1. Use of Computerized Clinical Decision Support System and Registry Functions to Track and Improve Clinical Outcomes Pamela Ferrari RN Director of Performance Improvement and Clinical Knowledge Support Open Door Family Medical Center Inc

2. What is CDSS? (Clinical Decision Support) "Clinical decision support (CDSS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care." AMIA, A Roadmap for National Action on Clinical Decision Support, June 13, 2006.

3. Goal and Aims of CDSS  To bring relevant knowledge to bear on the health care and well being of a patient or a population of patients. 1.To make data about the patient easier to access or more apparent to a provider. 2.To foster optimal problem solving, decision making and action by a provider “Clinical Decision Support-The Road Ahead” edited by Robert Greenes

4. Types of CDSS  Pop-ups and out of range alerts in the EMR- Example out of range vital signs, and labs.  Templates Structured data collection  Order sets Recommend treatment of specific conditions  CDSS/Alerts Based on preventive guidelines and medical history  Provider reference Up-to-date, Epocrates

5. Pop-up alerts: Red Font Identifies Elevated Blood Pressure

6. Templates: Structured data collection

7. Order Sets: Hypertension

8. CDSS/Alerts: Based on preventive guidelines and medical history

9. CDSS Alerts: Trigger an Order Set for BP control

10. Provider Buy-in  Good ideas are not adopted automatically. They must be driven into practice with courageous patience. Hyman Rickover US (Polish-born) admiral (1900 - 1986) Hyman Rickover

11. The Importance of Provider Panel Integrity

12. Provider feedback needs to be applicable to their patients  We use Rendering Provider/Primary Caregiver for most reporting,  We expect each patient to be seen by Primary Caregiver at least annually.  We set a goal that 80% of our patients should be seen by PCG annually.

13. PI Project for 2009

14. Examples of CDSS that have improved care  Diabetes A1c screening lab alerts  Hypertension EKG Order sets  Self management. Structured data templates.  Asthma Action Plans. Structured data templates.

15. Improving A1c screening for diabetic patients

16. The CDSS Alerts remind Providers to get an A1c

17. Order Sets tell Provider when the last A1c was performed

18. Provider/Site Feedback Reports

19. Self-management template, increased compliance with documentation of goals

20. Structured text is inserted into progress note

21. Examples of structured data we collect  Diabetes and hypertension control  Medication adherence  Diet and exercise assessment  Last eye exam and result  Last foot exam and result  Self-management goals  Results of autism screen  Asthma control and Asthma Action Plan

22. Examples of templates we use  Well-baby visits--include all anticipatory guidance as well as developmental screening  Chronic Disease Templates--Asthma, Hypertension and Diabetes  Acute Disease Templates  Pregnancy test templates encourage enrollment in prenatal care

23. Diabetic foot exam

24. Structured data flows to Chronic Care Outcome reports and Flow sheets

25. Diabetes Flow sheet

26. Hypertension order set increased the number of patients with ECG.

27. Asthma Template documents both underlying severity and current control

28. Using data to improve care  List all diabetic patients whose last A1c was >9 and call them to come in for diabetes education.  List all patients without an Asthma Action Plan and invite them to an Asthma Night  List all hypertensive patients who said that they were not watching their diet and invite them to a presentation on the Dash Diet.

29. Improved Outcomes for the Practice

30. Clinical Performance Indicator Goal/National Benchmark 200620072008YTD 2009 Percent of patients who have had more than one visit in the reporting year and have seen their PCG at least once Goal 80% Not Collected 29%75% Percent of adult women screened for cervical cancer according to standard of care. Medicaid 64% 63%21%59%54.34% Percent of women >42 years of age who have had a mammogram in the past two years. Medicaid >50%33512%26%33.66% Percent of Patients with asthma who’s current level of control is assessed * measure changed in 2008 Goal 80%unknown 42% Percent of Patients with asthma who’s current level of control is well controlled * measure changed in 2008 Goal 80%unknown 32% Percent of Patients with asthma with a current Asthma Action PlanGoal 50%0%2%10%25% Percent of patients who initiate their prenatal care in the first trimester. Medicaid 81%80% 52%72% Average last A1c for all Diabetic patients with an A1c measured in the reporting year. Goal <78.28.0 8.2 Percent of Diabetic patients with HBA1C in past yearMedicaid 78% 60%73%89%96% Percent of Diabetic patients with A1c <7.0 Percent of Diabetic patients with A1c>7 and <9.0 Percent of Diabetic patients with A1c < 9 Medicaid 51.2 * lower is better Not Collected 42% 32% 24% 35% 33% 32% Percent of Hypertensive Patients ( no Diabetes) with Blood pressure control <140/90 Medicaid 53.4 Not Collected 45.44% Percent of Hypertensive Patients with Diabetes with Blood pressure control <130/80 Medicaid 29.5 Not Collected 26.85%

31. Provider Report Card for Diabetes Provider Clinical Report Card May 2009 Provider/Measure DGVKPMMRPSRARLRDWTYTotal #Diabetics 7611772139152183702171111 # A1c 7511771139142183702141058 % with A1c in past 6 months 99%100%99%100%93%100% 99%95% Average A1c 8.2%8.4%7.9%7.7%8.2%8.6%8.4%7.4%7.8%8.0% # A1c <7 2644235817253791409 %A1c <734.2%37.6%31.9%41.7%6.7%33.3%30.1%52.9%41.9%36.8% # Lipid 4761 10612164948140686 % Lipid61.8%52.1%84.7%76.3%80.0%76.2%59.0%68.6%64.5%61.7% # Microalbumin 26533275455744134540 % Microalbumin34.2%45.3%44.4%54.0%26.7%23.8%68.7%62.9%61.8%48.6% % DM BP Controlled <130/80 29.0%16.0%21.0%34.0%57.0%25.0%23.0%55.0%25.0%37.0%