EHR Innovations for Improving Hypertension Challenge

EHR Innovations for Improving Hypertension Challenge


We’re recording. Great. Thank you everyone
for joining today’s webinar on EHR Innovations for Improving Hypertension Challenge in which
we are hosting the winners. And talking a little bit about phase II and what’s to come.
Next slide please. I don’t want to take up too much time so that we can get into our
content.But my name is Adam Wong and I am the prize challenge manager at ONC. The Office
of the National Coordinator for Health IT. And joining me today are Hilary Wall from
CDC Million Hearts about their blood pressure protocols. Then we will get to Holly Dahlman
with Green Spring Internal Medicine and the team at Vibrant Family Health Clinics.
Christopher Tashjian, Mary Boles and Roseanne Matzek. What we are going to do is have them
each present on their winning submissions and processes that they developed internally.
After they have spoke, each one, we will host a Q&A. So please enter your questions in the
Q&A box at the bottom right of your screen. They will take questions and then we will
move to a quick discussion about phase II and what is entailed there. This webinar is
being recorded and will be posted on the challenge website where you can find all the details
about the challenge both phase I and phase II. We will be hosting the webinar there and
that is also where you will be able to download each winner’s participant materials that can
be used for phase II. So without further ado, I’m going to pass this over to Hilary. Thanks
so much Adam. Hi everyone, I’m Hilary Wall, the Million Hearts science lead as Adam said
with the Centers for Disease Control and Prevention. And I just want to talk for a minute about
cardiovascular disease. We’ve seen a gradual decline in mortality in cardiovascular disease
over the last forty years. But it still remains the nation’s leading cause of death for men
and women of all races and ethnicities. And every year in the US more than 1.5 million
people will have a heart attack or stroke and 800,000 of them will die. It’s the leading
preventable cause of death for people under the age of 65.So back in 2012, to address
the burden of cardiovascular disease in our country, the US Department of Health and Human
Services launched a Million Hearts. And a Million Hearts is being co-led by my agency,
the CDC, and the Centers for Medicare and Medicaid (CMS) but many Federal agencies like
ONC are invaluable partners as well. So he overall goal of our initiative is to prevent
1 million heart attacks and strokes by 2017 and as you can see from the slide we have
a two-pronged for achieving our audacious goal. We need to keep healthy people healthy
by changing the environments in which we work and live. That includes reducing smoking prevalence
in communities through smoke free laws as well as reducing the sodium and eliminating
the artificial transfats in our food supply. But we also need to improve health care for
those who need it. And we can do this most impactly through three strategies. First by
focusing on the ABCs. Aspirin for those who need it. Blood pressure control, cholesterol
management and smoking assessment and treatment. Second, through harnessing the power of health
information technology, like thoughtful clinical decision support tools to improve health outcomes.And
third by encouraging health innovations like teen-based care and self measured blood pressure
monitoring with clinical support. And we’ve determined that blood pressure control is
the most impactful strategy for reaching our goal of preventing 1 million heart attacks
and strokes. So we’ve been busy mobilizing the nation on this issue.
And so the ONC EHR Innovations for Improving Hypertension Challenge that we’re here to
talk about today is a terrific opportunity to address all three aspects of improving
cardiovascular care for disease prevention. Next slide. But let’s be clear. I don’t mean
to glaze over this. Hypertension control is complicated. It relies on commitment from
both the clinician and the patient. And there are many choices to be made about type, number
and dose of medications. When to up-titrate or add additional medications and what the
optimum follow up time is. There is also the issue of white-coat and resistant hypertension.
But despite these complications, we know one thing for certain. That improved blood pressure
control equals fewer heart attacks and strokes. Next slide.
We believe that one of the answer to relieving some of the complexity of hypertension control
is adopting a standardized hypertension treatment protocol.Protocols are called all different
things. Care Algorithms. Care pathways, care plans. Whatever you call it, it is a standardized
approach to blood pressure treatment. We’ve seen a number of healthcare treatments adopt
standardized protocols And see great improvements in blood pressure control likely because protocols
support evidence-based Medicine and enable all members of care teams play an integral
role in caring for patients with hypertension. For me the challenging part is figuring out
how best to integrate treatment protocols into electronic health records so that care
is optimized and streamlined throughout the workflow while trying to minimize the burden
on clinicians. And we are absolutely thrilled to have the two phase I challenge winners
tell us today how they’ve been able to do this kind of work and I’ll be honest. I’ve
seen a sneak peak and they have some fantastic tools to showcase. I’m really excited. Next
slide. I will just quickly mention for anyone interested, here is the Million Hearts website.
And we’ve listed some evidence-based protocols that have been successfully integrated into
health systems like Kais Permanente and the VA. Now they don’t have the electronic components
of them but you might find them to be helpful resources for phase II of the EHR Innovations
for hypertension control challenge. And with that I’ll turn it back over to Adam to introduce
our phase I winners. Okay, thank you very much Hilary. Now we are going to move onto
Holly Dahlman with Green Spring Internal Medicine located in Lutherville, Maryland. We were
really impressed with what Holly was able to do in her small practice. So I will turn
it over to her. Holly. Thanks and thanks Hilary for a great presentation. Good afternoon everyone.
I want to thank all of you for the honor of presenting our EHR innovation
for improving hypertension. I also want to give a special thanks to the Maryland Multi-payer
Patient-Centered Medical Home Program which is a pilot of 50 practices throughout our
state. All working towards advanced primary care practice. Especially, I want to thank
our leader, Dr. Niharika Khanna who spurred me on to apply for this award. And to the
Maryland Department of Health and Mental Hygiene who nominated us. Congratulations as well
to Vibrant Health Family Clinics for their award. Today I titled my talk “IT Toolkit
for Hypertension Control.” The objective of the talk is to demonstrate how our small practice
(Patient-Centered Medical Home Pilot) uses a team-based approach, combining health IT
tools with evidence-based medicine to improve hypertension control. So here are some of
our statistics. Back in 2011, using NQF measures 0018, we realized we had a weakness. Only
47.71% of our patients with hypertension had blood pressure under control. This is approximately
only 1% above the national average at the time. So we realized we needed to something.
