Using TELUS Wolf to Support Patient s Medical Home

Using TELUS Wolf to Support Patient s Medical Home Contents Introduction... 3 Patient s Medical Home... 3 Foundation for Success - Commitment to Standardization in the EMR... 4 Help Files... 5 References... 6 Panel Identification... 7 Patient Panel Definition... 7 Demographics... 7 Basic Demographic Information... 7 Verification... 8 Status... 8 Configuring Status... 9 To Delete a Status... 10 Searches Getting Started... 11 Producing a Provider s Panel List... 11 Initial Panel Clean-Up... 16 Bulk/Batch Actions... 18 Panel Maintenance... 20 Deceased Patients... 21 Panel Management... 22 Approaches to Panel Management... 22 Opportunistic... 22 Outreach... 22 Panel Management: How to Get Started... 23 Preventive Screening Care... 24 Disease Management... 24 Management of Complex Patients... 24 Panel Management Examples... 25 Preventive Screening... 25 1

Rule Exemptions:... 44 Registries... 45 Disease Management... 48 Tools for Panel Management... 48 Clinical Decision Support: Population-wide point-of-care reminders... 48 Individual Patient Alerts... 48 Clinical documentation so that data may be searched... 49 Scanned Documents... 49 Manual Entry of Lab Data... 50 Measurement... 51 Verification Rate... 51 Screening Rate Based on Completed Screens... 53 Disease Management Rate... 55 Advanced Features of Wolf... 56 Custom Templates... 56 Flowsheets... 57 Appendix A: Lists of scanned document index words/keywords... 58 Appendix B: High Value Tips... 61 Notes (in Patient Maintenance)... 61 Configuration Settings... 61 Exam Templates... 64 Page 2

Introduction Patient s Medical Home When an EMR is used in a meaningful way within the Patient s Medical Home (PHM) model it supports effective patient panel identification, panel maintenance, panel management and will enable proactive panel-based care for patients in a practice. Meaningful use of the EMR will enable Panel & Continuity, knowing which patients are active with each provider and using this information for scheduling purposes and to monitor supply, demand and continuity with the provider. This work is foundational for success, and must be discussed with the entire practice, arriving at agreed upon policies and procedures on what, why and how data is to be captured and maintained with the EMR. Organized Evidence Based Care for preventive screening is a logical place to start to learn how to use the EMR for panel management, or in other words, proactive panel-based care. Page 3

Foundation for Success - Commitment to Standardization in the EMR Successful standardization of data entry for improvement or change, apart from leveraging the inherent functionality of the EMR, relies heavily on three people and process principles in conjunction with the EMR functionality for adoption and use. These are: 1. Team Includes having engaged leadership and inclusive team representation within each clinic or organization; A clinic champion for EMR standardization can be named EMR improvements or changes do not happen in isolation, and require commitment of time and resources to happen Combining EMR improvement with enhanced use of team, process improvement and practice facilitation is the ideal strategy in working toward adoption of the PMH 2. Data Quality Leverage PCN supports where they exist (i.e. Improvement Facilitators, Panel Coordinators, etc.) Data Standardization for the main areas of data input, the entire clinic team should discuss and agree upon: o o o o o use of fields in a standardized way, create structured exam forms or templates for the consistent capture of patient information utilizing standardized text or macros (auto-replace text) whenever possible instead of free text develop verification processes to ensure over time that data recording is reliable (e.g., BP is always in the BP field and not in a text box in a SOAP note) processes to record patient problems with the appropriate ICD9 identifier (highly recommended) where appropriate, to more clearly identify who documented the information in the chart, it is recommended to use the individual initials in areas outside of chart notes (e.g., in demographic notes or while providing a reason for a bulk/batch change) Develop and provide staff education with associated job aids for consistent patient data chart entry (e.g., attaching keywords to documents to patient charts) It is advised that one person or a small group provide direction for patient data entry to ensure high quality in the clinic and minimize data inconsistency. Creating Good in, Good out processes at the practice Documentation of Standard Operating Procedures (Policies, Procedures and Processes) assists a clinic team in having a common understanding of workflow; these should be reviewed periodically Communicate with the practice team the linkage between data entry and the ability for a pointof-care reminder to function and inform reporting Page 4

3. Incremental Change A key recommendation is to take baby steps in EMR changes, especially when it concerns practice-wide point-of-care reminders. These can be managed to make the changes small and sustainable for the practice team Use the simple but effective Model for Improvement method including applying plan-do-studyact (PDSA) cycles to identify and test small incremental changes toward the desired and clearly identified improvement goal When a new point-of-care reminder is put in place an associated, documented people process needs to be developed and implemented; thus making the change effective and sustainable, by embedding it into the work process and clinic culture Help Files Along with the EMR tip sheet and videos made available on the TOP website, the embedded EMR Help Files from TELUS can be a great untapped resource with detailed instructions on how to optimize EMR functionality. Help files and videos are searchable within the Wolf help files. Click Search and type the words to search for in the window. Telus Wolf Recommended help files will be referred to throughout this tip document as these are available to all users. Page 5

Additional learning opportunities exist with the Telus Health Wolf EMR Community Portal: All Wolf users have access to the Community Portal from the home screen. References Patient s Medical Home http://www.topalbertadoctors.org/change-concepts/introduction/patientsmedicalhomeinalberta Patient s Medical Home Implementation Field Kit http://www.topalbertadoctors.org/patients-medical-home-implementation-field-kit/ Patient s Medical Home Assessments: Readiness http://www.topalbertadoctors.org/file/pmh-assessment-for-practices--readiness.pdf Phase 1 http://www.topalbertadoctors.org/file/pmh-assessment-for-practices--phase-1.pdf Phase 2 http://www.topalbertadoctors.org/file/pmh-assessment-for-practices--phase-2.pdf Page 6

