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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
Jerri Hiniker
952-853-8500
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