To pour a little bit of effort into our processes. Our protocols. And by 2012, that blood pressure
control had improved to 66. 04%. And by 2013, a little
over 80% which was sustained last year in numbers that are still being finalized. Our
team is made up of
one physician. That’s me. We also have a nurse practitioner who serves one-third of her position
as a care manager. We have three certified medical assistants and one medical office
assistant. We have seen approximately 2,700 patients in the last three years. Most of
our patients have more than a high-school education but do come from culturally diverse
and economic backgrounds. Our practice model as I mentioned is around the patient-centered
medical home. And we have been a level 3 NCQA-recognized medical home since 2011. And that was the
same year that we joined the MMPP pilot. We have a team-based approach and our vision
is to equip, empower and engage patients in their own healthcare.
Our steps to hypertension control can be summed up by what I call the “three R’s.” First of
all, we use our registries. The registry tool is a clinical tool to identify any patients
with hypertension who have not been seen in the past 12 months or patients who had hypertension
that was uncontrolled in the last visit. We bring our patient resources and many of them
are online. We have the DASH diet linked on our website. We also have other resources
powered by our information technology. And the third thing is that we go over our patient’s
home blood pressure readings. We really believe that reporting and reviewing blood pressure
readings helps patients control their blood pressure.
So the use of our registries is a quarterly process where basically we go into a clinical
record’s registry feature and we do two registries. One of them is to identify patients who have
not been in for the past year who have a hypertension diagnosis. And the other registry is to find
the patients whose blood pressure was greater than 140 over 90 at their last visit. And
then we call those patients into the practice. We might use a telephone or send them a web
message through our patient portal. We also have an automated system called v-messenger.
Here’s some features of our registry. And you can see that there are various categories
that we can use for our 11:17 search. We have encounters which allows us
to look for a certain date range which allows the registry to look for the date of last
visit. We can also run registries according to ICD and CPT codes. And there’s even a section
on medications. Once we have the patient in the office, we check their vital signs, and
you can see here under this slide that there are red letters under both blood pressure
checks. In fact, the body mass index on this patient is also listed in red. And what the
red letters in the vital section mean is the patient has readings that are out of range.
We use protocols in our practice in order to improve hypertension control as well. First,
we perform medication reconciliation at each and every visit. Second, we use the browse
section in our electronic health record to quickly pull down detailed information on
the DASH diet actin plan. And also self monitoring instructions. Since we opened in 2006, all
of our patients receive a note at the end of their visit, so that they will receive
all these instructions in writing and they can review them at their leisure. In addition,
we use evidence-based prescription favorites which is a feature within our electronic health
record. So here’s a slide that shows the unique features of our medication reconciliation.
And here you can see that there’s a little checkbox where we can check off that we verified
the prescription and there are additional features here. The little balloon boxes are
to designate whether the patients are taking, not taking or discontinued taking their medications.
And there is also an unknown box to check off if we are not sure. There is also a little
note section we can use to describe the reason
why the patient might not be taking their medication. For example, if the patient stopped
taking quinapril due to a dry cough. Here is a picture of Shannon who often times does
medication reconciliation using an I-Pad feature with the electronic medical record. We use
a browse section in our electronic record to populate standard instructions that we
are frequently giving. Here is an example of instructions that we have given the patient
on the DASH diet action plan. And also on the use of their home blood pressure monitor.
We have the DASH diet action plan website linked on our practice website. I’ve created
what’s called the e-library which has indexed references for a variety of illnesses the
patient might have. And under hypertension, the top link is the DASH diet action plan.
And this is a one-page reference for people who just need to get the basic idea about
the diet. We do ask our patients to try to obtain the DASH diet book and read the whole
thing. And try to incorporate what they are able to. But at least this provides a quick
reference. In addition,e-Clinicalworks provides a wonderful patient education feature. In
this case, it is integration with frames, which has low health literacy resources in
English as well as in a variety of different languages. And these resources can be published
to our patient portal or printed out at the time of the visit. Our Rx favorites feature
is on an evidence-based protocol for hypertension control and in our office, we base our hypertension
control protocol on the National Committee recommendations. And here is the slide with
the My Favorites feature. Once we check off the first few letters, in this instance “HY”
a pop down will come out showing the top three prescribed medications for blood pressure
control. Finally in the space of our visit, we like to encourage our patients to do home
self monitoring of blood pressure and we coach them how to use it. And once they are back
at their follow up visit, we reinforce the proper way to do self monitoring of their
blood pressure. Patients report their blood pressure readings to us even in between their
visits. And they can do that by mailing them to us, or sending us a portal messager even
faxing us their readings. In the space of the office visit, we have the time to review
the home blood pressure log or journal and provide feedback to the patient. A lot of
the times, in this process our patient has a self discovery or self sensitivity. Other
patients realize the role of stress in causing blood pressure spikes. We can also see if
we over treated as their readings are actually low at home. And based on these readings we’re
able to coach the patient on targeting their lifestyle change to what has 17:04
the most impact. We take the time to do motivational interviewing on lifestyle changes. Sometimes
that is counseling on weight management or incorporation of exercise. Or cutting back
on alcohol. Other times, we are exchanging recipes within the DASH diet family of foods.
