Using an EHR and Quality Data to Improve Hypertension

Using an EHR and Quality Data to Improve Hypertension


Operator: Ladies and gentlemen,
thank you for standing by and welcome to the “Using an
EHR and Quality Data to Improve Hypertension” webinar,
presented by HRSA OHITQ. During the presentation, all
participants will be in a “Listen Only” mode. However, you may submit
questions to the speakers at any time during the Webinar in
writing using the chat feature located on the left
side of your screen. Questions will be
addressed as time allows following the second
presentation. As a reminder, today’s
webinar is being recorded. It is now 2 PM Eastern Standard
Time on February 22, 2013. There will be two presentations
during today’s webinar. In a moment, we will be sending
all attendees a link through the chat feature that they can click
on to download copies of the two slide presentations
for today’s webinar. Additionally, all registrants
will receive an email following today’s webinar that will
include an email address where you can send requests for
copies of the presentations. I would now like to
turn the call over to Lieutenant Michael Banyas from the Office of
Health IT and Quality at HRSA. Please go ahead,
Mr. Banyas. Lt. Banyas: Hi I just want
to welcome everyone to this afternoon’s webinar production
Using an EHR and Quality Data to Improve Hypertension. Um, just a few quick
announcements from HRSA before we turn the webinar
over to the presenters. First, all of HRSA’s previous
webinars as well as HRSA’s health IT adoption tool boxes
for quality improvement resources, and other web
pages focusing on mHealth, meaningful use,
workforce and ICD-10, specifically for safety net
providers can be accessed at hrsa.gov/healthIT and
hrsa.gov/quality. Additional questions can be
sent to [email protected] Next, just a few other health IT
and quality announcements for today’s audience. The first is, expiring April
1st is the competency exam for health IT professional. HRSA has free vouchers available
for free exams and you can email [email protected] to
request a voucher. These exams are a great way to
get your staff credentialed in one of the five ONC
sanctioned workforce areas. And they’re a great way to train
staff in the areas of health IT that the office of the
national coordinator has found to be of value in
implementing and adopting health information technology. Once again, to request
a free voucher, please email [email protected]
and the free voucher program expires on April 1st. The next HRSA health
IT and quality webinar, “Using Clinical Decision Support
in the Safety Net Provider Settings” will be
Friday, March 22nd, at 2 PM Eastern Standard Time. Registration is now open on the
HRSA health IT webinar page, and we’ll be, and the link will
be posted on the HRSA health IT page shortly this afternoon. This webinar um, is
a fantastic way to, for safety net providers to find
out best practices as well as the importance of
clinical decision making, and how to use your EHR for
this meaningful use objective. Next, coming soon in March,
HRSA will be launching new HRSA health IT workforce
modules for help centers. The purpose of these modules is
to educate and train safety net providers working
in health centers on the areas of health IT. Once again, an announcement for
when those modules will be live in mid March will
be sent through the HRSA health IT listserve as well as posted on the
HRSA health IT website. The Associations for
Clinicians for the Underserved is hosting their conference on
Health IT and the Underserved on March 7th and 8th in
Poughkeepsie, New York. Registration is available
by visiting ACU’s website. Um, HRSA’s TXT4Tots Library is
now live on the HRSA mHealth webpage and the
HRSA health IT website. This resource just went live
yesterday and is a fantastic way to determine how to send text
messages and other mHealth related resources through
an mHealth system. Um, and lastly, two new grantee
spotlights went live yesterday that align with
American Heart Month. The first is on the
HRSA health IT website, we profile the
Marshfield Clinic. A recent winner or the
ONC innovation award for, for healthcare applications, and
this article focuses on how they used mHealth to
support heart health. The second is, on the HRSA
Quality Improvement website, we focus on project renewal
which is a help center that services the New York
City’s homeless population and how they increase access to
high quality healthcare within the homeless
population and we use, we spotlight their use of
controlling hypertension as an example for how
they provide care. I would now like to, I would now
like to introduce my colleague, Anthony Oliver, to
introduce today’s speakers. Oliver: Thank you
Lieutenant Banyas. I’d like to welcome all HRSA
grantees and members of the safety net community, health
resources and services administration, health
information technology and quality technical
assistance webinar. Today’s presentation is entitled
Using an EHR and Quality Data to Improve Hypertension. Future safety net providers who
have successfully used health information technology to
improve health outcomes in patients with hypertension. It will provide an overview of
useful strategies to address this prevalent condition which
is a core clinical quality measure in the meaningful use
incentive program and a priority within the national
quality strategy. Before I continue with
today’s presentation, this afternoon’s presentation,
I’d like to add a disclaimer. HRSA would like to add that this
webinar is intended to serve as a technical assistance resource
based on the experience and expertise of independent
consulting and HRSA grantees and its contents are solely the
responsibility of the authors and do not necessarily represent
the official use of HRSA. In addition, HRSA does not
endorse any health IT vendors or software systems including the Health IT
assistance featured in this webinar. Now, I pleased to introduce
this afternoon’s presenters. Christopher Tashjian is board
certified by the American Academy of Family Practice,
and currently serves as the chief of medicine for the
River Falls Area Hospital, a regional facility of
Allina hospitals. His areas of special interest
include electronic medical records, public health, and quality care in measurement. Dr. Tashjian also currently
serves on the Office of National Coordinators Information
Exchange Workgroup which focuses on meaningful use of
stages two and three. Dr. Tashjian realizes the
importance of practicing quality care at an affordable
price, and has implemented a state of the art
electronic medical record which allows direct
access to patient data. This has allowed the clinic to
change the management of chronic diseases from reactive to
proactive and contributed to the clinic’s recent ranking
as first in western Wisconsin for quality and
value in diabetes and heart care by
consumer reports. We also have Sarah Woolsey who
is board certified in family medicine and is also a medical
director with Health Insight, a community based organization
focused on redesigning healthcare systems. She has worked with power care
providers to improve diabetes quality care and is
the clinical lead with the Utah Beacon
Communities project which uses health IT
to improve diabetes care in 60 primary care offices. Dr. Woolsey has worked on
quality improvement in outpatient primary care setting
