AAIM Meaningful Use Panel. Pete Stetson, MD, MA CMO & CMIO ColumbiaDoctors, New York
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1 AAIM Meaningful Use Panel Pete Stetson, MD, MA CMO & CMIO ColumbiaDoctors, New York
2 Background - ColumbiaDoctors 1,100 doctors Specialists/Primary Care 150 practices (40 sites) MDs admit to NewYork- Presbyterian Hospital Teaching Hospital for two campuses: Columbia Cornell 550 Eligible Providers Quality Division: 5 FTEs IT Resources: 40 FTEs on financial systems 25 FTEs on clinical systems Subset of tri-state sites
3 EHR Current State CROWN = Allscripts Enterprise EHR V months live Total Patient Lives in CROWN/IDX: 3,000,000 Total Users: CROWN: 5000 (1082 Attending MDs) in 27 months IDX Flowcast: 1,700 Total Charges annually: $1.5Billion Total Visits Annually: 850,000 MU Status: 125 Medicaid Providers made it for CY Stage 1 made it in first 90-day period for CY2012 Second 90-day attempt underway NOTE: Different EHR in inpatient setting
4 Early things we did right This is a quality improvement project a platform for organizational improvement! 1 of 6 P4P programs, but it s the biggest by an order of 5 erx Program MU Program Run out of Office of CMO (Quality Division) Governance (this is really 20% IT, 80% leadership) Early penalties, clear language on incentive sharing 75/25/10 Rule Easiest Menu Items possible Medicaid AIU 2011 as early win 2 tries for Stage 1 in CY2012 Cleaned up Scope of Practice policies Lots of education Centralized reporting; distributed registration/attestation Lots of transparent reporting; spur on competition
5 Our Menu Items 1. Drug Formulary Checks (done by EHR) 2. Structured Lab Data (already at 90% because of interface strategy) 3. Patient Lists by Dx (done by EHR+Analytics) 6. Patient Education (the only one they had to do actively) 10. Immunization Registry (done in background)
6 Oops Initial educational materials were too complex In the end, don t bother trying to explain CQMs, just give them what to say on the attestation website Focus on The Nine, and The Two Patient Education & Clinical Summaries Daily gotchas, for example: Visit type definitions Patient Ed has to be in context of a visit Some surgical practices don t document enough encounters to make the 10% threshold Still haven t nailed down the clearest educational message on CPOE vs. erx and their interplay with Med Lists
7 MU Support Kickoff x 2 User Groups Thursdays at 2pm Meetings with Departments Videos online at CROWNPearls vlog How-to materials on CROWN Website NYC REACH education and support for registration and attestation Reports delivered weekly to each Department
8 Stage 1 Measures Overview You can do this! 15 Core 5 Menu 2 Adult 6 CQM * * * PEDS 4 Adult 6 PEDS 25 Total Done by System, nonprovider staff, or secondary effect Provider To-Dos Done by System, nonprovider staff, or secondary effect N/A Provider To-Dos Done by System, nonprovider staff, or secondary effect Provider To-Dos Note: Core 10 (Clinical Quality Measures CQMs) is 6 Measures in one *Assumes there are check-in staff, check-out staff, back office staff, and medical assistants.
