1. Chapter Quality Network (CQN) Asthma Pilot Project Primary Care: a Registry for ME! Stephen DiGiovanni, MD Bayview Pediatrics MMC Physician Hospital Organization

2. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Clinical Improvement Registry CIR Data highlights CIR What’s New! Flu Shot: Santa Redux Clinical Uses: Beyond the numbers

4. 193 additional patients received complete process care in 2009 Office Visit, Severity Class, Controller, Asthma Plan, Tobacco Assessment

6. Clinical Improvement Registry: What’s New! Agnostic Approach: Continue to expand generic interface to work with multiple EMRs. Data Interfaces: NORDX, IMMPACT2 Prompting Data Reports Self-Care Reports Shared Patient Registry Reports: NCQA, ARRA meaningful use

7. Moving beyond “compliance”… Think differently! Focus on collaborative goal setting with patients Effectively support behavior change with patients: 1.Do you want to make a change? 2.How are you going to make the change? 3.What can I do to help you? “Non-compliant patient”

8. Bayview Pediatrics: Flu Shot Objective: >80% of asthmatic patients receiving a flu shot each year Create the team: not physician dominated “Santa Theory”: The LIST –Who has been naughty, who has been nice –TRACK’ em –BUG’ em –Repeat

9. Bayview Pediatrics: Flu Shot Integrate the registry into your office design Year round CIR is utilized to schedule Asthma reviews on a 4 to 12 month basis –Opportunity to sell the FLU shot Each September: CIR generated mailing list CIR data highlights before all visits if the patient is due for a FLU shot. –Standing Order to give FLU shot

10. Bayview Pediatrics: Flu Shot Integrate the registry into your office design November: Santa Theory Redux –3 calls per patient The Physician Steps in.... Review success and difficulties with staff –CELEBRATE –Compare against local and national data

11. Bayview Pediatrics: Flu Shot results YearBayviewMMCPHONational 2007 30% 200889% 200992% Shared Patient Registry: Collaborative methodology

12. Clinical Approach Our numbers in the CIR looked great but…still felt there were patients slipping through the cracks. (>90% with core process care Wake-up call… 2 asthmatics admitted to the BBCH with under-controlled asthma this fall. –Challenge: how to use the registry and our asthma teams to measure and improve clinical outcomes

13. Clinical Approach Education –New guidelines, accurate classification, emphasis on control Track the data: expanded asthma vital sign for nurses New Team Design and Schedule Utilize community resources: Asthma Education, home visiting nurses, MMCPHO Care Managers, Specialists. Started work with MMCPHO to generate more clinical based reports