Targeting Care Gaps in Primary Care: Utilizing EMR Dashboards to Improve Population Health

Transcription

1 Targeting Care Gaps in Primary Care: Utilizing EMR Dashboards to Improve Population Health Daniel Ngui, MD, CCFP, FCFP, Clinical Associate Professor, University of British Columbia, Vancouver, Canada Clinical Lead, Fraser Street Medical

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Session Learning Objectives 1. Analyze Electronic Medical Record (EMR) Queries, EMR Dashboards and Population Health Management in primary 2. Understand the potential to use EMR Dashboards to improve patient recalls, team-based care and help in achieving better population health 3. Discuss potential Advantages and Barriers to Uptake of a EMR Dashboards when implementing in Primary Care 4. Interpret examples of team-based workflows, EMR efficiency tips and how to utilize in primary care Western EMR User Conference

4 Disclosure Passionate about EMR Dashboards Published posters and presented at the following conferences.

5 The Nostalgic Challenge for Family Medicine of Old...Information Overload!

6 6 Data it provides the Impetus to Change DOCTORS WONT change unless.

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8 Optimizing the Chronic Care Model: Wagner et al

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10 The Evolution of EMR adoption What is true meaningful EMR use?

11 What is Population Health? Population Health Management is the aggregation of patient data and the analysis of that patient roster data into actionable interventions in which care providers can improve patient care, and financial outcomes 11

12 Key Principles of Population Health Management and EMR

13 The EMR Dashboard Value for patients? We can ensure patients are offered the best guideline based care We can begin to provide Planned Proactive Accountable care which is a huge paradigm shift Recalls identified by the dashboard can actually improve the patient experience, patient engagement and trust in clinicians Improved chronic disease management can actually increase access to care to team members and free up time for urgent visits Family health physicians and family health teams can better identify care gaps to systematically address Dashboards can help with the delegation of care to team members Improve self management education through in person visits or telephone outreach Western EMR User Conference

14 I m too busy why consider using a EMR Dashboard? EMR Dashboards for Improving Patient Care: A Review of the literature - Dowding et al After reviewing over 500 studies There is some evidence that implementing clinical and/or quality dashboards that provide immediate access to information for clinicians can improve adherence to quality guidelines and may help improve patient outcomes. International Journal of Medical Informatics February 2015, Vol.84(2): Overall, searches of Medline, Embase and Google Scholar have resulted in conclusion there is a Paucity of study of Primary Care EMR Dashboards for to improve uptake and adherence to CPG to improve patient care.so more study is needed. Western EMR User Conference

15 Queries and Software Widgets FINDING THE NEEDLE IN THE HAYSTACK

16 What is an EMR Query? A customizable search criteria for the electronic medical record to conduct identifying 1. A distinct patient population or demographic eg. Age or postal code 2. A specific provider or team eg. Single or multiple MDs 3. A specific observation or profile item eg. HgA1c, BMI, smoking 4. A specific task eg. Adding a profile, icd 9 code or recall task EXAMPLE: All patients from 13-60, who are smokers, who live in Vancouver, should be recalled to come for a group visit for a free smoking cessation program 3/6/

17 The Basics: What is an EMR Dashboard? A Dashboard is a practice reflective tool instantly accessible, real-time, drillable and customizable representation of data already within the EMR which allows for easy information management to enhance patient recalls, CDM billing, practices finances and to assist with workflow/workload management. A BEST HITS compilation of several EMR Queries organized together

18 MedAccess/Telus EMR Dashboard for Managing Chronic Diseases

19 CDM Coordinator CDM RN or CDM MOA Family Physician MOA Clinical Pharmacist Or Allied Health Team

20 When it comes to helping with optimizing CDM recalls at the center.you need a dashboard and a CDM Coordinator Family Physician CDM RN or CDM MOA CDM Coordinator MOA Clinical Pharmacist Or Allied Health Team

21 EMR Dashboards as part of the Family Physician EMR Ecosystem Western EMR User Conference

22 Distinct Advantages and functions of EMR Dashboards that can help Family Physicians 1. Patient roster/panel clean up: to ensure patients are optimally identified for analysis 2. Identifying investigation and/or monitoring care gaps to improve patient safety 3. Identifying opportunities to improve shared care between team members and patient education 4. Identification of medication care gaps to improve patient morbidity and mortality by practicing evidence based medicine 5. Supporting a Sustainable Business Plan to reinvest in additional clinic resources 6. Individual clinic or Clinic Network Data Analysis and Reporting 7. Quality improvement and CME opportunities via real time clinical audit and outcome tracking Western EMR User Conference

23 EMR Dashboards. The pre-requisite tool for team based care A data driven delegation system for the multidisciplinary team Helping to support referrals to the team Increasing access for patients to team members Western EMR User Conference

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26 CHEP (Hypertension) Guidelines Based Dashboard It IDENTIFIES REAL TIME CARE GAPS!!! In reverse engineering the CHEP guidlelines we created a HTN EMR dashboard for the clinic we were able to create the following; 1.Grade A Recommendation= 5 widgets 2.Grade B Recommendation= 4 widgets 3.Consensus Evidence and Practice Management Based= 5 widgets For the entire clinic, the potential number of patients eligible for recall based on GRADE A and B recommendations after verification = 1084 patients WHO COULD BE RECALLED Grade A Widgets: 626 patients Grade B Widgets: 458 patients 3/6/

27 How? GOAL: To create a practical useful EMR Tool REVERSED ENGINEERED Hypertension Canada s 2014 Canadian Hypertension Education Program Guidelines asked our colleagues feedback Asked an EMR programmer WHAT WERE OUR CARE GAPS IN HYPERTENSION?

