession” refer to the practice potential for trying to make the numbers look good in the registry versus being a clinical tool to organize population and individual care.
To highlight differences in how IT is used in care see Kilbridge, Peter.. “Crossing the Quality Chasm with Information Technology.” California Healthcare Foundation Ihealth Reports, July 2002.

12. 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
Need real time, current access to information and across settings (clinic-hospital-home care)
Guidelines are embedded in the system (a reference to the Decision Support part of the model.) Prompts are such things as a flag that notes a diabetic patient is due for a foot exam, that someone on an ACE hasn’t had their kidney function tested.
A population would be the patients with diabetes, the women above 40. Subpopulations would be patients with heart disease who smoke, people with diabetes not on an ACE inhibitor..
Hunt et al, 2001 Use of an electronic medical record in disease management programs: A case study in hyperlipidemia. Medinfo 2001:

13. Can I…(cont.)
If…
Allows stratification of patients (complexity, disease severity for case management services)
Captures outcomes by provider
Captures all critical clinical information
Stratification is a key function for case management services—this is addressed in the delivery system design element of the chronic care model.
The EMR needs to be able to capture what is necessary for your measurement system.
It has to capture all the data points necessary to track the best clinical care. ICIC has lists of key clinical information available on their website.

14. Timely reminders for providers and patients
Change concept #1

15. Prompts to deliver evidence-based care. They can be delivered :
At the time of visit
Through population reports
Via exception reports
The first change concept.
Discuss the need for reminders and how the information system should be able to provide them in a variety of ways to facilitate point of care as well as population planning.
The Cochrane Collaborative reviewed the evidence on point of care reminders. The general conclusion was that reminders are effective if the providers have a system upon which they can respond to the reminders. The take away is that reminders are great but if the system doesn’t facilitate acting on them, they will be ineffective. Example: If a reminder prompts the team to call a patient and no one has time to make outreach calls….nothing will happen.

16. Populations and sub-populations
Relevant for proactive care.
Second change concept

17. 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
Highlight the goal of population based care, and how information systems are the only way one can know who their patients are, how they can be reached and what they need.

18. Individual Patient Care Planning
Third change concept

19. 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 the all routine care is delivered at the appropriate time
Whether patients are being seen in planned visits or acute care visits, having the right information about their chronic, preventive and self care needs is the only way one can assure the right routine services are delivered and the appropriate intensity of self care is supported. Emphasize the info systems ability to reduce the burden on the providers memory.
Patient summaries that can function as encounter forms and flowsheets can make visits more efficient.

20. Manifestations of care planning
Summaries provided to patients
Description of patient actions and provider actions
Shared care plan
This could take the form of print-outs from the registry or EMR or a web-based shared care plan.

21. Share information
To coordinate care
Fourth change concept

22. 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!
This slide is self evident. Cite as examples of frustrating interactions those where the patient has to repeat their story to every provider they see. Also cite provider frustration as they learn from the patient or another provider that new treatments have been implemented that do not coordinate with past treatment recommendations or worse yet dangerously conflict with existing ones!

23. Monitoring performance
Of the provider and system
Final change concept.

24. Use the CIS to: Create population-specific reports
Facilitate external reporting requirements
Create dashboard reports of the practice as a whole
Performance feedback can be very motivating for teams. In the absence of data, many providers will assume they are doing okay. Data to the contrary provides the motivation to improve. Continual monitor of performance allows providers to know if the improvements they are trying result in true change. The information systems should be able to accommodate the types of reporting mentioned above.

25. 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
The next few slides address fears your audience will likely have. The first being resistance to doing anything new. In this slide you want highlight the benefits of using registries. You want to appeal to your audiences’ desire to be doing better quality care, and registries are a way to get there.
There is good evidence that using a registry with reminder capabilities improves processes of care, and facilitates improved clinical outcomes if the practice is addressing disease control through planned care. See:
Montori et al. The Impact of Planned Care and a Diabetes Electronic Management System on Community-based Diabetes Care. Diabetes Care v25 n11 Nov 2002.
For observational data on the impact of registries on patient care see McCulloch’s follow-up article:
McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. Improvement in Diabetes Care Using an Integrated Population-Based Approach in a primary Care setting. Disease Management. 2000; 3(2):

26. 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.
While this fear may present itself in an angry fashion, it really is based in the fear that patients are slipping through the cracks of the hectic acute care day.
The surveys referred to in the slides were conducted at Group Health Cooperative of Puget Sound by David McCulloch et al. When asked how many patients with diabetes are in your practice, the randomly sampled group of 80 physicians consistently under estimated the number by 50% when compared to billing, lab and pharmacy data.
When asked about their patient process outcomes (A1c testing, renal screening,etc) they consistently overestimated by as much as double the rates. This is because they remembered that patients they have seen, and typically remember positive outcomes versus negative ones.
When shown their actual data, this provided strong motivation to seek out way to improve care….that is the initial power of the registry….motivation to improve.

