1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: OREGON Practice Name: Doernbecher General Pediatrics Team Members: Art Jaffe, MD, Lisa Johnson, RN and Julie Johnson, RN

3. Progress Summary Since Learning Session 1 1.Engaged QI Team and Practice -- QI team is actively functioning -- Clinic staff, faculty, and residents participating -- Dept Chairman and hospital administrator providing financial and advocacy support -- Have had formal and informal conferences for clinic staff, residents and faculty -- Update monthly progress on our clinical bulletin board in practice

4. Progress Since Learning Session 1 2.Using A Planned Care Approach -- Have developed a triple-tiered system to ensure use of CQN form with all asthmatic patients -- Have done small-scale PDSA to evaluate use of home-made EMR template to replace CQN, and elected not to change -- Implemented ACT (Asthma Control Test) as our validated instrument tool along with CQN form.

5. Progress Since Learning Session 1 3.Developing An Approach to Employ Protocols -- Have developed consistency in listing “asthma” on the EMR’s Problem List - may be a foundation for eventual registry -- Created and implemented use of Asthma Action Plan in EMR -- Using ACT (Asthma Control Test) as a standardized assessment tool and now investigating use of a TRACK in conjunction with ACT -- Spirometry approved and investigating type of spirometer to be ordered -- Established workflow to documenting ACT scores in EMR

6. % of patients who have a current written asthma plan explained to them at this visit

7. What We Have Learned 1.Paper asthma action plan too cumbersome and did not allow flexibility to update and review. 2.Asthma action plan in EMR allows us the flexibility to update and review with each visit. 3.We need colored printers to allow us to give current asthma action plan to families in useful and meaningful format.

8. % of patients in which a validated instrument is used to determine the current level of asthma control

9. What We Have Learned 1.We determined a process to document ACT scores in EMR using PSDA ramps. 2.We needed a formal process to disseminate information to our large practice and staff. 3. We need a validated instrument to determine the current level of asthma control in our younger population (currently investigating TRACK form).

10. PDSA Cycles PDSA Title: Evaluate an EMR template to replace the paper CQN form  Plan: Write and load a template for a CQN form into EMR; use it for 5 days; evaluate perceptions about its utility.  Do: Clinic residents only used it for 2 to 3 patients and found it too cumbersome and time consuming to use.  Study: Electronic template was too inefficient.  Act: Senior resident and QI team decided to ADAPT the form by creating a shorter version to try.

11. PDSA Cycles PDSA Title: Evaluate a simpler EMR Template  Plan: Write and load a new and simpler form into EMR; use it for 5 days; evaluate perceptions about its utility.  Do: The template’s author tried it with one patient; found it was still too cumbersome.  Study: Electronic template was too time-consuming to use.  Act: Senior resident and QI Team decided to ABANDON designing an EMR template, and to continue using CQN form or an alternative.

12. PDSA Cycles PDSA Title: Using Asthma Control Test (ACT) in conjunction with CQN form (paper version) and document ACT score in the EMR problem list.  Plan: Implement use of ACT form and document score.  Do: Put ACT and CQN on one sheet of paper; distribute to asthmatic patients. Have provider add ACT score to the EMR problem list.  Study: ACT form distributed, but score not reliably entered in EMR problem list. 4/11 were entered into EMR.  Act: ADAPT. Further educate MDs to document ACT score in EMR problem list.

13. PDSA Cycles PDSA Title: Educating MDs on documenting ACT scores.  Plan: Educate MDs to document ACT scores on the EMR problem list.  Do: Educate MDs at monthly division meeting and weekly residents’ continuity conferences.  Study: Increased compliance, but found difficulty in accessing score in EMR problem list. 8/10 ACT scores entered.  Act: ADAPT. ACT scores not easily viewed in EMR problem list. Noticed if ACT scores documented in details section of problem list, ACT scores were easily viewed.

14. PDSA Cycles PDSA Title: Documented ACT scores easily viewed in EMR  Plan: Educate MDs to document ACT scores in the details section of EMR problem list.  Do: At monthly staff meeting, QI team educated MDs where to document ACT scores in EMR.  Study: Scores easily viewed in EMR. Increased compliance. 10/11 ACT scores entered. Staff is engaged in this process!  Act: ADOPT!

15. PDSA Cycles PDSA Title: Develop Asthma Action Plan for EMR  Plan: Develop Asthma Action Plan for EMR  Do: EPIC Physician Champion and CQN QI MD will develop an asthma action plan in our EMR and roll out in our practice.  Study: Personalized asthma action plan documented in EMR, but unable to give asthma action plan to patient at end of clinic visit.  Act: ADAPT. Need to find a process to give patients asthma action plans at end of clinic visits.

16. PDSA Cycles PDSA Title: Asthma Action Plan in After Visit Summary (AVS)  Plan: Using a dot phrase, asthma action plans will be placed in AVS “patient instruction’s section” of EMR, so patients can receive personalized asthma action plans at the end of their clinic visits.  Do: Educate MDs in practice to implement above plan and elicit feedback.  Study: Feedback is positive. Asthma action plans being distributed at clinic visits, but we need colored printers for patients to identify which zone they are in (green, yellow or red).  Act: ADAPT: Submitted request for colored printers and waiting approval from administration.

17. TEST 1 What: Create EMR template Who: for MD use Who: QI resident Where: Clinic When: 10/8 PD SA TEST 2 What: Simpler EMR template Who: for MD use Who: Senior clinic resident Where: Clinic When: 10/15 PD SA EMR TemplateValidated InstrumentValidated Instrument - continued PDSA Ramps TEST 1 What: CQN EMR Who: Resident Who: Sr Resident Where: EMR When: 10/19 to 10/23 PD SA TEST 2 What: CQN EMR #2 Who: Sr. Resident Where: EMR When: 11/2 to 11/6 PD SA TEST 3 What: ACT Form Who: Clinic Staff Who: MDs Where: Clinic When: 3/22 to 3/30 PD SA TEST 4 What: Educating MDs Who: MDs Who: QI Team Where: Clinic When: 3/31 to 4/7 PD SA TEST 5 What: Document ACT score Who: MDs Where: Clinic When: 4/8/ to 4/14 PD SA

18. TEST 1 What: Asthma Action Plan in EMR Who: EPIC MD Champion and CQN QI MD Who: MDs Where: Clinic/EMR When: 2/1 to 3/11 PD SA TEST 2 What: Asthma Action Plan in AVS Who: Patients with asthma Who: MDs Where: Clinic When: 3/12 to 3/18 PD SA Asthma Action Plan PDSA Ramps

19. Office Flow Document

20. Copy of Our CQN Encounter Form

23. Other ACT forms are available in Spanish

24. Key Learnings that include Barriers and Successes 1.Our practice isn't as good at providing asthma care as we thought we were, but we are improving with our participation in this QI project. 2.A registry is a critical component of improving care to a population. Our EMR does not support a registry at this time. 3.A large and very complex social structure, such as an academic medical center, provides both support for, and challenges to, quality improvement. 4.Despite the challenges, our practice can do meaningful QI studies.

25. Future Plans 1.Implement spirometry use in our practice. 2.Implement TRACK form to our younger population in our practice. 3.Create a document flow sheet in EMR to record, track, and trend ACT scores. 4.Continue to explore possibilities of developing a registry within our EMR.