for over ten years and has 13 years of experience with
underserved populations in Salt Lake City as a full
spectrum family doctor. She currently maintains an
active practice with the community health centers of Salt
Lake City and was chosen as a centers for Medicare and
Medicaid innovation advisory in January of 2012. I’d like to thank
the HRSA grantees and safety net community for
participating in this event or individuals using the PDF. We’ll be starting on page 26. I’d now like to turn the
event over to Dr. Woolsey. Dr. Woolsey? Dr. Woolsey: Alright. Thank you for the
invitation to speak. I am delighted to be here today
and share some information that I hope will make a difference
for the folks that are doing excellent outpatient care. I am a community health center
physician at heart and I also get to work with an amazing
community in Beacon Communities which I’ll share about and I
just appreciate everyone’s time and interest in making care
better for patients today. As introduced I am a family
physician practicing in a community health center. We are in the heart
of Salt Lake City. We have four practices. I’m having trouble
advancing slides, guys. Can you see my slides? Okay. We have four urban
community health centers. You can see our
demographic breakdown. We implemented E-clinical work,
electronic health records in 2010 and also joined
the Beacon Communities project at that time. Active participation
began in early 2011. The Beacon Communities project
is a project that is assisting providers to demonstrate that
health IT can improve care as well as demonstrate the
improvement of care and of course that entails putting
the HIT into the workflow. In my clinical setting, I work
with an amazing team of folks and I just want to give a
shout-out to the Beacon team members from Community
Health Centers of Salt Lake. Jennifer, Chris, Sue,
Linda, and Monica and Keith. And they are the folks
that make things happen in our clinical setting. So when we joined the
Beacon Communities project, we had been working on diabetes
improvement for quite a long time and the first aim
that we set as a group was on blood pressure control. And I have to admit that when we
started I had a funny feeling in my stomach, I wasn’t sure
we’d actually do this. I was a little bit concerned
that this wasn’t something we’d be able to
tackle or take on. We’d done a lot of other areas: A1C control and lipid screening, but we had not
taken on blood pressure. But we set the goal, we began
to look at the information, and as you can see
here on the slide, I want to tell you
three things about it. Number one, is that we did
improve care up to ten percent goal of our patients. So of our 2,000
diabetes patients, we were able to
improve ten percent, and we were surprised
with that result. It started with a five percent
goal, went to ten percent. Number two, is we were proud to
begin to approach the Beacon Community benchmark. So on this slide, the green
graph is our data of our patients, the red line
is our ten percent goal, and the community
benchmark, the blue line, is the compilation
of 22,000 patients across the (inaudible) front, their diabetes control measures. And so not only were we
improving our care but we were beginning to meet the standard
of care in our community. You can see that we’ve improved
and sustained over time. We still have work to do to
hit the community target, but we’re providing care that’s
equivalent to all the providers in our community, whether
insured, clinics, or hospital based clinics, we’re
meeting the standard of care in our community. We felt that was
really important. This is just a map showing
the Beacon clinics. So again, 60 clinics
across the (inaudible) front. And the content of my talk is a
combination of my experience as a clinician and my experience
of working with these amazing providers across my valley and
watching them do all the amazing things they do to improve
care using their HIT and their clinical
system improvements. And I just want to also thank
my Beacon team for all the work they’ve done with this
broad group of folks. So you might ask, ‘Why is
all this important anyways? Why are we talking about
hypertension in Heart Month?’ We know hypertension is
epidemic and it’s treatable. Okay, you guys can
see the numbers there. 30 percent of us have blood
pressure that’s over a goal that’s healthy for us. And you’ve invested lots of
time and money in your EHR. You want to make a difference
for patients and you want to get some value out of
that implementation. EHRs can enable efficient team
care and all of us know that working in a team can make
a huge difference for our patients. It’s a lot of fun, and
EHRs can improve that. And finally, as we’re talking
about meaningful use, stage 2’s gonna ask us to
demonstrate our ability to manage our population health. So it’s time to get going on
demonstrating all the things that we can do. So, what is an EHR from a
chronic care point of view? Okay, so an EHR isn’t gonna
make your patient care better. It’s actually a tool. And in the ideal state, it’s a
tool that stores data and allows you to run patient
lists accurately. It’s a place to streamline
processes of care for your staff and your providers. It allows you to
demonstrate your quality, both to yourself as
well as outside folks. It reminds you of
things you might forget, and there’s a lot
more things every day that we need to remember. It allows you to provide
evidence-based care to your patient at the point of care,
and it can be a point of communication with your patient. So how do we use that thing? I’m gonna suggest there’s seven
core ways to use your EHR for population management. And I’m gonna say
that many of you are probably doing these things. Many of you might be doing some
of them, but not all of them. Use this talk as an opportunity
to do a checklist of what you’ve implemented in your setting. If there’s something you’re not
doing, consider making, uh, making gains in that area. And I want everybody to walk
away with one action from my talk or Dr. Tashjian’s talk that
they’re gonna implement when they leave this webinar. So the most important
thing about EHR youth, is you’ve got to pick
something that’s important to you to work on. Take a compelling
clinical problem. Today we’re talking about
hypertension, it’s important, you may have another condition
that’s important to you, but the importance of patient
care is gonna drive all the things that you need
to do to get your system to the next level. So when patients and providers
are working together for better care, we all think
we’re doing the right thing that we signed up for when
we went to medical school or medical assistant
school or nursing school or PA school, or
nurse practitioner school. So, pick something
that’s important. And then, here’s
seven steps to try, and I’m gonna go
through each one. Registries and patient lists. These are core to
population management. All EHRs have some
functionality in this area. Now, the first thing
you’ve got to do though, is make sure your registry has
reliable patient lists in it. How many of you have run a
registry of your hypertensive patients and you find out
there’s maybe six people in it? There’s something disconnecting. The identification of those
patients and their care to the actual registry. So if you find that’s the case,