After we have done that counseling, if need be, we will add medication according to our
protocol. Before the patient leaves the office, we reinforce ongoing blood pressure monitoring
and make sure they have a scheduled follow up appointment before they go home. We use
other electronic tips and tricks. One of them is called
eClinisense which is a feature in our HER that learns our regular practice and provides
little boxes that we can check to populate our note with recommendations that we have
commonly used. We also have a smart phone app called Healow which is free and available
on droids and iphones and ipads. This allows patients to do all the things that a patient
can do on a normal computer portal but also integrates with tracking devices and allows
for reporting of readings to our office through the patient portal. We recently came up with
a care plan template that I’ll talk about in a minute. And then we use other social
media for a like facebook, twitter and pintrest to engage our patients in their health. Here’s
an example of our facebook page. A couple of weeks ago, I posted an article on the benefits
of the DASH diet which happens to be particularly effective in African Americans. So we wanted
to make this avaialble to our patients so that they can read the same article that we
are reading in plain language. The newest addition to our electronic protocols is the
care plan template. And here is the author of the care plan template who is the nurse
practitioner and care manager. And she works together with our consultant to design a care
plan template that satisfies all the criteria of the new Medicare chronic care management
code. And this involves phone calls to patients who are high risk to do various assessments
and help people with their self management. So we are really excited about this new automated
feature In summary, we have used the three “R’s,” registries, resources and reporting
to improve hypertension control in our practice. In so doing, we are using population tools.
We are using resources and we are using self management and efficacy tools to empower our
patients for better hypertension control.Thanks so much for the opportunity to bring you all
this exciting development from our practice. I would
like to acknowledge a large number of people who have contributed to our success. Adam
thanks to you for questions. Great. Thanks a lot Holly. That’s terrific. So can we go
to the last slide. Jennifer do we have any questions queued up. No, no questions have
come in. We’ll give people a minute. If things are not coming at the moment, we can tackle
them later in the webinar. I have a question for you Holly. How are you using Pinterest?
And how are your patients responding to that? Yes, I’m trying to get more of our patients
to be engaged in social media. How I’m using it is to actually Post photographs of really
healthy food and to post how to grow food. We live in the Baltimore area andwe have a
very lush Spring, Summer and Fall. So our area is really great for growing fresh fruits,
vegetables and herbs. So I’ll post photos of growing ideas or cooking ideas. I was very
inspired by the healthy kitchens, healthy lives conference last year out in Napa valley
that Harvard School of Health puts on with the Culinary Institute of America. A lot of
great ideas came out of that conference. But one of the funny points that was made was
there is so much food marketing out there that is marketing unhealthy food, so why not
market really healthy food. So I’m using pinterest to really market healthy food and health ideas.Okay,
we got a question in. This person is interested in the care plan format and who initiates
the care plan. And at what point in the process is it initiated? And also are the MDs actively
involved?That is such an excellent question. So, the use of care plans has really evolved
over the years. In our pilot program, our care program wasn’t even a participant in
our MMPP pilot. Just this month, Medicare has incorporated a chronic management code
which will actually pay practices up to $42/month to call patients and assist patients with
coordination of their healthcare or to try to intervene with
patients who have declining health due to multiple chronic conditions. And patients
need to meet two chronic conditions to qualify for that code. We are just starting a protocol
and reaching out to our high risk patients. The trick of the Medicare chronic management
code is that you actually have to obtain written consent for the service. So we are going to
try to use the office visit to identify some of our patients who are at high risk and sign
them up at the time of the visit. The other trick of the Medicare chronic management code
is you have to actually collect an $8.52 co-pay which is the patient’s responsibility for
the visit. So those are some of the obstacles. We just created an information page that provides
an advanced beneficiary notice and that has all the information about what the chronic
care management call is all about. And apprising patients of their responsibility payment-wise
and what our responsibility in that service will be. The Care plan is often carried out
by people with a nursing license although some practices use medical assistants as their
care managers and others have had physician assistants. I even know of some practices
where the physician himself or herself is actually doing the
care plan. I think in terms of what makes business sense, it probably a non-physician
task. So at this point we are planning to have our care manager conduct the care plan
calls. It’s a really good thing with some of our patients to realize that they may not
be taking their medication not because they don’t like us or they don’t like the recommendation
or the medicine. Sometimes they don’t take the medication because they can’t afford it.
Or sometimes they don’t take the medication because of the belief about their medication
that they got from talking to their neighbor. So the care plan conversation allows our nurse
practitioner to really identify the barriers to care and work with the patient. It’s a
really great thing to do. And now that Medicare pays for it, there should be a lot more uptake.Okay,
I have another question. Does your registry include patients with HTN diagnosis who have
only been in for an acute visit in the past year? I would say that our registry is more
blunt force. It is not going to tell us who is on for an acute visit versus who is in
for a physical. We can use the E&M code so we can look to see who is in for a V70.0 versus
a 99213. We haven’t chosen to differentiate between acute visits and regular check ups
because we think hypertension is something that we can address at every single visit.
But I will say a number of people with high blood pressure readings will come in when
they have fallen and their hips hurt or they’re in a family crisis. But one of the things
about hypertension control is that we should not be
aiming for 100% hypertension control. There are always going to be some patients who should
not have a blood pressure of under 140 over 90. I don’t know if that answers your question.
Okay I have another one. Great presentation. Can you discuss your metrics and outcomes
including cost savings? Yes, so I’m not fully prepared to discuss all of those matters.
One of the challenges that we face is that we don’t get a lot data back from payers as
of yet. So, for example, the PCMH pilot just provided data from 2013. We don’t have data
back to our practice in real time so that we can actually use it to modify a process.
I wish it were otherwise. Do I believe that controlling hypertension will generate cost
savings to those of us who are in models of shared savings? I do believe so. I believe
it might take a number of years because this is a long view of prevention. But if you only
costs $300-400 to control hypertension on a yearly basis and then a bypass grafting
is over $100,000. Dialysis is $80,000/year. Renal transplant is $100,000+, it kinda does
make sense. Because someone who has a heart attack has an expensive hospital stay. I wish
that we had the cost data in real time. We just joined the Medicare shared savings program
ACO so my hope is that we will at least have Medicare cost data back. But not super frequently.
Maybe quarterly. It would be great to have cost data. I think if the payers can recognize
that primary care can really save money, they would share cost data with us more expediently.
