Cover Page Menu Item: Population Management Name of Applicant Organization: Fremont Family Care Organization s Address: 2540 N Healthy Way, Fremont, NE 68025 Submitter s Name: Elizabeth Belmont Submitter s Title: Advanced Practice Registered Nurse, Director of Primary Care Clinics Submitter s E-mail: bbelmont@famc.org Executive Summary Fremont Family Care is part of Health Care Professionals which is a wholly owned 501(c) -3 subsidiary of Fremont Area Medical Center (FAMC). The mission of our organization is to improve the health and wellness of the people in the communities we serve. Fremont Family Care implemented eclinicalworks electronic medical record in October of 2010 and shortly after the initial implementation and go live began tracking and improving population health in our communities. This case study will describe the steps we took as a clinic to implement the electronic medical record, track our patients, and improve the health of the population we serve. Page 1
Background Knowledge In October of 2010 Fremont Family Care implemented eclinicalworks electronic medical record with the help of a EMR support team and Curas our support/vendor. The goal was to improve the care of the patients in the population we served. With the innovative forward thinking leadership team we embarked on EMR implementation to achieve this goal. The team began to develop population management and quality improvement goals. Within a year of implementation of the EMR we felt that we had enough data entered in to the EMR to begin this process. Population management has been something that Fremont Family Care has desired to accomplish for many years however without the technology it was virtually impossible. After the initial implementation and go live period was complete we began to embark on a process of population management. Initially our goal was to promote preventive health care knowing that frequently in health care our treatment is reactive, once a disease process has started, rather than preventive. Fremont Family Care felt we could make a difference by preventing disease processes if possible. Our goals were to increase the percentage of patients who had age appropriate screening testing including mammogram, colonoscopy, and pneumonia vaccine. The Nebraska Cancer Registry report from 2006-2010 indicated that cancers of the prostate, breast, lung, and colon accounted for more than half of the deaths in our state. Among women, breast cancer was the most common cancer diagnosis in Nebraska. The Centers for Disease Control report that if everyone age 50 and older had appropriate colon cancer screening we could prevent 60% of colon cancer. With this knowledge we felt that by promoting preventive health care we could hopefully prevent some of these cancer deaths or at least identify cancer at a stage where it would be treatable. Given this data we as a practice embarked on a mission to improve the health and wellness of the people in the communities we serve. We decided we would notify each patient that they were due for one of these screening tests and recommend they contact us to schedule an appointment. Local Problem and Intended Improvement The most recent data in Nebraska indicates that cancer is the leading cause of death surpassing heart disease. Our goal was to prevent as many cases of preventable cancer as possible. Our practice knew the best way to accomplish this goal was to get our patients age appropriate cancer screening. The problem was how do we contact those patients we don t see frequently or who do not have a scheduled follow up to remind them that they are due for cancer screening. Engaging our patients in their health care had been something that was difficult utilizing the paper chart. Patients were lost to follow up as we had no reliable method of tracking or following up with these patients. With the implementation of eclinicalworks we had tools that allowed us to track, monitor, and contact these patients that were reliable and accurate. The EMR allowed us to search using the registry feature a list of patients who were part of a specific age group who had not had specific cancer screening or immunizations in the appropriate time frame. We were then able to develop a letter that could be sent to the patients by mail or electronically using the patient portal indicating they are due for cancer screening and asking them to contact our practice to schedule. Page 2
Design and Implementation After our initial go live in October of 2010 the providers now had instant access to the patient s past results, all tests following go live were ordered within the EMR and could be tracked. We scanned in past results so they were available for review during the patient s appointment. Ordering tests in the EMR made them searchable and we were able to begin to build our database indicating where we were missing opportunities for scheduling or recommending cancer screening. The practice also implemented education process for providers and staff on Clinical Decision Support System (CDSS). This tool alerts providers and staff if the patient is due for age appropriate preventive screening as well as certain chronic care management items. We began to have nursing staff check the CDSS and implemented standing orders based on CDSS alerts. This process was completed during each morning and afternoon team huddle. The clinical staff would then write in the chief complaint what the patient was due for to remind the provider to discuss this with the patient. We also implemented standing orders using the CDSS allowing the clinical staff to order a mammogram, discuss colonoscopy, or administer pneumonia vaccine if it was indicated that they were due by CDSS. This eliminated barriers for clinical staff members waiting for an order from the provider and increased efficiency within our practice. As a practice we then began to identify patients who had abnormal testing and needed more frequent follow up. We struggled with a process