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29 In a Nutshell... Objective to focus on hypertension care gaps and measure EMR Dashboard and chronic disease coordinator effect on some SURROGATE MAKERS generated patient recalls for annual hypertension reviews created physician reminders Identified patients for physicians to refer to team members: nurses and clinical pharmacists Goal to improve patient and clinican adherence to guideline based care based through 1:1 patient education and review

30 Reverse Engineered selected Hypertension Canada Guideline Recommendations

31 Level I Grade A Evidence Widgets

32 Identifying Care Gaps & Opportunities for RECALLS for Better Care For our group of 7 doctors

33 Our Quality Improvement Results OVER 6 MONTHS Retrospectively

34 Financial Analysis: A CDM Coordinator utilizing the EMR Hypertension Dashboard in a Incentivized Payments System Is this Sustainable?

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36 2013 CDA Guidelines Based EMR Dashboard It IDENTIFIES REAL TIME CARE GAPS!!! In our reverse engineering the CDA guidelines, we were able to create a DM dashboard for the clinic. We were able to create the following; 1. Level 1, Grade A Evidence = 5 widgets 2. Level 2, Grade A Evidence = 4 widgets 3. Consensus Recommendations, Grade C= 5 widgets For the entire clinic, the potential number of patients eligible for recall =1783 patients WHO COULD BE RECALLED! 1. Level 1 Widgets: 1308 patients 2. Level 2 Widgets: 138 patients 3. Consensus Recommendation Widgets: 337 patients 3/6/

37 Reverse Engineered the 2015 CCS A. Fib Guidelines. All proof of concept projects to see Is there is a novel, sustainable method of CONTINUOUS QUALITY IMPROVEMENT BASED ON EVIDENCE BASED MEDICINE GUIDELINES FOCUSED ON IMPROVING PATIENT OUTCOMES using population health management principles?

38 What are the Barriers to using EMR Dashboards in Primary Care? 1) A LACK OF CLINICIAN ENGAGEMENT What is the evidence of benefit? What is the return on investment? Who is going to make up the dashboards? Who is going to study the evidence it actually improves the Triple aim? 2) A LACK OF FUNDING How can we make this sustainable and self funding? Who will be the change agents and fund the spread? Who will pay to develop the dashboards and validate them? 3) The NEED for A TEAM AND TRAINING for TEAMS CDM coordinators in primary care MOAs Physicians

39 What are the Barriers to using EMR Dashboards in Primary Care? 4) ENGAGEMENT AND SUPPORT FROM VENDORS and NGOs Need integrated EMR tools to support AUTOMATED TEXT AND recalls 5) A LACK OF PATIENT ENGAGEMENT: Why is my doctor working in a totally new way? Patients need to understand shift to planned proactive care Takes up patient time and runs the risk of duplication with different team members 6) DATA STEWARTSHIP What can family practice clinics do with the data? What is the fine line between CQI and research? Who owns the aggregate data? Is it okay to be compared to peers? Can you live with the report card 3/6/

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41 Distinct Advantages and functions of EMR Dashboards that can help Family Physicians Patient roster/panel clean up: to ensure patients are optimally identified for analysis 2. Identifying investigation and/or monitoring care gaps to improve patient safety 3. Identifying opportunities to improve shared care between team members and patient education 4. Identification of medication care gaps to improve patient morbidity and mortality by practicing evidence based medicine 5. Quality improvement and CME opportunities via real time clinical audit and outcome tracking

42 Patient Registry Management Themes Identified 1. Patient Panel/Roster Clean up. Overall, we were able to improve our identification patients with A. Fib through improved ability to review cases. Although, we had a expected ebb and flow in our numbers, we had an overall increase in clinic patients identified with A. fib. Those with discrete INR data more than 3 times but without a ICD9 coding for 427.3

43 Patient Registry Management Themes Identified 2. Identification of Investigation and Lab Monitoring Care Gaps WHICH LEAD TO PHONE CALL OPPORTUNITIES those pts with icd with no discrete egr in 1 yr identify patients and drill down to patient charts who were missing up to date kidney function tests which could affect treatment. Within the few short months, there was a 75% improvement for one physician piloting the system as we decreased our numbers from 4 to 1 patients. identify patients who may have been overdue for a repeat INR to ensure safe monitoring

44 %20Conferencing%20and%20Telephone% pdf

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46 Lab Care gaps: Renal Safety and Anticoagulants While in Berlin from the comfort of the balcony of the hotel. Created 3 tasks assigned to a covering physician to call and arrange tests for patients I had not seen for a while reminding them to do their electrolytes and kidney function whilst on anticoagulants

47 Patient Registry Management Themes Identified 3. Increased opportunities for shared care with team members to improve patient education. patients who would be eligible for a medication review by the clinical pharmacists co-located in our office. This model could be a novel method of overcoming both patient and clinician inertia. We also had nine A. Fib medication reviews done for patients over several months.