9 Snapshot Provider Report
10 Provider Dashboard Report
11 Overall Provider MU Stats by Department: Example early report to create competition end of first attempt on Stage 1 Department Meeting Total % of providers meeting MU Surgery % Neurology % Medicine % OB/GYN % Anesthesiology % Dermatology % ENT % Naomi Berrie % Ophthamology % Orthopaedics % Pediatrics % Psych % Rehab Medicine % Urology % Total %
12 Who Does What in CROWN? Patient Flow CORE CROWN + Stim Set Check In MA RN PA/NP MD Check Out Back Office Medical Records 1: CPOE 2: Drug Alerts 3: Problem List (MA s can record using intake forms into CROWN) 4: erx 5: Med List (MA s can record using intake forms into CROWN) 6: Allergy List (MA s can record using intake forms into CROWN) 7: Demographics 8: Vital Signs (MA s can record this if trained and delegated ) 9: Smoking Status (MA s can record using intake forms into CROWN) 10: CQMs See Below for ADULT and PEDIATRIC Clinical Quality Measures (CQMs) 11: Decision Support Rule 12: ecopy of Record 13: Clinical Summary 14: Exchange Info 15: Security/HIPAA Key: Done Could Do It Should Do It with MD Verify Should Do It 1: Drug Formulary Checks 2: Structured Lab Data 3: Patient Lists by Dx 6: Patient Education (Depends on whether done with orders or drug monograph) 9: Immunization Registry MENU CROWN + Stim Set Check In MA RN PA/NP MD Check Out Back Office Medical Records ADULT Clinical Quality Measures (CQMs) - CORE 10 above See Appendix A for measure details CROWN + Stim Set Check In MA RN PA/NP MD Check Out Back Office Medical Records CORE 1: NQF 0421 (PQRI 128) Adult Weight Screening and Follow up CORE 2: NQF 0013 Hypertension: Blood Pressure Measurement Done as part of CORE 8 CORE 3: NQF 0028 Tobacco Use Assessment and Cessation Intervention ALT CORE 1: NQF 0041 Influenza Immunizations Probably N/A ALT CORE 2: NQF 0024 Pediatric Weight Screening and Follow Up Probably N/A ALT CORE 3: NQF 0038 Childhood Immunization Status Probably N/A ADDITIONAL 1: NQF 0059 (PQRI 1) Diabetes HbA1c Poor Control > 9% ADDITIONAL 2: NQF 0575 Diabetes HbA1c Good Control < 8% ADDITIONAL 3: NQF 0061 (PQRI 3) Diabetes Blood Pressure Management Done as part of CORE 8 PEDIATRIC Clinical Quality Measures (CQMs) - CORE 10 above See Appendix A for measure details CROWN + Stim Set Check In MA RN PA/NP MD Check Out Back Office Medical Records CORE 1: NQF 0421 (PQRI 128) Adult Weight Screening and Follow up CORE 2: NQF 0013 Hypertension: Blood Pressure Measurement Probably N/A CORE 3: NQF 0028 Tobacco Use Assessment and Cessation Intervention Probably N/A ALT CORE 1: NQF 0041 Influenza Immunizations Probably N/A ALT CORE 2: NQF 0024 Pediatric Weight Screening and Follow Up ALT CORE 3: NQF 0038 Childhood Immunization Status ADDITIONAL 1: NQF 0001 (PQRI 64) Asthma Assessment ADDITIONAL 2: NQF 0036 Appropriate Medications for Asthma ADDITIONAL 3: NQF 0047 (PQRI 53) Asthma Pharmacological Therapy
13 Provider To-Do s: The Nine Shoulds CORE 1: CPOE > 30% CORE 3: Problem List > 80% CORE 4: erx > 40% CORE 5: Med List > 80% CORE 6: Allergy List > 80% CORE 8: Vital Signs > 50% CORE 9: Smoking Status MENU 6: Patient Education > 10% Coulds CORE 13: Clinical Summary > 50%
14 Provider To-Do s: The Two Shoulds CORE 1: CPOE > 30% CORE 3: Problem List > 80% CORE 4: erx > 40% CORE 5: Med List > 80% CORE 6: Allergy List > 80% CORE 8: Vital Signs > 50% CORE 9: Smoking Status MENU 6: Patient Education > 10% Coulds CORE 13: Clinical Summary > 50%
15 CORE 13: Clinical Summary Threshold: Clinical summaries provided to patients for more than 50 percent of all office visits within 3 business days. Exceptions: No office visits during reporting period. QuickTips: There are 2 ways to do this: 1) From Clinical Summary icon off the Schedule - preferred 2) Patient Summary note output Option 1: Clinical Summary Icon Option 2: Patient Summary Checkbox