Okay, another question. When did you change the blood pressure control protocol? And what
was the percentage of patients with uncontrolled blood pressure before and after the new protocol?Yes,
if you can go back to my slides. About the fourth slide please. The year that we joined
the PCMH pilot was also the year that we tested Meaningful Use. So we were really getting
our act together as far as capturing quality measures. So that year, 2011, we figured out
how to capture hypertension control and I think hypertension control out of all
our Meaningful Use measures was the most reliable because it’s a super central data capture.
So when I saw this number, I was pretty surprised. I thought I was a pretty good doctor actually
and this is only slightly above average. That made me realize we needed to do something
about blood pressure control. We were also asked to present our efforts with hypertension
control to a Million Hearts symposium. I started to say yes but we really hadn’t done that
much so it spurred me on to do something more. So that’s a true confession. We chose the
three conditions at the beginning of our PCMH pilot program. We chose obesity, hypertension
and diabetes as our disease conditions of focus. So we poured extra energy into those
conditions. We not only run hypertension registries, we run registries on obesity and diabetes
that is not well-controlled. Or the diabetes patient who we haven’t seen in a year. And
believe me there is a lot of crossover between the three conditions. So a lot of those patients
are on our registry calls but we try to call just once a quarter. I think the use of registries
really began solidly that first year. I have been recommending the DASH diet action plan
for over five years since data was presented at Border U courses, mainly Dr. AJ ?? who
is a pathologist at Brigham has presented powerful evidence that the DASH diet can result
in a 10-point in blood pressure. And a lot of our patients want to know what they can
do with their lifestyle to control their blood pressure. They don’t just want to be treated
with medicine. Some of our patients are resistant to being treated with medicine. But if we
bring in a lifestyle that empowers them to control their blood pressure, a lot of them
have expressed real satisfaction. One of our patients actually lost 30 pounds on the DASH
diet. So it sometimes can help achieve multiple goals in one. So we have really been recommending
the DASH diet for some time. The self monitoring, I’m not totally positive when that became
our strong recommendation. But I’m pretty sure it was pretty early on because..right
along with the DASH diet data that was presented. Research that has basically shown that home
blood pressure readings correlate more tightly with long term hypertension outcomes than
in office blood pressure readings. So I would say we are privileged to be in practice in
a community where most of our patients can afford a home blood pressure monitor. A lot
of others can’t afford a blood pressure monitor which is a limitation in our protocol.
But really we tried to push all three “R’s” all at once pretty early on in our pilot program.
And that actually leads to another question. How are you coordinating care for patients
who may not be able to afford a home blood pressure monitor? So that’s an excellent question.
So in some cases pharmacies have blood pressure cuffs. I’m never sure how reliable those really
are. Some of our pharmacies have a clinical pharmacist who has some clinical skills in
counseling. They tend to have a higher quality blood pressure monitor in those pharmacies.
I would love to see more access for home blood pressure monitoring. For example, in the city
of Baltimore, hypertension is highly prevalent but is perhaps unrecognized. It’s out of the
state of my expertise but I think that it is low hanging
fruit that people might want to invest in so that patients can get a sense of control
over their conditions. We are able to have our patients come through the office here
and have the staff check the blood pressure as well. But usually I try to make sure that
anyone coming through a blood pressure check is on my schedule because I want to be able
to be involved in real time decision-making once we know what the blood pressure really
is. And the last question I have is have you considered using the American Heart Association
e-health tool Heart 360? Would this be a good idea to supplement what is being done in the
clinic or is it something extra that may not be needed in the care of hypertension? I’m
unaware of that so I’m unable to comment on that. Holly, could you talk a bit about the
logistics such as setting up your EHR patient wise? How it has been for your office? I think
that we’ve been using e-clinicalworks since 2006 so the implementation was quite some
time ago. But we had a second build-live in 2011 which simply involved mapping all of
our quality measures so that we would actually capture data reliably at every visit. So as
far as mapping, it would be ideal if her companies would actually do mapping for practices so
they wouldn’t have to try and figure out workloads for their data capture. We wound up doing
quite a bit of it ourselves. What we realized when we decided to focus on blood pressure
and obesity and diabetes was that it was critical to have these vitals checked at every visit.
So basically what we calculate is when our patients check in we do their blood pressure,
height and weight to get the body mass index. The body mass index as a number allows us
very quickly to know if a patient is overweight or obese. And that has greatly helped us to
improve recommended weight loss to our patients. So that is a workflow where we insist on vitals
getting into the chart at every visit. As far as setting up the browse feature, it really
evolved into thinking about how it works in plain language for the patient. I recommend
reading the DASH diet action plan book. The info about the diet is linked on our practice
website and my specific instructions about home blood pressure readings. So once I draft
what to say for 95% of our patients about hypertension, I’ve been able to create macros
that allows the information to be populated without me having to think about it. And that
allows me to spend more time with the patient. So getting the EHR set up with some of the
customizations are helpful. I would say customize the EHR enough but not too much is what is
critical for data capture. I know some practices are having a really hard time because one
doctor captures measure this way and another that way, but people need to adopt the same
work flow in order to capture accurate quality metrics. And accurate quality metrics are
of the essence that doctors actually buy into them and believe in them. Especially doctors.
Because doctors are cynical about whether their data is accurate and become disengaged
in. Doctors need to stay engaged in quality measure efforts in order to succeed. In some
ways I think we were blessed because we are a small practice and we can implement changes
and make them across the board without having to have a committee meeting. But because we
are small a lot of the ability to address all these tasks fell upon me. And it was hard
work. But it was good thinking about how to set it up in the beginning saved hours and
hours of training time. We are hoping to use our IPad for home visits and use the blood
pressure data and other data at home visits. Basically including in our office quality
measures so that we can more hone down elderly patients and their care is captured. So the
IT is definitely an evolving process. I have an affection for technology so I was drawn
to it. If someone throws out an idea, I wanna try it. A lot of this was trial and error.
One challenge we had was there were many paths to the same data capture in our electronic
medical record and there are several different ways of reporting data. So it was also deciding
what reporting software feature you were going to use. What shortcuts you were going to decide
to use or not use. What clinical decision support is actually supportive of the decision.
