(CPG) NCQA Reference: PCMH 3 Element A Objectives Review evidence-based clinical practice guidelines Select clinical practice guidelines for JumpStart Level I Review NCQA requirements for evidence-based guidelines Review BizMed clinical guidelines templates and resources Unit 4 Assignments Evidence-Based Clinical Practice Guidelines (CPG) Overview Clinical Practice Guidelines are intended for use only as a tool to assist a clinician/healthcare professional and should not be used to replace clinical judgment. Practice guidelines are not intended to enable cookbook medicine, but instead are aimed at assisting the practice team in providing consistent and proactive care to all patients, reducing variability and disparities in care. Definition Clinical practice guidelines are recommendations for the performance or exclusion of specific procedures or services derived through a rigorous methodological approach that includes the following: determination of appropriate criteria, such as effectiveness, efficacy, population benefit, or patient satisfaction; and literature review to determine the strength of the evidence (based in part on study design, e.g. randomized versus nonrandomized, controlled versus uncontrolled, blinded versus unblinded, etc.) in relation to these criteria Purpose Rather than dictating a one-size-fits-all approach to patient care, clinical practice guidelines offer an evaluation of the quality of the relevant scientific literature and an assessment of the likely benefits and harms of a particular treatment. 1 The purpose of clinical practice guidelines is to assist clinicians and patients alike in determining the best treatment options for a particular disease or condition, and when thoughtfully used, can promote shared decision making. The primary objective of implementing guidelines is improving patient outcomes - not controlling or reducing health care costs. 2 Clinical guideline can support quality improvement initiatives by enabling the design of various assessment tools (standing orders, reminder systems, critical care pathways, algorithms, audits, etc.) Limitations Clinical guidelines are one of many options for improving quality of care and by no means a magic bullet 3. Guidelines may be inherently flawed if the consensus developers fail to accurately account for the evidence, or are biased due to personal experience or outright conflict of interests. Guidelines that are too prescriptive may deprive patients with special needs of individualized care, and frustrate clinicians. Furthermore, clinical guidelines may provide conflicting advice and may become outdated within very short periods of time. www.bizmedsolutions.com Page 1 of 15
It is therefore imperative that physicians exercise clinical judgment when selecting practice guidelines and each time they apply them in practice. The largest repository of clinical guidelines in the U.S. is the National Guideline Clearinghouse which houses guidelines from a variety of developers, and it is maintained by the Agency for Healthcare Research and Quality (AHRQ). Utilization The utilization of standardized guidelines may enable participation of team members in patient care to various degrees based on staff licensure and expertise, thus providing more time for clinicians to spend with their patients. For example, established clinical guidelines could be used to develop sets of standing orders to be followed independently by staff during patient intake and/or between visits for outreach purposes. Establishing evidence-based goals for treatment of various conditions will also allow practices to evaluate their performance against their own goals and national benchmarks, and initiate quality improvement projects. Various technology vendors (EHRs, registries, etc.) provide template based care guidelines to be used for documentation and clinical decision support. These technology tools enable automated delegation of tasks to staff and in pertinent instances to patients themselves. If you use an advanced technology tool such as this, make sure you review the clinical guidelines, understand the evidence it is based on, and configure the tools to adhere to your clinical judgment. A Tale of Two Visits Do physicians really need evidence-based clinical practice guidelines for kids with a sore throat? Of course not, so how can guidelines for Pharyngitis help a practice? Visit 1: Child with Sore Throat www.bizmedsolutions.com Page 2 of 15
