1. Improving Asthma Care in Cincinnati: The Journey
Stephen Pleatman, MD
Pediatrician, Suburban Pediatric Associates, Inc.
Board Member, Ohio Valley Primary Care Associates, L.L.C.
Cincinnati, Ohio
Keith Mandel, MD
Vice President of Medical Affairs, Physician-Hospital Organization
Cincinnati Children’s Hospital Medical Center
2009 Annual Meeting & Fall Pediatric Update
Alabama AAP Chapter
September 19, 2009

2. Objectives
To describe the Physician-Hospital Organization (PHO) at Cincinnati Children’s.
To review overall objectives and key interventions of asthma improvement initiative.
To review impact of interventions on asthma process and outcome measures.
To review key learnings from large-scale improvement efforts.
To discuss improvement journey from the practice perspective.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

3. PHO Background Cincinnati Children’s launched the PHO in 1996.
Strategic objectives:
Extend efforts to improve effectiveness and efficiency of care beyond the hospital setting.
Strengthen improvement knowledge/capability within primary care practices, thus enhancing sustainability.
Spread successful improvement models/interventions among primary care practices, within and beyond the PHO.
Communicate measurable improvements to payors and employers.
Support the business case for quality improvement.
Focus on “triple aim”: patient, population, costs.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

4. PHO Background (cont’d)
3 constituents:
Cincinnati Children’s Hospital.
Specialists: 500 (majority employed).
Primary care physicians: 150 (across 39 practices).
Independent practice association; 39 primary care practices in 8 county primary service area (only 1 practice is owned by CCHMC).
200,000 patients age 0-21 yrs. (Cincinnati MSA: 500,000).
Separate board with strong physician leadership.
Practices vary in size from one to 12 physicians.
30% of practices contract with hospital-owned billing company.
20% of practices have an EMR.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

5. PHO: Background/Structure
Primary Care Practices (IPA)
PHO QI Focus
PHO QI Focus
39 pediatric practices
40% of regional pediatric population
12,500 asthma patients
Effectiveness/efficiency
Effectiveness/efficiency
Specialists
Hospital
CCHMC QI Focus
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

6. “Success” = PHO Network-Level Improvement of Outcome Measures (the “Big Dots”)
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7. Conceptual Model for Moving the “Big Dots”
Reinforces Sustainability
Highly engaged
leadership group
Highly scalable
interventions
Moves the
“big dots” +
Network-level incentive
Transparent, comparative data
(catalysts)
Enabling Factors
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

8. PHO Asthma Improvement Initiative (Launched October 2003)
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9. PHO Asthma Initiative: Key Driver Diagram
KEY DRIVERS/INTERVENTIONS
(high scalability focus)
Physician leadership at Board and practice level
Network-level goal setting by Board (network-level performance defines success)
Measurable practice participation expectations/requirements (linked to ABP-MOC approval)
Multidisciplinary practice quality improvement teams
Web-based registry, with all-payor population identification/reconfirmation
Real-time patient, practice, and network-level data/reporting
Transparent, comparative practice data on process and outcome measures
Concurrent data collection/use of decision support tool, based on high reliability principles/workflow changes
Aligning P4P/incentive design with improvement objectives
Key components of evidence-based care (“perfect care”)
Population segmentation, with focus on “high-risk” cohort
Cross-practice communication/shared learning to spread successful interventions
Integration of multiple administrative/electronic data sources (hospital, practice, payor)
Network and practice-level sustainability plans
AIM
To improve evidence-based care for 12,500 children with asthma across 39 primary care practices (40% of regional pediatric population), with at least 90% of all-payor asthma population receiving “perfect care” (composite measure), thus reducing asthma-related ED/urgent care visits, admissions, acute office visits, missed school days, missed work days, and activity limitation; and, improving parent/patient confidence and degree of asthma control
AIM
To strengthen improvement knowledge/capability within primary care practices, thus enhancing sustainability of current and future improvement efforts
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

10. Impact on PHO “Big Dots”
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11. Results: Process Measures
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12. Network Performance: Process Measures (as of September 8, 2009)
Population-Based Measures
(Network all-payor asthma population = 12,500)
PHO
Literature
% of asthma population with flu shot:
flu season
flu season
flu season (delayed vaccine delivery)
flu season
flu season
flu season (baseline)
66%
60%
54%
62%
40%
22%
10-40%
% of asthma population with management plan
93%
50%
% of population with “persistent” asthma on controller medication*
96%
70%
% of asthma population with severity classified
95%
% of asthma population receiving “perfect care”**
92%
not available
* “Persistent” asthma defined per NHLBI severity classification criteria.
** “Perfect care”: composite measure of severity classification, written management plan, and controller medications (if patient has “persistent” asthma)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