Hypertension is something that we do multiple times every day in practicing medicine so
having algorithms or having guidance for what we do clinically but we really haven’t memorized
because we do it all the time is probably not as necessary. The cardiovascular tool
which is an app that I do use is the atherosclerotic cardiovascular disease or ASCVD calculator.
That gives me the patient’s ten year risk for a cardiovascular event. And then I can
get more aggressive with their therapy. Focus more on blood pressure control or what not.
Thank you Holly. I’m afraid I’m going to have to cut you off so we can get to our next group.
But that was terrific. Thank you very much. We look forward to seeing Holly as a panelist
at the upcoming ONC annual meeting which is coming up on February 2nd and 3rd. While online
registration is closed, you can still attend and register onsite. Next up, we have our
second co-winner from Vibrant Health Family Clinics with Chris Tashjian, Mary Boles and
Rosanne Matzek.This is Dr. Tashjian and all three of us are here and happy to participate
in any forward. So we are Million Heart winners. We actually have won Million Heart Challenges
two years in a row and this is something that we have taken seriously and like Holly did,
we made it an imperative in our group to provide better care. And we have found that the way
to do that is teamwork. So if you look here, we have the entire team on the left. And even
though our Packers lost last week, we are still avid Packer fans. We are still vibrant
members of the community which you see in the upper right hand corner. That’s also important.
Community involvement and making them part of the solution. So who we are. We are a family
practice clinic with a couple internists, a pediatrician. We have a general surgeon
and one obstetrician. We have cardiologists and ENTs in our clinics but not part of our
group. But we do have direct access on site. Our primary care team members and our care
coordination members include the providers. We have both physicians, PAs, nurse practitioners.
We use medical assistants extensively. We have care coordinators whose sole role is
to handle the care of our chronic disease patients. We use midlevel as we talked about
before. We use front office staff. I think this is one of the most overlooked team members
that we pay close attention to. And people ask why do the front staff need to know about
hypertension? Well the bottom line is that nobody gets into see me and nobody can get
through the phone bank to talk to our coordinators if they can’t get through the front office
staff. So we have included them in all of our planning and coordination. And again,
we think of them as an active member of our team. We have been NCQA certified, Level III
(Patient centered medical homes) since 2013. In three clinics that we server, we see 65,000
patients annually. This is our improvement philosophy.We come at it from different ways.
We obviously use a registry. We implemented our EMR in 2010 but we have been driving for
a registry since day one because we think that’s the best way to do population management.
And it is the best way to manage the data. We are continuously looking at ways to develop
and utilize direct patient care staff, health coaches and care coordinators to make the
offices last more than the 10-15 minutes of the provider. There has to be a discharge
process in which patients know what our expectations of them are and what we want them to do. And
with the medical home closing the loop to ensure that they do the follow up and we keep
engaging with them. Then in the bottom right hand corner is engaging community members
and resources. We use the pharmacists in the community. We will use who ever we can. Public
Health and anyway we can get more involvement and engagement we do that. And this development,
creativity and engagement is how we really bring everything together. So this slide is
complicated but a couple basic points that we wanted to go over.
Basically in the center where it is supposed to be, we talk about medicine being a team
sport. This is a philosophy that we will be talking about over and over again. My role
is actually at the top. And you can see the interaction between me and the patient is
very small. I tend to spend 10-15 minutes with them in the exam room. I may be the leader
to the team but clearly the patient does not spend the most time with me. He or she can
interact with the clinical staff, the hospital, the care coordinator, and then all the things
that go around outside of the clinic as a satellite. We view our role is to coordinate
those activities and use those activities to help get better control because I think
like everybody on this teleconference, we really think that if we can control blood
pressure, we can improve our patients’ lives.It is not about getting a number down. It is
about getting a blood pressure low enough so the patient doesn’t have a stroke, can
play with their grandchildren. Doesn’t suffer a heart attack, incur costs that they can
no longer afford. So we are really talking about people here. So the way to do it and
the way to solve something is through the use of the team. Again as the physician, I
spend the least time win direct patient care. So we also develop protocols. We have a philosophy
that if you care enough to call, we care enough to see you. And we want to be your primary
care. So we have ways and I talked about our front staff. We talked about getting people
in and making sure that they have their appointments and are able to get in when they need to.
That they keep their appointments and we close the loop. Our appointments are twenty minutes
and for a lot of primary care that is a long appointment. But we want to have enough time
to go over everything with our patients and make sure they understand how to interact
with the rest of the staff and what they should expect. The other thing we look at with appointments
is that anyone with a chronic disease has a return to clinic order with a specific date.
One month, two months, three months, six months, once a year. Whatever is appropriate. So when
this patient leaves, everyone know what the physician or provider wants in terms of seeing
them back. So it gives them a timeline and sets the timeline up so that they can be clear
and very objective so people can plan accordingly. So we track it and use our AHB version which
means that the actual EHR is in Kansas City. That has been quite beneficial to us.
Because like our colleagues in Maryland, we are a small clinic and we can’t afford a large
IT staff. So having it there has been real helpful. You can see that it will flag blood
pressures that are elevated. It will compare the last three blood pressures every time
we open the chart so we can look at it. You can see the BMIs on there. Height, weight,
temperature, heart rates. Those are all things that were already made. We did nothing to
create this. This is all out-of-the-box in 51:00
the EMR. Very helpful. Very useful. In the lower right hand corner you can see what our
team did. I’d like to say that I had any input in this but our team did this themselves.
