Using Quality Improvement and Health IT Innovations to Transform Care in the Primary Care Setting

The Greater Cincinnati Beacon Collaboration

Date: Monday, Apr 8, 2013

Time: 9:30 AM - 12:30 PM

These presenters have nothing to disclose

Session ObjectivesAfter this session, attendees will be able to:•1.) Learner will understand the use of Health IT tools to catalyze quality improvement work in a primary care setting•2.) Learner will be able to discuss the intersection of quality improvement and Health IT in meeting the requirements of a Patient Centered Medical Home. •3.) Using the Transformation Equation, the participant will be able to identify a component(s) of the equation as a starting point for transforming care in their own setting

An Overview of the Greater Cincinnati Beacon Collaboration

Pattie Bondurant DNP, RNGina Carney

Greater Cincinnati Beacon Collaboration (GCBC)

Beacon Goal •Provide funding to communities to strengthen health ITinfrastructure and exchange capabilities •Achieve measurable improvements in health care quality, safety, efficiency, and population health

Funding

$13.75 million award to Cincinnati

Cincinnati Project Demographic•200+ Adult PCPs•35,000 patients with Diabetes•300+ Pediatricians•30,000 patients with Pediatric Asthma•21 Regional Hospitals

AwardedSeptember 1, 201030 month initiative

Why is technology critical to improving health and health care?

“Information is the lifeblood of medicine. We are only as powerful as the information we have, whether we are a nurse practitioner, a physician, or a respiratory therapist.”

Dr. David Blumenthal, former National Coordinator for Health Information Technology

Patient Care is at Stake

• More than 40 percent of outpatient visits involve a transition of care

• 1 in 5 discharged Medicare enrollees are readmitted within a month – most are preventable

• Referring physicians receive feedback from consultants 55 percent of time

• Physicians make purpose of referral clear 74 percent of time

Incomplete Knowledge of Diabetes and Asthma Care Quality:• Data exists in silos – need more complete data for improvement• No single health system, hospital or practice has complete view of

patient care • Many gaps in information, data sharing only partially electronic

Preventable ED visits: • Patients need appropriate primary care rather than emergency care

Hospital Readmissions:• Hospitals will be challenged on reimbursement for readmissions – big

financial impact• Patients need appropriate primary care to prevent readmission

Transitions in Care: • PCP lacks information from patient’s hospital visit• Specialists lack most current information from PCP

Case for Intervention

GCBC Adult Diabetes ProjectWhat does success look like?

Goals:• 5% improvement in overall

D5 composite score (Registry or EHR-MU Stage 1)

• Reduction of ED/Admissions by 10% (ED/Admit Alerts)

• 80% of Beacon adult PCP practices will achieve at least Level II recognition .

• 10% Improvement in Aggregate Culture Survey Scores

GCBC Adult Diabetes ProjectClinical Transformation

Results/Progress To Date

100% of Beacon adult PCP practices achieved Level III recognition, the highest possible distinction

Achieved 10% Improvement in Aggregate Culture Survey Scores

Interim results (2010- 2011) 7% Increase in Beacon Cohort III teams, 3% Increase in Beacon QID5 teams

Transforming Healthcare

Pattie Bondurant DNP, RNGina Carney

Transformation EquationWhat Did We Learn?

Patient Centered Primary CareExtreme Makeover

• Uncoordinated care

• Over-loaded schedule

• Physician & practice-centric

• Arbitrary quality improvement projects

• Lack of clear leadership & support

• Team-based approach• Open access • Patient engagement & empanelment• Data directed quality improvement

efforts• Engaged leadership

Using the NCQA FrameworkStandard 1: Enhance Access and Continuity of Care

Standard 2: Identify and Manage Patient Populations

Standard 3: Plan and Manage Care

Standard 4: Provide Self-Care Support and Community Resources

Standard 5: Track and Coordinate Care

Standard 6: Measure and Improve Performance

Emphasizing Sustainable Change

HITECH: Policy Framework

Better care for individuals, better health for populations, and lower per-capita costs. IHI-Triple Aim Initiative

• The 2009 ARRA/HITECH Act authorizes incentive funding for health care providers who demonstrate “meaningful use of health information technology.”