of identifying this specific patient population and contacting them for follow up. The EMR leadership team developed a process of using the action feature in the EMR to bridge this gap. The EMR leadership team educated staff and providers on this process and implemented the use of actions to follow up on those patients who needed more frequent cancer screening. The actions are created for each specific patient indicating the abnormality and when follow up is due, they then remind providers/staff when the timeframe for follow up has lapsed. The provider or clinical staff member will start a new action for example if the patient has an abnormal mammogram that needs repeat in 6 months. This action would be dated 6 months from the abnormal mammogram date and assigned to the clinical staff member who would then get an order to repeat mammogram from the provider. This process was very beneficial in tracking and keeping follow up with those patients. This process the paper chart was nearly impossible and we relied heavily on the patient to come back or call to schedule appointments. This was an inefficient process and erroneous process. The actions allowed us a reliable feature to track and manage our patients efficiently and effectively. Our practice then began to use the registry feature to create lists of patients who were due for cancer screening, create letters, and send them to the patient s home indicating they should call for an appointment. We started with preventive care but then this grew to include chronic care reminders as well. We began to remind patients who were due for hemoglobin A1C, hypertensive s due for blood pressure check, and patients who had not been seen in more than a year. This was highly successful. We would send these letters initially through the mail and people would create appointments or contact the office to schedule the appointment or test. This was a successful way for us to implement change by tracking patients who may have otherwise been lost to follow up. The number of letters initially was large and our practice saw an Page 3
opportunity to communicate with our patients electronically. In we implemented patient portal where we could communicate with our patients electronically. The patients were also able to see preventive care reminders on the patient portal. We were able to then send their reminder letters electronically. As a practice we began to measure the results of our efforts by tracking the percentage of patients who had the age appropriate screening. We reported this data at the provider level. These results were shared across the clinic with the staff and providers regularly. This helped remind providers and clinical staff of the need to offer cancer screening to their patients. This initiative was a success and we began to see steady improvement in the percentage of our patient population who had obtained cancer screening. Utilization of Health IT The EMR was essential in us developing and executing population management using these quality goals. Tracking improvement or even developing a patient list was impossible in the paper chart. We used the EMR to compile data to create our patient list and the EMR to create patient letters. The addition of the patient portal to electronically communicate with the patients was also beneficial in increasing patient engagement and reminding the patient in real time of preventive health care they may be due for. The EMR was also used to determine numerator and denominator of those patients who have had screening. This data is then reported across the practice and among the providers. This has been helpful in keeping cancer screening top of mind for our employees and helped to allow our staff to celebrate the success of improving their scores. All of this data would not have been available in the paper chart. The EMR has truly allowed us to provide better care to our patients in the community we serve. Value Derived The implementation of eclinicalworks EMR has been invaluable to us as a practice. Our practice has used the EMR to manage our populations. See Core Case Study: Clinical Value for additional details. We have seen an improvement in the percentage of our patients who have received cancer screening by sending registry letters and electronic communications and reminding providers and clinical staff of the importance of cancer screening. We have also seen great benefit in use of the actions within the EMR. This allows us to remind ourselves when the patient is due for repeat mammogram or colonoscopy if it is before the regular timeframe due to polyps or other abnormality. This has been very helpful and popular among our staff and providers. This has also increased patient satisfaction as we are now being more proactive in their care rather than reactive. We have seen a substantial benefit in implementation of the EMR. We have continued to demonstrate increased percentage of our patients being screened for cancer. We also track and follow up on chronic care quality initiatives which has been very beneficial to our practice. We have currently been tracking diabetes, hypertension, and preventive care as outlined above. Page 4
