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Great Plains QIN Using Your EHR to Improve Population Health

April 19, 2016

Lisa Gall, DNP, FNP, LHIT

Jerri Hiniker, RN, BSN, PHN

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Today’s Goals

The participant will be able to:

• Improve public health reporting and surveillance

• Better their organization’s ability to prevent disease

• Expand communication by health care providers

Using clinical decision support, registry functions, preventive reminders and HIE

Diagnosis and Problem Lists

Data Management

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MU Objective # 2: Use clinical decision support to improve performance on high-priority health conditions

• Implement 5 CDS interventions related to 4+ Clinical Quality Measures (CQMs) at a relevant point in patient care for the entire EHR reporting period

• Drug-drug and drug-allergy interaction checks enabled and implemented for the entire EHR reporting period

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Use CDS to Drive Quality Improvement Goals and Support Clinical Quality Reporting Requirements

MU Measures

• Drug formulary check

• CPOE

• Patient specific education

• Secure message

• PH Measures

• Reportable labs (EH)

Clinical Quality Measures (CQMs)

Registries for PH measures

• Immunization Registries

• Syndromic Surveillance registries

• Specialized Registries – Public Health Registry (State Health

Department)

– Clinical Registries (by specialty)

– Case Reporting (by diagnosis)

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Align Clinical Quality Measures and QI Aims

• Determine Quality Reporting Requirements

• Establish Quality Improvement (QI) Aims: – Can you align CQMs across programs?

– PQRS/VBM, MU (PH, CQM), Other state/federal programs, payers

• MU: 9 CQMs across 3 NQF domains

• PQRS: Choose reporting method/ registry type – Group Reporting (GPRO) vs. Individual Reporting

– Claims, registry reporting, EHR, Clinical Data Registry

– Individual Measures vs. Group Measures Individual Measures 9 CQMs across 3 NQF domains

• MACRA: MIPS/APM – 2019 payment adjustment based on 2017 reporting period

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Use the CDS “Five Rights” to Develop Interventions

• The right information

⁻ evidence-based, actionable…

• to the right people ⁻ clinicians and patients…

• in the right intervention types ⁻ answers, documentation tools, data display, alerts…

• through the right channels ⁻ EHR, internet, smartphones, smart pill bottles…

• at the right points in workflow ⁻ decision/action …

Osheroff, Gall, Kleeberg (2013). Clinical Decision Support-enabled Quality Improvement for

Meaningful Use. Learning and Action Network, Webinar presentation

CDS is about quality and process improvement,

NOT about interrupting workflow or a MU checkbox!

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Alerts and Reminders

• Can be passive

highlights or

interruptive “pop-ups”

to alert user to a

problem (allergy alert),

new data (lab result)

or passage of time

without a specified

event

• Important to strike a

balance between

desired outcomes and

interruption of

workflow

Osheroff, Gall, Kleeberg (2013). Clinical Decision Support-enabled Quality Improvement for

Meaningful Use. Learning and Action Network, Webinar presentation

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Linked References in your EHR

Providers: Medline, Up To Date

Patient Education:

Krames, Lippincott

Value/Cost Tool: ABIM’s Choosing Wisely Campaign (choosingwisely.org)

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• Relevant lab, age or

weight display when

writing orders

• Creatinine when

ordering metformin

• Last filled date when

renewing medications

• Suggested medication

list showing generics

• Targeted patient lists

based on diagnosis

Relevant Data at Point of Care

Osheroff, Gall, Kleeberg (2013). Clinical Decision Support-enabled Quality Improvement for

Meaningful Use. Learning and Action Network, Webinar presentation

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Using Data and Technology to Improve Patient and Population Health Outcomes

Clinical Data

Dx, age, reason for visit

CDS Trigger

Alert, Reminder, orders

Intervention

Best Practice, Standard of Care

Improved Outcomes Patient and Population

Relevant data, Reports and Summaries

• Monitor and Manage HIE, referrals, Utilization and costs

Dashboards & Patient data reports

• Provider/Group/Organization: MU, CQMs, Benchmarks

• Patient/Population/Cohort: (age or diagnosis specific)

