Davies Ambulatory Award Community Health Organization (CHO) Name of Applicant Organization: Community Health Centers, Inc. Organization s Address: 110 S. Woodland St. Winter Garden, Florida 34787 Submitter s Name: Kim Barkman Submitter s Title: Director of Clinical Informatics Submitter s Email: k.barkman@chcfl.org Core or Menu Item: Core Case Study Clinical Outcomes/Patient Centered Medical Home Executive Summary: Community Health Centers Inc. s (CHC) mission is to provide quality and compassionate, primary and preventive medical, dental, and pharmaceutical services to Central Florida s economically and culturally diverse communities. CHC is a patient-oriented organization providing special assistance to the medically underserved, uninsured, and at risk populations of Central Florida. Established in 1972, Community Health Centers has built 11 medical and dental centers throughout several counties, serving 53,610 patients annually. In looking to the future for how to best provide and improve the quality, safety and efficiency of care within the organization, CHC turned their focus to the Patient Centered Medical Home (PCMH) model. The CHC Quality team then embarked on a journey to implement PCMH programs to support patient care planning, patient care coordination, chronic disease management and patient engagement. To achieve the outlined goals of becoming a PCMH, the team worked to establish processes for how to most optimally utilize the Electronic Health Record (EHR) to meet the patient centered standards for the delivery of primary care.
1 Background Knowledge CHC provides comprehensive services including medical and dental care, health education and promotion, health assessments and screening, pharmaceuticals, laboratory, and X-ray services. These services are provided by a combined total of 62 physicians, dentists, ARNP s, and hygienists that include providers who are board certified in Family Practice, Pediatrics, Obstetrics/Gynecology, Internal Medicine and Optometry. CHC has approximately 400 employees, with most based at the centers providing patient care, as well as administrative support teams. All provider disciplines and staff members utilize a single integrated EHR. The use of a single EHR at CHC allows for patient clinical care information to be collected, stored, managed, and shared across care teams and among providers. The requirements for achieving medical home recognition in accordance to the National Committee for Quality Assurance required that CHC meet the standards of: 1. Ensuring patient access to care during office hours and after. 2. Identification and management of patient populations through the utilization of data for disease management. 3. Documentation of patient care coordination. 4. Patient engagement. 5. Tracking and follow up documentation for labs and referrals. 6. Quality improvement reporting. Embedded in each of the 6 requirements for medical home recognition are elements that provide the baseline for how to best manage the patient s needs. The following elements for patient centered medical home recognition are where CHC focused their attention related to the use of the EHR: Access to care during office hours and after hours. Patient access to electronic health information. Provide patients with an electronic copy of their after care summary. Documentation of planned care through pre visit planning. Identification of patients with important diagnoses and conditions in practice. Exchange clinical information among providers. Identification of patients with care gaps and care needs to send reminders for preventive and follow-up care to patients. E prescribing of medication. Computerized physician order entry of medication and labs. Tracking, flagging and follow up for labs, referrals and diagnostic imaging. Maintaining up to date and active list of patient diagnoses. Medication and drug allergy interactions. Clinical data reporting. Electronic chart documentation. Managing care coordination during care transitions.
2) Problem identified and Intended outcome CHC s main objectives in undertaking this initiative were to improve patient care and provide the best quality of healthcare services to our patient population. A gap analysis review was conducted which included an assessment of documentation in the EHR related to each of the standards and elements required for patient centered medical home recognition, use of the EHR functionality, and interviews with staff related to documentation processes. As a result of this review, CHC identified several problem areas. CHC did not have standardized processes for documentation in the EHR for patient education, patient engagement, patient care management and patient care coordination. Inconsistencies of patient care management documentation caused quality reporting and evaluation to not be accurate. CHC s initial baseline for documentation of self management goals was 26.57% in 2012 for patients with diabetes and 50.89% for self management goal documentation in 2012 for medication adherence. As of March 2014, self management goal documentation has improved to 94.12% for patients with diabetes and 60.07% for documentation of self management for medication adherence. During March through May of 2013, the baseline for pre-visit planning documentation in the EHR for planned care outcomes for patients was an average of 49% with a target goal of 75%. As of May 2014 CHC documentation of pre-visit planning in the EHR for planned care was at 99%. PVP chart audits 2013 2013 2013 2013 March April May Average Manual Chart Audits PVP completion rate 21 39 42 34 Charts Audited for PVP 70 70 70 70 % of completion 30.00% 55.71% 60.00% 49.00% Target 75% 75% 75% 75% 2013 2013 2013 2014 2014 2014 2014 2014 Oct Nov Dec Jan Feb Mar Apr May PreVisit Planning Completed 5130 7315 7925 9091 7808 8174 9210 8788 Appointments scheduled within 24 hours and that meet the requirement for PVP 5594 7419 8069 8929 8665 8733 9491 8856 % of completion 92% 99% 98% 102% 90% 94% 97% 99% Target 75% 75% 75% 75% 75% 75% 75% 75%
