Take Home MessagesTake Home Messages

•Increasing Pressure to Assure Increasing Pressure to Assure Attention to GuidelinesAttention to Guidelines

•Clinical Judgment Counts as long as Clinical Judgment Counts as long as the Guidelines are Recalledthe Guidelines are Recalled

•Payers Will be Looking for Practice Payers Will be Looking for Practice MetricsMetrics

•There Has to be a Way to Support There Has to be a Way to Support this.this.

ADHERENCE TO QUALITY INDICATORSADHERENCE TO QUALITY INDICATORSMcGlynn et al NEJM 2003McGlynn et al NEJM 2003

QUALITY IMPROVEMENT ORGANIZATIONS ARE QUALITY IMPROVEMENT ORGANIZATIONS ARE TOOLING UP DEMAND FOR METRICSTOOLING UP DEMAND FOR METRICS

• ..

COMING EVENTS: ARE YOU COMING EVENTS: ARE YOU GOING TO BE READY IN FOUR GOING TO BE READY IN FOUR

YEARS?YEARS?1.1. Federal Pay for PerformanceFederal Pay for Performance

2.2. Private Payer P4P Contracts and Web Private Payer P4P Contracts and Web Based Display of AdherenceBased Display of Adherence

3.3. Expectations of the publicExpectations of the public

4.4. Your own Web Based highlightsYour own Web Based highlights

5.5. Patient SatisfactionPatient Satisfaction

6.6. Practice SatisfactionPractice Satisfaction

““HEALTH CARE INFORMATION HEALTH CARE INFORMATION TECHNOLOGY CHANGES THE TECHNOLOGY CHANGES THE ECOSYSTEM OF PRACTICE”ECOSYSTEM OF PRACTICE”

William W. SteadWilliam W. Stead

Clinical Decision SupportClinical Decision SupportClinical decision support systemsClinical decision support systems

“ “an an automated processautomated process for for comparing patient-specific comparing patient-specific characteristics against a characteristics against a computerized knowledge base computerized knowledge base [a [a set of guidelinesset of guidelines]] with with resulting resulting recommendationsrecommendations or reminders or reminders presented to the provider presented to the provider at the time at the time of clinical decision-makingof clinical decision-making” ”

Hunt, Haynes, Hanna, & Smith, JAMA. 208 Hunt, Haynes, Hanna, & Smith, JAMA. 208 (15) 1998.(15) 1998.

STEPS TOWARD DESIGNING AN OFFICE BASED STEPS TOWARD DESIGNING AN OFFICE BASED CLINICAL PRACTICE GUIDELINE DECISION CLINICAL PRACTICE GUIDELINE DECISION

SUPPORT AND METRICS SYSTEMSUPPORT AND METRICS SYSTEM

1.1. Must have an EMR Must have an EMR 2.2. Must have Practice buy-inMust have Practice buy-in3.3. Must have a decision support system that:Must have a decision support system that:

• Reliably search, obtain, and organize clinical Reliably search, obtain, and organize clinical datadata

• Reliably translate the data into applicable Reliably translate the data into applicable information information

4.4. Must have agreement (or near agreement) on Must have agreement (or near agreement) on clinical guidelines used for corrective actionclinical guidelines used for corrective action

5.5. Must deliver content at the point of patient Must deliver content at the point of patient contactcontact

6.6. Must create a culture where metrics are Must create a culture where metrics are acceptable without anger or fearacceptable without anger or fear

CDSS Protocol Content: CDSS Protocol Content: NephrologyNephrologyChronic Kidney Disease Management Chronic Kidney Disease Management

National Kidney Foundation KDOQI GuidelinesNational Kidney Foundation KDOQI Guidelines

• ACEI / ARB Therapy, with and without ProteinuriaACEI / ARB Therapy, with and without Proteinuria

• Anemia Screening / ManagementAnemia Screening / Management

• Vitamin D / Calcium Deficiency ManagementVitamin D / Calcium Deficiency Management