set a billing or clinical team on pulling hypertension
patients another way, based on their pharmacy
prescriptions, based on labs that you do, based
on old reports you have or third party
payer information. And then, make sure that
electronic health records automatically updates the data
that you put in every time a patient arrives for visit
and clinical work is done. If for some reason this
isn’t working for you, have your vendor teach you
how to do this properly. This is base line work for
building your chronic care model with your EHR. This is a list of ICD-9
codes for hypertension. You need to get your patients
attached in their problem list to proper codes. Take a course set that
you’re comfortable with. Again, like I said, have someone
help you update those patients and get everybody in your
practice on that registry list. Then, you’re gonna want to set
registry care and recall into an office job description. You’re gonna have this be part
of the metronome of your care. The cycle of caring your office
includes regular attention to your registry. You’re gonna want to allow your
providers to give you feedback and update the registry
and ensure it’s correct. If you don’t give them the
chance to give you feedback, you’re not gonna get buy in and you’re not gonna
get an accurate list. In our work in the Beacon
Community we had a geriatric office that had a number of
patients who’d both passed away or they had moved to a chronic
care, long term care facility. Those patients getting
cleaned out of the list, they spent less time
working their lists, and the providers responded
better to the lists when they got them because they
knew they were accurate. So clean up your lists. Like I said, provide regular
lists to your teams, to update and recall their
patients not at goal. That may be something you
do in a centralized fashion, or in a team fashion. And set standards for use
of the lists in the office. In our E-clinical work system,
this is an example of chronic care reports that we can run
by facility, by condition, by provider, by care. Begin to learn to use these. Get experts in using these. In my system, I’m happy to have
a QI team that’s expert at running these lists, helping us
update them and clean them up, and we do that on
a regular basis. Next, we’re gonna
talk about templates. So templates. Everybody’s got them, but not
everyone knows how to use them. They maybe come with your EHR, but they’re not customized
to your workflow. If your templates are not
capturing data correctly that you want to track, fix them. Get your vendor to assist you. Get the guy down the road using
the same electronic health record to help you if
he’s doing successfully. Ensure that all your staff and
providers are trained on the process for using the templates,
and satisfying alerts or captures for data
inside of those. They key to standardizing
processes can be templates. If all teams are on
the same template, systems of consistent care
develop in the office, and this can be better
for quality care. Here’s an example in our system
of a hypertension template. We’re very interested in home
blood pressure monitoring and medication adherence. We want all patients
asked about this. Our medical assistants,
when trained, can ask these questions
as a patient enters, and we get actionable data
from the patient’s history. Clinical decision support tools. Again, there are
many types of those. Every system has a
different flavor. They may be reminders,
alerts or flow sheets for evidence-based care. You’re gonna want to turn on a
few meaningful alerts, okay? Too many is gonna have
people ignore them. You’re gonna want to use the
alerts to remind your teams of missing care,
standards that you set, or that are set by
national organizations, you’re gonna teach
your team to respond and satisfy those alerts. Nobody likes it when
you do the care, and the alert doesn’t disappear. They begin to ignore them. So pay significant attention
to fulfilling those alerts. And remember, overload
causes a team to ignore them. Here’s an alert that
I have in my system. A big, fat, red blood
pressure that’s abnormal. Hopefully myself, my
assistant, won’t miss that, and we can kick in our
protocol of what do we do when we see a high pressure? We may have the patient sit for
five minutes and recheck it. We may inquire more carefully
about medication adherence. But we’re gonna take action
as we see that big, fat, red number. Another important
tool are order sets. These can be very customizable. For hypertension patients,
we can put in order sets for common medications
that our practice uses. Generics and 90 day prescriptions encourage medication adherence
for chronic disease. Program them in. What about labs that
must be done regularly? Make it easy for
your team to order. Home monitors, we’ve picked a
home monitor that we prefer for our patients because it’s
low cost, accessible. We’ve put it into an order set. It’s easy to order and print
or send to the pharmacy. The patient can then get it. Sodium reduction education
materials or referrals to dietary educators. If it’s at their
fingertips, it’s easy. Like I say, if it’s easy to do
the right thing they’ll do it more often. Here are examples of some
registry alerts for diabetes patients
in my system. Medication adherence. This is a place where your
electronic records can help you as well. Consider putting a medication
adherence assessment into your template. Ask every patient every time
about their ability to adhere to their medications, and I’ll
show you an example in the next slide. Ensure formularies are added
to your E-prescribing list. If meds are affordable
to patients, they’re gonna be more likely
to fill them and take them. Enable a fill
review in your EHR. Some electronic records
have communication through SureScripts back and
forth from the pharmacy and you can actually check and
see if your patient has filled their medications regularly
and make follow-up calls to those who have not. This is not available in
every electronic record, but it’s worth inquiring if that
service is available for you. And then finally,
like I said before, E-prescribing 90 day supplies,
for most patients that will be appropriate and
it will enable adherence. Here is an example of the medication
adherence assessments. So asking patients
what gets in the way of taking your medications. This comes from the New York
Health Department Clinic. They had a great paper tool. We’ve now put it into
our electronic record. We’re assessing patients for
their ability to take their medications or for
any barriers to them. Visit summaries. One of our favorite
things in my office. One of the most difficult things
for us to complete in our meaningful use measures. Okay? ‘Cause people couldn’t
find the value. Here’s three ideas for you. Use the visit summary to provide
a teach back about medications, appointments, and
lifestyle goals. Teach back is a method where you
have the patient express back to you their understanding of
everything they’re gonna do when they walk out of your office. If you’d like more
information about teach back, please send me an email and I’ll
send you lots of links to that great method. Second thing is present the
visit summary ahead of your visit. There was a pharmacist
who taught me about this. Have the patient do their own
medication reconciliation before they see you. It provides them time to
look at their visit summary, they can correct things
