Quality and the Electronic Health Record

Qualityand the

Electronic Health Record

595 Lyndon Road

Cuba, New York 14727

Phone 716-676-3635

Fax 716-676-2404

[email protected]

Darlene D. Bainbridge & Associates, Inc. ©

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

The most important meaningful use that will come out of the advancement of the

EHR will be the ability to advance quality.


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Quality lives in health care when, as providers, we:

1. Maximize the chance that we get patient care and operations right the first time2. Minimize the risk that an error will make it all the way to the patient or into operations 3. Ensure that care and operations are consistent with the most current standards.


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Meaningful Use for the:1. Patient

a. Easy access to information

b. Receive the right care the first timec. Minimized risk of error and harmd. Access to the best care known to medicine

2. Provider

a. Deliver the above for the patient in an environment that

supports the workforce in a user-friendly way

3. Organizationa. Deliver the above for the patient and care givers with

automation of quality control and timely assess to important leadership information

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Possibly the Most Important

Rule in Healthcare Reform

1:10:100 Rule

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Old Approaches to Quality

1:10:100 Rule

New Approaches to Quality

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


James Reason,

1990

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Practice

PROCESS

+ + + +PracticePractice Practice Practice

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Chance favors only the prepared mind.

Louis Pasteur


Using the EHR to Improve Quality f Patient Care in Boston HealthNeto

Richard Kalish, M.D., MPHMedical Director, Boston HealthNet

PCP, South Boston Community Health Center

About Boston HealthNet

Established in 1995 to create an integrated health care delivery system among its members

Members are Boston Medical Center (largest safety-net hospital in New England), Boston University School of Medicine and 15 CHCs

Over 200,000 patients make in excess of 1.2 million visits to the 15 BHN CHCs annually Roughly 62% have Mass Health, Commonwealth Care and

Medicare; 25% have private insurance; 13% are uninsured/self-pay

64% are racial/ethnic minority (10% unknown)

BHN health centers are located throughout Boston’s most impoverish neighborhoods and extend as far as Quincy and Hull on the South Shore of MA.

Information Technology @ BHN

BHN has developed a highly evolved HIT infrastructure over the past decade Awarded $5.9 million from an anonymous foundation to

implement Centricity Electronic Medical Record at 8 BHN CHCs in 2001

Today, all 15 CHCs have implemented an EMR

Information Technology has expanded significantly since initial EMR award T1 line connectivity

ISDI grant (2002-2005; Referral & Consultation Module)

Interfaces with EMR and other applications (lab, etc.)

Electronic prescribing

Developed a BHN IT Strategic Plan in 2006

BHN Primary IT Goals:

Provide an electronic tool set at each site that functions well, provides a sense of satisfaction to the providers, and contribute to advancing clinical care

Provide the Boston HealthNet and its partners with a network-wide utility to track referrals, focus on patient safety issues and allow for robust reporting and research

(BHN 2006 IT Strategic Plan)

Our Vision: Community of Care

Applications

Transaction Services

BMC CHCa

Analytics

Surveillance

eReferrals

Health / Wellness Alerts

Clinical Decisio

n Support

Information

Exchange

Pt Info Reconciliati

on

Family

Patient

CHCB

Another HIE

Community Information Exchange

HRSA funded IT enable QI project (2007) 3-year $746,000 grant

Connects the Centricity EMR of BMC and the CHCs

Standards compliant

Cornerstone of EMR strategy

Providers are able to access medication lists, problem lists, allergies, lab results and consult notes Displays H1N1 and seasonal flu vaccine information

First CHC and BMC went live in April 2009 11 CHCs and BMC are using the CIE

Non Centricity site expected to participate in the near future

Using the CIE to Improve Patient Care

Goal 1: to improve patient safety @ CHCs

Improve Creatinine monitoring for patients on Metformin

Improve liver function tests for patients on Statins

Goal 2: to improve diabetes control as measured by

HBA1C ≤ 7%; HBA1C >7 and < 9%; and HBA1C ≥ 9%

Goal 3: to improve physician compliance with minimum standard for testing HBA1c and/or LDL in patients with diabetes and/or heart disease