And this is probably the third or fourth iteration of this. They do a pre-visit screening and
planning. My medical assistants will go over the chart. They will find out about immunizations,
about when they had their preventive services done. When the labs were done. And all of
that will come through the protocol. So when I see the patient, it is already prioritized
as one of the things that I need to do to make sure this patient is up to date. For
example, if they haven’t had their mammogram in over a year, our expectation is for them
to have one annually. We are a little bit more aggressive than the medical services
task force. If they haven’t had their electrolytes checked in over a year and they are on diuretics,
we are going to want to know that. So those are things that are brought to the forefront
on those pre-visit screenings. Again, this is done even before our patient is seen in
the clinic. And this is done by our medical assistant and as I said, they were the ones
that created this form. They were the ones that knew what we were asking for something
that worked better for them. You can see right there, bolded at the top, recheck blood pressure.
We know that sometimes we need to check blood pressure twice because the original blood
pressure when they first sit down and haven’t had a chance to rest and collect their thoughts,
the patient may have elevated numbers so we want to recheck it to see if it is truly an
elevated blood pressure. Again this is another screen shot from our EMR which is making recommendations
by our medical assistants on what services are needed, what are essential. And
it also helps in our reminder process. So we think communication is a big key. Anytime
you are working with a team, you need to communicate in a clear concise manner. Our EMR allows
us to do that. We can send messages back and forth. Those messages can either remain part
of the chart. Or they can be just like a post it note. They can be removed when we’re done
with it. It is up to the person reading the message to decide what they want to do with
it. But it makes it clear. You can see this is a message from a care coordinator to a
provider asking things 53:38 about like would you like to restart the hydrochlorothiazide.
The patient doesn’t have to come in for this to happen. The provider can answer the question
and the care coordinator can take over and see that it is done and make sure that it
is taken care of. If you look at the bottom, it is more of a reminder process with a little
bit of how we set up or turn the clinic. We use part of our EMR as a tickler file so if
I ask as a provider that the patient comes back in six months and they don’t, someone
will look through that and say “Gee they are not on the schedule so let’s
call them up and see what’s the problem.” We found that we catch a lot more people that
used to fall through the cracks. This is interesting. We went to low tech before we started high
tech. So what you see here on the left hand side is a simple little red sticker that says
recheck blood pressure. And that is because my medical assistant checked the blood pressure
when the patient entered the room. If it is elevated, above 140 over 90, she puts the
red magnet on the door or inbox. And it reminds me when I go in that no matter what I see
that patient for that I need to recheck the blood pressure or address it.
Or do something with it. But ignoring it, isn’t an option. And it brings it to the forefront.
This piece of paper probably costs a quarter to make and is one of the cheapest things
you can do and have a big impact. But if you notice on the right hand side a green piece
of paper that says blood pressure check. And again this is another recurrent theme. The
staff changed it. They said while this red magnet works, we think we have a better idea.
So they came up with a pad of paper with this blood pressure that has a little bit more
information. And they stick it on my keyboard and my EMR. So when it is on my keyboard,
I physically can’t ignore it. I can’t say sorry I missed it.Or I rushed by it. So it
is a one step improvement but again it was an improvement that I had nothing to do with.
Our staff took the ball and ran with it. They made it better and it gives us better control.
So now there is the expectation that if there is a green slip in our keyboard, you have
to do something with it. That second blood pressure will be written on the green form
and will be taken by the provider. Very clearly spelled out and not ambiguous. We know it
is expected of us. It shows the value of a team.That my MA is helping me to not let things
drop through the cracks. So these are other things that you can get patients involved
in. I will show these patients these graphs that our EHR can print out. It can be weight.
It can be blood pressure. It can be cholesterol. But these graphs are very easy to come by.
We can it put on the IPad app or the desktop and they can see what their pressure has done
and they cansee where we started this medicine or that medicine. For those of us that are
more pictorially oriented rather than looking at just raw numbers. I think this is a very
effective way to communicate with the patient something important. Something that we engaged
our staff in is that every patient with a blood pressure is a hypertension patient.
We made notepads with “Why does my blood pressure matter?” And we can pull it off just like
a stickee note with the website of the CDC. It gives them the opportunity to further engage
and to understand the reasons why. So again patient education, we actually useEducare
like what was talked about earlier. It is built into our EMR. We use it. It is part
of our Meaningful Use. We’ve also been able to customize it. If you look at the bottom,
they are very specific customized education forms that we basically
configured our EMRs to do and that gives us two values. One is its readily available.
I don’t have to worry if it is stocked in the room and two I can give it to our patient
with printers in every room. And three it documents it so I know exactly what I have
given to the patient. It handles everything in one fell swoop without having to do the
same process more than once.So that is one of the things that we really try to make our
EMR do. We think of it as a tool not a hurdle.Let’s have it make our work life easier not harder.
And let’s make it more efficient for us.This is an example of how that works. Fun ways
to have Blood Pressure recheck competitions with our office staff. We don’t think this
has to be all nuts and bolts. That making it fun helps all the way around. So the care
coordinators keep track of the medical assistants as they document. And when you redocument
they end up in the file and someone wins something. Again something simple but also motivating.
And it emphasizes that we are a team. It doesn’t happen by itself or because of one person.
But because of all of us. And that goes a long way. So again, we use titration methods.
We have algorithms that we’ve established. We got together as a medical group and the
physicians agreed that this is a reasonable algorithm that our share coordinators to work
off of. As you saw earlier, they have the ability if they don’t feel comfortable when
using the algorithm to shoot a message to the provider. But we don’t wait for the provider
to say “now you move from plan A to plan B.” But we give the ability of our care coordinators
to say “So we are not where we want you to be. The plan is for you to do this and have
you follow up with the provider.” The provider is engaged but they are not the stumbling
block or the reason things don’t get done. The providers have all agreed to this protocol
so it is helpful and gives our care coordinators some leeway to improve the care of our patients.