that are incorrect, um, and it may actually
give you feedback into a better visit summary. Finally, make the visit summary
speak to the patient in their language at their
health literacy level. We’re all waiting for the
day when our EMRs are gonna translate our visit summaries
into the language of preference for our patients,
but until that time, let’s make them as
useful as we can. So, one community health center
that I have worked with did a focus group with some of
their patients and asked, “What do you want the visit
summary to look like? What would be the most useful
thing for you to go home with?” The patients gave them feedback. They were actually surprised at
the number of alterations needed to be made weren’t as
many as they thought. Patients really appreciated
the information, they asked for a few
different areas of content, but they were able to make
this patient-friendly. Self-management. This is the key to patients
taking care of themselves and having hypertension control. So how do we do
that with our EHR? Things that might help. Number one. If you find a patient
that’s not at goal, not adhering to medication,
there’s a barrier, consider using electronic
health records, depression screening function. Most EHRs have PHQ-9 in them
and make a protocol and assess patients with either barriers
or all patients with chronic disease for depression,
treat them appropriately, and it may decrease the
barrier to them taking care of themselves. Number two, use recall functions
to support patients of self-care goals. I do this often with
smoking patients. The patient makes a quit date in
two weeks and I put a prompt in my electronic records to remind
me to have my staff or myself call them in a couple weeks. That reminder makes a huge
difference in their ability to continue with their
path to quit smoking. Upload motivating patient
education tools that you like for easy print into your EHR. There may be your favorites. Make them easy to get to and
use and share them with your patient. And then portals. Having patients connect you
through the electronic records is a way to have them report
home blood pressures to you. Imagine walking in on a Monday
and having a whole list of blood pressures from a patient
who’d been taking them for the last couple of weeks. If the patient was
at goal you can send them a
congratulatory message. If they weren’t yet at goal, you
can have a conversation about titrating their medication and
know that the patient needs an intervention before they come
back to see you in a month. It’s a great way to help your
patients adhere to goals they’ve set. This is just an example of
self-management goal setting that we’ve put into a template. These are some of my
favorite handouts. Okay? Patients taking blood
pressures at home thanks to the Utah Department of Health. Salt and sodium in Spanish, and
then this is a template we have patients use for
home monitoring. This is not in any electronic
format at this point, except to be printed, but
patients even with low literacy levels can make Xs on their
blood pressure marks and bring you in a really useful graph to
help you manage and assist them with management of
their blood pressures. Last couple slides. Report quality, okay? When we talk about quality, we
want to talk about it inside our organizations, and
outside our organizations. We want team or
provider-specific report cards on measures. This is gonna help you know
where you need to target improvement. This is gonna get
people in action. Get those type A, straight A
student doctors in line by showing them report cards and
comparing them in a safe way to their peers. Let the providers correct
errors on reports. Let them give you feedback
where something’s not working. They’ll have much more buy in to
your quality program if they get a say in what the data looks
like and how it’s recorded. Trend your improvement. Many electronic health records
are not trending the improvement month to month at this time. You could do that in a very
basic Excel spreadsheet. If anyone’s interested,
please email me. I’ll send it to you. Watching your numbers improve or
not improve over time can really spur action and
improvement activities. Use your EHR Clinical
Quality Measures functions. Begin to learn how
to put the data in. How to get the data out. How to make that data represent
your population accurately. Use third-party reports if
needed to validate the data from payers, from outside labs. Consider working back and forth
until you get a good product in your CQM. So this is our result. You see our trend in data. You see I’m able to demonstrate
that we’re heading toward a community benchmark in care. We’ve hit our ten percent goal. Should we be hitting more? Yeah, probably, and we
know where we need to go. This is something we can look at
each month and see what’s next. Never forget workflow. Imagine a patient
arrives at the clinic, how will you ensure they get
all the care elements done and documented properly. This is the question to ask as
you’re working on implementing EHR functions that
make a difference. And second, imagine
they don’t come in but they’re a
patient of concern. What do you do? That’s the workflow you develop. So here’s seven ways that
you can use your EHR. Use your powers for good. I hope that makes a difference. I hope you’re doing all of them
and the quality of care for your hypertension patients is
demonstrably improved, and then brag about it. I’ll take questions at the end,
after Dr. Tashjian and here’s my email
contact information. Thank you so much. Moderator: Thank you
Dr. Woolsey. I would now like to introduce
our second presenter, Dr. Christopher Tashjian. Please proceed Dr. Tashjian. Dr. Tashjian: My clinic is a
small rural clinic in western Wisconsin. In a town of about 2,000, there are two physicians
and a PA in our clinic and I’m gonna show
you what our story is, kind of tell you are story and
actually I think it will go nicely with what
Dr. Woolsey said. First of all, we as
physicians had to change our overall way of thinking. We have pretty, two motivated
physicians and motivated PA and the best thing we could get to
was about 70 percent control and that’s because we held
onto the problem. We felt that it was, we as
physicians had to take on it, and we had to be in control. It’s pretty interesting, it was
pretty hard to do but we had to say, and change it to say that
it’s not a physician problem but it’s a team challenge, and we
had to include everybody because one of the realizations
we had was is that we don’t see every patient
that walks through our doors. Sometimes they come
in for an INR check, sometimes they just come in
for a blood pressure check, sometimes they come in to see
somebody else, the dietitian, and so unless we
included the whole team, we weren’t gonna move
beyond this 70 percent. So, again, we had to
give up total ownership. As a physician, you can
probably bet that’s hard to do. Actually in retrospect it was
the best thing we did and it actually makes our life easier, and it actually
makes it more fun. The second thing we had to do
is we had to train our staff to understand the problems and
we’re just gonna talk about hypertension now. We needed to let our nurses
know that 130/90 was what we considered the upper limit of
acceptable and that anything more than that required uh,
