IMPLEMENTATION OF MU: HOSPITAL BASED PRACTICEMark Huang, M.D.Chief Medical Information OfficerRehabilitation Institute of Chicago

REHABILITATION INSTITUTE OF CHICAGO

Hospital based practice with academic affiliation to Northwestern University– 65 medical staff including mid level providers– 40 residents, 6 fellows

Main hospital outpatient clinic Cerner EHR (Powerchart) Offsite clinics on the main EHR Partnerships not fully on EHR

DECISION TO PURSUE MU

Cost analysis: – software costs– incentive payments– impending penalty consideration

Roughly break even for the organization Overlap with PQRS compliance Some aspects were “meaningful”

– Eprescribe– Problem list– Visit summary for instructions– Patient portal

IMPLEMENTATION STRATEGIES

Establish implementation task force– Weekly status updates

Analyze current clinic workflows Review proposed changes with EHR

– Extra tasks needed for MU– Review exactly who does what for each measure to

ensure this will be completed

Involve clinical staff in decisions

ADDITIONAL OFFICE STAFF TASKS

Invite patients to participate in patient portal (automate registration, encourage use for refills, electronic communication)

Record demographic information (race) Record vital signs (BP, height and weight) Record smoking status

– Document smoking cessation plan

Record family history Update allergies and medications Generate transition of care document

WHAT PHYSICIANS NEED TO DO?

Medication reconciliation Maintain/update problem list E-prescribe Generate clinic visit summary Patient education Secure messaging with patients via the EHR

WORKFLOW IMPACTS

Less clinic efficiency– Clinicians taking longer to complete visits per

patient– Office staff duties diverted to meaningful use

compliance tasks– Increased after hours catch up work

Information given to patients not relevant to scope of practice

VITAL SIGNS

Height, weight, BP, BMI– Growth curves in children 0-20

Target: 50% of unique patients Exclusion: < 3yrs Establish process with office staff that ensures

height and weight routinely obtained– Obtain scales for clinic– Height recording

Those in wheelchairs, ask for estimated height Many EHR uses metric system Issue quick conversion charts for english to metric

SMOKING

Target: < 50% unique patients older than 13 Smoking

– Ensure staff assess for smoking– Can also use documentation to record any

interventions (one of the clinical quality measures includes smoking cessation)

PROBLEM LIST

Target: 80% of patients must have a problem documented

Maintain active problem list Encourage use of problems, often these can

be used to create diagnosis for charges Clinician needs to review PRIOR to printing

visit summary Strategy:

– could have clinical staff enter initially and physician review/edit as approp

PROBLEM LIST

VISIT SUMMARY

Target: 50% of all office visits Provide summary within 3 business days

– Excludes procedures

Include at minimum following information– Problem List – Diagnostic Test Results – Medication List – Medication Allergy List

VISIT SUMMARY

Providing clinical summary one of most challenging objectives to meet

How will patient get document?– End of visit– If not done at end of visit who will track visit

summary completion and how patient will get document

Mailed to home Patient portal

Need to ensure process for completion– Can use extender to print document

VISIT SUMMARY WORKFLOWS

Physician or designee updates medication list before patient leaves clinic.

Visit Summary replaces patient’s copy of the Med Reconciliation List

Physician or designee will sign visit summary document

Front desk staff will print visit summary and distribute to patient at check out– this was later changed to clinician prints to front

desk

VIEW TRANSMIT DOWNLOAD

Target 50% of unique patients Patients are provided online access within 4

business days to their health information– Problems, allergies, medications, vitals instructions

Patients only need to be invited to have access, they do not actually need to view or access the actual online content

Emphasize enrollment with patients– Allows easier access to visit summary if done after

the visit

ELECTRONIC PRESCRIPTIONS

Target: 40% of eligible prescriptions must be sent electronically

Electronic prescription of non controlled substances– Must be sent directly to the pharmacy

Controlled substances Controlled eprescribe requires 2 levels of

authentication

E-PRESCRIBE

Clinicians route prescription directly to pharmacy

DECISION SUPPORT

Create decision support that may assist in other areas (clinical quality measures)

MEDICATION RECONCILIATION

Target: 50% of visits must have medication reconciliation performed

At each office visit, review medications patient is taking

Most EHRs offer some method of medication reconciliation (must be able to simultaneously compare 2 different lists of medication)

QUALITY MEASURES

Few measures are applicable to PM & R Even those that seem applicable may not Not all measures are built within EHR reporting Consider group reporting for quality measures

and PQRS

QUALITY MEASURES:

Measure #238 (NQF 0022): Drugs to be Avoided in the Elderly

Measure #312 (NQF 0052): Low Back Pain: Use of Imaging Studies

Measure #39 (NQF 0046): Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

QUALITY MEASURES

Measure #48 (NQF 0098): Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Measure #154 (NQF 101): Assessment of Fall Risk in the Elderly

MU REPORTS

Status reports– Ensure accuracy of reports– Use reports to target providers at risk– Deploy resource to assist with education and

support

Early intervention critical to compliance– Identify personnel to review reports– Examine feedback from users in regards to

workflow– Observe for best practices that can be applied

across users

REPORTS

REPORTS

ATTESTATION

Ensure that you have supporting information Begin registering early Complete attestation by end of Feb of

subsequent year BE SURE TO KEEP CAREFUL RECORDS OF

COMPLIANCE in case of an audit

STAGE 2 CHALLENGES

TRANSITION OF CARE

Provide a summary of care document for more than 50% of transitions or referrals to another provider of care– Includes therapy and home health referrals

A further 10% of these summary of care documents need to be sent electronically– Challenge is finding enough referral sources who

can receive these

Conduct test with a another separate EHR or conduct successful electronic exchange of information

TRANSITION OF CARE

Sometime difficult to determine exactly which provider to send document– Patient has not decided on provider– May not know by end of office visit– Requires process to follow through

Identifying referral sources that can receive the information– Many therapy sites and home health agencies not

equipped to receive transition of care electronically

SECURE MESSAGING

5% of patients need to message provider via secure messaging means (patient portal)

Email does not count Challenging for certain disabled populations

– Often requires use of email to enroll– Many clients do not use email or have a computer

Elderly, indigent population, those with language barrier

SECURE MESSAGING

Strategies– Automate enrollment in patient portal– Ask patient to review portal information– Message patients who have signed up to get them

to respond– Discourage email communication

CONCLUSION

Workflow analysis EHR usability critical to success and

satisfaction Reports key to measuring progress Feedback from providers critical