So again, reporting and registries. We didn’t have registries when we got our EMR. They
didn’t understand why we needed them. We made it really clear that we need them. We use
the report writer in our EMR and export all our data to excel. Then we wrote an excel
spreadsheet that had all the parameters that we wanted. So if you notice anything in yellow
is out of parameter. We have excel do that rather than having to do that manually.So
it gives us a list of our patients and targets the people we need to work on and the people
we need to help. You notice across the top, we are looking at systolic, diastolic, PM
level ACs, LDLs, alcohol use, tobacco use. So the computer can’t keep track of all of
that but we can spit that out on one sheet of paper. And with that one sheet of paper,
I will sit down with my care coordinator and my medical assistant and we will go over the
patients that we’ve seen in the last 40 days that are out of parameters.We used to do it
every month and switch between diabetes, hypertension and then heart disease. Our staff decided
it would be better to wait three months to focus on a patient to look at every patient
in the last 40 days who are not in parameters. And let’s keep it fresh. Again another example
of the team taking the ball and saying I have a better way of doing it. In the bottom, you
see the averages. Every provider gets this every month which they go over with the care
coordinators. And they can see how many patients they have, the various kinds of diseases and
what their control rates are. And our care coordinators create a plan. And like our colleagues
in Maryland, we also plan on submitting our coordination through Medicare. It means the
plan has to be there. It has to be written out and available to everybody. It is in a
place where we can talk about it. So if there is a question about what we do with this patient,
there is a direction in the plan. It’s organized by patient. By provider. There are patient
goals and self management. So measuring success and staying connected with the data. As you
can see we work our EMR hard. Our expectation prior to 2010 was to do this manually so at
best we could do this once a year. But now we can do it on a monthly basis. And we have
far more data to work with. So we look at our data monthly. We report it annually on
the web through Minnesota community measurement. We share it with the health plans. Our patients
have access to it through these various websites if they are so inclined. We are also transparent.
We’ve been this way pretty much from the start. If you look at the bottom left hand graph,
you are seeing all the providers in the clinic across the bottom and their “n” number. And
these are their hypertension control rates. And the other thing we attach is their MAs.
And I go over this with my MA. The format above the clinic average if I’m leading it
or close to leading it, I find the MAs are competitive as the physicians are. So we are
working that dyad. It spurs people to work better and try harder. Our focus is on any
patient with hypertension including those with co-morbidities. We don’t just look at
their blood pressure but their LDL, their AICs, their tobacco cessation. We look at
their using aspirin. We are big believers that if we want to get the best results. And
by results I’m not talking numbers. If we want the most stroke preventions, the most
preventions of heart attacks , we have to attack all 5 in our diabetics and all 5 in
our hypertension and coronary artery disease patients. So we believe getting blood pressure
control is important, but it is more important if we do all of it. The blood pressure, the
cholesterol. The aspirin. We stop the smoking. We do all the ADS’ of Million Hearts. So why
this all works. The leadership is behind this. The physicians are engaged. Patients are engaged.
Staff are engaged. We believe it is important to help our patients get well and then stay
well. We have done that through care coordinators. And more importantly, this is
nobody’s problem. This is everybody’s problem. We share our successes as a team and work
on our improvements as a team. That is the most fulfilling for us as providers. And it
has shown the best improvements as far as actual numbers such as reductions in strokes
and heart attacks. We can quantitate that number over the last four years. We know there
are people in our community that are out walking, playing with their grandkids. Doing things
that they wouldn’t have done had we not helped them get things under control to prevent a
heart attack or a stroke.Thanks a lot Chris. That was terrific. So we will move to the
Q&A section. Do we have any questions? No, I have not received any yet. So let me ask
you a question that was asked of Holly initially. Chris, have you considered using the American
Heart Association’s ehealth tool Heart 360? And do you think it would be a good supplement?
We haven’t spent a lot of time into it. A lot of our partners are looking at the American
Heart 20 and whether these people should be on a statin or not. We are trying to figure
out if that is something we want to distribute clinic wide since the data is pretty clear
that the risk estimators are we can do that. We’ve not actually done the 360. Something
we will be looking into after this. I have a question. Tell us what it is like to integrate
the care coordinators into your practice. Were they already part of your team and took
on the responsibility or did you hire somebody else? What we did and maybe Roseanne can speak
to this as a care coordinator. Roseanne used to be my
medical assistant. And she was looking for something more. So we developed this position
and she essentially along with her cohorts and Mary created this position. And we modified
it as time went on to adapt to what our needs were. Care coordination started five years
ago and we didn’t know what it was or what our job entailed. And through trying, we found
out what the needs of our patients were. Right now we are doing hospital discharges. Patients
were coming to the clinic who had no idea of medical changes that were made at the time
of discharge. That was a very important part of care coordination. We also not only started
calling patients and saying that you are overdue for a visit, but also diving into why they
are not taking care of their medications. We are helping them find resources for medicine,
outside care. Just a simple thing like finding volunteer activities. We’ve helped patients
find transportation to the clinic. So we’ve discovered that the little time our patients
are in the clinic is not what is going to keep them healthy. We’ve had some wonderful
success stories of keeping patients on the edge, healthy and alive far more years than
we thought they would be. This is Mary. We also just historically took medical assistants
who had been with the clinic quite some time who were
knowledgeable with all our processes as they needed to know what was happening throughout
all our clinic. And then we participated with one of our third party payers to do a research
project related to cardiac disease and that was focused around having an RN in the care
coordination team. So we did go through a three-year process and hired an RN on a temporary
basis through this research grant. We then went to our clinics and developed our medication
titration process and some protocols. Since that time, we hired an RN to help us to get
it implemented. She’s since left so instead of hiring another RN, we’ve decided to use
our midlevel group to continue with the medical titration process. So the patients identified
by the care coordinator off of our registry list can have the mid-level provider be the
Intermediary to help the patient with medication management without having the physician involved.
That’s all the questions I have at this time. Chris for us here at ONC, we are all about
pushing forward the e-health record and the digital tools. You guys have several steps
that are more analog or at least not digital that are very important and are not huge lifts
in terms of getting new things into your work flow. Do you anticipate at some point feeling
like you won’t need the little slips of paper on the Keyboard. That the behavior will become
ingrained enough. That new doctors will come in and pick up where that is? Or do you see
analog steps continuing? Are there any other things that might be helpful in your process
use? No, I look at the analog things as an adjunct.