bringing it to our attention or reassessing it in ten
to fifteen minutes depending on which was sooner. We had to let the lab tech know. And you said, “Well
why the lab tech?” Well sometimes the lab tech
draws up INR or they draw lab work and they get a blood
pressure and we’re not aware of it and so if she
knows that, you know, that elevated blood pressure
requires treatment, she’ll intervene at the point
where she sees that patient and actually bring it to our
attention or make sure that the patient gets seen or set
up for an appointment. Next is care coordinators. That’s something
we had to develop. We talked earlier, as we said
earlier is we really changed our practice being reactive/proactive. That’s where the
care coordinators come in. In our group, they’re nursing
assistants so they’re, or medical assistants,
they’re not nurses, they’re not the PAs or anything
like that but we’ve trained them to say, this is what’s important
to us, this is how you, you know, query the charts and
find out and create lists so that we know who needs to
be seen and who doesn’t. These are patients at risk, we
want the care coordinators to call them, make
sure they get in. And we found that to be
incredibly successful. And patients really, really like
it when their providers office calls them and says, ‘Hey we
haven’t seen you for a while, the last time in the office your
blood pressure was elevated. You know, we don’t want you
getting a stroke or a heart attack, you know,
that’s important to us, we know it’s important to you’. The patients really,
really relate to it. And last but not least, people
wonder, well, why do you have front office on here? Front office is an integral
part of our practice. If people can’t get
through the front door, they can’t get treated. And so we made it clear to our
front office personnel that it’s important to get these people in
and get them seen in a timely manner and they want
to get in, you know, we need to do everything
we can to get them seen. We’ve gone to advanced access
scheduling so we do as many things, same day,
as we possibly can. Okay, the second
thing is what does our overall pattern mean, is
we’ve gone away from my patients versus my partner’s patients
versus the PA’s patient and the answer is they’re
all of our patients. So if I see my partner’s patient
and their blood pressure’s too high, it’s my responsibility
to address it. It’s not my
responsibility to say, ‘Gee your pressure’s a little
high why don’t you go back and see Dr. Lijewski and see what, you know, if she
wants to do something about it.’ Same thing as I expect her to do
the same thing for my patients. And last but not least,
as part of (inaudible) to get a blood
pressure on everyone. And we, you know, even before
that we got a blood pressure on everyone and bottom
line is, in our office, every visit is a
hypertension visit. If their blood
pressure’s elevated, we feel a need to address it
and to pay attention to it. And even if they’re in
for some other reason. Now if the other reason explains
why their blood pressure’s up, that’s fine, we’ll
deal with that. But if they’re in for a rash
and their blood pressure’s up, we know the rash
isn’t causing that, we’re still gonna address the
blood pressure at that visit and for us, that’s a change. So first I’m gonna go over the
low tech solution and I’ll be honest, we stole this from
or cousins in New Richmond, another clinic, a small clinic
who developed this and this is kind of one of my basic rules
of quality, is you know, beg, borrow or steal anything and we just took a piece
of construction paper, we printed out
‘recheck blood pressure’ and we taped a
magnet to the back. And it does a couple
different things. Every time my nurse takes a
blood pressure and it’s above 130/90, she takes this magnet
and she takes it from the inside of the door and puts it on
the outside of the door. What that means is that it cues
her to keep paying attention to it and she knows that if their
blood pressure’s elevated and I see that and that not on the
outside that we’ll at least have a brief discussion on
how important it is. The second thing is, is it
cues me as a provider to say, ‘Hey this person’s blood
pressure’s elevated’. I don’t have to turn
on the computer, I don’t have to
look at anything. I see this red little magnet,
probably cost 25 cents, and it automatically
cues me into saying, ‘Time to do something or
pay attention to this’. At the very minimum recheck it
and see and if it is elevated, to deal with it. So then we move to high tech,
and as Dr. Woolsey said, she, you know, they implemented
eClinicalWorks, we use Cerner Ambulatory and you know,
I think all the EMRs, you know, you could make this availability
if you work with them. We work with our
vendor quite closely. But the first thing we
had to do, as I said, we get a blood pressure on
every single patient that walks through the door. So the first thing we had to do is export it to an
Excel spreadsheet. Since our data manipulation
people know how to use best. From there, we take it from that
Excel spreadsheet and we put it in an access database, and the
reason we do that is it allows us to manipulate the data, we
can use and access database viewer that we can
put on every desktop and we don’t have
to pay for that. You know, Microsoft gives the
viewer away so we really only have to buy one or two copies
for the data people to work the data and then the rest of us access database right on our
desktops in our exam rooms. And so we have that there. And then what do we
do with our data? The first thing we so, is
we generate patient lists. So, again, here would be a case
obviously for a couple reasons. These are all test
patients and hypothetical. But what you see here is it
gives me a list and if you look up there’s a little box you can
check diabetes, hypertension, ischemic vascular disease. You can choose
age, and you can parse it anyway that you
want to set it up, that your docs
think are important. And then what this does is it
uses a computer just as what it is. It’s a tool and it uses the
computer to help you identify who needs help and who doesn’t. So everything in these means
they’re out of parameters. And sometimes they’re out
of parameters because of date, so their blood pressure was good
but it’s been over a year since we’ve checked it. Sometimes, like if you
look at some of these LDLs, they weren’t done, and so
obviously missing data also would be (inaudible). And then our care
coordinators, as we said, will use these lists and they’ll
sit down with the provider at least once a month and we’ll go
over what it is that we want to do with these patients. Most of the time I’ll tell
them, please call her or him, and have them come in and have
them do this before I see them. But again, it creates a much
more proactive way of looking at the chart. Next thing, as I said,
we can use filters. So we can filter by
primary care provider, we can filter it by disease,
we can filter it by age, and we can filter it by anyway
that we want to do so that, you know, some providers are
more interested in one thing or the other and you can do
that, and again, what it is, is taking that data and
putting it to work for you. Most of the times I tell people,
boy you really like your EHR and I remind them, I don’t work
for it, it works for me, and it is nothing
more than a tool. A lot of people, I think it
caught up as trying to make it fit in the EMR’s parameters, and
