1. H ealth and C hronic D isease M anagement (HCDM) BEACON 9.8.2010

2. Overview 4 year project Purpose: Leverage the MHS EMR to deliver point-of-care tools to providers and care teams Develop detailed provider level reporting to advance ambulatory quality care in areas of prevention and disease management Collaboration between Cerner and Mayo 3 components – separate rollouts

3. HCDM Resources Project Team Dr. Rick Fleming – Physician Lead – ISJ Primary Care Provider Jason Buckmeier – Project Manager Divya Pathak – Senior Analyst/Programmer Lakshmi Kharidehal - Senior Analyst/Programmer Cerner Engagement Team Discern ABU ASYST Leadership Analysts Mayo Health System Quality Dept Leadership MHS Expert Teams Diabetic Registry programmers & AQM programmers Ambulatory Care Committee Site Quality Coordinators HICS/Design Council as the oversight body

4. HCDM Project Metrics AMB, ED, IP Summaries - ~ 6200 users (providers/nurses) Condition Management Rules: 435 MHS Providers (Primary Care) Populations Evaluated - Current Hypertension 51,777 patients Asthma 7,696 patients Depression 19,130 patients Diabetes 21,903 patients Vascular Care 9,412 patients Records reviewed nightly - 30-35,000 patient records per topic The total for all topics ~ 180,000-210,000 Largest population monitoring of any Cerner client

5. HCDM MHS Quality MHS CDR Site Quality Directors ASYST Site Liaisons ASYST Clinicals MHS Expert Teams Mayo-JAX Technical Team ASYST Technical Team ASYST Reporting Team HICS PWG MHS EMR User Groups – FirstNet, Ambulatory, IP ASYST Leadership Cerner Engagement Cerner Development – Discern ABU MHS Ambulatory Care Committee HCDM Interaction ASYST Learning Team Determines “what” we build & deploy Determines “how” we build & deploy & integrate into MHS EMR “Does” majority of HCDM Build Oversight

7. HCDM Components 10 Algorithms 1 Patient Summary Page 4 Condition Summaries w/ Performance Measures MPage 2.0 Summaries – AMB, ED, IP Reminder Letter functionality Team tools (provider schedule icons and scheduling solution integration) October 2009 July 19, 2010 Q4 2011

8. Algorithms included: Asthma (Adult & Ped) Depression Diabetes (Diabetic Hypertension) CAD Hypertension Hyperlipidemia Heart Failure (Diastolic Heart Failure) Link Algorithms Launchable from: desktop intranet condition summary EMR link

9. Functionality Goals Improve data capture (Tool: Ambulatory Summary) More efficient documentation of quality metrics at point of care (foot exam, eye exam, PHQ-9, recheck BP, Asthma Control Test) Advances ability to have responsive reporting Educational (data to help support adoption – i.e. PHQ-9 utilization) Aids in data collection for 3 rd party submission (MNCM - DDS) Point of care patient metrics (Tool: Condition Summary) Displays to provider/nurse how the patient is performing on quality targets Population Reporting (Tool: Discern Analytics) Care-Coordinator/Quality Analyst focus All measures, all conditions, all patients – updated nightly “Show all patients with HgbA1c not done in past 6 months for Dr. Fleming”

10. Improve data capture (Tool: Ambulatory Summary)

11. Condition Summary LINK

12. Population Reporting (Tool: Discern Analytics)

13. Invitations & other.20 functions Reminder letters Health Maintenance displays HM: Lipids, Mammo Top half shows health maintenance overdue and coming due in defined time frame Scheduler ability to see HM due items HM brought into Depart Summary Health Maintenance Invitations for Asthma Depression Diabetes(10) Vascular Hypertension Cervical CA Breast CA Colon CA Lead Screen

15. Up to 60 Clicks … 5 minutes Provider adoption and efficiency locate 10 elements on a diabetic patient … 2 Clicks < 1 minute

16. Customizable – by Mayo Open Source Sharing - http://mpagescommons.org/ New Summary Pages New Analytics Reports

17. MPage 2.0 Development – via Bedrock IP Discharge Process Nursing Communication

18. Utilizes more of the Care Team to deliver Health Maint and Disease Mgmt Care Coordinator Patient List Reminder Letters Scheduler Notification of due items

19. Thank you!