using ehrs to support pcmh workflows for medical homes: get … · 2019. 1. 29. · why is this so...
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Using EHR Information to Using EHR Information to Support Workflows for Support Workflows for Medical Homes: Get the Medical Homes: Get the right tool for the jobright tool for the job
Jeff Hummel, MD, MPHMedical Director for Clinical InformaticsQualis HealthJanuary 26, 2010
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ObjectivesIntroduction: Which comes first, accurate reporting, or getting the workflow right?
Workflows necessary for medical homes and the reporting functionality to support them
AttributionCare ManagementTest and Referral TrackingPopulation ManagementPerformance Reporting
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Why is this so important
PCMH effort is the only strategy out there for saving primary careEvery system is perfectly designed to give you exactly the outcome you getOur system is broken: we are getting mediocre outcomes despite best effortWe can’t improve what we’re doing without:
Better organized informationMeasuring what we’re doing
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Which comes first?
Outcomes measures and workflow are interdependent and inseparableWorkflows depend on information
Reports, dashboards & rules engines are all ways to organize information effectively
Outcomes reporting is completely dependent on workflow:
To deliver the care being measuredTo generate useable data for reporting, through standardized data entry
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Information is inseparable from workflow
Target
Chart opened by clinical
team during encounter Rules engine
calculates if immunizations are indicated
Clinical team updates chart information
Clinical team orders needed
immunization
Clinical team gives
immunizationClinical team documents
immunization given
Population outcomes report reflects current
information
Pop Mgr uses action report to identify Pts
needing immunization
Pop Mgr contacts Pt, creates action
plan & updates EHR information
Date5
PneumocoocusTDAP
Diphtheria TetanusVaricella Zoster
Hepatitis BHepatitis A
Date4
Date3
Date2
Date1
Immunization TableReporting Database
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The report as change catalystReports expose unstable workflows & performance variationStart with mapping current workflow and creating a future state to:
Standardize workflow & reduce wasteStandardize how data are captured
Only by problem-solving reporting issues can the workflow be fixedOnly by problem-solving unstable workflows can the reporting problems be fixed
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4 levels of reporting toolsExcel spreadsheet:
Not scalable
Internal EHR features: Often not very robustUsually require programming
Business Intelligence Query Engines:Complex reporting tools for DB analysts; costlyMay be hard wired to a specific EHRResult is “canned reports”
Custom QI “aftermarket” products:Agile dashboards designed for QI end-userOften a service agreement
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The Key Workflows for PCMHAttribution: who is the PCP?Care Management: Dashboards
PreventionChronic illness care
Referral and Test Tracking:Overdue resultsAbnormal results
Population Management:Generating action reports: Pts needing services
Measuring performance: across practices
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Attribution: Foundation for Empanelment
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Attribution: Defining the goalsData definition: designate the PCP fieldCreate a report for initial attribution:
Define criteria for attribution, e.g.• Provider seen most often• Provider seen most recently
Define mechanism for entering the decision into the PMS/EHRDefine a workflow for Pt to validate & update attribution with each visit
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Workflow for Attribution
Scheduler proceeds to appoint Pt
Report writer creates
attribution report
Attribution report is run
Report output populates
PCP field in PMS
Patient makes appt
Scheduler asks Pt to
validate PCP
PMS has correct PCP?
Yes
No
Scheduler corrects the
PCP field entry in PMS
Pt has office visit
EHRPMS
Reporting Database
PMS updates PCP field in EHR
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What IT Tools Did We Use?
Report from Reporting Data Base (or PMS)
For each active PtFor each office visit in past x months
• OV Date• Encounter Provider
Apply agreed upon rulesProgramming to auto load output into designated fieldMaintenance: Workflow only
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Care Management: GoalsNo one leaves the clinic without it being addressed
The power of physician recommendationIf we can’t deal reliably with patients who are already in the clinic, it makes little sense to ask people to come in for preventive care
Strategy: standardized workflows, integrated with information, that involve the entire team, to guarantee results
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The Care Mgmt Workflow
Patient makes appointment
Day of visit team huddle
to review charts & plan
Pt arrives at clinic and is given Pre-
visit summary
MA rooms Pt and updates HM data from
PVS
MA discusses with Pt, orders and pends HM interventions
Provider sees Pt and signs
pended orders
Pt leaves with HM issues
addressed & info updated
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The clinical decision-making information assembly line
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Care Mgmt: Chronic Illness
Identical workflow strategy for gathering the information during a visit:Plan for today’s patients in the HuddlePre-visit summary to help activate PtGather and organize as much info as possible before provider enters room
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What IT Tools Did We Use?