Panel Identification Patient Panel Definition A patient panel, or roster, lists the unique patients that have established relationships with a provider. There is an implicit agreement that the identified physician will provide primary care services. Relational continuity, or an ongoing relationship between a physician and a patient, is a key objective of establishing a patient identification process. Demographics Basic Demographic Information In Patient Maintenance, the demographic area of the patient chart, the basic information that is needed for patient panel identification is: Full Name Date of Birth Gender Complete address Phone number(s) Primary provider Patient status (Active or Inactive) o Status Date o Verification date Alberta Patient Healthcare Number (PHN) Page 7

Verification Wolf has a designated field for patient demographic data verification. Marking this field/box indicates that the address, phone, patient status and provider attachment are up to date. The field also applies a date stamp so that all know when it was last done. The verification rate may be measured using Practice Search. Please see the Measurement section. Status In Wolf, the patient status is entered in Patient Maintenance on the Patient Status tab: Patient Status is a searchable field in the EMR so it is important for panel identification. Page 8

Configuring Status In Wolf a system administrator can customize patient statuses for the practice in addition to what is available in the EMR at Go Live. This will allow the practice to narrow down various types of active and inactive patients in patient lists, reports or for setting up Practice Search Rules. From the Home screen, choose Configuration > View > Patient Data Codes > Patient Status Page 9

1) In the Patient Status Maintenance screen, complete the Description, Status Code (an in-clinic code you give to the status) and the sort order, which organizes the order they appear in the drop down menu. The Location code is optional and can be left blank. 2) Click the Inactive box if the status is to NOT be included for the physician s active patient panel. 3) Save (by clicking the floppy disk icon). 4) If creating another status click on the New icon (piece of paper icon), and begin again. 5) Click Exit when done. To Delete a Status 1) Click on the Status Code 2) From the top menu in Patient Status Maintenance choose File > Delete. 3) You will be asked to confirm Page 10

Examples of Patient Status Used in Primary Care Status Status Name Additional Information Active Office Patient Active office patient attached to a provider in the practice Specialty Service This patient may be active in the practice but only for a given service (e.g., vasectomy, aesthetic, maternity care, aviation medical, circumcision, IUD). Some clinics give a status to each type of specialty service. Temporary Applied to a patient seeking walk-in care. These patients are not considered part of the provider s panel. New When a practice is still accepting new patients, a patient may not be confirmed as an office patient until after a first or second appointment. Orphaned/unassigned When a provider leaves a practice resulting in an unassigned panel, these patients may be identified. Emergency Department Mainly in rural centres, where a patient record exists for a visit that occurred in ER of a non-clinic patient. Long term care For a group of patients seen in a long term care site but not the practice. Lapsed or Dormant Some clinics prefer to use this term for patients that are inactive, with no clinic visit in a period of time (e.g., 3 years). They will be given this term during panel clean up or maintenance. Inactive Inactive Includes formerly active patients with no clinic visits in a period of time defined by the practice, (e.g., 3 years.) Deceased Patient is deceased. Non-clinic patient / Not Our Patient Duplicate or Archive When a patient chart is created for lab work received at the practice or for a patient never seen at the practice (may apply to a new patient that made an appointment but never visited the practice). When a patient has accidentally been registered more than once and the EMR does not have the ability to merge duplicate records the archived record has this unique status. Searches Getting Started When learning to create searches the following tips will assist in obtaining accurate data: Be informed on how data is recorded at the clinic; this will provide direction on which fields to search Build the search one parameter at a time Validate, as each line of the search is created, that the results are correct before adding another parameter to the search Search for the positive first then search for the negative o E.g., if you are searching for female patients 50 74 y that have not had a mammogram in the past 2 years, first identify all patients that have HAD a mammogram in the past 2 years. Once you have validated that your search criteria are correct it is easy to search for patients that have NOT had a mammogram. Verify that your results are correct by checking the data in 3-5 charts on the list Producing a Provider s Panel List During the panel identification process the first step is to produce a list of all active patients attached to a provider using the report/search functionality of the clinic EMR. Last Visit Date may assist with determination of which patients are active: Page 11

o Patients with a visit in clinic during an agreed-upon, predetermined period (e.g., last 3 years) These lists usually create awareness for initial panel clean up. Verification of the data produced on the lists with the primary provider and team will help to determine validity of the information. Further panel clean-up is assisted by additional searches in the EMR. Page 12

Producing a Physician Patient List in Wolf: These initial searches inform your initial panel information processes. From the Home screen, choose Practice Search Once Practice Search opens: 1. Choose Primary MD under Demographics. 2. Click the box beside Search All Patients in the upper right. 3. Click the third icon from the left to show search results as a Patient List. Page 13

When a list is produced it looks like this: The columns may be sorted by the headers by clicking on the header. Sort by Last Visit Date: Sort by Age: Page 14

TIP: Wolf EMR will produce the list with Practice Search but also offers exporting the list as a csv file for further sorting and analysis in Microsoft Excel or another spreadsheet. To do this, select File > Export All to CSV. Basic spreadsheet training is recommended and be mindful of privacy requirements; handle and dispose of that data appropriately. Using the Demographic Viewer In Wolf, instead of producing a list of patients, it is possible to produce a pie chart of results. The advantage of this is that the results are generated much quicker and there are ways in the menu to sort by age, gender and smoking habits. If the desire is to simply get a number, this is the fastest way to achieve those results. Page 15

Initial Panel Clean-Up Searches/reports that assist initial panel clean up include producing a list of active patients attached to a provider, with the additional search parameters of: o Last visit date (and no future appointments) This search produces a list of patients assigned to Dr. Adams WITH a visit in the last 3 years. Page 16

This search produces a list of patients attached to Dr. Adams with NO visits in the last 3 years and NO future appointments booked. o Age: Sorting the list of active patients by age is valuable. In viewing the list of active patients over the age of 90 years, a provider is usually able to indicate if there are patients on the list who should be marked as deceased No visits to the practice (and no future appointments) producing a list of patients that are attached to a provider will identify patients that registered but may have never shown up to the practice. This search may also identify registrations of patients where lab results were received to the practice but the patients were never seen at this practice. Another scenario where this applies includes where a physician has imported charts to the practice from another practice. Page 17