• Elevated Phosphorous ManagementElevated Phosphorous Management

• Medication Avoidance or Cautionary UseMedication Avoidance or Cautionary Use

• Vein Mapping / Cardiology Consult/Surgical Referrals (CKD Vein Mapping / Cardiology Consult/Surgical Referrals (CKD 4 or CKD 5)4 or CKD 5)

• Education OptionsEducation Options

• Measure of: Measure of: – Renal Function (eGFR)Renal Function (eGFR)– Parathyroid hormoneParathyroid hormone– Vitamin DVitamin D– CalciumCalcium– PhosphorousPhosphorous– HemoglobinHemoglobin– Iron saturation and Ferritin (ESA Therapy)Iron saturation and Ferritin (ESA Therapy)

CDSS Protocol Content: CDSS Protocol Content: NephrologyNephrologyCardiovascular Disease ManagementCardiovascular Disease Management

American College of Cardiology, National Cholesterol Education Program American College of Cardiology, National Cholesterol Education Program (NCEP) / ATP III(NCEP) / ATP III

• CAD or CAD Equivalent Dx: Anti-platelet TherapyCAD or CAD Equivalent Dx: Anti-platelet Therapy

• CAD, CHF, or CVD: Beta Blocker TherapyCAD, CHF, or CVD: Beta Blocker Therapy

• CAD, DM or CHF: ACEI / ARB TherapyCAD, DM or CHF: ACEI / ARB Therapy

  

Diabetes Screening & ManagementDiabetes Screening & Management

American Diabetes AssociationAmerican Diabetes Association

• HgbA1c MonitoringHgbA1c Monitoring

Hypertension Screening & ManagementHypertension Screening & Management

JNC 7JNC 7

• Management with and without Diabetes or Renal DiseaseManagement with and without Diabetes or Renal Disease

Preventive Screening Preventive Screening

US Preventive Services Task ForceUS Preventive Services Task Force, , Centers for Disease ControlCenters for Disease Control

• Tobacco Use Screening and ManagementTobacco Use Screening and Management

• Advanced Directives ScreeningAdvanced Directives Screening

• Influenza VaccinationInfluenza Vaccination

• Hepatitis B VaccinationHepatitis B Vaccination

Overview of CINA Overview of CINA TechnologyTechnology

Electronic Medical Record

Practice Management System Data

Lab DataRegistry DataHospital Data

CINA Data Source

Mapper

CCR / CCD(Standardized)

Reports

Analyses

StandardizedCINA CDR

CINA Protocol Engine

Evidence-basedClinical

Guidelines

Overview of CINA Overview of CINA TechnologyTechnology

EMR Data

PM Data

Lab Data

CINA Data Source

Mapper

CCR / CCD(Standardized)

Reports

Analyses

StandardizedCDR

QED Protocol Engine

Evidence-basedClinical

Guidelines

Payer DataCINA

Data Source Mapper

Dialysis data, Patient Entered Data, etc

CINA Data Source

Mapper

Other Sources of Data

Point of Care Point of Care Decision SupportDecision Support

Patient Specific

Automated

Produced for every patient, at every visit,regardless of

theReason for Visit

Utilized by allproviders

(MD, NP, PA, nurses)

•Active Active DiagnosesDiagnoses

•Prioritized in Prioritized in accordance accordance with the with the Protocol Protocol content / content / chronic chronic disease(s) disease(s) addressedaddressed

•Active Active MedicationsMedications

•Prioritized in Prioritized in accordance accordance with Protocols / with Protocols / chronic chronic disease(s) disease(s) addressedaddressed

Point of Care Point of Care Decision SupportDecision Support

Point of Care Point of Care Decision Decision SupportSupport•LabsLabs

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

Point of Care Point of Care Decision Decision SupportSupport•Measures / Measures / CalculationsCalculations

•Referential data Referential data from the EMR (vital from the EMR (vital signs) as well as signs) as well as certain calculated certain calculated resultsresults

•Diagnostic TestingDiagnostic Testing•Referential data Referential data from the EMRfrom the EMR•Indicates date of Indicates date of last procedurelast procedure

