CSI-RI Best Practice Sharing ConferenceFriday January 21, 2011Hillside Family Medicine

Chris Campanile, MDJessica Spellun, Quality Assistant

OPTIONS: You Can….Not Collect Data

Collect Data and Do Nothing With It

Collect Data and Discuss It

Collect Data, Discuss It, and Act on It

Organizational StructureDesignate a core Quality Team

Physician ChampionAdministrator/Practice ManagerData/Quality AssistantNCMIT

Regular Meeting Times Quality TeamProvidersAll Staff

Formation of a Core Improvement Teamto Review Data and Oversee Process Changes

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Example: Mammography ScreeningPrevention Measures

Monthly Report Data Guide for

Report Due: 10/17/2009

Prevention Measure Numerator Denominator

Mammography

Number in denominator who received one or more screening mammograms 10/11/07 through 10/10/09

Number of active women patients appearing in the EHR on 10/10/09 who are between the ages of 52 and 69

Colorectal Cancer Screening

Number in the denominator who received any of the following:

FOBT 10/11/08 through 10/10/09 Colonoscopy 10/11/99 through

10/10/09 Flex Sig 10/11/04 through

10/10/09

Number of active patients appearing in the EHR on 10/10/09 who are between the ages of 51-80

Influenza Immunization

Number in denominator who received one or more influenza immunizations in current or most recent flu season: 9/1/09 through 10/10/09

Number of active patients appearing in the EHR on 10/10/09 who are age 65 or older (born on or before 10/10/1944)

Pneumococcal Immunization

Number in denominator who received at least one pneumococcal immunization in their lifetime

Number of active patients appearing in the EHR on 10/10/09 who are aged 65 or older (born on or before 10/10/1944)

So You Have Data, Is It the Truth?

Are we really only getting 40% of women 52-69 to get mammograms?

Tracking Data Trends Highlights Areas that Need Improvement

How can we begin to improve our trends? Do we have an appropriate procedure for capturing data? Are mammograms being ordered regularly by the physician? Do patients understand the importance of a mammogram?

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Example: Mammography ScreeningPatient Name

Evidence Based

Data That Drives

Improved Outcomes

1. Decision Support

2. Physician Prompts/Alert

s

3. Patient Engagement

4. Data Flow and

Documentation

5. Reporting

6. Analyzing/Shari

ng/Acting

Data Flow and Documentation:Paper Results

Results Received by Office

Provider Reviews

and Places in Quality

Box

Quality Team Enters

Data Into Reportabl

e Field

Testing Complete

d by Pt

Data Flow and Documentation:Interface Results

Results Received Through Interface

Provider Reviews Results

Results Auto-

Populate Reportable Data Field

Testing Complete

d by Pt

Reportable Data Fields

The Fruits of Our Labor

Template prompting and a refined data capture process led to 24% improvement!

Being Able to Show Physician Identified Data

Tackling the Plateau Phenomenon

Coordinating More Timely Referrals

Better Utilization of the Clinical Team

Patient Outreach and Education