Appointment Type/Reason If the practice uses the appointment type or reason when scheduling visits, searching by this information will allow you to exclude or target patients that are not family practice panel patients such as aviation medical or Botox injection. See Wolf Help files Appointment Reason Maintenance to set up apt types. Billing code - If the clinic offers specialty services to patients that are not members of the physician s family practice, they may be identifiable by billing code from the Schedule of Medical Benefits o Ask the providers if there are any billing codes that they routinely use for patients that are not members of their family practice panel o Procedure codes Address or postal code o E.g., searching by procedures offered at the practice, but all the patients may not belong to the practice, such as vasectomy (75.64) Long term care patients are billed with an 03.03E billing code Sorting of active patients by the address or postal code searches can be valuable in identifying groups that may not be part of the family practice panel due to their place of residence; temporary workers to an area may be identified this way Last Name is Test each clinic has test patients that were created for training or practice purposes, for reporting and analysis they should not be included in the family practice panels. These will need to be found in the patient search window from the Wolf Appointment Scheduler. (first, be sure there are no real practice patients with the surname Test) IMPORTANT: The primary provider and/or the practice team need to review the data from reports to ensure that the correct information is being pulled into them. Due to unique protocol at a practice, fields may be used in a specific way and this may impact the accuracy of reports. Bulk/Batch Actions Once a list is produced and sorted, Wolf is capable of applying a bulk change to the entire list or a group within the list. Making bulk changes makes the process of initial clean-up and ongoing panel maintenance faster and easier. TIP: Carefully verify data with the primary provider and/or care team before making a bulk change. Page 18

Deactivation is a two-step process: 1. Deactivate 1) Produce a verified list of patients that the clinic wishes to make inactive. 2) Choose Selection > Select All or click the box beside the patient names that you wish to inactivate. 3) Choose Selection > Deactivate Selected. 2. Change Status to Inactive 4) Choose Selection > Update Patient Status 5) The Change Patient Status for Selected Patients window appears. 6) Change status to Inactive Patient 7) In the Reason box write the person s initials doing the inactivating and a reason. Additional notes may be added in the box below. 8) Select the current date at the Start Date. Click OK TIP: Making a chart Inactive does not delete the chart. A chart may be made Active and a patient re-introduced to a provider s panel. Page 19

Panel Maintenance Once an initial clean-up is complete there are several processes that support maintaining a clean patient panel list for each provider. Those processes include: 1. Ongoing phone/address data, physician attachment and status verification at patient check in. 2. Developing and monitoring a process for all staff that works the front desk with expectations for data verification is required. This process can be checked using the EMR reporting. Run a search to produce a list of patients with visits in a given period of time and determine what percentage of patients was verified during that time frame (See Measurement Page 50) Standard operating procedures should be in place for front desk staff for: o Patients no longer part of the clinic o Patients not seen in the clinic (e.g., records created for patients where lab work was received or seen at another facility like the local hospital) o Patients seen at your clinic but not your family practice patients (e.g., walk-in or temporary patients) o Patients scheduled for a meet and greet appointment 3. Conducting searches at regular intervals and applying bulk actions to patients that are no longer active at the practice. The regularity of the intervals varies by practice. It may be monthly for the first year and then every six months thereafter. Reports that assist identifying these patients include searches by: Last visit date (and no future appointments) Age No visits to the practice (and no future appointments) Appointment Type/Reason Billing code Address or postal code Last Name is Test (first, be sure there are no actual practice patients with the surname Test) 4. Patient outreach. Some practices identify active patients with no visits in the past 3 years (and no future appointments), prioritizing those overdue for preventive screening care, then reaching out proactively to determine if they are still members of the practice. The outcomes of the outreach involve updating the patient demographics, physician attachment and offers of preventive screening care. Page 20

Deceased Patients When the need occurs, marking patient records as deceased supports maintaining clean patient panels. In Wolf, change the patient status to deceased. The start date of the status should be the date the patient is deceased. Add notes including the initials of the person making this change in the record. Once a patient is marked as deceased, to view their information in Patient Search, select the Include Inactive check box. Patients with a deceased status are no longer active and will be excluded in Practice Search when the Not Deceased box is checked. Page 21

Panel Management Panel management, also known as population management is a proactive approach to health care. Population means the panel of patients associated with a provider or care team. Population-based care (or panel-based care) means that the practice team is concerned with the health of the entire active population of attached patients at the practice, not just those who come in for visits. 1 The Patient s Medical Home implementation element of Organized Evidence Base Care involves embedding evidence-based guidelines into daily clinical practice where each encounter is designed to meet the patient s preventive and chronic illness needs. Setting up population-wide point-of-care reminders supports these planned interactions and EMR functionality supports appropriate follow-up care. Approaches to Panel Management Opportunistic When approaching panel management opportunistically, it means catching a patient while they are in the practice or on the phone with a team member, to offer care. For example, a 52 year old female is in the practice for an appointment to inquire about the vaccine for shingles. While in the office her blood pressure is taken and she is offered requisitions for a FIT test, plasma lipid profile, fasting glucose and mammogram because they are all overdue. Methods to identify patients that are overdue for clinical services may involve: Setting up population wide Practice Search Rules that alert a team member that a patient is due for a clinical service Creating a Follow-up for the individual patient to proactively set up for the next intervention A team member that combs through the charts of patients meeting certain criteria who have an appointment to identify clinical services that are due (e.g., screening) and alerting the appropriate team member to offer care Outreach An outreach method to panel management involves identifying active, paneled patients overdue for clinical services that do not have appointments and reaching out to offer care. This process involves using the Practice Search in the EMR to produce lists of patients. For example, a 58 year old male was last in the clinic 2.5 years ago for a knee injury. The panel care coordinator (PCC) at the practice has run a report that shows this patient is overdue for a plasma lipid profile, a FIT test and a fasting glucose. The PCC phones the patient and verifies that he is still a patient in the practice attached to his paneled physician. * As per clinic protocol, the PCC makes an offer that the patient can come by the clinic and just pick up the lab requisition to get the overdue screening done and the clinic will follow-up if/as necessary. The patient agrees. 1 Module 20. Facilitating Panel Management. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod20.html Page 22