in my world I make the EMR fit my parameters. Um, next thing is you can
get patient scorecards. So what you could do is, is we
try to run these squares at least one a month, but often
times more than that so the data is never older than that. But again, we’re doing
this on you know, that we fully expect our vendor
to be able to have the time within this year, but we’ve been
doing this for three years and, as you pull up, so
if this patient, this Laurence test
patient calls in, my nurse can pull
this up and glance and say, ‘Huh, Laurence hasn’t had his
LDL done’ and she can go ahead and order it, and get it
set up by standing orders, and she doesn’t even
need to contact me. That goes again, back
to this team concept, is that it’s you know, if
you let the team help you, the team could, can see patients
that you don’t see or take care so that you as a physician
don’t have to deal with it. Again, I think that’s where the
strength in our numbers are. The other thing as Dr. Woolsey
commented on is as physicians, we like to do well, we
like to look at each other, we like to compete. We share provider statistics
and I’ve blanked them out here but again, it’s just which
provider has which kind of control and again, if
you can see what we did, this is for optimal vascular
care there’s four controls, and you see the overall control
for each individual item, blood pressure, LDL,
Aspirin, and tobacco, but then to the right of it
you can also see that which, you know, how many of the
patients are in all four, how many have three of four,
how many have two of four, and so forth. Why this is valuable is we
found out that some patients, or some providers are really
good at stressing LDL or tobacco sensation, but maybe not as good
at Aspirin or paying attention to blood pressure. So you can see as a provider
where your strengths are, where you tend to do well and
where you tend to fall short so you can concentrate on it. The second thing you can do is
you can start working on those people that are
three out of four, or in diabetes four out of five,
in kind of what we would call the low hanging group, and try
and get those people back to ideal control. So it just allows you to be more
efficient and better able to manage your population. So again, and they told you
we’ve been doing this for four years now. We’ve been measuring for
a long time and as I said, we were stuck at that
70 percent number. So again, this is again a small
rural clinic that’s literally the cheese curd
capital of the world, we’re in western Wisconsin where
we have more cows probably than people, but we were able to bump
those numbers up from 73 percent to 97 percent
controls for people with ischemic vascular disease. But the one we’re most proud of
because it’s the one we spent the most time on, is this as of
December of last year, all our patients with hypertension,
regardless of anything else, we were finally able to get
that number over 90 percent. You know, and you got to
remember the national average is about 50 percent. So again, it shows you
that hard work pays off. Now why is that important? Well just doing those numbers, we figure we stop two
or three strokes a year. That means two or three
more of our patients can play with their grandchildren. You know, we stop four
of five heart attacks. Same thing. Those people can live the lives
that they wanted to live and they have, they have less
morbidity and less mortality. I mean, ’cause to be honest,
we’re not treating numbers, we’re treating people. So, we were pretty excited
when Janet Wright came out and recognized our little bitty
clinic along with a clinic from, another small clinic,
Kaiser Permanente, with having excellent
blood pressure control. Um, and for the business
guys and the you know, I run my own business,
it’s a private clinic, it makes a difference. Consumers Reports comes out
and says, you know, ‘You’re the most
effective clinic in your neck of the woods’. That’s really helpful
and it helps that way. So in the end, the bottom
line, it takes team work. This is our team and in summary,
I’d like to say, you know, the biggest thing that we
found is we needed a different mind set. We address blood
pressure at every visit, we use low tech
and high tech tools and we use everything we have. There’s no point in
leaving anything on the table. Anything you can use,
take advantage of it. We call it a team
sport and as I said, most importantly it
makes a difference in your patients’ lives. It does allow patients
to live better. Last but not least, and I’ll
be really quick on this, ’cause I know we’re
starting to run out of time, is I wanted to sell a different
way to look at quality. As most of you know,
about a year ago, the pharmacy people
came out and said, simvastatin and
Amlodipine which is right… and I don’t know if that’s
gonna work or not but I’m going to red towards the bottom, you
shouldn’t use those together. Well we use a tremendous
amount of generics. You know, that’s one
of things we measure. I have over 80 percent in
generics and so we use a lot of Amlodipine and a
lot of simvastatin so in all of our clinics,
including the two clinics north of town that we have that’s
a bigger clinic than ours, we have 241 people that were
on Amlodipine and simvastatin. Because we e-prescribed it,
because we used our electronic record, we were actually able
to reach out to them and find a better solution for them,
each individualized, without, actually without much work
at all, just doing a query. In the old days, I’d be
surprised if we got ten percent of them covered and we just had
to wait to wait for them to come in and
hope we remembered. So that’s a different
way to look at quality, but one we think is important. So last but not least, you know
if you’re gonna make a big step, don’t be afraid to take
one on what is needed. You can’t cross
the quality chasm, two little baby
steps won’t make it. Thanks very much. Moderator: Thank you,
Dr. Tashjian. Um, I’d like to thank both the
presenters and now move into the question and answer session. Um, I’ll, going forward
I’ll be asking questions. In some cases they’ll be
directed to a specific presenter but I’d like to open it up to
your thoughts from both the presenters on anything that
you’d like to speak to with respect to the question
whether it’s targeted or not. I’d like to start, Dr. Woolsey,
there was a question with respect to how you, if you
could discuss a little more, how you reached the Hispanic
community and in that regard, whether you got the Hispanic
patients to use the ECW patient
portal, and if so, how? Dr. Woolsey: So, again
this is Sarah Woolsey. We have just begun
outreach on that. We first had started
with just text messaging, text message tools, and our
portal is still slow and coming. I’ll be honest, I do not have
any Spanish speaking patients on the portal at this
moment, but we’re in an active recruitment phase,
so we’re just starting that. Now, in, I know that our, my
partners who are in our homeless works, have done quite a bit of
outreach with cellphones and texting, but
not portals yet, and we’re gonna be
building that capacity. We’re collecting emails,
though, to start, and we’ve been surprised
at the number of emails we’re getting back. We did a survey ’05 and didn’t
find a lot of email addresses with patients as we were
beginning to look at that as a new avenue, but now in 2012, we’re starting