Network QI initiative using the chronic care model

Comparison of Baseline Data vs. CIE Implementation DataCHC Yearly Average

CHC Percentage of Diabetes patients with at least one A1C

within the past 12 months

Percentage of Diabetes patients with at least one

LDL within in the past 12 months

2006 2009 2006 2009

CHC 1 94.88 94.08 79.07 83.26

CHC 2 88.93 92.76 82.53 57.57*

CHC 3 71.72 82.92 66.31 84.46

CHC 4 74.35 87.60 42.31 50.70

CHC 5 87.64 94.28 64.69 71.40

CHC 6 90.83 95.06 83.89 90.97

CHC 7 92.06 94.12 78.25 80.96

CHC 8 92.58 90.68 88.41 85.95

* Site experienced technical issues with data collection

CIE Based Application: #1

eReferral Portal: a solution to the BMC-CHC referral problems process cumbersome and lacked standardization; insufficient

tracking (lesson learned from ISDI – referral and consultation module)

Inadequate information provided to specialists; little PCP feedback

Solution: develop eReferral Portal HRSA funded 2-year $543,000 HIT initiative

eReferral Portal developed with vendor CareFx

Send referrals electronically, ensure comprehensive information gathering

Using the eReferral Portal to Improve Patient Care

Improve care coordination (measured by timeliness of Specialist Report post visit): July 2009: 77.3 days July 2010: 8.9 days

Decrease no-show rates for colonoscopy screening, echocardiogram and cardiac diagnostic testing Colonoscopy from 48% to 30% Echocardiogram from 42% to 14% Cardiac diagnostic stress test from 48% to 19%

Decrease lag time between appointment request and visit: July 2009: 57.3 days July 2010: 22.7 days

CIE Based Applications: #2

Flu Vaccine Tracking: a solution to a public health problem

New H1N1 tracking requirements from CDC

BMC needed to service community

Multiple entry points and complex algorithm

Needed to match patients

Our EMRs cannot deliver an integrated solution

Mid-October vaccine availability

only 3 weeks to develop and deploy

Solution: Develop VaxTracker

Leverage CIE’s EMPI and CCD

Leverage CareFx Portal

VaxViewerLaunched from the any BHN/BMC local EMR

Delivered in 3 weeks

Solution that is cost effective and reusable

Benefits of the CIE

Quality and safety application Responsive to 2010 National Patient Safety Goals

Effectiveness of communication among care givers enhanced

Good patient care

Provider workflow will be made easier as CIE evolves

Enhanced Reimbursements Meaningful use

Medical Home Initiative

CIE Based Applications – In Process

2010 HRSA $2.98 million to implement the BHN IDEAS Project

Implement the Centricity® Practice for Community Health Centers (an integrated EMR/PM product) at five CHCs

Build a data warehouse to house CHCs clinical and financial data

Develop clinical registries for immunization and diabetes

Implement CPOE for lab orders and result retrieval

Automate UDS reporting

Using the IDEAS Project to Improve Patient Care

Increase the number of children fully immunized by age 2

Decrease duplicate immunizations for children up to 24 months

Increase adherence to NCQA standards for diabetes care

Decrease the percent of patients with uncontrolled diabetes (HbA1c > 9)

The BHN Diabetes Registry will:

“track key clinical conditions and communicate that information for care coordination purposes” across the care continuum

“implement clinical decision support tools to facilitate disease and medication management”

How are we Doing?

Achieving meaningful use of EHR

Health Outcomes Policy Priority Stage 1 Objectives (2011)

Improve quality, safety, efficiency and reducing health disparities

•CPOE for medication orders•Drug/ Drug, Drug/Allergy Interaction Checks; formulary checks•Electronic transmission of prescriptions•Record Patient Demographics: preferred language, gender, race, ethnicity•Maintain Active/up-to-date Problem list•Maintain Active Medication List•Maintain Active Medication Allergy List•Record & Chart changes in Vital signs, Ht, Wt, BP, BMI•Record Smoking Status (13 and older)•Implement One clinical decision support rule•Report ambulatory clinical quality measures•Incorporate clinical lab test as structured data•Generate patient lists by specific condition•Send patient reminders for preventive care per patient preference

Engage patients and families •Provide patients with electronic copy of health information (labs, problem list, medication lists, allergies) upon request•Provide clinical summaries for each office visit•Provide patients with timely electronic access to health information within 4 business days of info availability•Patient-specific educational resources

Improve care coordination •Capability to Exchange key clinical information among providers ofcare electronically•Perform medication reconciliation at each transition in care

Improve population and public health •Submit electronic data to immunization registries•Submit surveillance data to public health agenciesbased on applicable law and practice (two CHCs and BMC)

Ensure privacy and security protection •Protect electronic health information created or maintained by the certified EHR through the implementation if appropriate technical capabilities

How are we Doing?

