Post on 04-Jan-2016
HHealth and ealth and CChronic hronic DDisease isease MManagement (HCDM)anagement (HCDM)
BEACON
9.8.2010
Overview
• 4 year project
• Purpose: • Leverage the MHS EMR to deliver point-of-care tools to
providers and care teams• Develop detailed provider level reporting to advance
ambulatory quality care in areas of prevention and disease management
• Collaboration between Cerner and Mayo
• 3 components – separate rollouts
HCDM Resources• Project Team
• Dr. Rick Fleming – Physician Lead – ISJ Primary Care Provider • Jason Buckmeier – Project Manager• Divya Pathak – Senior Analyst/Programmer• Lakshmi Kharidehal - Senior Analyst/Programmer
• Cerner• Engagement Team• Discern ABU
• ASYST • Leadership• Analysts
• Mayo Health System• Quality Dept Leadership • MHS Expert Teams• Diabetic Registry programmers & AQM programmers• Ambulatory Care Committee • Site Quality Coordinators
• HICS/Design Council as the oversight body
HCDM Project Metrics• AMB, ED, IP Summaries - ~ 6200 users (providers/nurses)
• Condition Management Rules: 435 MHS Providers (Primary Care)
• Populations Evaluated - Current• Hypertension 51,777 patients• Asthma 7,696 patients• Depression 19,130 patients• Diabetes 21,903 patients• Vascular Care 9,412 patients
• Records reviewed nightly - 30-35,000 patient records per topic
• The total for all topics ~ 180,000-210,000
• Largest population monitoring of any Cerner client
HCDM
MHS Quality
MHS CDR
Site Quality Directors
ASYST Site Liaisons
ASYST Clinicals
MHS Expert Teams
Mayo-JAX Technical Team
ASYST Technical
Team
ASYST Reporting Team
HICS
PWG
MHS EMR User Groups – FirstNet,
Ambulatory, IP
ASYST Leadership
Cerner Engagement
Cerner Development – Discern ABU
MHS Ambulatory Care Committee
HCDM Interaction
ASYST Learning Team
Determines “what” we build & deploy
Determines “how” we
build & deploy & integrate
into MHS EMR
“Does” majority of
HCDM Build
Oversight
HCDM Components
• 10 Algorithms
• 1 Patient Summary Page
• 4 Condition Summaries w/ Performance Measures
• MPage 2.0 Summaries – AMB, ED, IP
• Reminder Letter functionality
• Team tools (provider schedule icons and scheduling solution integration)
October 2009
July 19, 2010
Q4 2011
Algorithms included:
• Asthma (Adult & Ped)• Depression• Diabetes• (Diabetic Hypertension)• CAD• Hypertension• Hyperlipidemia• Heart Failure• (Diastolic Heart Failure)
Link
Algorithms
Launchable from:• desktop• intranet • condition summary• EMR link
Functionality Goals• Improve data capture (Tool: Ambulatory Summary)
• More efficient documentation of quality metrics at point of care (foot exam, eye exam, PHQ-9, recheck BP, Asthma Control Test)
• Advances ability to have responsive reporting• Educational (data to help support adoption – i.e. PHQ-9 utilization)• Aids in data collection for 3rd party submission (MNCM - DDS)
• Point of care patient metrics (Tool: Condition Summary)• Displays to provider/nurse how the patient is performing on quality
targets
• Population Reporting (Tool: Discern Analytics)• Care-Coordinator/Quality Analyst focus• All measures, all conditions, all patients – updated nightly• “Show all patients with HgbA1c not done in past 6 months for Dr.
Fleming”
Improve data capture (Tool: Ambulatory Summary)
Population Reporting (Tool: Discern Analytics)
Invitations & other .20 functionsInvitations & other .20 functions
Reminder letters
Health Maintenance displays
HM: Lipids, Mammo
Top half shows health maintenance overdue and coming due in defined time
frame
Scheduler ability to see HM due items
HM brought into Depart SummaryHealth Maintenance
Invitations for Asthma Depression Diabetes(10) Vascular Hypertension Cervical CA Breast CA Colon CA Lead Screen
HCDM Project TimelineHCDM Project TimelineQ4Q3Q2Q1 Q4Q3Q2Q1 Q3Q2Q1
2011 2012 2011Q4Q4Q3Q2Q1 Q4Q3Q2Q1 Q3Q2Q1
2008 2009 2010Q4
Phase 2 Design
Phase 3 Algorithms
Phase 4 Patient & Condition Summaries, Performance Reports
Phase 6Invitations/.20 functions
Phase 7Refinement/update
Project year 4Project year 3Project year 2Project year 1
Phase 1Feasibility
HCDM Programmer/Analysts (2.0 FTE)
Next 4 sites go-live Last 4 sites go-live ASYST code upgrade
Physician Lead and Project Manager (0.4 FTE & 1.0 FTE x 4 yrs)
Cerner Programmers (contract)
= Functionality Rollout
This timeline is reflected in the current ASYST Roadmap
Up to 60 Clicks … 5 minutes
Provider adoption and efficiencyProvider adoption and efficiencylocate 10 elements on a diabetic patientlocate 10 elements on a diabetic patient
… 2 Clicks< 1 minute
Customizable – by MayoCustomizable – by Mayo
Open Source Sharing - http://mpagescommons.org/
New Summary Pages
New Analytics Reports
MPage 2.0 Development – via MPage 2.0 Development – via BedrockBedrock
IP Discharge Process
Nursing Communication
Utilizes more of the Care Team to deliver Health Maint and Disease
Mgmt
Care Coordinator Patient List
Reminder Letters
Scheduler Notification of due items
Thank you!