to collect a lot more and especially with our
younger patients. So, the news is to come on that. Sorry. Moderator: Great, thank you. Question two to both presenters,
the question is how do you, how do you answer a provider
that tells you that signing the encounter and providing a
visit summary is challenging? It specifically just concerns
about making sure all the information’s been
entered, any potential legal implications,
those types of concerns. Dr. Tashjian: I’ll take the
first stab at that ’cause we provide
a summary after, and I’m sure Dr. Woolsey
does too, after every visit. But the answer is, that’s where
you work with your vendor, because our vendor makes it easy
that the visit summary pulls in all the necessary data
and one of the big, probably the most key important
data is that we have our docs do, routinely, and say when
is that next appointment, and we actually make that in the
EMR right there at the visits that it goes both to our
scheduling people in case that patient doesn’t show up so it
helps you with your, you know, patient centered medical whole,
but it also automatically shows up on that visit summary, for which I circle it and just
remind the patient, this is when we want to see him
and this is what we plan to do at the next visit. So the answer is, you take
the time necessary to do it. Does that mean that
you see fewer patients? I haven’t found that to
be the case, but again, I think that goes
to the workflow. If you set it in and make
it part of your workflow, it just becomes habit. Dr. Woolsey: I’ll
just add two cents. So number one I agree. The vendor can work with you to
have flexible choices so in my visit summary I can actually
check how much or little information gets in there. Of course you have to have a few
basic parts to have anything there, but of course follow up
appointments and medication lists are standard for us. The second piece I would say, so
one is allow them to customize it as you’re getting
used to them using it. Ideally it’ll become a tool
that’s more and more valuable and we’ll all just
want to use it. Number two is, there is a new
shift happening, where you know, in the old school, and I’ve had
physicians say this to me in presentations, especially about
health information exchange, that’s not the patient’s
chart, that’s my chart. And really, there’s a whole new
opening of access to patients, for patients to their
own medical records. There’s a culture change that is
happening in medicine where the patient’s information is
the patient’s information. Right then, right there. So whatever you put in it,
you’re gonna want to make sure that it’s appropriate to the
context of you and the patient are using that information. So I think there’s a little bit
of a culture shift we have to be aware of, but this is the
patient’s record and they’re going to have increasing
access to every part of it, and that’s something
that physicians will need to move forward with. So that’s just another comment. Moderator: Excellent, thank you. The next question was directed
Dr. Tashjian, to you, but I’d actually like to
open it up to both of you. Can you speak more to how you
create the patient scorecard? Dr. Tashjian: Yeah, well again, when we create the
patient scorecard, we look at what their
chronic diseases are, their chronic illnesses, and
because there’s a fair amount of overlap, we kind of check for
the five basic things that we see with diabetes and if they
don’t have diabetes we just ignore
the A1C and so for ischemic vascular disease
or hypertension, then those come up. And again, the way we do it, is
we have it so that that nurse or my medical assistant pull
that up when she sees that this patient
is on the list. It’s kind of a form of
electronic pre-visit planning and you know, we try to
pre-visit plan all of our patients prior to them coming in
and this has made it a way to do it more easily when they
have same day appointments. So, we generally look at the
five things that we look at for ideally controlled diabetes and
if they’re not diabetes we just kind of ignore
the A1C component. Dr. Woolsey: And this is Sarah,
and we do not have an electronic scorecard, but we have hand done,
I guess you’d say, scorecards in English and
Spanish and really we use it as a teaching tool, either having
patients enter their own information in it as we
talk, or we do it with them, in an educational
settings with ourselves, our health educator staff
if that’s available, or in some settings I’m seeing
care coordinator or medical assistants who are functioning
in a higher capacity in education to go through
those scorecards. So we’re at low tech. Moderator: Okay, thank you both. Dr. Woolsey, actually let
me follow up with you. Can you, there’s a couple
questions on explaining the business summary
ahead of time concept. Actually this is kind
of getting at more um, what it means from a practical
aspect of how it works. Dr. Woolsey: Yes, so,
this is something at our practice we
experimented with. I currently don’t
do that anymore, but one thing is so you can
print, you have schedule, you print the visit
summaries ahead of time. Now, those aren’t going to
be updated with the current information, yet it can be
used as a couple of things. Number one, a tool as described
by my pharmacist friend where you give it to the patient,
let’s say the front desk gives it to the patient and they
review their medication that are on that list and could
make corrections, so that’s one option for
medication reconciliation. Number two, I have a very, I
would call meticulous internist that has been a mentor
and educator for me. He prints them
out ahead of time, and any changes that he
makes in the patient’s care, he actually thinks the exercise
of discussing the visit summary, crossing out medication changes,
doing that by hand is an opportunity to be an
education with the patient. So that’s another opportunity. You actually demonstrate
to the patient, you’re making a change by
slashing out that dose and increasing the dose. Again, if your handwriting is
legible and you have time, that can be a very engaging
way to deal with the patient. So those are two options. I would advise that if you did
the med reconciliation model where the patient’s
writing the meds, you know, that they’re taking
ahead of time, you’re gonna want to give
them another one at the end. Okay? But this is just a way to
communicate that information and actually have the patient get
familiar with the visit summary and used to how it looks
and what’s on there such that they use it as a valuable tool
sometimes when they go home. So just two ideas. Moderator: Great, thank you. The next question was directed
to you, Dr. Tashjian, but again I’d like to open
it to both presenters. The question is, do you think
it’d be beneficial to shift to thinking of the patient as a key
member of the team who needs to adopt this improvement
challenge? As physicians,
you’ve shifted focus, do you think a new view
of the patient is needed to achieve meaningful change? Dr. Tashjian: Yeah, I think
that’s exactly right. As we put the patient at truly,
you know, on a patient centered, but we also, when
we look at the team, we really tend to
have looked at the patient as the captain of the team now. And part of that, then, is
making sure they understand what we expect of them. They understand that we expect