• The federal government will pay eligible professionals that meet meaningful use (MU): o Up to $44K under Medicare or o Up to $63,750 under Medicaid

• Eligible hospitals can receive millions.• Payments come in 3 Stages – with increasing

requirements.

Meaningful Use & Incentives

Stages of Meaningful Use

Stage 12011*

Stage 22014*

Stage 3TBD*

1. Capturing health information in a coded format

2. Using the information to track key clinical conditions

3. Communicating captured information for care coordination purposes

4. Reporting of clinical quality measures and public health information

Capture information….

1. Disease management, clinical decision support

2. Medication management3. Support for patient access to

their health information4. Transitions in care 5. Quality measurement 6. Research7. Bi-directional communication

with public health agencies

Report information…

1. Achieving improvements in quality, safety and efficiency

2. Focusing on decision support for national high priority conditions

3. Patient access to self-management tools

4. Access to comprehensive patient data

5. Improving population health outcomes

Leverage information to improve outcomes…*Indicates “payment year” in which each Stage is first introduced.

Actual compliance timeframe depends on an EP’s first payment year.

Quality Reporting: Monitoring Progress

HealthBridgeHealth Information Exchange

In operation since 1997 as a 501c3 Not for Profit

One of the nation’s largest, most advanced and successful health information exchanges

One of only a handful of HIEs nationwide with a sustainable business model

Provide HIE services for Greater Cincinnati and four other HIEs – Dayton HIN, CCHIE, HealthLINC, NEKY RHIO, Quality Health Network • What Does an HIE Do?

• Delivers 3-6 million clinical messages PER MONTH;

• 2011- more than 60 million messages;

• 3+ million unique patients, 50 total hospitals, 7500 physicians

Like any good transportation system, our health information system must have two parts to work well: HIT = health information technology (e.g., EHR)

+HIE = health information exchange and interoperability

But the business case for HIT and HIE in health care is challenging.

Two Remedies for Better Information

ED/Admission Alerts • Goal: reduce readmissions and prevent subsequent ED visits by enhancing the delivery of better coordinated, preventive care in the primary care setting• Process

• Electronic Alerts triggered on registration at ED or hospitalization•Alert sent through HealthBridge to Primary Care Physician (PCP)•Alerts are Patient Centric-alerting PCP where the patient presents for care, anywhere in the region• Practice intervenes – schedules follow up appt. w/patient, informs of same day/open scheduling for future, get copy of discharge

HealthBridge ED Alert Architecture

Hospital

Admission

ADT

1 Patient Hospital Visit

The patient goes to the hospital and is admitted to the ED.

HealthBridge

Alert Aggregator

2

Clinical Messaging

A

D

C

B

Practice

HealthBridge Integration

HealthBridge receives the ADT and matches on the patient. If the patient is part of a subject group, an alert will be created from one of the four options (A, B, C, D).

ALERT

3 Practice Follow-up

Practice receives preferred alert from HealthBridge and calls patient for a follow-up visit.

ED/Admission Technology

Data Element HL7 Field Description

Last Name PID.5.1 Patient’s last nameFirst Name PID.5.2 Patient’s first name

Birth date PID.7.1 Date of birth for patientAdmit Date/Time PV1.44 Date and time patient was admitted to

hospital

Facility MSH.4 Hospital where patient was admittedVisit Type PV1.2 Patient class type associated with the

hospital visit

E-Emergency Department visit

I-Inpatient admission

Diagnosis Code DG1.3 Diagnosis CodeDiagnosis Description/Chief Complaint

DG1.4 Diagnosis Description

MRN MSH.10 Medical Record NumberPhone Number PID.13 Patient’s home phone number

Data Elements of ED/Admission Alert

Direct with PDF Attached ED/Admission Alerts

ED Alerts Project

University Internal Medicine - Pediatrics Experience

Jonathan “JT” Tolentino, MD

Assistant Professor of Internal Medicine and Pediatrics

University of Cincinnati

UC Internal Medicine-Pediatrics Clinic at Hoxworth

• Hospital-Based Clinic• Combined faculty-resident

teaching and private practice• NCQA Level III-Certified Patient

Centered Medical Home.• Many unique challenges

associated with combined practice.