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Synergistic Effects of Correct and Current Problem and Diagnosis List

Undocumented problems = missed CDS opportunities

• Integrate standardized problem list (SNOMED) with CDS systems for better/ faster outcomes – Involve clinicians and support staff across all care settings

– Interoperable across settings and between HIE and other HIT

• Clinical Quality Measures used for – Data analytics

– Benchmarking

– Public Reporting (Physician Compare)

Huizenga, 2013. Problem lists drive CDS systems and population health management

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Use Problem List to Generate Structured Data for Population Health Management

• Registry reports of patients with chronic/high risk conditions – Establish Care Teams

– Identify patients due for follow-up: appointments, labs, med refills

– Scope out incomplete medical treatments or diagnoses

• Clinical Data Registries can generate data for – reporting CQMs to CMS (MU, PQRS, VBM…..)

– Generating utilization reports, cost reports, QRUR

Using the EHR to monitor and improve population health

Chronic Condition Management

Patient and Family Engagement

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Ten Recommended Health IT Tools to Achieve Population Health Management

• Electronic Health Records

• Patient registries

• Health Information Exchange

• Risk stratification

• Automated outreach

• Referral tracking

• Patient portals

• Telehealth/telemedicine

• Remote patient monitoring

• Advanced population analytics

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Using EHRs for Population Health

Benefits

• Timely availability of data

• Cost-efficiency of data collection

• Access to detailed clinical and laboratory information

• Ability to evaluate changes in health over time

Limitations

• Challenges associated with sharing data

• Data quality

• Lack of established standards

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EHR Reports

EHR Reports that Support Population Health and Chronic Disease Management

• Health/functional status, by patient and population

• Provider use of recommended treatment guidelines, decision support use, and literature searches.

• Referral patterns – Internal: for specialists and supportive services such as social work and

nutrition

– External: for specialists and community-based organizations

• Educational materials provided to patient and family

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Development Considerations

• Data Structure and System Design

• Standards

• Data Quality

• Selection of Population Health Indicators

• Inclusion and Exclusion Criteria

• Duplicate Records

• Measurement Error

• Uncertainty in Analyzing Trends

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Development Considerations - Supporting

• Mapping workflows

• Standing Orders

• Identification of patient education materials ⁻ Patient appropriate

• Registries

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Key Attributes

• Person-centered

• Comprehensive

• Coordinated

• Accessible

• Committed to safety and quality improvement

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Addressing the Challenges

• Payment reform that encourages population approach

• Improvements to Health IT products

• Enhance workforce education and training

• Engaging the Patient

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Why We Need to Engage Patients/Families

• Better understand their own current care and treatment, as well as that of family members in their care

• Coordinate care and reduce duplication of services among multiple care providers

• Maintain a personal health record that tracks their health conditions and care provided over time

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Patient Health Information

Must be:

• Timely

• Accessible

• Accurate

• Understandable

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Best Practices for Patient/Family Engagement

• Establish organizational patient engagement committee or council

• Support electronic access of patient health information by automated workflows

• Enhance patient portals functionality

• Provide a “one-stop shop” for patients/families

• Create policies for managing patient-generated health information

• Stay up-to-date with public policy proposals and standards addressing patient/family engagement

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Questions?

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Dr. Lisa Gall

952-853-8500

lgall@stratishealth.org

Jerri Hiniker

952-853-8500

jhiniker@stratishealth.org

Contact Information

This material was prepared by Telligen, the Quality Innovation Network

National Coordinating Center, under contract with the Centers for

Medicare & Medicaid Services (CMS), an agency of the U.S. Department

of Health and Human Services. The contents presented do not necessarily

reflect CMS policy. 11SOW-QINNCC-00720-04/07/16