And I don’t see them going away for two reasons. One is because, and I’m a big technology person,
as much as we use technology, sometimes over-designing it can actually make life more difficult.
A single paper like that conveys a tremendous amount of Information yet it costs almost
nothing to do and it keeps everybody engaged because multiple people have to touch that
piece of paper. And the patients are really intrigued by that. They want to know what
that’s all about. So it engages them as well. So personally, I don’t see that as going away.
Do I see it being modified. Probably. Because I didn’t see it being modified before and
they modified it and made it better. I have no doubt that our staff can continue to improve
on that. I actually have another question. You mention that you are NCQA certified. In
your opinion, was the process worth the outcomes? Yes. It was a lot of work but I do believe
that in order to move forward in this team-based care, we
needed to put all those processes in place. Not they are so ingrained in our practice,
that is has done nothing but help improve the care of our patients and got everyone
engaged. Because when you went through the process you had to engage everyone in the
facility as part of the team. And I think really helping everybody like the front office
makes them feel valued and they are part of the team. This came to focus when we worked
on that project. It also helped us to help advance the things in our EMR. There were
some things in our EMR that weren’t there. So we had to develop our own process to get
certified.It pushed us to work with our EMR vendor to make sure that they understood the
things we needed and they were really great about working with us to get those things
put into our EMR. So I think it was well worth the process. Let me give you another example
of where it really helps. And that’s in closing the loop. We knew we needed to close the loop.
Whether x-rays, lab work. Things like that. Never occurred to me that we needed to close
the loop for our referrals to our specialists and making sure that they got done. So it
allowed us to get much more organized and a more systematic approach. So fewer bad outcomes
slip through the cracks. Okay, I have another question. What training on the proper way
of taking blood pressure is provided to the medical assistants and nurses? My sense is
that there is variability in the reading unless BP training is institutionalized in a practice.
When we decided to move forward with this, we had classes with everyone on how we wanted
to take it. For example, your feet can’t be crossed, you can’t sit on the floor. This
is how you inflate it. And to be honest, we didn’t just teach the medical assistants but
the doctors as well. This is the standardized way of doing it. I have another one. Who is
your EMR vendor? We use Cerna. We use their ASP. Cerna houses it in their facility in
Kansas City as an application service provider. So we access our EMR over the internet. If
we have an internet connection anywhere in the world, we can access our EMR and it is
safe and secure. And we found that to be very helpful. Because everything is there. We don’t
need a special connection. We just need internet. We don’t have to maintain servers. It just
works. Cerna has been good to us. But just using an application service provider has
been a huge plus with the EMR stuff. And I have another one. Is your practice a
partner in your state Million Hearts partnership. If so what has been the nature of your participation?
We’re not actually a partner in that other than I do a fair amount of advising for them.
We have been trying to get grants and things going. But it hasn’t been as successful as
we would have liked but we keep plugging away at it.
Okay that’s all I have for right now. I want to reiterate to say how important this is
to me. Million Hearts is really great for what it does. Preventing heart attacks and
strokes. That’s where the focus has to be. You can look at numbers and the ways to convey
it but in the end what we are looking at is reducing heart attacks and strokes in real
lives. People that we live with, see in the grocery store, work with. People in our community.
That is the most compelling reason to be doing this.Great. Thanks a lot Chris and Mary and
Roseanne. We got some great questions in today. We are going to take these last few minutes
to talk about phase II of the challenge. So just to reorient, our original goal of this
challenge was to celebrate improvements on the Million Hearts blood pressure goals. Reward
innovation and enable quality improvement. To promote evidence based treatment protocols.
Leverage clinicians expertise and recognize real-world successes. And reward scalable
resource tools that are being used effectively across many clinical practices. These last
few are what we are focusing on for Phase II. So what we are looking to accomplish in
Phase II is to spread these two Phase I winning Interventions to as many practices as possible
and to demonstrate success in that. Submissions for phase II must include CDS intervention
details. So not just which of these two were utilized but also any changes to them that
were used. The actual results from any practices where they were implemented. So this is not
just demonstrating the actual improvements of blood pressure control but we also want
to know how many new practices it was implemented in or have demonstrated a commitment to implementing
them. And finally to learn more, we want to know about your spread strategy. So how you
decided to reach out to the ones you talked to. What key points you hit upon to convince
practices to make these implementations. And note that by CDS, we mean that large scale.
Like registries,reminders and protocols are included. The challenges website is there
on the screen. We will be awarding one final winner with a $30,000 prize. So the review
criteria stem from those submission aspects I just detailed. So the number of practices
the interventions were implemented or is underway.Or the number of practices that have expressed
interest in doing the implementation. Demonstrated blood pressure control improvements. And if
that is not quite available yet, then any leading indicator that would lead one to believe
that blood pressure will be improving. We want to know about the comprehensiveness and
innovation in supporting blood pressure protocol with CDS tools. And lastly, the capacity for
the implementation spreading strategy to be scaled and used outside the challenge on a
further basis. So we have a nine-month long submission period that will end on October
23, 2015. We will be announcing winners in November or December. Again, the grand prize
is $30,000 and we will be having honorable mentions depending on the types of submissions
and the entities that are targeted. And along with the $30,000 prize, you will be receiving
recognition, publicity, credibility and reach. So again the challenge site url is up there
at top along with the Million Hearts address. If you have any
questions, please email them to [email protected] We did receive a number of questions
about the webinar and we will be emailing everyone with the recording of the webinar
and the basic slide deck. And slides for each of the submissions are available for download
at the challenge site right now. We have about two minutes for questions. Otherwise, I just
want to thank again Holly and her team and the team at Vibrant Health Clinics. They’ve
done some excellent work and we are really excited to see how Phase II goes and how many
new practices can utilize these fantastic blood pressure protocols and implementations.
In lieu of dead space, we are going to close up shop. You will bereceiving the recording,
slides, and urls of everything shortly. Thank you and have a good day. 27