*Note: such protocols vary from practice to practice. It is an important process that must have provider agreement before implementation. TIP: It is recommended that a practice initiating outreach begin with patients that have been verified as attached, active patients. This will prevent the experience of contacting patients that are deceased or no longer active at the practice. Panel Management: How to Get Started Once patient panel identification and maintenance processes are in place, it is recommended to begin proactive panel-base care with the following approach: Panel Identification & Maintenance Panel Lists Patient Verification Preventive Screening Care Foundational Learning Simple to Complex Point-of-Care Reminders Reporting Disease Management Disease Registries Proactive Panel-based Care More Complex Pointof-Care Reminders Complex Patients Automated processes to support uncommon care requirements With ICD-9 codes in place identify complex patients for systematic care Page 23

Preventive Screening Care Preventive screening care involves a smaller number of data elements than disease management There is benefit to starting with some clean sources of data like electronic lab feeds Clinic team will learn the importance of and begin standardization of naming protocols for scanned documents (e.g., mammograms and colonoscopy reports) Patterns will become apparent in their data entry and corrections can be made to previously entered data and new incoming data for future meaningful use of EMR Clinic team will start standard operating procedures that enable proactive panel-based care The searches and population-wide point of care reminders start simple and can build to the more complex Clinic team can build on: the number of screening maneuvers they are addressing and/or the population of patients at the practice that point-of-care reminders are set for (e.g., gender and age) Provides a foundational experience for process improvement Disease Management Clinic team can take lessons learned from less complex preventive screening care processes that can then be applied to disease management Involves more complex searches with more data elements than screening A dependency exists on reliable registries of patients with a given disease Providers will learn the importance of consistent coding in the Problem List of the EMR Clinic team will build on the benefits of standardized data entry Building of more complex point-of-care reminders with increased reliability of planned prioritized care Management of Complex Patients With a solid foundation in preventive screening care and disease management, patients with complexities and multiple, co-existing conditions will have visits that address many predictable health issues by using available resources more efficiently to reliably meet patient s most important needs Page 24

Panel Management Examples Preventive Screening As per the Alberta Screening and Prevention (ASaP) Program Page 25

Preventive Screening Searches: Use the EMR Practice Search capabilities to identify patients due for preventive screening care: Vitals: Practice Search will be looking at vitals entered in the Vitals entry area or from Vitals within an Exam of a SOAP note: From F6 Vitals Entry From SOAP Note Exam Vitals Entry Page 26

1. Identify patients 18 + with no height recorded in Vitals on the chart 2. Identify patients 18+ with no weight recorded in Vitals on the chart in the past 3 years Page 27

3. Identify patients 18 + without a Blood Pressure recorded in the Vitals area in the last year. 4. Identify patients 18+ that have not had a tobacco use assessment in the past year. Identifying whether patients have not had a tobacco use assessment will depend on where tobacco use is documented. It is recommended to document tobacco use in the Personal Risks area of the chart. This is accessible from the SMART menu (right mouse menu) or in the Personal Hx tab in the Harmful Substances area. This is the only place to document tobacco use that will impact the SMART banner. When in the smoking area, if the drop-down menu is not changed, the box must be checked that the smoking status has been verified. Page 28

In Practice Search, to identify patients 18+ that have not had their tobacco status verified in the past year, use the following search. 5. Identifying patients due for exercise assessment. In Wolf EMR there is not a pre-built field for exercise assessment. To document (as per the ASaP recommendations to assess patients that are above or below the recommendation of 30 minutes 5 days per week, or 20 to 25 minutes every day; major muscle groups and bone strengthening activity >2 days per week) another field must be used. One option is to use an exam template with a designated field for exercise assessment. This can be created using the Custom Exam Template Wizard, or available from TOP. Page 29

Exercise recorded in a custom exam template: Custom exam field searched in Practice Search to identify patients without the exercise field used in the last year: Other approaches to recording and measuring exercise: Manual lab results (may require assistance for set-up) Create an Investigation Type called screening in configuration and an Investigation called Exercise Assessment This will allow any team member to record that an exercise assessment was completed and measured in Practice Search Page 30

Auto-text replace can be used to create a consistent term for exercise assessment and thus it is searchable in practice search. 6. Identify females 25-69 y that have not had a Pap test in the past 3 years Before beginning this search it is necessary to identify how the pap is coded by the regional lab service and received in the EMR. In Calgary lab zone it is coded as Gyn Cytology. In the Edmonton zone it is coded as anatomical pathology so there is a special trick to finding lab results that only contain gynecological cytology results. Another point of awareness is the use of the Preventive Care Procedures area of Wolf on the Investigations tab of the Medical Summary. This field is also searchable independent of the lab results. If a provider documents all interpretations in the Preventive Care Procedures area, it is searchable from there as well. In Practice Search it may be searched under History > PAPS Exclusion: Female patients that have had a surgery documented as a total hysterectomy for benign disease may be excluded from a preventive care search for a pap, however, most practices have not had reliable and consistent documentations of surgery in the patient history tab so it may be safer to include all patients and exempt patients from Practice Search Rules individually. This decision in Page 31

Practice Search may be made by practice or by provider. Patients with a subtotal hysterectomy and retained cervix continue with screening as per cervical cancer guidelines. Anatomical pathology In Calgary lab zone this area should read: Gyn Cytology In the DKML/Edmonton zone this area should read: anatomical pathology, Where Text Has Phrase cervical. Page 32

7. Identify females 50 74 y that have not had a mammogram in the past 2 years (a mammogram may be a scanned document and/or an electronic result, depending on the region). This search is looking for females 50 74 y attached to Dr. Adams that have not had a document with the keyword mammogram nor a Preventive Care Procedure documented in the past 2 years. If a clinic is receiving mammogram results electronically as an investigation, as in the Edmonton Zone, mammograms would need to be searched in Lab Results. Page 33