13. Results: Outcome Measures
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

14. PHO vs. Comparison Group Asthma Admissions: Pre/Post Impact
56%
36%
Commercial insurance only
CCHMC encounters only
Patients ≥ 2 yrs. of age
8 county primary service area
ICD-9 code of 493.xx in primary position
Baseline: 3 year average (10/1/00-9/30/03)
Post: 2 year average (10/1/06-9/30/08)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

15. PHO vs. Comparison Group Asthma ED/Urgent Care Visits: Pre/Post Impact
55% 9%
Commercial insurance only
CCHMC encounters only
Patients ≥ 2 yrs. of age
8 county primary service area
ICD-9 code of 493.xx in primary position
ED/urgent care visits not tied to admissions
Baseline: 3 year average (10/1/00-9/30/03)
Post: 2 year average (10/1/06-9/30/08)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

16. PHO Network: Asthma Outcome Measures
Baseline
8/04 - 7/05
Current
8/08 - 7/09 %∆
% parents missing ≥ 2 work days due to child's asthma over prior 6 months
18.0%
10.2%
43% ↓
% parents rating confidence in managing child's asthma < 7/10
11.1%
6.7%
40%
% asthma population missing ≥ 2 school days due to asthma over prior 6 months
26.5%
17.1%
35%
% activity limitation reported as “not at all” or “a little of the time”
Not captured as these questions were initiated in 6/06
89.7%
n/a
% receiving oral steroids within prior 12 months
19.4%
% parents rating asthma as “well” or “completely” controlled
89.6%
% physicians rating asthma as “well” or “completely” controlled
90.0%
% parent and physician agreement on rating degree of asthma control
89.9%
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

17. Asthma Decision Support/ Data Collection Tool (primary focus: degree of asthma control) (available at
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

18. Web-Based Registry
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

19. Asthma Pay-for-Performance (P4P) Program
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

20. Archives of Pediatrics and Adolescent Medicine, July 2007
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21. American Board of Pediatrics: Maintenance of Certification

23. ABP-MOC Criteria Practice-level: (sign-off by IPA Board Chair)
80% of asthma registry population with data collection form completed on annual basis.
90% of asthma registry population receiving “perfect care” (composite measure of severity classification, written management plan, and controller medication (if patient has “persistent” asthma)).
Asthma registry population denominator re-confirmed on annual basis by reviewing hospital and practice billing data.
Sustaining multidisciplinary quality improvement team (physician, nurse/medical assistant, office manager).
Quality improvement team representation at network meetings.
Physician-level: (sign-off by practice leader)
Completing data collection/decision support tool at time of patient visit.
Reviewing patient-level data (e.g., “high-risk” report, visit planner).
Reviewing practice-level performance on process and outcome measures, via data/erports posted on web-based registry.
Attending at least 4 in-practice meetings on asthma initiative since project inception. (required by ABP)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

24. Large-Scale/Population-Based Improvement: Lessons Learned from PHO Journey
Be clear on defining “success”—unit of analysis (practice, region, state, multi-state); process vs. outcome measures.
Allocate significant time/energy to establishing/sustaining highly engaged leadership group.
Bring key physician leaders to the table with quality improvement management/operations team.
Focus on highly scalable interventions.
Consider network-level incentive as a catalyst to accelerate engagement/improvement.
Allocate significant resources to establishing/sustaining highly reliable data collection systems within practices, and to integrating administrative/electronic data sources.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

25. In Summary…… Population identification/registry creation + Reliability
“Real-time”/transparent/actionable data
Segmenting population
Board/practice-level leadership
Communication/collaboration among practices
P4P
Highly-scalable interventions
Intense focus on sustainability =
Builds improvement capability and accelerates improvement
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

26. Practice Perspective

27. A real community pediatrician in practice in Cincinnati
I have been in practice for 25 years
Our practice consists of 9 physician, 4 PNPs
3 office locations
Beginning our 2nd year of an EMR
Suburban practice with mostly commercial payer population
Put in picture of staff/office, comment on administrative staff and numbers; prior QI experience e.g. immunizations, AFIX; large practice

28. Urgency for Change Parental perceptions of variation in care.
Adoption of medical advances in asthma care.
Population identification and severity classification.
Data collection made knowledge gaps visible.
Documenting quality.
Earning P4P reward.
Transparency of comparative practice data.

29. Challenges “Our practice is already busy enough.”
“There’s no additional pay for the extra work.”
“We’re already doing a good job.”
“I already have my way of doing things—it’s ok if others want to go down this path.”
Sensitivity to measuring quality of care among physicians.
Reluctance to “standardize” practice around evidence-based care.
“Research project.”
“Not sure initiative will improve care.”
Communication within practice.

30. Getting Started Pre-existing focus on asthma population.
Recruiting practice commitment—connected with inherent desire to “do the right thing.”
Leadership.
Committed quality team.
Defining key roles.
Communication, communication, communication.
“Realistic” decision support/data collection tool.
Our core team consists of a physician, a pediatric nurse, and our office manager
Other members of our staff are frequently involved
“I am too busy to do this”, “I give great care already”, “It sounds like a research project to me”, “I’m tired of hearing about evidence based medicine”, and “What am I going to get paid to do this?”