These results are reported to the providers and across the practice which has also been helpful in tracking and identifying gaps between our goals and our performance. Lessons Learned Implementation of an EMR system is a challenge across the practice however it is a much better way to care for our patients. Starting from paper charts and converting to electronic medical record is a challenge for staff and providers. It is essential to have a strong EMR leadership team with clinical background. This team can lead the initiatives you develop. At our practice a nurse practitioner along with the administrator and community EMR specialist (RN) developed and tracked improvement as well as created and implemented improvement plans. The implementation of quality goals are extremely important in improving the care of your patient population. Provider/physician buy-in to improving care is also essential. Ensure that you are able to accurately extract the data you need to report on the goals and to send the letters. Initially this process was burdensome for us as we created the list of patients who were due for preventive health care however as not all of the data was in the EMR as structured data yet we went through each electronic chart on this list to ensure that the patient was in fact due for the testing. There were still cases where a patient received a letter and wasn t due for the testing. Our practice took the approach that it would be better to remind the patient twice rather than not at all. We then were able to develop a numerator and denominator for the entire practice and per provider. Reporting performance across the practice by provider and sharing with the staff has been extremely beneficial to benchmark the clinical teams and improve performance. This allows us to identify gaps in our performance compared to our goals. The data was reported individually as well as at the staff and provider meetings. Reporting the data at this venue was helpful in brainstorming ideas for improved workflows and/or identifying areas for improvement that would drive better care. Creating clinical teams composed of regular assigned clinical staff and the provider is beneficial as the they work as a team and improvement in performance can be directly related back to this team. This allows the clinical staff and providers to celebrate their successes and take pride in improvements they make. Our teams consist of two clinical staff members per physician and one clinical staff member per APRN and PA. Our workflow includes development of strong clinical quality goals, educating staff, creating teams, and sharing the Page 5
data. We have seen improvement in all of our goals and we continue to routinely report on these goals and modify workflows as necessary. Financial Considerations Fremont Family Care s initial investment in the EMR has been detailed in the ROI core case study. The additional costs include staff training including paying wages outside of patient care hours. This time has not been significant as training is typically added in to our monthly staff meetings. Our nurse practitioner has been the clinical quality leader for our practice. There has been additional overhead for using her as a resource outside of patient care hours to develop, implement, train staff, and report on the quality measures. Seeing real time data demonstrating improvement in clinical measures and population management is something that is invaluable to the practice and the population we serve. The financial return on investment for these measures has been in additional revenue from increasing the number of pneumonia vaccines administered. We also realized a return in investment by increasing the number of colonoscopies performed by the two physicians within our practice who perform colonoscopies. We did not see a financial return on investment by increasing the percentage of our patients who had a mammogram as our practice does not perform the actual mammography testing. However, our practice felt the benefits of proactively notifying patients, training staff, and sending letters to patients far outweighed the cost associated with this. As a practice we saw a significant increase in the percentage of patients who had received a colonoscopy. We tracked patients age 50-75 who had a colonoscopy in the last 10 years. Initially our practice did not do so well with only 37% of our patients having a colonoscopy. Over the last 3 years the percentage of patients who have had a colonoscopy has climbed to 70%. Percentage of patients age 50-75 who have had colonoscopy 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 37% 43% 42% 45% 45% 49% 48% 57% 56% 63% 64% 66% 65% 2014 70% 2014 Financial Reimbursement for Colonoscopies Performed Page 6
$ 243.00 $ - $ 1,542.22 $ 720.55 $ 592.00 $ 1,032.32 $ 2,972.27 $ 2,850.64 $ 7,731.39 $ 8,819.31 $ 18,048.37 $ 18,146.88 2014 $ 21,923.61 detailed below. The financial return on investment is detailed in this table. As a clinic Fremont Family Care has realized increased revenue each quarter with a substantial increase from to 2014. The financial reimbursement continues to grow each quarter. Fremont Family Care also saw an increase in revenue by increasing the percentage of pneumonia vaccine given to our patients age 65 and older. Initially the percentage of patients who had received a pneumonia vaccine in was 56%, over the course of 3 years this percentage has risen to 75% as 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 56% 58% 56% 58% 58% 60% 58% Patients age 65 and older who have had a pneumovax 64% 69% 71% 71% 71% 72% 75% 2014 2014 Financial Reimbursement for Pneumonia Vaccines Administered $ 328.60 $ 149.19 $ 859.61 $ 1,460.76 $ 114.38 $ 511.71 $ 712.03 $ 3,708.38 $ 2,831.25 $ 2,434.04 $ 3,586.25 Page 7
$ 2,852.07 2014 $ 583.25 Financial return on investment has been realized as well by administering more pneumonia vaccines as detailed here. The increase is somewhat seasonal as many of these patients were given pneumonia vaccines around the season for influenza vaccines. We have also noted a decline in reimbursement in the last quarter which we suspect is partially attributed to the season but may also indicate that as more of our patients are vaccinated the demand will begin to decrease. Fremont Family Care did also increase the percentage of patients age 50-74 that had a mammogram in the last 2 years. These patients were contacted using the same procedure as those patients who needed colonoscopy and pneumonia vaccine. We did see a return on our investment in terms of quality with the mammogram measure but not a hard dollars and cents return on our investment. Screening Mammogram for Women age 50-74 100% 80% 60% 40% 20% 0% 20% 28% 33% 35% 38% 39% 42% 43% 48% 48% 49% 50% 54% 55% 56% 2010 2014 2014 Page 8