8. Identify females 50 74 y that have not had a lipid profile in the past 5 years. A lipid profile includes total cholesterol, HDL, LDL and triglycerides. Since HDL, total cholesterol and triglycerides may be ordered separately, an LDL result indicates a completed lipid profile. This search looks for a patient that has not had anldl cholesterol that is reported in a lipid profile. Option: Patients already identified at risk of cardiovascular disease and are taking a Statin (HMG CoA Reductase Inhibitor) are no longer being screened for lipids (because they are already identified at being at risk) and lipid screening is no longer required in this population, as per the Prevention and Management of CVC Risk in Primary Care Clinical Practice Guideline. If the active medication list in the EMR is reliable, to Exclude Matches of patient taking this medication, this may be added in practice Search: Page 34

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9. Identify patients 40 + that have not had a fasting glucose OR a HbA1c test in the last 5 years Option: If the Problem List is reliable and coded consistently, patients with the diagnosis and problem entry of Diabetes may be excluded from this search using History Problem (ICD9) or History Problem (Specific) and Exclude Matches. Another consideration is that if the problem list is unreliable, patients with a diagnosis of diabetes should be having a test for HbA1c or fasting glucose more often than once every 5 years anyway and would not appear in the search results. Page 36

10. Identify patients 50 74 y that have not had a fecal immunochemical test in the past 2 years OR a flex sigmoidoscopy in the past 5 years OR a colonoscopy in the last 10 years (where a FIT test is a lab result and a flex sig or colonoscopy can usually be identified by a scanned report). This search relies on consistent document keywords for colonoscopy and sigmoidoscopy reports. Page 37

CV Risk Calculation This is a highly valuable tool to assess risk in patients with no previous cardiovascular disease (e.g., NOT taking a statin class of medication) as per the Prevention and Management of CVC Risk in Primary Care Clinical Practice Guideline. Conduct on males 40 74 or females 50 74 every 5 years Requires other data held in the EMR: gender, tobacco use, BP, non-fasting lipid data and diabetes diagnosis (for some CV Risk calculators) May use an internal EMR CV Risk Calculator or an external calculator such as: http://chd.bestsciencemedicine.com/calc2.html#basic o Dependency on where the provider records the result or if it is auto created from the internal calculator in the EMR The preventive care screening search is to identify: o Males 40 74 y, not taking a statin, that have not had a CV Risk calculation in the past 5 years o Females 50 74 y, not taking a statin, that have not had a CV risk calculation in the past 5 years To conduct a CV Risk Calculation using the Wolf access the Cardiac Risk Worksheet: Using the SMART Menu (Right Mouse Menu) From a SOAP note See the Wolf Help File: Cardiac Risk Worksheet Page 38

While in the Cardiac Risk Worksheet, if the print icon is used, a document is created with the document keyword Cardiovascular Risk Profile that is available in the Document Tab of the patient s Medical Summary. To use Practice Search to identify male patients 40 74 y, that have NOT had a cardiovascular risk calculation/cardiac risk worksheet in the past 5 years, use the following search: Page 39

To exclude patients currently taking a statin class of medication (HMG-CoA reductace inhibitor) from the search for patients that have not had a cardiovascular risk calculation: Use a separate search for female patients 50-74y, Page 40

Preventive Screening Searches to Rules Wolf EMR has an innovative tool called Practice Search Rules or commonly called Rules. These rules are used to manage a set of patients defined in a practice search and automatically trigger reminders and notifications for physicians and front staff if a patient matches any rule criteria. This tool enables proactive panel-based care. Important help files in Wolf EMR to review regarding Rules: Practice Search Rules Wolf EMR Pre-Defined Practice Search Rules Practice Search Rule Exemptions Tips in using Practice Search Rules: A Rule is built from a validated search The Rule will turn off when the criteria to meet the rule has been completed. So a Rule that identifies patients due for diabetes screening will turn off when the HbA1c or Fasting glucose lab result is received into the patient chart. This will allow the practice team to remind the patient to complete a recommended maneuver until it is completed Rule Matches View (accessible from the Workdesk) has some useful filters that allow a practice team to conduct proactive panel-based care and identify a list of patients with appointments today that have active Rules Managing exemptions or deferrals in Rules allows for customization to individual patient care o o o A rule can be deferred for a day (does not accept the offer of a pap today) or a complete exemption (a patient with a complete bilateral mastectomy Rules are available in the SMART Menu (right mouse menu) to see all the managed rules for that patient Rule exemptions can be actioned from the Rule Matches View as well as from the Patient Record Use the pre-defined Rules to learn how to build rules then customize your own searches to build Rules Page 41

Start incrementally and have a clinic team process ready for each active rule A rule can be created, made inactive and turned on when a practitioner or practice is ready Rules can be built for one provider to start and additional physician panels added incrementally If Rules are being ignored it is recommended to make them not Active and incrementally make the Rules active in a sustainable way in the practice Example Using Practice Search in Wolf EMR for Preventative Screening in the General Adult Population. Height - Identify active (not deceased patients) age 18+ with no height in their record. Rule: No Height on record Save Current Search Show Search Results as a Patient List 200 Show the Search Results as a Patient List to validate. This list can be printed or saved as a csv file to open in Excel or Open Office Calc. Page 42

To save this as a Rule, click on the Save Current Search icon, then, the following screen appears: To Save the Search as a Rule: 1) Write some informative text to display when patients match the rule 2) Assign a priority (default is 5) 3) Click Active 4) Save as New Page 43

Rule Exemptions: Important points from the Wolf Help file on Practice Search Rule Exemptions: Enter an End Date, or choose from the quick-pick intervals when exempting patients. No end date means a permanent exemption (though, it may be edited) When there are patients exempt from a Rule it will indicate so in the Practice Search results. To view the list of exempted patients, click View > List Exempted Patients. Page 44

