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

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.

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

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

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

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.

Billions Too Expensive $4.48 Trillion 19.3% GDP $4,500 19.5% $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 $1,000 17.0% $500 16.5% $0 16.0% Health Affairs 2008 version of the National Health Expenditures (NHE) released in January 2010

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

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

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

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

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

IC 3 Beacon Challenge 2010-2013 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)

Results

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

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

Connection to Current Climate

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 4 2012 2013 2014 2015 2016 2017 2018 2019 2020 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

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 1 2011 Year 2 Year 3 Year 4 Year 5 Year 6 2016 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

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.

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

$$$ 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)

Ongoing change & improvement processes using evidence

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

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

Utah Diabetes Practice Recommendations Diabetes Management for Adults Updated in 2011/12 http://health.utah.gov/diabetes/diabetespracticerecommendations/udpr.htm

Data= quality benchmarks + accurate actionable patient data

No Data

Clinic Name: NPI: Intermountain Internal 0 Diabetes-related measures Trend* Comparative Performance & Percentile** 84 71 84 68 92 42 55 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 84.3 21570 91.0 646 62.2 21570 70.1 646 73.2 21570 86.5 646 44.7 21570 53.1 646 75.8 21570 91.2 646 66.2 21570 65.3 646 19.1 21570 20.4 646 0 Percentage of adults with diabetes who receive foot exams 0 50 100 19.3 21570 0.0 0

Motivating Data

Meaning to Meaningful Use and Data to the chie

Care Team Engagement

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

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

Provider and Staff Training on EMR

Learning Sessions

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)

Patient engagement

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.

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

Results

Percent Results Percent of Blood Pressure In-Control, by Quarter, for Beacon Clinic Affiliations 95 90 85 Independent Clinics* 80 75 70 65 70.9 73.7 64.9 74.5 66.7 75.6 75.2 68.9 69.0 75.2 69.0 76.2 70.0 76.9 76.0 76.5 70.9 71.0 70.0 Community Average 60 62.2 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013

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

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

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

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

Questions? Contact information Sarah Woolsey, MD, FAAFP Medical Director Main (801)892-0155 swoolsey@healthinsight.org www.healthinsight.org