31. Executing the Work Developing the data collection tool
Mapping our process to build a foundation of highly reliable data collection
Keeping it simple; it will evolve over time ( see tools)
Utilizing the form in real time during the visit
Work flow management
Avoiding missed opportunities
Paper-based process for our office and how it looks today with an EMR
What mistakes did we make with our EMR conversion?
What did I learn from the process? Pay attention to the details; don’t assume anything; and keep educating everyone

32. October, 2003
Form designed to be collected at the visit concurrently and get parent feedback and data visible and it can change nature of dialogue
Keep it simple
Easily completed with patient
Began the discussion with the parent about asthma

33. 10 months later… Assessment tool became more robust
Improvement in outcome measures became more visible

34. 2 ½ years later…
This was designed with the new NHLBI guideline and specialists were involved at the time
Our current state
Large set of core data is collected
This has allowed for more complete outcome data and better intra- and inter-practice comparisons and has enhanced shared learnings

35. Reliability
System designed to reduce “missed opportunities” to capture data
from parents/providers and address key issues at point of care
Prior to visit:
Asthma sticker placed on chart and data collection form inserted.
On arrival:
Registration staff asks parent if child has asthma at check-in.
Parent/patient completes data collection form while in waiting area.
Exam room:
Nurse/medical assistant reviews medication list (to identify asthma patients) and collects data when patient taken to exam room.
Parent/patient completes form while in exam room.
Physician completes form while in exam room.
“Reminder” built into EMR.
Before departure:
- Nurse/medical assistant assures data collected and issues addressed; collects missing data prior to patient departure.
Beyond typical office visits:
- Data captured at time of parent phone call to refill asthma medications.
Data captured at flu shot-only visits.
Data captured via regular mailings.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

36. Describe old paper vs. EMR process

37. Practice Improvement Capability: Areas of Focus
Commitment.
Leadership.
Communication.
Reliability of data collection.
Data entry.
Interventions to improve clinical asthma care.
The subjective elements were adapted from the literature. Our assessment of each practice required targeted interviews and QI team deliberation around practice patterns that would support evidence of behavior that demonstrated the desired behavior.
We looked at the objective measures as surrogates that demonstrated the level of engagement in the project.

38. The “Ideal”…..
Physician, nurse, and practice manager (quality leadership team) meets regularly to review project status/data/reports, and discuss improvement opportunities.
Physician administrative leader visibly supports project and encourages improvement work.
Project information/updates discussed with physicians and staff at regular practice meetings, data/information shared, and input/feedback recruited.
Quality leadership team discusses data collection process at regular intervals and identifies/pursues opportunities to improve reliability.
Accuracy and timeliness of data entry monitored and addressed.
Improvement interventions pursued using test of change methodology.
In TOTALITY…a difficult level to attain AND sustain..
How many of your practices would be GREEN?
Look at our results…

39. Using Registry/Data to Drive Improvement

40. Dashboard Process Dashboard (Year End 2008 Results)
Outcomes Dashboard (Year End 2008 Results)

41. State of Asthma Care

42. Key Outcome Statistics

43. Visit Planner

44. High Risk Patient List

45. Utilization Report

46. Improving Influenza Immunization Rates

47. Key Learnings Leadership Develop quality improvement team
Effective communication
Build consensus within practice
Use disconfirming data to drive improvements and sustain engagement
Recruit parent involvement/feedback to accelerate improvement.
Improve “reliability”—build improvement into daily work.
Learn from others—don’t reinvent the wheel.
Discuss what worked well and what would I do differently

48. Impact on Our Practice Parents more confident and knowledgeable.
Nurses report reduced volume of phone calls.
Positive feedback from families has energized practice and helped sustain improvement work.
Clinicians proactively engaging patients and parents in more meaningful dialogue to improve care vs. more “passive” approach of the past.
Data has uncovered issues/gaps not previously identified.
Discussing how to spread improvement work to other conditions.
Positioned to win on current/future P4P programs.
Appreciate value of registry.
Staff roles/responsibilities revised to sustain improvement efforts.
Copyright © 2006 Cincinnati Children’s Hospital Medical Center; all rights reserved

49. Patient/Parent and Staff Perspectives

50. This is Hard Stuff
This takes lots of work to initiate and sustain.

51. Thank You!!

52. Questions?

53. Contact Information
Stephen Pleatman, MD
Pediatrician, Suburban Pediatric Associates, Inc.
Board Member, Ohio Valley Primary Care Associates, L.L.C.
Keith Mandel, MD
Vice President of Medical Affairs,
Physician-Hospital Organization
Cincinnati Children’s Hospital Medical Center