their blood pressure to be at lower than 140/90
and we tell them why. We tell them that you know, this
will create fewer heart attacks, you’d be less likely
to have a stroke, you’ll have more time to play
with your grandchildren or children and that we’re not
doing this just because we’re looking at numbers, and
they can relate to that. But you need patient involvement
and patient engagement if you really want to see
the numbers change. Now, living in a
small community, that’s one of the key advantages
that we may have is, you know, I know virtually everybody that walks
through that door. I’ve delivered most of them. Dr. Woolsey: So, I would like
to just comment that this, this isn’t a key
focus of this talk but there’s another one
that I’ve done around self-management. We’ve really opened up our
self-management in hypertension in our practice. And I want to just challenge
the group to think about this. Would you ever put a patient
on insulin or a hyperglycemic agent without at least
considering a glucometer? We consider patient
self-management and knowledge of their blood sugars
as standard of care for much of our diabetes care. Not everybody but many people. Well, what do we think
about blood pressure? Are we aggressively having our
patients have access to their blood pressure? And I will tell you, just a
quick story of a gentlemen with low literacy could not figure
out what the heck was going on with his blood pressure
at his clinical visits. With a cuff at home, and that check box
form that I showed you, and he’s an English speaker,
but a check box form, he was able to begin to bring
me blood pressures on a regular basis. And with feedback in six weeks, we had his blood
pressure at goal. And he continues to be at goal. His cardiologist loves that fact
that he has a home monitor and he checks that. We have gone to providing lower
cost monitors that we trust that are FDA approved and we have a
way to train our patients to use them because it’s not the
easiest thing in the world to take a good blood pressure. So we have a training module,
we provide the patient with a monitor, and we ask that
they track just like sugars. So really consider that that’s
the ultimate goal is that the patient knows exactly when
they need to call you because something’s
out of range. Moderator: Thank you both. Next question is
to both presenters. Could either of you elaborate on
reporting out of the controlling high, excuse me, controlling
high blood pressure CQM? Specifically has it taken a lot
of resources to develop the reporting out tools, especially
to report to entities outside of EMS and with this focus, did you
rely mostly on internal staff or vendors to assist
in this process? Dr. Tashjian: I’ll go first.
Dr. Woolsey: Want to go first? Dr: Woolsey: Yep. Dr. Tashjian: Yep. Be
happy to go first. We use our vendor and our
vendor could do part of it. He could not, they could not
do all of it so we got like an advance reporting system that
was available with our EHR and through that advance
reporting system, were able to pull out
all the data we need, both for our PQRS and for, and for any of our payer
plans that want it. So it’s like anything else,
it took a little bit of extra effort and a little bit of
extra money to get it set up, but once it’s set up, it runs
much more seamlessly and much, much more efficiently than we
ever had in the paper world. As I said, we measure
these every single month, not for the payers, but
just for our own knowledge, and in the paper world we were
lucky to run it twice a year and even that was
prohibitively expensive. Dr. Woolsey: And I’ll just
comment on working with, we’re actually working with 19
electronic health records in our Beacon Community and there’s a
wide range of answers to that question. Some platforms have had a better
ability for a third party vendor, like Dr.
Tashjian’s talking about, to be able to do this stuff. Other folks are able to do
it within their CQM in their electronic health record. But it varies. Vendors can be
extremely helpful, partners that are doing it with
the same EMR in your community can be extremely helpful. And unfortunately trial and
error, putting patients in, seeing if they track through. Our process is has been, we’ve been working
on that extensively. Literally, there’s a point at
which we just put the blood pressures, you know, in a wrong
place and they wouldn’t track, they wouldn’t get
picked up by the CQM, they would get picked
up by the registry. So we have had quite a
bit of trial and error. We have had to use third party
sort of data lists to compare to what our EHR is doing to
learn how to use it better. And so I would say that the
answer’s still out and it very much is vendor dependent, but
most likely you’re gonna need to do some extra work to make
these CQMs as valuable as they are designed to be. Moderator: Very good. Thank you. Given the time, let’s finish
with one last question here which I, again, will set
out to both presenters. How do you encourage
portal use within the safety net population? Specifically access to computers
and, and public information, public health information on
public machines is always a concern. Can you address those
ideas, concerns? Dr: Tashjian: We actually have a
fair number of (inaudible) in our rural community of
smartphone users and we’re finding that that’s probably
going to be even more than the desktop, going to be the
biggest access issue. We still have people that
use the public library, and you’re right, those
are public computers, but as long as they
close out of the browser, all of that information
is, is removed. We are working with our vendor. We would really, really like
to have either an iPad or an Android app, or preferably
both, that’ll allow us to text information to our patients as
well as deliver it to an app that they don’t
have to log in with, but that they could just use on
either their smartphone or their iPad. Dr. Woolsey: Yep,
and I’ll agree. Just in our community at
this point, smartphones, but also just plain old phones
with texting ability seem to be the common place
that people have, even people with low
income and transient people, are maintaining phones. It’s amazing. And so that will be the way. I agree, you know, secure email
or portal logon are designed to be opened and closed
so training patients on the importance
of that is good. I suppose someone could go print
out extensive amounts of labs or something and they’d be
on a printer somewhere, but to you know, maybe
training patients of that importance is there. But we’re experimenting texting. It is just a thing we’re really
experimenting with to see how much we can get and ideally two
way texting is a thing that we’re looking at in our system. Moderator: Thank you
both very much. In conclusion, we would like to
thank everyone who submitted questions during
today’s webinar. Any questions that were not
answered during today’s webinar will be addressed
following this event. The question and answer session
summary will be posted on the HRSA OHITQ website along with
the recording of this webinar. We would like to thank
everyone who attended today. We very much value your feedback
and use it to plan upcoming webinars, so please take a
moment to provide your feedback on today’s event by completing
the questionnaire that will appear on your screen shortly. Operator: This webinar
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