This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement #90BC00006 from the Office of

Transcription

1 This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement #90BC00006 from the Office of the National Coordinator, Department of Health and Human Services.

2 Transforming the Culture of Diabetes Care, The IC 3 Beacon Way: Health Information Technology as a Catalyst for Quality Improvement and Culture Change Project Management Institute Professional Development Conference May 21,22, 2013 Sarah Woolsey, M.D. Medical Director HealthInsight Utah

3 Objectives Describe the IC 3 Beacon project at the primary care clinic delivery level Describe our strategies to altering care delivery, improving health Discuss Biggest Barriers to success Share Next Steps

4 Where it started Published in 2001 by the Institute of Medicine Call to action to transform the US healthcare system Data and computer records as a platform for improving safety, patient centeredness, communication, coordination and lowering cost

5 Then. It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-federal public sector.

6 Billions Too Expensive $4.48 Trillion 19.3% GDP $4, % $4,000 $3,500 $3,000 $2.57 Trillion 17.3% GDP 19.0% 18.5% $2,500 $2,000 % GDP 18.0% 17.5% $1,500 $1, % $ % $0 16.0% Health Affairs 2008 version of the National Health Expenditures (NHE) released in January 2010

7 Too Inefficient Colwill J M et al. Health Aff 27:w232 (2008) 2008 by Project HOPE - The People-to-People Health Foundation, Inc.

8 ARRA American Recovery and Reinvestment Act (ARRA) February 2009 Health Information Technology for Economic and Clinical Health Act (HI-TECH)-$25.8 billion Computerized Health Record incentives, Vendor Certification Beacon Communities Initiative

9 Not just about the technology- Ideal Understand Outcomes, Reassess Trained People, Efficient Processes and Easy Tools Quality Analysis, Interventions $ Data Systems, Structured Data Health Information Exchange

10 Not just about the technology- Current State Limited Understanding of Outcomes, Labor Intense Reassessment Informal process, Poor Training, Digitized Paper Labor Intensive Quality Analysis, Interventions Paper Based Systems, Nonstructured Data Fragmented Health Information Exchange

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12 Beacon Primary Care Clinics 9 University of Utah employed 19 Intermountain employed 1 Hospital Corporation of America employed 21 Independently owned clinics 19 different electronic health records Few using electronic records well Varying size, QI infrastructure, QI experience

13 IC 3 Beacon Challenge Increase : HbA1c testing (20% improvement) HbA1c control (10% improvement) LDL-C screening (20% improvement) LDL-C control (10% improvement) Blood pressure control (10% improvement ) Medical attention for kidney disease(20% improvement) Retinal exam (10% improvement) Foot screening (10% improvement) EHR Meaningful Use (to 65% of target providers)

14 Results

15 What worked Strategies Connection to Current Climate Ongoing change & improvement process Data Office Care Team Engagement Patient engagement $$ (?) Methods Learning Sessions Coaching Peer-to-Peer Story-telling Advocacy

16 Beacon Clinic Intervention QI Process Select Clinic Provider Champion Designate the clinic QI team Complete assessment with HI coach Feedback session, review clinical data, Set SMART QI aim chie State, national political arena UCIT Learning Sessions DATA Begin PDSA cycle with HI support Other Beacon Sites IC3 Beacon Community Public Health registry HealthScape website

17 Connection to Current Climate

18 Utah House Bill 128 begins requesting reporting on clinic level measures for all state providers 2 Programs Requiring Provider Reporting for Participation or by Law House Bill 128 adds 5 new measures yearly 2 Utah Medicaid Accountable Care Organization 3 Utah Health Insurance Exchange Accountable Care Organization Formation (Shared Savings) 9,10$$ Continued Meaningful Use Stage 1 $6 Meaningful Use Stage 2 $6 Meaningful Use Stage 2 6,11$$ (initial penalties) Meaningful Use Stage 3 6,11$$ Meaningful Use Stage 4 (TBD) 11 Continued E- Prescribing 7 $$ (initial penalties) Continued PQRS 5$ Federal PQRS 5 $$ (initial penalties penalty assessed in 2015 for 2013 reporting) CMS Value Based Purchasing $=incentive payments $=penalties ---future

19 Meaningful Use of Computer Records 864 page Final Rule released July 13, 2010 by CMS Defined criteria needed for meeting meaningful use and earning incentives 3 Components of Meaningful Use: Use certified EHR technology in a meaningful manner Exchange health information to improve the quality of care Report on clinical quality measures Incentives Year Year 2 Year 3 Year 4 Year 5 Year Total Max Medicare $21,250 $8,500 $8,500 $8,500 $8,500 $8,500 $63,750 Medicaid $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000

20 SPEAKIN BEACON CORE MEASURE I Objective Use computerized provider order entry (CPOE) for medication orders directly entered by a licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. Measure More than 30% of all unique patients with at least one medication in their medication list seen by the Eligible Professional (EP) have at least one medication order entered using CPOE. Example To enhance the ability of the physician in improving their care for diabetes, your system may have the ability to: Create a short list, template or order set of recommended medications for diabetes. In addition to the medications, you could also prescribe items like syringes and needles. Some suggested items may follow. Lantus Insulin 20 units SQ at bedtime Metformin 1000mg po twice daily Glimepiride 4 mg po daily Lovastatin 40 mg po daily Lisinopril 40mg po daily Aspirin 161 mg po daily Syringes 30 unit Lancets Glucometer strips Nopal powder Garlic pills Notice that the units, types of medication and methods of prescribing could also be included on those saved scripts to save time and improve care of your diabetes patients.