Registries A registry identifying patients with a coded (disease) condition is the first step in preparing for panel management of patients with a given condition. The formation of coding of patients with a condition is called a patient registry. Ideally, all patients with a condition will have the condition noted in their Problem List in a consistent way. For example, Diabetes is always called Diabetes Mellitus and will likely have the 250 ICD-9 code attached to it. It is important that an entire practice agree on terms for the conditions to create registries. In this example Diabetes is not named with other inconsistent terms such as Diabetes, DMII, DM2, Diabetes M, etc. TIP: Free typing in the problem list is NOT recommended. Physicians should use the drop down list when coding problems. In some cases a clean-up of the list may be needed to enable consistent coding moving forward. While the Service Codes used in claims or billing is a very useful search to inform the practice when forming registries, it is not always accurate enough to be used when creating point of care reminders. An accurate problem list should be the trigger for the point of care reminders. Important Wolf Help Files: Problem List Problem Index Quick Entry Problems tab Page 45

Problem List Tips: Avoid free typing and adding descriptions to the master list problem in your clinic database; search for the coded problems Have the providers agree on a limited list of problems that you may wish to search or create Rules for (up to 10-15 to start) Agree on consistent naming for those problems Place a list of those problems and codes at each workstation (example below) Family Clinic Problem List Hypertension 401 Obesity 278 Diabetes Mellitus 250 Tobacco 305.1 COPD 496 Asthma 493 Heart Failure 428 Angina 413 Coronary Artery Disease 414 Chronic Renal Failure 585 Add to your clinic problem list over time Extra words or descriptors may be added in the Qualifier field and will appear in Problem list but not be coded. In this example the patient is diagnosed with hypertension as the problem but extra information is added in the Qualifier field The extra information in the qualifier appears visible in the problem list but does not impact the ICD-9 coding. This patient would be included in a search for any patient with hypertension. Tip: Favourites can be created in Wolf by the clinic administrator in the Problem Maintenance by adding a star icon * to the beginning of the problem list names the clinic wishes to favour. Users need only to put a * in the problem list to bring up the favourites. Page 46

Forming Problem Registries There are useful searches that will support the development of disease registries. By looking in other areas of the EMR, patients without the problem in their Problem List can be identified. Feature of EMR Example 1 Data that would inform Diabetes Mellitus Registry Example 2 Data that would inform Hypertension registry Billing Diagnostic code 250 Diagnostic code 401 Medications Currently taking metformin or insulin Currently taking an antihypertensive Lab HbA1c over 7 % BP > value specified by clinic MDs Example: This Practice Search identifies patients prescribed Metformin or Insulin but the patient Problem List does NOT contain Diabetes (250) Problem List does not contain Diabetes Patient is prescribed Metformin or Insulin Page 47

The bulk action feature from reporting area of the EMR is a useful tool when producing a list of verified patients with a given condition to add it to the patient problem list in bulk. Disease Management Proactive panel-based care of a cohort of patients with a given condition (e.g., Diabetes or hypertension) is enabled by certain EMR features: Problem list Rules set for a population of patients Pop-up notifications from Notes in Demographics (for very important concerns) Follow-ups, worklists Tools for Panel Management Clinical Decision Support: Population-wide point-ofcare reminders Most EMRs have a tool that will search the database for specific criteria to identify patients due for clinical service. Population-wide point-of-care reminders may be called rules, triggers, alert, notification etc., and these are really just searches that run in the background of the EMR and provide notifications when a patient meets the criteria. These can be created based on internal clinic information such as charting, scanned documents, billing or external information such as incoming lab or imaging data. These point-of-care reminders will automatically go away when the search criteria are met. Population-wide reminders are key enablers of proactive panel-based care. The higher the data quality in a practice the more reminders a practice team are able to create and use reliably. Recognizing that individual patient care will be tailored and that there are exceptions to the rules, reminders have the ability to be individualized for patients and modes of documenting exemptions. Individual Patient Alerts At the individual patient level, EMRs have the ability to create a note or alert for an individual patient. Individual patient alerts can vary from critical pop-ups to notes that appear in certain areas of the EMR such as scheduling, appointments or in charting. Page 48

Clinical documentation so that data may be searched EMR users need to be aware of the search capabilities of their EMR. Where information is entered matters! In general, fields that can inform a search or report include: Drop down lists Radio buttons Boxes only designed to record certain information like blood pressure or weight Templated fields in an exam template Even in an area where free text can be entered, if certain information is entered with a consistent term, it may be searched. Where common repeated text (macros or auto-replace) is used, it may be uniquely searched. Important Wolf Help File: Practice Search Parameters Scanned Documents Every clinic receives electronic faxed documents which get linked to individual patient records. The naming or indexing of these documents as they are attached should enable two processes: 1) When a provider is viewing the patient chart they should easily identify the information and be able to find it quickly or by filtering the view to show documents with the same keyword (e.g., all mammograms, colonoscopies, etc.) 2) In the Practice Search it is possible to produce a list of patients that have a type of linked document within a period of time. These same document names can be used to create a population-wide point-of-care reminder or to populate a flowsheet. Key principles for linking scanned documents Create a list of acceptable document keywords that can be used at the practice that is agreed upon by the clinic team (clinicians and team members). See Appendix A for examples. Once the list is established, Use the drop down list in the EMR; avoid free typing Certain clinical reports need to be distinguished to enable panel management and Rules o o Distinguish mammogram results from all diagnostic imaging Some consult reports need consistent naming: Colonoscopy reports Flex sigmoidoscopy report Colposcopy report Provide training to staff and place a printed list of acceptable keywords with indexing tips at every workstation where documents get linked to patient charts Name the document based on type of consultation rather than the name of the consultant o E.g., If a referral is for gastroenterologist consult, name the letter Gastroenterology consult not Dr. Black consult Only central clinic EMR administrator(s) should be allowed to add, delete or modify the main list of keywords Free text can be added in the Notes field Page 49

