06 Am09 Presentations Gutman

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  • 1. Take Home Messages
    • Increasing Pressure to Assure Attention to Guidelines
  • Clinical Judgment Counts as long as the Guidelines are Recalled
  • Payers Will be Looking for Practice Metrics
  • There Has to be a Way to Support this.

2. 3. 4. ADHERENCE TO QUALITY INDICATORS McGlynn et al NEJM 2003 5. QUALITY IMPROVEMENT ORGANIZATIONS ARE TOOLING UP DEMAND FOR METRICS

  • .

6. COMING EVENTS: ARE YOU GOING TO BE READY IN FOUR YEARS?

  • Federal Pay for Performance
  • Private Payer P4P Contracts and Web Based Display of Adherence
  • Expectations of the public
  • Your own Web Based highlights
  • Patient Satisfaction
  • Practice Satisfaction

7. HEALTH CARE INFORMATION TECHNOLOGY CHANGES THE ECOSYSTEM OF PRACTICE William W. Stead 8. Clinical Decision Support

  • Clinical decision support systems
  • anautomated process for comparing patient-specific characteristics against acomputerized knowledge base[a set of guidelines ]withresulting recommendations or reminders presented to the providerat the time of clinical decision-making
  • Hunt, Haynes, Hanna, & Smith,JAMA. 208 (15) 1998.

9. STEPS TOWARD DESIGNING AN OFFICE BASED CLINICAL PRACTICE GUIDELINE DECISION SUPPORT AND METRICS SYSTEM

  • Must have an EMR
  • Must have Practice buy-in
  • Must have a decision support system that:
    • Reliably search, obtain, and organize clinical data
    • Reliably translate the data into applicable information
  • Must have agreement (or near agreement) on clinical guidelines used for corrective action
  • Must deliver content at the point of patient contact
  • Must create a culture where metrics are acceptable without anger or fear

10. 11. CDSS Protocol Content: Nephrology

  • Chronic Kidney Disease Management
  • National Kidney Foundation KDOQI Guidelines
  • ACEI / ARB Therapy, with and without Proteinuria
  • Anemia Screening / Management
  • Vitamin D / Calcium Deficiency Management
  • Elevated Phosphorous Management
  • Medication Avoidance or Cautionary Use
  • Vein Mapping / Cardiology Consult/Surgical Referrals (CKD 4 or CKD 5)
  • Education Options
  • Measure of:
    • Renal Function (eGFR)
    • Parathyroid hormone
    • Vitamin D
    • Calcium
    • Phosphorous
    • Hemoglobin
    • Iron saturation and Ferritin (ESA Therapy)

12. CDSS Protocol Content: Nephrology

  • Cardiovascular Disease Management
  • American College of Cardiology, National Cholesterol Education Program (NCEP) / ATP III
  • CAD or CAD Equivalent Dx:Anti-platelet Therapy
  • CAD, CHF, or CVD:Beta Blocker Therapy
  • CAD, DM or CHF:ACEI / ARB Therapy
  • Diabetes Screening & Management
  • American Diabetes Association
  • HgbA1c Monitoring
  • Hypertension Screening & Management
  • JNC 7
  • Management with and without Diabetes or Renal Disease
  • Preventive Screening
  • US Preventive Services Task Force ,Centers for Disease Control
  • Tobacco Use Screening and Management
  • Advanced Directives Screening
  • Influenza Vaccination
  • Hepatitis B Vaccination

13. Overview of CINA Technology 14. Overview of CINA Technology 15. Point of Care Decision Support Patient Specific Automated Produced forevery patient ,atevery visit , regardless of the Reason for Visit Utilized byall providers (MD, NP, PA, nurses) 16.

  • Active Diagnoses
    • Prioritized in accordance with the Protocol content / chronic disease(s) addressed
  • Active Medications
    • Prioritized in accordance with Protocols / chronic disease(s) addressed

Point of Care Decision Support 17. Point of Care Decision Support

  • Labs
    • Includes Labs that are pertinent to the Protocol content and referenced by the Action Items
    • Goals can reference as many labs as desired by the practice

18. Point of Care Decision Support

  • Measures / Calculations
    • Referential data from the EMR (vital signs) as well as certain calculated results
  • Diagnostic Testing
    • Referential data from the EMR
    • Indicates date of last procedure

19. Point of Care Decision Support

  • Labs
    • Includes Labs that are pertinent to the Protocol content and referenced by the Action Items
    • Goals can reference as many labs as desired by the practice

20. Point of Care Decision Support

  • Risks
    • Based on Age, Sex, Risk Factors, and Diagnoses
  • Goals
    • Specific metrics of interest to the practice and addressed within the protocols
  • These 2 areas are the basis for the Recommendations / Action Items

21. Point of Care Decision Support

  • Action Items
    • Divided into Action items for theNurse/ MA and for the Provider
    • Action Items relate to Medications, Labs, Procedures, Vaccines, Documentation
  • Visits
    • Derived from the EMR / billing data

22. Point of Care CDSS Workflow

  • Front Desk / Reception
  • Reports are automatically generated prior to the start of the work day and at noon for afternoon add-ons
  • Additionally, the receptionist can generate ad hoc reports for a single patient
  • Nurse / MA
  • Completes missing documentation
  • Administers/ queues vaccine / lab orders
  • Medication reconciliation
  • Communication tool for provider
  • Provider
  • Addresses recommendations as appropriate
  • Communication tool for staff
  • Educational tool for patient

23. DNA Baseline Data 24. Improvements In Prevention in Primary Care with Point of Care CDSS 25. Improvements In Diabetes Management in Primary Care with Point of Care CDSS 26. Diabetes Measures: Showing Consistent Improvement from both High Performing & Low Performing Clinics 27. WHAT ARE GUIDELINES?

  • FROM GHOSTBUSTERS:
  • Murray to Weaver (she was hitting on him):
  • "I make it a rule never to get involved with possessed people." (pause-looking camera):
  • "Actually, it's more like a GUIDELINE than a rule..."

28. 29. REACHING AGREEMENT WITHIN THE PRACTICE

  • Several of the algorithms are CKD level specific
  • So: what or who decides on the CKD level?
  • Can the practitioner tolerate using the last eGFR found in the computer to correct the last diagnosis?
  • If one is too few to correct, can we use two consecutive?
  • How old can the data be?

30. REACHING AGREEMENT WITHIN THE PRACTICE

  • Do we want a reminder to use ACEI and ARB for all CKD patients?
  • Or only those with proteinuria?
  • Can we tolerate being reminded if we have already decided it is not safe?

31. REACHING AGREEMENT

  • Can we agree on a reminder to check vitamin D levels?
  • Which moiety?
  • What are the correct targets for PTH
  • Can we relate them CKD level?

32. MAPPING ISSUES

  • How Does the CDR Recognize proteinuria?
  • How does it find the primary physician?
  • How can it tell when we refer to a vascular surgeon if all the users dont have a uniform method of entering the information or leave it out

33. Expected Benefits and ROI

  • Process in place for improving outcomes / guideline compliance
  • Positioned to participate in P4P
  • Ability to incorporate data from outside sources
  • CMS PQRI Reporting (Registry Based)
    • Failed efforts in Claims based reporting 2007
    • Registry reporting requiresNOphysician effort
    • PQRI bonus funds CINA solution, other quality improvement efforts
  • Per Visit Revenue Increase
    • Primary Care groups report avg $5-15 / visit increased revenue

34. INTRODUCTION OF I.T. SHOULD BE APPROACHED AS AN INTERETIVE PROCESS-- A FAMILY OF