48 Patient Registry Management Themes Identified FOR TARGETED CME 4. Identification of Medication Care Gaps. This widget is an example of a tool which allowed real time drillable data enabling us to review patients who might require a review of their medication given their individual patient characteristics. Doctor 1 Doctor 2 Doctor 3 Doctor 4 Doctor 5

49 Patient Registry Management Themes Identified 5. Identification of opportunities for improved clinical audit and monitoring effect of interventions. These data can act as a stimulus for clinician peer to peer discussions and improved continuous quality improvement projects as well allow us to better target professional development education to address knowledge gaps.

50 2. BC Tip #2: Hire A CDM Coordinator An IMG? When it comes to helping with optimizing CDM recalls at the center.you need a dashboard and a CDM Coordinator Family Physician CDM RN or CDM MOA CDM Coordinator MOA Clinical Pharmacis t Or Allied Health Team

51 What type of Issues did CDMCR identify over a few hours? Provider Laboratory Care Gap(eGFR) Issues Encountered MD Inertia due to pt factors Team based care opportunity(med R) Total 8 4 5

52 How did the EMR A. Fib Dashboard Affect Team based care? FSM Afib Observation Template (Share Care Opportunity) Provider #charts opened Templates used MD visit Pharm visit yes no Total

53 What was the Cost Analysis for CDMCR reviewing the Dashboard? CDMCR Wages $15 per hour Who was our CDMCR? A trained IMG clinician who had some training on how to use the dashboard Split up costs of CDM CR Phone calls to patients $15 per Recall Visits $30/visit Total Fees X 35% overhead expenses Wages and Time spent reviewing dashboard Time spent (not included in cost analysis for identifying ways to improve the program) WE needed to develop templates to create various types of recalls NET BALANCE $40 for 2.6 hours of review 7X $15=$105 17X$30=$510 $615x35%=$ $175

54 3. CDM Coordinator Example of EMR Nudge Task Template

55 WHAT ARE BARRIERS/CHALLENGES/SOLUTIONS What are Primary Care Physicians real life issues Time, Time and Time: A CDM coordinator Already at capacity why add anything more? Use Team Lack of Allied health providers or Manpower for executing recalls and chronic disease visits Some provinces are ahead Does it make them more vulnerable to msp billing audits? Guideline based and good safe medicine Phone calls are meant to save a visit and improve care Training for MD, CDCR and medical staff Lunch and learns EMR Limitations in creation of Widgets and Dissemination Vendor issue CCS Guidelines: Belief in the recommendations and level of evidence (need to be prioritized in to levels of evidence) Focus on real world

56 Advantages of using an EMR Dashboard/CDM CR Potentially Improved Patient Care and Outcomes 1. Patient Roster/Panel Clean Up: to ensure you are patients are optimally identified for analysis 2. Identifying Investigation and/or Lab Monitoring Care Gaps: To improve patient safety 3. Identifying opportunities for Improved Shared care between team members focused on improved patient education: To Improve team based care 4. Identification of Medication Care Gaps: To Identify ways tooffer medications to improve patient morbidity and mortality 5. Improved Quality Improvement and CME Opportunities via real time clinical audit and tracking

57 What Barriers still need to be overcome to fully implement EMR Dashboards 1) FUNDING: Who is going to provide and fund the CDM Coordinator and Team based care required to help with additional work that will be identified? 2) TRAINING: Who will train the CDM coordinators and team how to work together in primary care? 3) PATIENT ENGAGEMENT: When will the EMR integrate improved automated recall systems and offer improved patient engagement through improved patient EMR portals and who will pay for it? 4) DATA STEWARTSHIP: Who owns the data and safeguards it?

58 Thank you Session Learning Objectives 1. Review Electronic Medical Record (EMR) Queries, EMR Dashboard and Population Health Management 2. Understand the potential to use EMR Dashboards to improve patient recalls and help in achieving better Population Health 3. Review the results of pilot quality improvement project utilizing an EMR Clinical Dashboard based on the CHEP Guidelines and its implementation with a CDM Coordinator 4. Discuss potential Advantages and Barriers to Uptake of a EMR Hypertension Dashboard

59 Session Learning Objectives 1. Review Electronic Medical Record (EMR) Queries, EMR Dashboard and Population Health Management in PRIMARY CARE 2. Understand the potential to use EMR Dashboards to improve patient recalls and help in achieving better Population Health 3. Discuss potential Advantages and Barriers to Uptake of a EMR Hypertension Dashboard Western EMR User Conference