16 MENU 6: Patient Education Threshold: > 10 percent of all unique patients seen by the EP are provided patientspecific education resources. Exclusions: None QuickTips: 3 ways to do this: 1) Order CQM-related Patient Instructions (e.g. Smoking or Weight instructions) preferred because these also count in numerator for CQMs, or 2) Order an Ad Hoc Patient Instructions (and then hand out your hard-copy education materials), or 3) Left click any med in the med list, then select Drug Ed (e.g. a new med you just started) Option 1 - preferred (e.g. Ordering Smoking or Weight Instructions) Option 2 Generic Patient Instructions Order Option 3 - Drug Monographs
17 75/25/10 MediCARE CD Penalty Year Stage of Program Incentive for CY MediCare Penalty 2012 Stage 1-90 Day $18,000 $500 $ Stage Day $12,000 $1,500 $ Stage 2-90 Day $8,000 $2,400 $ Stage 2 or 3 (TBD) $4,000 $0 1% in Stage 2 or 3 (TBD) $2,000 $0 2% in Stage 3 $0 $0 3% in Stage 3 $0 $0 TBD: CMS could go to 5% Total $44,000 $4,400 TBD: Depends on Medicare Allowable Charges
18 MU Take Homes Less is more on the to do s More is more on transparency Early penalties complement the incentives Clinical Summaries, Patient Ed AMC s challenged by the rule of 18 Centralize reporting Distribute registration/attestation Empower DAs & PMs they do the real work
19 Beyond MU The case for workflow integration and meaningful interoperability
20 Level 5 Workflow Integration: icharge Point of Work Decision Support SCM Custom MLM Collaborators: David Vawdrey, Innovations Team at Allscripts
21 icharge Module in Sunrise (integrated Charge)
22 Workflow Integration: icharge Point of Work Decision Support Collaborators: David Vawdrey, Innovations Team at Allscripts
23 Under the Hood: OPEN solutions Eclipsys Acute Care 5.5 Allscripts EEHR V11.2 IDX Provider, Patient, Problems Problems Past Diagnoses, Charge Favorites, ICD & CPT Master Provider, Patient, Problems, CPT4, NoteID ObjectsPlus UAI icharge
24 24 Semi-structured V11 Note Utilization January 2009-Present Note Type for Arrived Appointments - Overall User Department Arrived Appointments w. Semi-Structured Note Arrived Appointments w. Unstructured Note Arrived Appointments w. Scanned Doc Arrived Appts w. No Documentation Total Arrived Appointments Overall - Total 760, , , ,903 1,740,247 % of Total 57.5% 20.3% 22.3% % edocumentation vs. Scan 77.7% 22.3% Note Type for Arrived Appointments Top 25 Divisions using V11 Note Templates (from 600 active Templates) User Department Arrived Appointments w. Semi-Structured Note Arrived Appointments w. Unstructured Note Arrived Appointments w. Scanned Doc Arrived Appts w. No Documentation Total Arrived Appointments % Semi- Structured OB/GYN General 75,553 1,475 32,455 6, , % Dermatology 69,952 3,113 30,355 8, , % MED Heme/Onc 50,445 5,068 2,023 8,290 62, % PEDS General 25, ,036 11,800 38, % URO Oncology 24,882 1,998 3,700 7,061 36, % SURG Vascular 20,227 5,216 1,951 4,232 32, % OTO Pediatrics 19, , % ORTHO Hip/Knee 19,234 17, , % SURG Breast 16, ,903 1,043 19, % OTO Allergy/Rhinology 15, , % SURG Plastics 15,281 3,985 1,921 1,036 19, % OB/GYN MFM 14, ,128 43, % MED Cards General 12,949 2,388 13,233 4,244 32, % OB/GYN Oncology 12, , % URO Voiding Dysfunction 12, ,026 4,033 17, % MED Nephrology 12,232 9, ,769 28, % PEDS Oncology 12, ,704 15, % MED Pulm General 12, ,697 2,410 16, % PEDS Gastroenterology 10,728 6,144 2,458 5,138 23, % MED Internal Medicine 10, ,683 5,445 24, % PSYCH Anxiety 10, ,746 14, % MED Allen 9, ,679 3,817 15, % MED Cards CHF/Txp 9, ,392 8,066 20, % SURG GI/Endo 9,538 5,719 3, , % PEDS Allergy 9,161 1,615 2,538 49,093 61, %
