Cover Page Core Item: Clinical Outcomes/Value 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). In 2010 Fremont Family Care evaluated different electronic medical record vendors and ultimately chose eclinicalworks. Our practice chose eclinicalworks due to its ease of use, ability to customize workflows, patient recall and registry features, as well as preventative health care and patient specific alerts. Our organization chose to go live with the practice management portion of eclinicalworks in July of 2010. This allowed us to enter patient demographics and start to build our patient population in the system. Our clinical staff and providers were trained on eclinicalworks and our practice went live October of 2010. Since October of 2010 Fremont Family Care has realized a significant return on investment both from a financial perspective and patient care perspective. Using the EMR we are now able to track and report on quality measures which was virtually impossible utilizing a paper chart. Fremont Family Care Core Item: Clinical Outcomes/Value Page 1
Background Knowledge Located in Fremont Nebraska, Fremont Family Care serves patients of all age groups. The practice consists of four full time family practice physicians, one physician assistant, and a nurse practitioner. One of the family practice physicians is a gerontologist serving mostly geriatric population. The three other physicians, physician assistant, and nurse practitioner serve a more diverse population. Our population is predominantly English speaking however we do have a large Hispanic population. Our clinic employs two full time interpreters. We staff two outlying rural clinics in North Bend and Dodge Nebraska. The patients served at these clinics would frequently travel to Fremont for illnesses or follow ups if the rural clinic was closed. This posed a challenge for our practice as their information was stored in a paper chart at the facility. This paper chart environment created issues related to access to these patient medical record. We had no way to access it unless the office was open. The paper charts was becoming more burdensome as we were not able to track quality patient care, set goals for our practice, or effectively monitor patients. In October of 2010 our practice implemented an electronic medical record to address these issues. Fremont Family Care serves a wide variety of patients from different economic backgrounds and age ranges as demonstrated below. 02.54% 02.42% Local Problem and Intended Improvement The goal of EMR implementation through eclinicalworks was to improve quality health care, track outcomes, and improve the health of the patients we serve. We wanted to be able to set quality metrics for our practice, track our progress, and improve the patient outcomes. Using the paper chart we were unable to even establish baseline data on the quality of care provided by our providers. An accurate medication list was a significant burden in the paper chart. Keeping an accurate medication list was a daunting and ineffective process. The use of the EMR for medication reconciliation and eprescribing has helped us to accurately document while reducing medication errors. We also had no way of tracking preventative health care, no shows, or perform patient recall. With the EMR we have been able to track preventative health care using the registry feature and send electronic notifications and letters to patients who are due for preventative testing. We have also been able to establish baseline metrics showing how well we are caring for our patients with chronic medical problems. We have set preventive health care quality goals in regard to preventative health care and management of our patient population. Fremont Family Care Core Item: Clinical Outcomes/Value Page 2
The EMR has allowed us to notify patients who were due for testing or follow up visits based on their diagnoses/problem list. The EMR has allowed us to coordinate care in our patients with chronic medical problems. The implementation of the EMR has been essential in us to fulfill our mission to improve the health and wellness of the people in the communities we serve. Our goal to improve quality care for our patients has been realized and we are able to show this data to our providers and outside organizations. Design and Implementation After considering the options of implementation our leadership team chose to utilize a third party Curas to provide our eclinicalworks software support and implementation. FAMC hired a nurse to serve as the community EMR specialist to assist with EMR implementation and support following implementation. An EMR implementation team was developed that was composed of mangers, nurses, and a nurse practitioner. After the initial EMR implementation our implementation team devised a plan to implement clinical decision support among the providers. Initially we focused on the providers only and we saw a slight increase in preventive health care of our patients. Our practice began using the registry feature of the EMR to identify patients who were due for certain preventive health items these included mammogram, colonoscopy, and annual exam. We identified these patients and a letter or electronic message was sent letting them know that they were due for this screening or exam and they were asked to contact our office to schedule. Initially, this process was challenging, but ultimately gained popularity among our patients and staff. We then expanded this registry search to include patients with certain medical conditions including diabetic patients who had not had a hemoglobin A1C in the last 6 months, hypertensive patients not seen within the last year, and patients with hyperlipidemia who had not had a recent lipid panel. This was greatly successful. These patients began to make follow up appointments. This was a huge success for our practice as these patients would otherwise likely have been lost to follow up. Through this process we were able to re-engage these patients in their health care. We began to measure our progress on these items. We tracked by provider the percentage of patients (per national guidelines) who had a mammogram, pneumonia vaccination, or colonoscopy. These percentages were placed on a graph and displayed on communication boards in the clinic and provided to the providers. This sparked competitive behavior and nurses became involved in making sure we recommended mammograms, pneumonia vaccinations, and colonoscopies to our patients when it was indicated. At that time we also implemented the CDSS alerts as standing orders for nursing staff. We also began to track and report data on chronic care items as well. The first year we tracked blood pressure control among our diabetic patients and this data was pulled every month using a registry search and compiled, placed on a graph, and reported. This data was also reported to the Fremont Area Medical Center quality committee. We also reported data in the same fashion on patients age 65 and older who had a pneumonia vaccine previously. The reporting of this data was exciting for staff and providers to be able to track and see the difference we were making in managing our patient population. The past year we have been measuring and reporting to the FAMC Quality Committee the percentage of patients age 18-65 with a hemoglobin A1C less than 7.0. Without an EMR we would not have been able to track, manage, and improve the health of our patient population. We have seen substantial improvement in our initiatives and goals over that timeframe. Fremont Family Care Core Item: Clinical Outcomes/Value Page 3