Prevention and Chronic Illness CareRules EnginesDashboardsFlow Sheets
Workflow designed to gather and organize the information so the correct clinical decision was obvious
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Test and Referral Tracking
Workflow goal: Have a process to detect when Pts are lost to follow-upWhat is the workflow?
Whose job is it to track down overdue results?How do they do it, and when?
What tools support the workflowOverdue results rules engineReport showing name & date of orders that need attention
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Overdue results workflow
High priority test activates pre-set ODR
timer
Test is ordered
Pt given instructions
on how to get test done
Pt calls and is scheduled for
test
Pt goes to the facility and has the test performed
Results sent to ordering
provider
Ordering provider uses information to make
clinical decision
Option 1: Non-resulted test triggers alert to ODR in-basket
Option 2: Weekly report: Denominator is all Pts who have had the test ordered > set interval; Numerator is all of the denominator Pts with tests not resulted
ODR Mgr contacts Pt to
see what happened
Process is un-stuck and timer reset
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Don’t over-do over-due results
Don’t overload the workflowPick only high priority tests to track
Don’t over-build it: Automate the tedious tasks Leave clinical decision-making to humansKeep the action burden low
• Set up standardized responses to ODRs• Use automated messaging where it makes
sense
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Abnormal resultsWorkflow goal: Abnormal results won’t slip through the cracksWhat is the workflow?
Who does it? When? What tools do they need to do it?
Example: All women with abnormal paps
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A workflow for abnormal paps
Result returns to provider Normal?
Yes
Patient notified
NoProvider
selects abnl tracking interval
Provider makes clinical
decision(s)
Usual care including follow-up
After tracking interval is
elapsed, chart is reviewed
Pt on track?
Yes
No Pt contacted to assure not
lost to f/u
Pap smear done
Var 5
Patient 6Patient 5Patient 4Patient 3Patient 2Patient 1
Var 4Var 3Var 2Var 1
Abnl Paps
Reporting Database
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What does the report need?
Patient name, IDDate of last papThe f/u interval Some way to resolve or turn it off when Pt no longer needs tracking
Reset f/u interval to a new valueDelete f/u interval
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Population Management
What is the workflow? Goals:
• Automate monitoring• Early recognition of complications• Assure systematic interventions• Risk factor reduction• Empowering patients
• Self-management support• Patient education
Whose job is it?
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Workflow steps
Chronic Disease Manager runs & reviews action reportChronic Disease Manager contacts Pt
Orders testsAdjusts treatmentAssesses patient self-management needs
Coordinates with PCP forInformation flowClinic visitsGroup visits
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Information flow in Population Mmgt
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Anatomy of an action reportDenominators
Careful definition of the populationAccurate attribution is essential
Numerators: All the patients needing action
• Orders & results • Custom data entry fields
All the Population Manager needs to see is the patients in the numerator
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Outcomes ReportsSame principle as action reports except the numerator is reversed
Denominator: entire populationNumerator: Those meeting criteria
Must be able to drill down to clinic & provider but not to patient level
Attribution must be reliableTrending to monitor progress
External and external for incentivesAll you may need is percents
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Getting StartedIdentify a topic where success is likely
A clear planWidely shared motivation for changeOrganizational capability
Redesigning the workflow (another whole topic for discussion)Creating and maintaining the report
Whose job is it?Do they have the right tools?Do they have the right skills?
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Conclusion:Reports/Dashboards & workflow are inseparable, so build them togetherMedical Homes requires new workflows and new information management
EmpanelmentCare managementResults trackingPopulation managementOutcomes reporting
Get the right tool for the job
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Questions?