Point of Care Point of Care Decision Decision SupportSupport•LabsLabs

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

Point of Care Point of Care Decision Decision SupportSupport•RisksRisks

•Based on Age, Sex, Based on Age, Sex, Risk Factors, and Risk Factors, and DiagnosesDiagnoses

•GoalsGoals•Specific metrics of Specific metrics of interest to the interest to the practice and practice and addressed within addressed within the protocolsthe protocols

These 2 areas are These 2 areas are the basis for the the basis for the Recommendations / Recommendations / Action ItemsAction Items

Point of Care Point of Care Decision Decision SupportSupport

•Action ItemsAction Items•Divided into Divided into Action items for Action items for the the NurseNurse / MA / MA and for the and for the ProviderProvider•Action Items Action Items relate to relate to Medications, Medications, Labs, Labs, Procedures, Procedures, Vaccines, Vaccines, DocumentationDocumentation

•VisitsVisits•Derived from Derived from the EMR / billing the EMR / billing datadata

Point of Care CDSS Point of Care CDSS WorkflowWorkflow•Front Desk / ReceptionFront Desk / Reception Reports are automatically generated prior to the start of the work Reports are automatically generated prior to the start of the work

day and at noon for afternoon add-onsday and at noon for afternoon add-ons Additionally, the receptionist can generate ad hoc reports for a Additionally, the receptionist can generate ad hoc reports for a

single patientsingle patient

•Nurse / MANurse / MA Completes missing documentationCompletes missing documentation Administers / queues vaccine / lab orders Administers / queues vaccine / lab orders Medication reconciliationMedication reconciliation Communication tool for providerCommunication tool for provider

•ProviderProvider Addresses recommendations as appropriateAddresses recommendations as appropriate Communication tool for staffCommunication tool for staff Educational tool for patientEducational tool for patient

DNA Baseline DataDNA Baseline Data

Improvements In Prevention in Improvements In Prevention in Primary Care with Point of Care Primary Care with Point of Care CDSSCDSS

Improvement in All Preventive Screening Measures1/1/207 - 7/31/2008

0%

10%

20%

30%

40%

50%

60%

70%

80%

Improvements In Diabetes Improvements In Diabetes Management in Primary Care with Management in Primary Care with Point of Care CDSSPoint of Care CDSS

Diabetes Measures (4)1/1/2007 - 6/30/2008, Trended by Month

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

FootExam

EyeExam

MicroAlb

HbgA1c

Diabetes Measures: Showing Consistent Diabetes Measures: Showing Consistent Improvement from both High Performing & Improvement from both High Performing & Low Performing ClinicsLow Performing Clinics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Months

LowestPerforming ClinicRelatively LowPerforming ClinicHighestPerforming ClinicRelatively HighPerforming Clinic

WHAT ARE GUIDELINES?WHAT ARE GUIDELINES?

FROM “GHOSTBUSTERS”:FROM “GHOSTBUSTERS”:

Murray to Weaver (she was “hitting” on him):Murray to Weaver (she was “hitting” on him):

"I make it a rule never to get involved with possessed "I make it a rule never to get involved with possessed people." (pause-looking camera):people." (pause-looking camera):

"Actually, it's more like a GUIDELINE than a "Actually, it's more like a GUIDELINE than a rule..."rule..."

REACHING AGREEMENT REACHING AGREEMENT WITHIN THE PRACTICEWITHIN THE PRACTICE

• Several of the algorithms are CKD level Several of the algorithms are CKD level specificspecific

• So: what or who decides on the CKD level?So: what or who decides on the CKD level?• Can the practitioner tolerate using the last Can the practitioner tolerate using the last

eGFR found in the computer to “correct” the eGFR found in the computer to “correct” the last diagnosis?last diagnosis?

• If one is too few to correct, can we use two If one is too few to correct, can we use two consecutive?consecutive?

• How old can the data be?How old can the data be?

REACHING AGREEMENT REACHING AGREEMENT WITHIN THE PRACTICEWITHIN THE PRACTICE

• Do we want a reminder to use ACEI Do we want a reminder to use ACEI and ARB for all CKD patients?and ARB for all CKD patients?