21 Connectivity to Utah Health Information Exchange Monetary incentives offered to pay for initial connection of physician office to Utah chie First priority connection Planned technical assistance for rapid adoption/value

22 $$$ incentives Meaningful Use attainment chie fee reimbursement Later Pay for Performance Pilot for early outcomes successes (mid 2011) Fast Start 2 nd tier Pay for Performance (Spring 2013)

23 Ongoing change & improvement processes using evidence

24 Beacon Clinic Intervention QI Process Select Clinic Provider Champion Designate the clinic QI team Complete assessment with HI coach Feedback session, review clinical data, Set SMART QI aim chie State, national political arena UCIT Learning Sessions DATA Begin PDSA cycle with HI support Other Beacon Sites IC3 Beacon Community Public Health registry HealthScape website

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26 Fault Tree 1B. Blood Pressure Taken, but Reading is Inaccurate Equipment failure MA knows how to take BP measurement, but doesn t do it as indicated MA does not know how to take BP Practices leading to inaccurate measurements BP taken over clothing Patient s legs are crossed Equipment not working Equipment not checked regularly Rushed for time Patient is wearing a lot of clothes MA forgets to ask patient to uncross legs Patient prepares incorrect arm prior to MA instruction No instruction from provider Incomplete training Equipment has changed BPs not taken 5 minutes apart BP not taken while patient sitting, standing, or lying down BP taken in inappropriate arm (e.g., mastectomy side) BP taken in contra-lateral in arm Blood Pressure Measurement

27 Hypertension Control Barriers Inaccurate clinic improvement data Inaccurate recording patient B/P Incorrect diagnosis of HTN Therapeutic inertia Poor patient engagement No timely access to care HOW ADDRESSED EMR documentation improvement EMR training, Patient B/P home monitoring implementation Medical Assistant training on accurate B/P measurements, Purchase and training of automatic cuffs Educational session for all providers, Purchase and training of automatic cuffs, Medical Assistant training on accurate B/P measurements, registry recalls Patient B/P home monitoring implementation Walk in BPs, Home monitors, registry recalls

28 Utah Diabetes Practice Recommendations Diabetes Management for Adults Updated in 2011/12

29 Data= quality benchmarks + accurate actionable patient data

30 No Data

31 Clinic Name: NPI: Intermountain Internal 0 Diabetes-related measures Trend* Comparative Performance & Percentile** Measure Percentage of adults with diabetes with HbA1c screening Percentage of adults with diabetes in control (HbA1c<8%) Percentage of adults with diabetes with LDL-C screening Percentage of adults with diabetes with LDL-C in control (<100mg/dL) Percentage of adults with diabetes with BP in control (<140/90 mmhg) Percentage of adults with diabetes who receive medical attention for nephropathy Percentage of adults with diabetes who receive retinal eye exams Current Community Benchmark and Clinic Performance Rate Denominator Percentage of adults with diabetes who receive foot exams

32 Motivating Data

33 Motivating Data

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35 Meaning to Meaningful Use and Data to the chie

36 Care Team Engagement

37 Love and Vision Quality improvement begins with love and vision. Love of your patients. Love of your work. If you begin with technique, improvement won t be achieved. A. Donabedian, M.D

38 Keys to Engagement Strong Leadership commitment Time for meetings/routine Presentation of Actionable data Trainings Implementation of local solutions Willingness to try something new Multidisciplinary QI team

39 Provider and Staff Training on EMR

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42 Learning Sessions

43 Office Trainings-example Safe Start Insulin Assessment Checklist Patient meets criteria Patient is willing to consider therapy Patient has a glucometer/supplies Patient has reliable communication option Consider diabetes educator referral Patient knows how to use glucometer (documented) Patient has been taught hypoglycemia signs(documented)

44 Patient engagement

45 Patient Engagement I woke up one morning and told myself I needed to change. I was tired of feeling bad. Just do it, I told myself, and I did. Nagging absolutely worked; my wife had been after me for a long time to eat better. My wife was absolutely important in helping me change. I am married, and have two kids--i decided that I wanted to be around for my kids they re getting older and I miss them. Dr. Tran really helped me understand what I needed to do. He never gave up, and went out of his way to listen and educate me.

46 Patient Engagement Health Education, Diabetes Education Motivational Interviewing Patient goal setting Care Coordination Care4Life Group visits

47 Results

48 Results

49 Results

50 Percent Results Percent of Blood Pressure In-Control, by Quarter, for Beacon Clinic Affiliations Independent Clinics* Community Average Q Q Q Q Q Q Q Q Q Q1 2013

51 Meaningful Users of EHR Beacon clinics 98 % attested or in pipeline to attest Small % chie bidirectional interfaces

52 Incentives To date 6 of 12 Pay for Performance office have received incentive checks 3 Fast Starts in process 15/21 Independents have received chie connection fee reimbursement

53 Barriers Bandwidth Meaningful data retrieval Identifying champions Leadership buy-in Embrace of Patient Engagement

54 Next Steps Complete success of 7/8 measures for the high-performers Successful Fast Starts Increased chie connectivity and data sharing Sustainability and increased spread of community data processes for community quality Patient Centered Medical Home

55 Questions? Contact information Sarah Woolsey, MD, FAAFP Medical Director Main (801)

56 This material was prepared by HealthInsight as part of our work as the Beacon Community, under Cooperative Agreement #90BC00006 from the Office of the National Coordinator, Department of Health and Human Services.