Visit 2: Adult Knee Pain & GERD + DM Clinical Practice Guidelines are as much about ensuring consistency and efficient processes, as they are about dissemination of up-to-date scientific evidence, particularly for common conditions. Although there are multiple barriers to the implementation of guidelines in clinical practice 4, studies have shown that with proper assistance 5, clinical guidelines can improve patient care, particularly for chronic conditions 6, and increase delivery of appropriate preventive care. For NCQA recognition, the Medical Home JumpStart program will guide you through implementation of 3 CPGs for common conditions. Once your practice and your patients begin benefitting from this initial effort, you may choose to implement additional CPGs following the same methodology. NCQA Requirements for Evidence-Based Guidelines Must have 3 clinical guidelines in place One of the 3 conditions must be behavioral Must be evidence-based (including sources) Clinical Guidelines for JumpStart Level I For the BizMed JumpStart Medical Home program clinical guidelines for the following conditions are suggested: Adult Practice o PCMH3A#1: Diabetes o PCMH3A#2: Hypertension o PCMH3A#3: Obesity Pediatric Practice o PCMH3A#1: Asthma o PCMH3A#2: Pharyngitis o PCMH3A#3: Childhood Obesity You may choose other conditions that are important in your practice, but please note that at least one condition MUST be related to unhealthy behaviors, mental health or substance abuse. For additional guidance, see the Conditions Selection sheet in the BizMed Toolbox tab. www.bizmedsolutions.com Page 3 of 15
BizMed Clinical Guidelines In your BizMed Toolbox you will find the following resources to assist you with formulating clinical guidelines for your practice: Examples of clinical guidelines from reputable sources for a variety of common conditions A complete reference to the ICSI up to date reviewed clinical guidelines Resource page with links to authoritative sources for other clinical guidelines Unit 4 - Assignment This week your assignment is to identify clinical guidelines for three important conditions in your practice: 1. Select three clinical conditions (one behavioral) important in your practice. 2. Designate a clinician in your practice to review the clinical guideline available in the BizMed Toolbox. 3. If your practice is currently utilizing clinical practice guidelines, review and verify that these meet the NCQA requirements. 4. If you choose to use a guideline template and modify it to your practice needs, please make sure that the modified document meets the current evidence. 5. Label and upload your guidelines to PCMH 3A in the BizMed Toolbox. Unit 4 Materials All materials are attached in the order listed below: Important Conditions Selection sheet Instructions for Reviewing Clinical Guidelines in BizMed Reviewing Uploaded Guidelines Accessing ICSI Guidelines Uploading Clinical Guidelines to the NCQA Dashboard Addendum: Labeling a Document for NCQA References 1. Clinical Practice Guidelines We Can Trust, Report of the Institute of Medicine of the National Academies, March 2011. http://www.iom.edu/reports/2011/clinical-practice-guidelines-we-can- Trust.aspx 2. Clinical Practice Guidelines Primer: Management Decision and Research Center Health Services Research and Development Service Office of Research and Development Department of Veterans Affairs In collaboration with Association for Health Services Research, 1998 http://www.hsrd.research.va.gov/publications/internal/guideline.pdf 3. Potential benefits, limitations, and harms of clinical guidelines, Steven H Woolf, Richard Grol, Allen Hutchinson, Martin Eccles, Jeremy Grimshaw BMJ. 1999 February 20; 318(7182): 527 530. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1114973/ 4. Cabana MD, Rand CS, Powe NR, et al. Why Don't Physicians Follow Clinical Practice Guidelines?: A Framework for Improvement. JAMA. 1999; 282(15):1458-1465. http://jama.jamanetwork.com/article.aspx?articleid=192017 5. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10(1):63 74 http://annfammed.org/content/10/1/63.full#ref-96 6. Bodenheimer T, Wagner EH, Grumbach K. Improving Primary Care for Patients With Chronic Illness. JAMA. 2002;288(14):1775-1779. http://jama.jamanetwork.com/article.aspx?articleid=195368 www.bizmedsolutions.com Page 4 of 15
Unit 4: Instructions Locating the Important Conditions Selection Sheet To access this document, log into your BizMed Toolbox account and navigate to the Toolbox tab On the left navigation panel click on the small grey triangles to the left of each folder in the order illustrated above to display the Conditions Selection Sheet. Click on the document to read, download or print. This document is providing a listing of all PCMH Standards, Elements and Factors affected by your choice of important conditions. Being aware of how these conditions are utilized throughout the PCMH recognition process, should assist you in making a selection that will facilitate subsequent activities. www.bizmedsolutions.com Page 5 of 15
Reviewing Clinical Guidelines in BizMed Log into your BizMed Toolbox account and navigate to the Toolbox tab On the left navigation panel click on the small grey triangles to the left of each folder in the order illustrated above to display the Diabetes guidelines materials. Click on any document to read, download or print. The document titled Diabetes Practice Guidelines Template is an editable Microsoft Word template that you can customize with your practice name and use in your practice (see preview below). www.bizmedsolutions.com Page 6 of 15