• Diverse payer mix – 60% Medicare/Medicaid, 25% private, 15% indigent care

Clinic Characteristic

• Team: • 35 Attending providers and resident providers assigned to one of

five nurses for care management/coordination• 10 additional faculty preceptors present one half-day per week for

teaching• Medical Assistants – Clinic triage and immunization• Clinical Support staff - patient scheduling and referrals

Electronic Medical RecordGE Centricity EMR, not integrated with inpatient LastwordTransitioned in July 2012 to EPIC outpatient and inpatientED/inpatient notification available for those admitted to UC Health

facilities

Problem Definition

• Lack of meaningful data• No process to systematically identify patients visiting

the emergency room• Inconsistent process

Understanding our problem:Patient Visits to the ED

Patient visits the

ED

Patient admitted to the ED

Patient admitted to the hospital

Patient discharged

from hospital

Patient discharged from the ED

Admit?

Patient follows up

at MP Clinic

Patient sets follow up

visit

Patient sets follow

up visit

Y

N

Our process failures

Patient visits the ED

Patient admitted to the ED

Patient discharged from

ED

Patient sets follow up visit

• Incorrect PCP identified by ED or patient

• PCP not notified of the ED visit

• ED visit occurs during non-clinic hours

• PCP contact “non-critical” to the ED visit

• Patient visits a non-UC Health ED

• ED seen as primary provider for acute illnesses

• No appointment available

• Clinic closed

• No notification to the PCP’s office

• Vague discharge instructions

• Despite PCP notification, support staff/nurse not instructed to set follow up

• Information overload • Delayed notification of

ED visit to PCP

• Patient/family does not call

• Office unaware of need for follow up

• Home care services unaware of need for follow up

Patient follows up at MP Clinic

• Pt’s vague understanding of ED visit

• Late follow up • Incomplete or

delayed ED visit information

• Inability to communicate with ED provider

Recognized Barriers

• > 45 providers • Multiple hospitals and hospital

systems• Incomplete or missing medical

records• Teaching practice – trainees at

different levels of experience and understanding

• Diverse payer group • Provider-centered decision

making model

• Inconsistent practices and processes

• Lack of reliable information • Lack of coordination • Ineffective follow up

appointments • No tools or processes to

coordinate care and uncover gaps

System Created Implications of the System

Task 2: Create a High Level Transformation Process Outline

Identify Stakeholders:•-•-•-

Example: Process Outline:

•-•-•-

Aim Statement

and Charter

Kick OffConvene

Stakeholders

Action 1 Action 2 Action 3

Develop Your Process Map

Task 2: Create a High Level Transformation Process Outline

Aim Statement

Kick OffConvene

Stakeholders

Action 1 Action 2

Develop Your Process Outline

Action 3

TasksWhat Will Be

Done? Elements of theTransformation

Equation

ResponsibilitiesWho Will Do It?

  

TimelineBy When?

(Day/Month)  

ResourcesA.Resources AvailableB.Resources Needed (people, funding, equipment, supplies, IT, etc.)

Potential BarriersA.What individuals or organizations might resist?B.How?

Communications PlanWho is involved?

What methods?How often?

1: MU of Health IT

    A. 

B. 

A. B.

 

2: Patient Centric Care 

    A. 

B. 

A. B.

 

3:Point of CareData 

    A. 

B. 

A. B.

 

4: Value BasedPayment  

    A. 

B. 

A. B.

 

5: Culture ofReadiness 

    A. 

B. 

A. B.

 

Task 3: List Challenges in Your Transformation Equation

 Transformation

Equation Elements

 

Meaningful Use of Health IT

+Patient-Centered

CareX

Point of Care Information

XValue- Based

Payment=

Transformed Care

  Challenges

 

. . . . .

 . . . . .

. . . . .

 

  . . . . .