Use up to 3 keywords. Add free text in the Notes field. Notes are searchable in the Documents tab of the patient chart in the Search field. Manual Entry of Lab Data Most EMRs have the ability to manually enter lab data that may be received by fax or completed within the clinic. Data may be received by fax due to the lab originating from a source outside the region. If this lab data is entered as a Manual Result rather than a scanned document it can usually be trended and searched. Manual results may be entered from the Right Mouse SMART Menu while in a patient chart. Wolf is set up with many lab results but additional types of labs or data can be configured in Configuration with advanced training. Some clinics have set up to record screening offers as manual results. Page 50

Measurement While moving toward the Patient s Medical Home, a practice or team will not know how they are doing unless they measure for improvement. Reporting measures can provide information to inform both short term process improvements as well as long term effectiveness. Example measures are: Verification Rate One tool that can be useful is to measure how often the team is verifying the patient demographic information (address and phone) and physician attachment. When a clinic is new to patient verification it can be reported from Practice Search. For example a team that wants to measure how they did in a week: # patients verified this week x 100 = verification rate (%) # patient visits this week Tip: The numerator is the top number in the fraction; the denominator is the number on the bottom. To determine the numerator, the number patients verified this week, use Practice Search to identify Patient Data Verified and choose In Last 1 Week. The first time this search is done, produce the list to Page 51

verify that the results are what you are seeking but the fastest way to get the number is to use the Demographic Viewer. IMPROVEMENT TIP: Display your results in a Run Chart over time to show your improvement in verifying patient data. Page 52

To determine the denominator, the number of patients that had a visit this week, use Practice Search to identify Last Visit and choose In Last 1 Week. A clinic may also have an expectation for improvement over a period of time and can determine if they are meeting their goals. For example if a practice has an expectation that their verification rate over a year should be 95% the formula would be: # patients verified in the last year x 100 = verification rate (%) # patients with a last visit in the last year Screening Rate Based on Completed Screens A practice will also find that they are able to measure rates for preventive screening care. Measuring completed screens looks for completed results. The generic equation is: # patients in eligible population with a result during the screening interval + x 100 = screening rate (%) # patients in the eligible population* + The screening interval is the time frame during which the screening maneuver should be done * The eligible population would include all the active, paneled patients for a provider whether they came into the clinic or not, as all rates are calculated over the paneled population. Page 53

Example 1: Dr. Adams wishes to calculate the completed blood pressure screening rate for his active paneled adult patients. Blood pressure should be measured annually (ASaP) # active adult patients* (18 +) with a BP result in the last year x 100 = BP screening rate (%) # active adult patients* (18 +) * Attached to Dr. Adams in the EMR To calculate the top number of the fraction, identify Dr. Adams pts 18 + with any BP result: This search identifies all the patients 18+ attached to Dr. Adams with (any) BP result in the last year. If status is used in the practice it must be applied in the search as well. To calculate the bottom number of the fraction, identify Dr. Adams pts 18+: This search identifies all the patients 18+ attached to Dr. Adams. If status is used in the practice it must be applied in the search as well. Page 54

Example 2: Dr. Brown wishes to calculate the completed diabetes screening rate for her active adult paneled patients. Diabetes screening is: appropriate for adults 40 + recommended once every 5 years completed with a fasting glucose, hemoglobin A1c result or a diabetes risk calculator score # active adult* patients (40 +) with a fasting glucose OR HbA1c OR diabetes risk score in the last 5 years x 100 = Diabetes Screening Rate (%) # active adult patients* (40+) * Attached to Dr. Brown in the EMR Calculating a Screening Rate Based on Offers of Screening Care Practitioners participating in the Alberta Screening and Prevention improvement project will include both completed screens and offers of the screen. In this case, to measure with the EMR there must be a place that declined, deferred and exemptions for screening are reliably recorded. In this case the generic equation is: # active adult patients with an offer of screen or completed screen during screening interval x 100 = screening rate (%) # active adult patients It is recommended to use the chart audit methodology 2 instead of EMR measures if the offers of screening care are unable to be searched in the EMR. Disease Management Rate EMRs are capable of measuring around disease management parameters provided the information is entered in a place where it can be searched. Example: Dr. Brown wishes to measure how many of her active paneled patients with diabetes have an HbA1c result below 7% in the last year. Generic equation: # active patients* with diabetes + with an HbA1c result below 7% in the last year x 100 = rate (5) # active patients* with diabetes + + Patients are identified as diabetic when Diabetes is listed as an active problem in their Problem List 2 See ASaP EMR Chart Review Instructions: http://www.topalbertadoctors.org/file/asap-chart-reviewinstructions-emr.pdf Page 55

Advanced Features of Wolf Wolf has some advanced features that will assist in Patient s Medical Home work. Custom Templates Clinics can use the Custom Exam Subform Wizard accessible from a physician workdesk in Configure > Custom Exam Forms. This feature allows the clinic team to create custom exam forms that are accessible to the providers and team members. For team members that enter vitals there is a Structured Examinations drop down menu that allows access to entry of exam forms. Many clinics have created a custom ASaP exam form or downloaded the copy from the TOP web site. Those with advanced training can share exam forms with others. See the Wolf video Custom Exam Fields in the Wolf EMR Community. See the Wolf Help file: Custom Exam Subform Wizard Page 56

Flowsheets Wolf has some pre-built flowsheets, a table that displays data pulled from information that is already entered into the Wolf patient chart, and tracks it over time. Many are pre-built in the EMR and are called CDM Flowsheets. See the Wolf Help file CDM Flowsheets. Flowsheets can also be custom created by the practice to pull from history, examination fields, medication, lab, consultation, vaccination, preventive care and documents. When there is good standardization in place and patient data is entered consistently, the clinic is in a good place to use flowsheets for those areas. Because flowsheets consolidate a great deal of patient information on one place they are highly valuable for screening (ASaP) and chronic disease management. Page 57