Accessing ICSI Guidelines The BizMed Toolbox contains up to date guidelines for a variety of conditions from the Institute for Clinical Systems Improvement (ICSI). To access these resources, navigate to the Toolbox tab, expand the Clinical Decision Support folder and click on the ICSI Guidelines link. Note: Please be patient, these documents are large and may take a few seconds to load. The ICSI guidelines are comprehensive, well researched and pertinent, and do contain algorithms and materials you can pull out and use in your everyday practice. For example, see below for an Asthma management plan from the Mayo clinic. www.bizmedsolutions.com Page 7 of 15
Uploading Clinical Guidelines to the NCQA Dashboard Once you have a clinical guideline that works for your practice, either an existing one that you are already using or a new one created from the materials supplied in BizMed, you will need to upload the document to your NCQA Dashboard. Note: Make sure your guidelines have authoritative references, are approved, dated and signed. To upload your guidelines, log into your BizMed Toolbox account and navigate to your PCMH project by clicking on the My Projects tab Note: If your practice has multiple sites, you will need to repeat this process for each site in your practice. In your PCMH project click on the name of the site you are working on. Next click on the Tools folder and finally click on the NCQA Dashboard www.bizmedsolutions.com Page 8 of 15
Navigate to PCMH 3 tab and click on the small grey triangle next to Element A and note that the uploaded documents column under Policies/Process is highlighted, denoting that you need to upload documents. To upload your guidelines, click the upload icon on the far right of each factor and follow the instructions below. Note: All documents submitted to NCQA must be labeled with the appropriate Standard and Element and should include some explanation for the reviewer. See Addendum at the bottom of this document for labeling instructions. Once you click the upload icon, a pop-up dialog will display www.bizmedsolutions.com Page 9 of 15
Click the Browse button to locate your Guideline on your local computer After you click on the Open button, your Windows Explorer will close. www.bizmedsolutions.com Page 10 of 15
Note that your Document path is now populated. If you want to use a different name for your document, you can type in the Document Name field, otherwise the original name will be used. Click the Upload button to complete the process. A green message will display to let you know that your document has been uploaded. Click on the X in the upper right corner of the dialog to close the popup and return to you NCQA Dashboard. Note that the Uploaded column for Factor #1 is no longer highlighted and it shows that 1 document has been up loaded. Continue to upload the remaining two guidelines following the same steps. www.bizmedsolutions.com Page 11 of 15
To subsequently view, edit, replace or delete uploaded documents click on the View Uploaded Documents link. A popup will display, listing all your uploaded documents for the current Element. When you are done, click the Submit Feedback link and let us know that you completed this assignment. www.bizmedsolutions.com Page 12 of 15
Addendum Labeling a Document for NCQA We will use our Diabetes Guidelines template for illustration. The diabetes template is a Microsoft Word document, and the instructions below can also be applied to Excel documents. If your document is already in PDF format and you do not have the tools to edit it, please let us know and we will label these documents for you. Step 1: Open the document in MS Word Step 2: Click on the Insert tab and after it displays, click on the Text Box icon Step 3: Select the Simple Text Box from the dropdown by clicking on it www.bizmedsolutions.com Page 13 of 15
Step 4: The text box will appear on your document, most likely in an odd location Step 5: Click on the dotted outer line of the text box. The line will turn solid and your cursor will look like a crosshair (patience may be required to get the right effect). Once you do that you can drag your box to a more sensible location by just sliding your mouse to the desired spot. Once there click on the box and using one of the little blue markers on its sides as a handle, resize the box to your needs. Step 6: When your box is of the right size delete the canned text and type what you need instead. You can use the Microsoft Word toolbar to color your box and text in very creative ways. www.bizmedsolutions.com Page 14 of 15
Step 7: Save your changes. Step 8: When all your changes are complete, please save your document as a PDF file before uploading to BizMed. Select PDF in the Save As dialog and leave the Document name unchanged. You are now ready to upload the document to BizMed. Please let us know if you need assistance with this or other issues. www.bizmedsolutions.com Page 15 of 15