27. 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.
A legitimate fear! Quell it by pointing out that registry implementation while involving some up front work will reduce workloads by providing patient summaries at the time of visit that can be used as flowsheets, reminder for care, and if chart ready reduce charting time.
Address the data entry issue head on by pointing out that the patient summary can be key-punched in less than one minute for the typical patient. This is borne out by numerous practice teams around the country that have implemented registries.

28. 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
While there is no research evidence on this question, experience from teams implementing registries suggest that once a registry is in place, it is easy to add new patients and conditions.
Evidence presented earlier shows the connection between registries and improved process outcomes as well as demonstrating the critical role registries play in individual patient care.
Those using registries find they can plan care for disease populations which generate visits with higher RVUs versus trying to squeeze disease care into an unexpected visit for an acute (often minor) exacerbation.

29. Making Clinical Information Work for You in Clinical Practice
Next set of slides are a “how to” of registry implementation

30. 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 ICIC web site has a list of public domain and for profit registries. There is also a registry evaluation tool that can help users assess if the software the are reviewing possesses the required functionality mentioned earlier in the presentation. Point the audience to this URL for those two documents:
If the user is going with an EMR the evaluation tool is still a useful source that can be used to assess the EMR functionality.

31. 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.
Make sure audience doesn’t limit themselves to MD or RN as CIS managers. Many teams have had MAs, LPNs and office staff handle the registry; with accompanying increases in job satisfaction. Be sure that all registry task are clearly assigned to avoid confusion or duplication.

32. 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.
If you will be using a registry, here are some things to consider.
For some disease populations billing data is a great starting point for identifying the population. Example: Diabetes – Use two ICD-9 codes of 250.xx in the two year of billing data,. However using billing data for other populations will have varying degrees of sensitivity and specificity. For those (such as depression or CHF in the ambulatory setting) cleaning the billing data will be necessary. Or you may simply build the registry prospectively as patients are seen or newly diagnosed.
However one identifies the population be sure to systematize the process and delegate updating to someone on the team. Be creative….Example: provider offered receptionist $100 to populate diabetes registry from chartbase. Within one week receptionist had pulled 90% of appropriate population and put names and contact info in registry.

33. 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
Use only the critical data needed to manage the patient and population. Avoid including data simply because you have it! Example for diabetes the key indicators are HBA1c, LDL, BP, foot exam, microalb, eye exam and evidence of self-management goals.
If data can’t be downloaded from automated sources, use visit to gather data for entry into registry. Create an encounter form to gather the data. Test it until it works for most patients (80-20 rule applies here). Automate form so that it can be printed with prior visit information (most registries have this functionality built-in already)
If auditing charts to gather baseline data be sure to keep the audit short and simply. Go after key data only. Audit should be no more than 10 minutes per patient.
Once data gathering processes are stable, design and test how data gets from encounter form into registry. Example: provider hands encounter for to MA who keypunches new data, and then returns form to chart.

34. 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 the exam room.
Does the summary work for various patient types?
Ensure new data is captured on the summary.
Develop process for new summary data to be entered into registry.
Many teams use patient summaries (or encounter forms) produced from the registry to drive care in the visit regardless of being it being a planned or acute care visit. The summary contains the key clinical data from the last visit (or few visits) along with prompts and reminders of needed care. The provider can quickly assess patient care and spend more time working with the patient versus searching through the paper chart.
Establish a process for ensuring the summary gets on the front of the chart. Make sure the summary can capture new data from the visit so that the registry can be updated.

35. 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 and for what purpose)
Create process for updating/modifying reminders.
The slides are self-explanatory…the theme of the slide is “make sure you create a reminder SYSTEM!” You will need everything from what you get reminded about through the process of responding to the reminders. Without the infrastructure to respond, little will happen with the reminders.

36. Using Data to Monitor Performance
Determine what types of population reports are needed and reporting intervals.
Establish process for creating customized reports.
Who will generate reports?
Who receives reports?
Do the reports facilitate continued improvement?
Again slides are fairly straight-forward. Put emphasis on the last bullet by stating the importance of measuring those things that you are trying to change. Changes that aren’t measured cannot be changed! Think about reports that tie to quality improvement tools within the organization so the team has resources to make changes based on reports.

37. Keys to Success from Others 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 review time allotted.
Data are clinically relevant, and used for patient care first, and measurement second.
Data can be shared with patient to improve understanding of treatment plan.
Making sure team members see the value of the registry is critical to its success. Demonstrate the use of patient summaries or exception reports to create interest.
Don’t leave the management of the registry to chance….be clear about everyone’s roles and responsibilities, and make time to use it effectively.
Reinforce the registry as a clinical tool first….not a performance management tool.
Share data with patients…show them how the registry improves their care.

38. Keys to success for using an EMR
Participate in purchase and design decisions
Work up to full functionality (don’t turn all the reminders/prompts on at once!)
Get help from leadership and make sure the disease management needs are met.

39. 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
Convince nay-sayers with practical demonstrations of how CIS facilitates improved care.
Competing demands need to be addressed by senior leaders so that CIS work receives equal billing.
Teams need to understand how their daily flow works so that fitting the registry into the process is seamless versus an add-on.
Again, senior leaders need to free up IT support to facilitate CIS use and spread

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