Utilization of Health IT Following initial go live workflows were adjusted and modified as necessary until we achieved the best patient/staff flow for our practice. Initially to address inaccuracy of the paper chart we educated the patients during appointment reminder phone calls and requested they bring all of their prescription bottles to their appointment to ensure we had accurate data entry of their current medications. The clinical staff keyed this information into the EMR as well as the patient s smoking status, relevant additional medical, surgical, and family history. This was then reviewed and verified by the provider. This process was burdensome and time consuming in the beginning but taking this additional time in the beginning afforded us to provide better care to our patients as we ensured that the data that was entered was accurate to the best of our ability. We also began eprescribing prescriptions immediately. We requested all pharmacies send refill requests electronically. This allowed our practice to respond to refill requests quicker than in the paper chart and also provided drug interaction check and documentation of refills in the EMR. This freed up additional nursing time as they no longer had to track down charts. Due to changing workflows with the EMR, we implemented a process of nursing staff checking the patient out, printing out the visit summary, and going over it with the patient. This was a change in workflow for us, but has worked out wonderfully as the patient is then able to ask questions to a clinical staff member before they leave. I believe this has increased our patient satisfaction as well. Following implementation and after the clinical teams were comfortable and all data was being captured in the EMR we implemented two clinical quality improvement measures. We started with tracking our diabetic patients with a goal to improve blood pressure control in those patients. Our second goal was to increase the percentage of our patients age 65 and older who had a pneumonia vaccine. We used the registry feature of the EMR to search for these patients which provided us a list of these patients. We were then able to determine the numerator and denominator for these. This allowed us to calculate percentage of our patient population. This was exciting for our staff and providers to see this data as this was something that would not have been available in the paper chart system. We then began to implement more clinical quality improvement measures. This year we are tracking hemoglobin A1C control in our diabetic population age 18-65. We also have teamed with CMIRO of Nebraska s Million Hearts Initiative and report quality data across Nebraska on a quarterly basis. This data is all shared with the providers and clinical staff. This data has allowed us to evaluate our workflows and modify where necessary. For example with the pneumovax clinical quality goal we implemented standing orders using the CDSS alerts for nursing staff. This allowed nursing staff to administer the pneumonia vaccine for those patients who were due. The nursing staff and providers were educated and began to use the CDSS alerts which allows them to see in real time the testing the patient is due for. We were able to implement standing orders for the nursing staff using these alerts. This has been successful in increasing the preventive health care provided to our patient population. Fremont Family Care began a process of looking at quality data in early shortly after our EMR implementation. We determined that at baseline only 56% of our patient population had received a pneumonia vaccination. This percentage did not seem to significantly improve over the course of fiscal year. To address this Fremont Family Care set a goal during fiscal year to increase the percentage of our patient population age 65 and older who had been Fremont Family Care Core Item: Clinical Outcomes/Value Page 4
vaccinated against pneumonia. To accomplish this goal we initially used the registry feature of eclinicalworks to determine our baseline percentage. The registry feature allowed us to search our patient population age 65 and older who had an office visit in. We then used the registry to determine the percentage of patients who had received a pneumonia vaccine by provider. This information was distributed among the clinical teams and across the clinic. This information was shared with staff at the staff meetings as well. We then used the registry to develop a list of patients who had not previously received a pneumonia vaccination. We used this list to send a notification to the patient that they were due for pneumonia vaccination. We used the registry to send either a letter or an electronic message to the patient. We implemented standing orders for clinical staff using the CDSS feature of eclinicalworks. By seeing the data by clinical team the clinical staff became more engaged in the process. We continued to use the registry feature to determine the percentage of our patient population who received a pneumonia vaccine by provider and reported this across the clinic and to each clinical team monthly. This process allowed us to determine which clinical teams needed more education on the process. This process continued over the course of fiscal year and we were able to increase the percentage of our patients who had received pneumonia vaccination from 58% to 71%. Our practice implemented a patient portal to share secure electronic information with our patient population. This has been a successful endeavor in allowing the patient to be more engaged in their healthcare. Patients are able to track lab and radiology results, view medications, request Fremont Family Care Core Item: Clinical Outcomes/Value Page 5