• Or only those with proteinuria?Or only those with proteinuria?

• Can we tolerate being reminded if we Can we tolerate being reminded if we have already decided it is not safe?have already decided it is not safe?

REACHING AGREEMENTREACHING AGREEMENT

• Can we agree on a reminder to check Can we agree on a reminder to check vitamin D levels?vitamin D levels?

• Which moiety?Which moiety?

• What are the correct targets for PTHWhat are the correct targets for PTH

• Can we relate them CKD level?Can we relate them CKD level?

““MAPPING” ISSUESMAPPING” ISSUES

• How Does the CDR Recognize How Does the CDR Recognize “proteinuria”?“proteinuria”?

• How does it find the primary physician?How does it find the primary physician?• How can it tell when we refer to a How can it tell when we refer to a

vascular surgeon if all the users don’t vascular surgeon if all the users don’t have a uniform method of entering the have a uniform method of entering the information or leave it outinformation or leave it out

Expected Benefits and ROIExpected Benefits and ROI• Process in place for improving outcomes / Process in place for improving outcomes /

guideline complianceguideline compliance• Positioned to participate in P4P Positioned to participate in P4P

• Ability to incorporate data from outside sourcesAbility to incorporate data from outside sources• CMS PQRI Reporting (Registry Based)CMS PQRI Reporting (Registry Based)

– Failed efforts in Claims based reporting 2007Failed efforts in Claims based reporting 2007– Registry reporting requires Registry reporting requires NO NO physician effortphysician effort– PQRI bonus funds CINA solution, other quality PQRI bonus funds CINA solution, other quality

improvement effortsimprovement efforts

• Per Visit Revenue IncreasePer Visit Revenue Increase– Primary Care groups report avg $5-15 / visit Primary Care groups report avg $5-15 / visit

increased revenueincreased revenue

INTRODUCTION OF I.T.INTRODUCTION OF I.T.SHOULD BE APPROACHED AS SHOULD BE APPROACHED AS

AN INTERETIVE PROCESS--AN INTERETIVE PROCESS--A FAMILY OF APPROACHES, A FAMILY OF APPROACHES,

EACH WITH DISTINCT EACH WITH DISTINCT ADVANTAGES AND ADVANTAGES AND DISADVANTAGESDISADVANTAGESWilliam W. Stead MDWilliam W. Stead MD

IT HAS BEEN HARD TO SHOW IT HAS BEEN HARD TO SHOW QUALITY IMPROVEMENT.QUALITY IMPROVEMENT.

THE FAILURE IS RELATED TO THE FAILURE IS RELATED TO SOLVE A COGNITIVE SOLVE A COGNITIVE PROBLEM BY SIMPLY PROBLEM BY SIMPLY

INSERTING AUTOMATION INSERTING AUTOMATION INTO OLD PROCESSESINTO OLD PROCESSES

William W. Stead MDWilliam W. Stead MD

WHILE BETTER I.T. DESIGN WHILE BETTER I.T. DESIGN CAN MINIMIZE MISFIT, DOCS CAN MINIMIZE MISFIT, DOCS

ARE RESPONSIBLE FOR ARE RESPONSIBLE FOR MANAGING THEIR PEOPLE-MANAGING THEIR PEOPLE-

PROCESS-TECHNOLOGY PROCESS-TECHNOLOGY SYSTEMS TO GET THE SYSTEMS TO GET THE

PROPER OUTCOMEPROPER OUTCOME

William W. Stead MDWilliam W. Stead MD

Take Home MessagesTake Home Messages

•Increasing Pressure to Assure Increasing Pressure to Assure Attention to GuidelinesAttention to Guidelines

•Clinical Judgment Counts as long as Clinical Judgment Counts as long as the Guidelines are Recalledthe Guidelines are Recalled

•Payers Will be Looking for Practice Payers Will be Looking for Practice MetricsMetrics

•There Has to be a Way to Support There Has to be a Way to Support this.this.