Documentation of pre-visit planned care was not consistent in the EHR and was difficult to report. Patients were sometimes not contacted for needed preventative care or follow up due to non structured care management documentation processes. Prior to the implementation of the pre-visit planning (PVP) process, the average rate of patient contact for planning care was 49% (March thru April of 2013). Information was often missing from the electronic health record for timely review by clinical staff and providers due to inconsistent care coordination. CHC did not have a documentation process for patient care planning. CHC also identified that the organization was not optimizing its use of the EHR system for reporting, and improvements could be made to the following areas: Clinical data reporting through the use of Meaningful Use Assessment Quality (MAQ) dashboard. Identification of care management and care gap needs by using the evidenced based clinical decision support tool and diagnosis related care alerts. Identification of care management and care gap needs by using the system functionality to create evidenced based clinical decision support tools. Staff who were directly involved in the patient centered medical home project included the Chief Medical Officer, Medical Providers, Corporate Director of Nursing, Assistant Director of Nursing, Center Administrative Leaders, Director of Compliance and Performance Improvement, Director of Clinical Informatics, Medical Assistants, License Practicing Nurses, and the Referral Manager. 3) Design and Implementation Standardized of processes for documentation in the EHR for patient education, patient engagement, patient care management and patient care coordination. The CHC patient centered medical home project team identified that the first step in standardizing documentation processes within the EHR to improve the quality of care and to meet the requirements of patient centered medical home, was to develop templates within the EHR to guide documentation. Templates were developed for pre-visit planning, self management and elder care (activities of daily living).
Pre-visit Planning Template The purpose of the pre-visit planning template is to assist staff in planning, coordinating and managing patient care more efficiently. Documentation in the pre-visit planning template required staff to document for each component the completion, not clinically relevant or needs addressing status for the following EHR patient care items: Labs Diagnostic imaging Immunizations Referrals Telephone Encounters Clinical Decision Support identified care needs for the patient Diagnostic, Procedural, Lab, Diagnosis, Meaningful Use or patient specific Alerts Patient Documents Action Jelly Beans Care Gaps Notes identified from managed care reports Self Management Template The Self Management template was developed for increasing patient engagement and improving chronic disease management. The EHR allows practices to set up alerts via Diagnosis, so CHC used this tool to develop a Self Management Alert to inform staff which patients needed the Self Management goal completed. For each patient who is identified based on the at risk disease (Hypertension, Diabetes, Asthma, Obesity), the self management template would be pulled into the progress note of the EHR for documentation of self management activities and goals for the patient. The self management goals documented within the template are related to areas concerning the monitoring and management of patient care such as diet, physical activity, and medication adherence. Also disease management parameters are included such as diabetes testing, monitoring of glucose levels, monitoring of blood pressure, and avoidance of asthma triggers.
Elder care (ADL) Template The Elder Care template was developed for over 65 well male and female patients. A practice alert is also associated with this template to inform staff which patients need the goal completed. The focus of this template is on recording level of activities and need for assistance. 4) How was Health IT Utilized? CHC developed a written procedure to clarify when PVP s and Self Management goals are to be completed and the use of the templates. CHC also conducted retraining to emphasize that self management goal documentation was the role of the entire care team. Each staff meeting PVP s and Self Management goals are discussed and emphasized with staff. CHC utilized the health information technology system to develop alerts and templates within the EHR to guide documentation. The alerts are patient specific/practice specific diagnosis driven reminders used in conjunction with the embedded CDSS to assist staff in knowing what is due for the patient. The templates include prompts to provide ease of navigation for the staff to complete the documentation required for patient care planning, management and coordination with as few clicks as possible. Patients at CHC who are identified as needing patient care management based on the documentation in the problem list that the patient has a chronic care condition such as diabetes, asthma, hypertension or obesity will have self management goals developed to assist the patient in effectively managing their own care. Self management goal documentation is documented in the EHR via a template to assist the patient in identifying achievable goals and targets for their every day management of their chronic care disease. There are three areas that self management goals may be developed which are medication compliance, diet and exercise. This is based on the individualized needs of the patients and needed care management for effectively managing their chronic care disease.