refills, view visit summaries, view patient education published to the portal, request appointments, referrals, and communicate electronically with the practice. The data we were able to obtain from the EMR and the chronic care reports for use in diabetic patients allowed us to evaluate our management of our patients and make modifications in our workflows and increased awareness of clinical staff members of the goals and our progress toward those goals. This quality improvement would not have been possible using the paper chart system. 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. We began tracking progress on our initial two goals blood pressure and hemoglobin A1C control in diabetic patients and pneumonia vaccination on a monthly basis. We would report this data to FAMC s Clinical Quality team, to the providers and clinical staff, and across our practice. This data has continued to be tracked and demonstrates the improvement we have made as a practice in increasing our percentage of patients who received pneumonia vaccine and diabetic patients with controlled blood pressure. We continue to add new measures to this. Our data is reported to CIMRO of Nebraska quarterly and then we are compared to other clinics across the state of Nebraska. It has been very beneficial to benchmark our patient care internally and externally. This has helped providers increase awareness of the guidelines and standards as well as strive to provide the best patient care possible. 100% 80% 60% Patients age 65 and older who have received a pneumonia vaccine 69% 71% 71% 71% 72% 75% 56% 58% 56% 58% 58% 60% 64% 58% 40% 20% 0% In order to determine the outcome associated with the improved process associated with increasing pneumonia vaccination, Fremont Family Care partnered with Fremont Area Medical Center (now Fremont Health) in fiscal year to track and improve hospitalizations for pneumonia. Fremont Health began to collect data identifying patient admissions and shared admission rates specifically for Fremont Family Care patients. We were able to use this data to demonstrate that as we increased the percentage of our patients who were vaccinated against pneumonia our hospital admission rates for pneumonia decreased. Fremont Family Care Core Item: Clinical Outcomes/Value Page 6
As result of the CDS-enabled workflow and analytics functionality described in greater detail in the FFC Population Management case study, we observed a significant improvement in the number of diabetic patients who are keeping their hemoglobin A1C under 7. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of diabetic patients 18-65 with hemoglobin A1C <7.0% 36% 39% 41% 45% 36% 36% FFC was able to demonstrate slight decrease in overall cost of our diabetic patients. The graph demonstrates as hemoglobin A1C control improved there was a decrease in cost to the patient. Fremont Family Care Core Item: Clinical Outcomes/Value Page 7
We also started sampling our patient population using the CG-CAHPS survey for patient satisfaction. This data is reported to the providers and staff on a quarterly or semi-annual basis depending on number of returned surveys. This data has lead us to improve our quality of care. Our practice began using The Studer Group to educate our staff on AIDET and techniques to improve our communication with our patients. The EMR has allowed us to track and improve patient satisfaction. Without the EMR the data needed to survey patients would not be available. Care coordination of our patient population has also improved. Using the registry feature of the EMR we are able to query our patient population with multiple levels of filters. We have been tracking and sending registry letters to patients who are due for preventive health care. These letters for preventive health care have been sent to patients who are due for mammogram, colonoscopy, or annual exam. We have also used the registry feature to manage our chronic care population. We track hemoglobin A1C and send registry letters or electronic messages to those patients who have not had this testing in the last 6 months. We also send registry letters or electronic messages to our hypertensive and depression patient population not seen within the last year. This has been successful in assisting us to provide care to those patients who otherwise may have been lost to follow up. Fremont Family Care Core Item: Clinical Outcomes/Value Page 8
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Percentage of patients age 50-75 who have had colonoscopy 37% 43% 42% 45% 45% 49% 48% 57% 56% 63% 64% 66% 65% 70% Screening Mammogram for Women age 50-74 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20% 2010 28% 33% 35% 38% 39% 42% 43% 48% 48% 49% 50% 54% 55% 56% Our practice recently submitted an application to NCQA for patient centered medical home recognition. This would not have been possible without the EMR. Our use of the EMR to track and coordinate care, improve patient care, and engage our patients in their health and wellness has allowed us to take better care of our patient population. 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 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. Collaborating with the providers within the practice to develop mutually agreed upon clinical quality measures is Fremont Family Care Core Item: Clinical Outcomes/Value Page 9
essential. Ensure that you are able to accurately extract the data you need to report on the quality goals. In the beginning of our clinical quality reporting we had some providers who did not believe the data so we were able to print the patient list, hand sort these patients and prove correct data to the patient. You have to be prepared to back up your percentage with the numerator and denominator and be able to drill down to the patient level to prove that the data you are collecting from the EMR is in fact accurate. Reporting quality measure 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 data. We have seen improvement in all of our clinical quality 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 include 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 clinical quality measures. Additional ongoing costs have included purchasing additional reporting software (PCMH analytics) from eclinicalworks. We have also invested in the creation of some custom reporting tools. This cost has been covered by operational budget and has allowed us more accurate reporting of the data and easier extraction. This saves time for the person managing the quality thus decreasing some overhead. The ability to extract the data from the EMR is essential in reporting accurate data and worth the additional costs incurred by purchasing/customizing reports. The practice has also offset some of these costs by reporting to CMS Meaningful Use Incentive Program. Seeing real time data demonstrating improvement in clinical quality measures and population management is something that is invaluable to the practice and the population we serve. PCMH analytic software was purchased from eclinicalworks which allowed the practice to extract data on key elements related to patient centered medical home. The cost of this software is $75 per provider per month. The practice also chose three chronic care diagnoses to track for PCMH including diabetes, hypertension, and depression. There were custom reports built to help extract data related to these diagnoses. There was an initial onetime cost of $8,280 related to the customization of these reports. Fremont Family Care Core Item: Clinical Outcomes/Value Page 10