Appendix A: Lists of scanned document index words/keywords These examples are from real clinics. Example 1: ALLERGIST Appointment Appt Confirmation CARDIOLOGY Chart Colonoscopy Report Colposcopy Report Consult Letter CT Scan DERMATOLOGY Discharge Summary Driver s Medical ECG Graph ECG Report ENDOCRINOLOGY ENT Forms GASTRO GEN SURGERY INTERNAL MED Lab Lab Provincial Mammogram MRI Neurology Neurosurgery Notice of Admission Notice of Discharge OBGYN OPD Sheet Ophthalmology OR Report ORTHO Paps Parking Placard PEDIATRICS PLASTICS Prenatal US Pre-op Medical Referral Report Requisition RHEUMATOLOGY Rx Adaptation Rx Refill Ultrasound UROLOGY Vascular WCB Xray Page 58

Example 2: Admit Air Contrast ALT Anti-HIV Anti-Nuclear (ANA) Appointment Notice Attending physical statement Audiology Report Beta HCG Biopsy Blood Culture Blood Type Blue Cross Authorization Breast Ultrasound Body Fluid Culture Bone Density Bonnyville Cancer Centre Bubble Pack Authorization C-reactive Protein Cat Scan CEA Cervical Culture Chart Notes Chart Request Acknowledgement Chemistry Child Welfare Medical Chlamydia Claims Management Program Colonoscopy Report Colposcopy Report Consult Creatinine Critical Care Line Cross Cancer Cytology Report Diabetic Consult Discharge Instructions Discharge Summary Double Contrast Driver s Medical ECG Echocardiogram EA screen Endoscopy Ferritin Free testosterone Gastroscopy GC Probe Gynecological Cytology Report HBA1C Hematology Hepatitis Home Care Imaging Influenza INR Iron and TIBC Lipid Testing Mammogram Medical release and report Medications Mental Health Microbiology Millard Health WCB MRI MRSA Newborn Metabolic Screen NIHB Drug Exception No Show Occult Blood Oncology Imaging OPD Operative Report Ova & Parasite Paps Pathologist Comment Patient Photo Perinatal Phenytoin Physician Admit Advice Pre-op medical Prenatal US PSA Psychogeriatric Consult RAAPID North Patient Summary RAH Rapid Plasma Reagin Test Release of information Rx adaptation Rx request Serum Protein Elect. Slick Sputum Culture Stool Culture Superficial Culture Surgical Pathology Report Syphilis TB Update Throat culture Tom Baker Cancer Centre Troponin TSH UAH Ultra Sound Urethral Culture Urine Microalbumin Vaginosis Screen Vital Aire VRE WCB Wound Culture X-ray Page 59

Example 3: Appt Notice Attending Physician Statement Audiology Report Blood Glucose Readings Blue Cross Bone Density Cardiology Chart Notes Colonoscopy Complex Care Plan Consult Cross Cancer Inst. CT Discharge Summary Driver s Medical Echocardiogram EKG/ECG Email Emergency Record Exercise Stress Test Form Framingham Risk Assessment History Sheet HIV Test Results Holter Monitor Reports Home Collections Confirmation Injection Labs Letter Mammogram Medical Legal Medical Summary MRI Operative Report Outpatient Report Pacemaker Clinic Paps Patient Information PCN After Hours Clinic Prenatal US Pre-Op Medical Procedure Letter Prov. Lab Results Referral Rx Treatment Consent Ultrasound Vasectomy WCB Xray 60

Appendix B: High Value Tips Notes (in Patient Maintenance) Patient Maintenance has a Notes tab that can support panel management. Some notes need to be issued at the patient level. Active Notes will display at booking and confirmation, arrival or billing. Some important clinical notes may need to display at different points. Example: A physician has a few patients in the clinic with Multiple Sclerosis. Some are on a selfmanagement protocol for urinary tract infections and others are not. For patients that are not on selfmanagement protocol the following note appears in Patient Maintenance and will pop up at Booking and Confirmation MS Patient NOT on self-management protocol for UTI Urgent same day appointment needed for urinary tract infection. Configuration Settings Each user can adjust their workdesk settings to make their day go faster but adjusting settings in their workdesk from Configure > Configure WorkDesk. SMART (Right Mouse) Menu You can access the SMART Menu (also known as the right-click menu) from almost anywhere on the Physician or MOA WorkDesk by right-clicking your mouse when a patient is selected or highlighted. This menu can be configured so that the user only sees the menu items most frequently used. To adjust from Page 61

the WorkDesk select Configure > Configure WorkDesk. In the WorkDesk User Preferences select Manage Right-Click Menu Each user selects only those items in the right mouse menu they use frequently. Every use must set this individually. All menu items are available through Show All Menu Items at the bottom of the list. Page 62

Auto-Text Replace is available in the Spell Check tab. Anything that a user types frequently can be made as Replace Text. To create a new Replace Text: 1) Plan a code that would not otherwise be typed 2) Click the Keyboard icon 3) Fill in the Replace column 4) Fill in the Replace Text column with the long note. This may be planned in Word or Notepad and copied into the Replace Text area. It is worthwhile setting this up as it will provide great efficiency over time. See Wolf Help Files: Configure WorkDesk Spell Check tab Also recommended: on the Visit Exams tab select only those visit exams used by the user. Page 63

Exam Templates Wolf-created and user-created custom exam templates can assist in collecting information in a standardized format. Wolf has many templates that are available to MOAs from the F6 Vital Entry screen in the bottom right hand corner in the Structured Examinations Field: Page 64

For users on the Physician WorkDesk, these exam templates are available when selecting an exam template. The list of exam templates can be configured by each user in Configure > Configure WorkDesk. In the WorkDesk Preferences window select the Visit Exams tab. Select only those exams the user wants visible. Tips in using Exam Templates: Double click in any field to see a history of values of that field When an MOA enters data from the F6 entry, the information will be visible in the Physician WorkDesk in an encounter. On the Physician WorkDesk, a user can close one exam template and open a second or third in a single visit for additional entry Each field is reportable from Practice Search in the Exam Findings search parameter. Select Exam Findings Values. Page 65