25 Semi-structured Template Utilization Totals Year Totals , , , , ,380 Top 25 of 720 Template Count Patient Communication 48,512 PSYCH Day Treatment Group Therapy 45,500 OB/GYN General GYN Follow-Up Visit 43,060 DERM General Follow-Up Visit 34,914 MED Heme/Onc Solid Tumor Follow-Up Visit 24,486 OB/GYN General OB Follow-Up Visit 22,509 MED Internal Medicine Follow-Up Visit 19,038 OTO Allergy/Rhinology Consult Visit 15,445 MED Pulm General Follow-Up Visit 14,273 OTO Pediatrics Follow-Up Visit 14,252 MED Heme/Onc Malig Follow-Up Visit 13,965 PEDS Oncology Follow-Up Visit 13,351 Well Child Visit 13,087 PEDS General Follow-Up Visit 12,202 MED Cards General Follow-Up Visit 11,758 OB/GYN Oncology Follow-Up Visit 11,385 Result Letter 11,214 OB/GYN MFM Follow-Up Visit 10,686 URO General Follow-Up Visit 10,052 PSYCH Anxiety Follow-Up 9,716 SURG Vascular Follow-Up Visit 8,715 SURG Breast Follow-Up Visit 8,367 SURG Plastics Follow-Up Visit 8,346 Office Note/Letter 7,941 PEDS Gastroenterology Follow-Up Visit 7,921 25
26 NoteForm Utilization Totals Total , , , ,113 Top 25 of 1,954 NoteForm Count Discussion Text Templates HPI Text Templates General Multi-System Exam Reviewed Sections Complete-Female General Multi-System Exam (Brief) CROWN Letter Closing CROWN Letter Greeting Adult Complete ROS Attestation Complete-Male Complete ROS Group Therapy Message Text Template GU Female (Brief) Referring Provider Imaging Text Templates 9813 Medication Attestation PQRI 8606 Breasts (Brief) 8029 GYN History 6657 Chief Complaint 5929 OB History 5379 Vascular 4796 Procedure Text Templates 4794 Multiaxial Diagnosis 4681 Discussion
27 27 Note Data extraction for QA and Research: ColumbiaDoctors Clinical Data Warehouse Default Concept Control Parent Group Data Numeric Data Note Input Instance Created Date DTTM Mar 23, :54:07 AM High risk recurrence score (RS=51) Feb 3, :51:57 AM 8 8 Mar 29, :02:39 PM 17, risk: 11% Apr 1, :52:27 PM 12, score: 8% Apr 15, :09:01 PM Apr 26, :48:55 PM 17: 11% at 10 years: distant recurrence Jan 7, :01:22 PM 17: 11% at 10 years: distant recurrence Apr 4, :25:01 PM 4 4 Apr 26, :35:34 AM Jan 19, :27:13 PM Dec 22, :32:15 PM Mar 15, :11:42 PM 9 = 6% risk of distant recurrence after 5 years of anti-estrogen therapy 9 = 6% risk of distant recurrence after 5 years of anti-estrogen therapy Low risk recurrence score (RS=0) Dec 1, :28:08 PM Mar 9, :53:06 PM Feb 1, :51:30 PM 8 8 Feb 9, :10:38 PM 11 (8%) Jan 11, :37:28 PM 12: distant recurrence risk is 8% after 5 Apr 30, :15:56 AM years of tamoxifen 10 (7%) Feb 22, :58:16 AM 11, distant recurrence 8% Mar 4, :32:47 PM 11, distant recurrence 8% May 10, :12:40 PM intermediate risk of recurrence (RS=22) Feb 2, :49:52 AM 0 0 Mar 29, :25:56 AM
28 350 icharge Usage Stats icharge Distinct Users (Total = 569) Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul Monthly Charges Submitted via icharge (Total = 161,632) Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 28
29 E&M Count icharge Impact Stats Inpatient E&M Charges Average TAT Nov 2011 icharge TAT 4.42 non-icharge TAT 5.67 SD % CI non-icharge E&Ms icharge E&Ms Month 54% of all inpatient charges submitted via icharge Total Saves 7484 Ave Before Save 4.03 Ave New Issues 1.71 Total: Ave Already Existing 1.01 Total Saves with 0 Existing %
30 icharge Impact Stats 160 Inpatient E&M wrvus/provider Inpatient E&M wrvus/provider Linear (Inpatient E&M wrvus/provider) icharge Go-live 30
31 Workflow Integration Take Homes Note-writing in EHRs is a complex uplift But it s in Stage 2, so get ready Inpatient E&M Capture can have salutary secondary effects, especially if designed with Point of Work decision support Can support better analytics/business intelligence (including research)
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