When self management goals are set, documentation will indicate if the goal is a new or previously set goal for the patient. CHC utilizes the Practice Alert functionality in the EHR to alert staff of patients with a chronic care condition that requires the development or review of self management goals. The Self Management Alert will trigger on ANY patient, regardless of age, based upon assessment of Diabetes, Hypertension, Asthma or Obesity. If a patient has a combination of these, the Self Management alert will appear multiple times. However, satisfying ONE of the alerts will satisfy all of the alerts for the need for self management goal documentation for the patient. In this CDSS example, a patient who has been previously diagnosed with Hypertension is showing in red as noncompliant. The CDSS configuration for this alert is:
This workflow allows the option for staff to alert the provider via the PVP notes. In addition, the provider could also see this alert themselves by accessing the CDSS tab in the progress note when face to face with the patient. This alert would indicate to the provider to further discuss the diagnosis of hypertension with the patient. The EHR was also used to leverage its functionality of certain features that included the MAQ dashboard, patient education, alerts, and clinical decision support. The alerts and clinical decision support system of the EHR was designed to be used by staff to improve the quality of care by providing warning of potential adverse drug reactions from two medications being prescribed, provided reminders to staff about preventive screening exams and care opportunities for the patient. Each month reports are generated from the eclinicalworks Meaningful Use Adoption Quality (MAQ) dashboard. The MAQ dashboard generates reports on a monthly basis and the performance outcome data is displayed by the aggregate denominator and numerator for each performance measure, based on the documentation of information in a reportable format in the EHR. The MAQ dashboard reports are reviewed and monitored by the Director of Quality and Performance Improvement on a monthly basis for the identification of trends and opportunities to improve. The identified trends and opportunities to improve are then shared with the Quality Improvement Committee and focused efforts for continuous quality improvement. Efforts taken for improvement are the adjustment of workflows, review of process in monthly clinical performance meetings at each center location by the Assistant Director of nursing and highlight of the opportunity to improve in the staff newsletter. CHC also utilizes the wiki, an online searchable database of CHC information to include policies, procedures, training materials and processes to engage staff in improvement efforts.
The patient education tool embedded within the EHR provides education materials to the patient based on the assessment/diagnosis code chosen by the provider. The education provided to the patient during the course of the visit is also documented in the treatment section of the electronic progress note. It is also indicated on the Clinical Visit Summary the patient is given at the conclusion of the visit. In addition, if the patient has chosen to use the active Patient Portal, the education can be published to the portal for later review by the patient. 5) Value Derived/Outcomes Post implementation of the PCMH programs, the CHC percentage of patients with documentation of pre-visit planning rate is 95% of all patients with scheduled appointments.
CHC current rate for documentation of self-management goals is 56% for patients with diagnosis of a chronic care disease. CHC has seen significant improvement in adherence to best practice and a resulting improvement in the morbidity of our population. Since implementation in January, 2012, the percentage of hypertensive patients treated by CHC with the blood pressure under 140/90 has improved from 39.97 % to 62%.
Through improved documentation and the use of alerts and the MAQ Dashboard to identify atrisk patients, the actual % of patients aged 5 through 40 diagnosed with persistent asthma who have an acceptable pharmacological treatment plan has increased from 61% in 2012 to 84% in 2014. As a result, the percentage of patients that adhere to the treatment plan that have suffered severe asthma has decreased from 19% in 2012 to 6.5% in 2014. Other improvements have included A1C testing for patients with a diagnosis of diabetes as well as medication management for patients with coronary artery disease.
6) Lessons Learned Engaging leadership In the beginning of the process, to understand what procedures and standards a Community Health Center practice must follow in order to obtain recognition as a PCMH is complex. It requires engagement at the highest levels of the organization. Key to this level of engagement is getting early buy-in from the Providers to drive the care team approach. Our organization was able to get a good foundation in place to implement the programs but found additional responsibilities and procedures needed to be defined as the program matured. Clearly define level of effort required for effectively using templates We did train all care team members on the new templates. They were familiar with how to access them, how to navigate through the questions and how to provide the structured data responses. What we did determine is we could have better defined when to use the templates and provide more details on what type of patient and when. This was quickly improved once the problem was identified. Frequency of monitoring Our initial plan was to pull supporting data on a monthly basis to determine our progress with the target initiatives. But we found that in order to effectively make changes early in the adoption phases we needed to look at results weekly for the first few months to impact change.
7) Financial Considerations No capital funds were required for this initiative, but the design and development of the PVP templates involved a total of 12 hours of time from the informatics team to complete the steps of the development cycle. The total cost associated with the development of the templates is estimated at less than $1,000.00. This was a one time cost that included all the design, the development and the implementation phases to get the templates activated on our platform. This was done internally with our Informatics team and did not require the assistance of the EHR vendor or any outside party. The functionality to build these templates already resided in our EHR and did not require any additional licensing, software or hardware costs. Currently the templates are available for CHC users only but could be easily developed by other organizations using the same methodology. Training staff on how to use the templates was a separate cost. Staff members required a one hour overview and training on the new initiative and templates. This was done on site via classroom instruction. Training was mandatory and involved approximately 300 employees for an estimated cost of $10,000.00. This was a one time cost, with PVP training now being included as part of the EHR curriculum training that each new team member receives when coming in to the organization.
The corporate benefit of establishing this standardized approach to pre-visit planning has been improved clinical outcomes that contribute to quality incentive dollars associated with those measures.