 

Readiness for Change

 

 Challenges 

. . . . .

ED Alerts Post Intervention

University Internal Medicine- Pediatrics Experience

Jonathan Tolentino, MD

Assistant Professor of Internal Medicine and Pediatrics

University of Cincinnati

Objectives for the UC Med-Peds ED/Admit Alert Project

1. Characterize the use of emergency services by patients with diabetes

2. Develop a system that coordinates care after an emergency department visits in an environment with multiple providers

3. Develop clinic infrastructure to divert emergency department visits for non-emergent illnesses

EmpanelmentMeaningful ToolsDataTeam

Our Approach using the Transformation Equation

DataEmpanelment

EmpanelmentTeam Development

EmpanelmentMeaningful ToolsData

Team Development

Empanelment

Our patients with type II diabetes that are at high risk for complications will need close follow up after a visit to the emergency room for a diabetes-related visit. This risk stratification strategy will not include patients who are in the emergency room and admitted to the inpatient unit for a diabetes-related issue.

N=125 (out of 435 total)

Team

Clinical Support Staff

Medical Assistant

Nurse

Physician

Clinic Manager

System developed to empower support staff and MAs to become the key drivers to the success for care coordination.

Who is your “keystone?”

“Scope of training” vs. “Scope of ability”

Developing Tools for SuccessDiabetes-related ED visit is defined as a patient whose diagnosis description/chief complaint transmitted through the ED alerts system includes any of the following:

•Hyperglycemia, Elevated Blood Sugar, or High Blood Sugar

•Out of medications or in need of medication refills

•Infected foot or lower extremity

•Hypoglycemia or low blood sugar

University Internal Medicine/Pediatrics

Med/Peds ED/IP Alert Process Map

Patient in Emergency Department

ED Alert Triggered

Notification via Clinical

Update to provider

No F/u F/u Appointment

set up automatically

Low Risk

Follow-up Appointment

Within 3 days of ED Visit

Patient Status

High Risk

Diabetes Related ED Visit?

Yes

No

Our Johari Window*

“Ignorance is bliss”:

Moving out of the unknown.

* Luft, J.; Ingham, H. (1955). "The Johari window, a graphic model of interpersonal awareness". Proceedings of the western training laboratory in group development (Los Angeles: UCLA).

One Patient’s Story

FeedbackMD experience

• Positive, noted opportunity to reach out to patients who have not been seen in a while

• Notification of patients admitted helpful, especially when admitted to non-UC Health hospital

MA and CSC experience• Easy to use algorithm, no issues with determining which patients need to

be called• Highest volumes on Mondays• Difficulty getting records from some health systems

RN team• Positive – able to help manage patient team• Some difficulty getting records from health system with multiple hospitals • Uncertainty of follow up needed for patient who have been admitted• Late adopters – CSC and MAs were our earliest adopters

Our Lessons

• ED alerts coupled with a simplified algorithm empowers our nursing, MA, and CSC staff to assist MD/providers in decision making

• Coupling point of care information, meaningful use, and a simplified algorithm is easily adaptable to chronic care management of many diseases

• Limitations with current point of care information – ED visits vs. inpatient visit.

• Adding decision support for with risk stratification allows for additional empowerment of decision making.

• Some elements may not be in our control - Not all patients are willing to make a follow up appointment, even after reaching out to them.

Our Lessons

• Practice transformation is possible if all aspects of the transformation equation is addressed.

• We just now beginning to understand the process and our patients• Backing into optimized system of care – cannot always go in

without the data. • Only 16% of our diabetic patients use emergency care

services for diabetes-related reasons• Over 30% of our diabetic patients were going to other health

systems – what are we missing, what didn’t we know before.

Questions

Beacon web page • www.healthbridge.org/beacon

Social Media • Twitter: http://twitter.com/healthbridgehio • Facebook:

http://www.facebook.com/pages/Cincinnati-OH/HealthBridge/128672340540952

• LinkedIn: http://www.linkedin.com/company/healthbridge_3 • YouTube: http://www.youtube.com/user/HealthBridgeHIE

Thank You……….