NCQA Medical Home Criteria

NCQA Medical Home Standards & Guidelines

1. Access and Communication • eReferral project has “shined a light” on access to specialty appointment (data now available)

2. Patient Tracking and Registry function •EHR and PM systems have searchable patient information (e.g. name, DOB, etc.) •Clinical registries (immunization and diabetes) currently being built

3. Care Management •Age appropriate risk assessment (smoking, etc.,) and age appropriate immunization (pediatric, influenza) • Continuity of care (specialist notes and CCD document exchanged through CIE) Performance report used as a tool for care management

4. Patient Self-Management Support

5. Electronic Prescribing •CHCs use the EHR to electronically order prescriptions •Drug-drug; drug –allergy alerts built in •Advanced eRx being piloted

6. Test Tracking •CPOE for lab order and result retrieval being implemented •Have the ability to order imaging tests

7. Referral Tracking • Have the ability to track referrals using an electronic system (including origination, some clinical details, tracking status and administrative details)

8. Performance Improvement •CHCs have the ability to generate reports using standardized measures •CHCs are able to report on performance across the practice (individual provider reports generated by a few CHCs)

9. Advanced Electronic Communication •Have the ability to share important clinical information to case managers and other providers across care continuum

Richard Kalish, M.D., MPH

Medical Director, Boston HealthNet

660 Harrison Avenue, 3rd Floor

Boston, MA 02118

617-638-6903; [email protected]

mailto:[email protected]

RESULTS-DRIVEN QUALITY REPORTING

October 22, 2010

36

AGENDA

I. IntroductionII. Set Strategy and Define Your GoalsIII. How to Make Your Data Work For YouIV. Using the Right Tool for the JobV. Choosing Your Approach and ToolsVI. Examples of Quality Reporting

DEFINE YOUR GOALS

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• Set strategy and align business goals before implementation if possible and evolve with the changing environment

• Our goals are:

• Improving Care Delivery Quality

• Managing Data as an Asset

• Payment Reform: Managing to Performance Incentives

• Monitoring Patient Centered Medical Home

• Achieving and Proving Meaningful Use

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HOW TO MAKE YOUR DATA WORK FOR YOU

• Harness Structured Data from Practice Management and EHR Systems

• Train users to document using radio buttons, pick lists and other forms of structured data especially for required reporting elements

• Identify efficient workflows and approved documentation areas for these reporting elements

• Implement a change process for adding a new way to record information based on experience

STRUCTURED VS UNSTRUCTURED DATA

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Structured Data

Unstructured Data

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USING THE RIGHT TOOL FOR THE JOB

• The EHR Report Writer• Pre-built reports or One-off Reports like medication recalls

• Basic queries looking for few data points per patient such asMammograms for female patients >50 with encounters from x to y dates

• A Reporting Framework with SQL and BO Crystal Reports• Access longitudinal patient data using dynamic registries and summary tables• Automate cumulative reporting and comparative progress:

• Set up jobs to take snapshots of data for specific time periods

• Design reports for unique needs: • Implementation management, Practice Transformation, Incentives, Collaboratives, Grants and Federal Requirements

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CHOOSING YOUR APPROACH AND TOOLS

• Build or Buy?• Develop in-house technical report building staff

• Focus on Care Delivery and Management and hire experts to meet your needs

• Software Tools• Choose report tools that integrate easily with your system, some come with your EHR product

• Automate Report Distribution with Report Server software• Crystal Report Server distributes:

• Weekly visit-planning Reports• Monthly Performance Reports to providers with

summary metrics and comparative benchmarking for providers

QUALITY REPORTING

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• Prospective- Visit-Planning• Diabetes Report for patients with appts in the coming week to plan care for visit

• pre-order labs and other services with standing orders and update chart

• Retrospective- Exception Reports• Diabetes Report for patients with kept appts in past week to

identify and remediate missed opportunities for care delivery• Use as an outreach list for other staff to schedule care

• Performance and Regulatory• UDS Clinical Core Measure Report• Collaborative Reports – PECS/CDEMS

• Using EHR data and a registry list of patients by ICD-9, not from a

separate registry database

PARAMETERS AND SELECTING A REGISTRY

Patient Identifiers

Dr. BlackstoneDr. Blackstone

Contact Information

Heather Budd

Director of Quality Management

Blackstone Valley Community Health Care, Inc.

Email: [email protected]

O:(401) 312-9879

M: 617-899-4681

Ray Lavoie

Executive Director



O:(401) 729-0080

Jerald Fingerut, MD

Medical Director



O:(401) 729-0080




Quality and the Electronic Health Record

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