HHealth and ealth and CChronic hronic DDisease isease MManagement (HCDM)anagement (HCDM)

BEACON

9.8.2010

Overview

• 4 year project

• Purpose: • Leverage the MHS EMR to deliver point-of-care tools to

providers and care teams• Develop detailed provider level reporting to advance

ambulatory quality care in areas of prevention and disease management

• Collaboration between Cerner and Mayo

• 3 components – separate rollouts

HCDM Resources• Project Team

• Dr. Rick Fleming – Physician Lead – ISJ Primary Care Provider • Jason Buckmeier – Project Manager• Divya Pathak – Senior Analyst/Programmer• Lakshmi Kharidehal - Senior Analyst/Programmer

• Cerner• Engagement Team• Discern ABU

• ASYST • Leadership• Analysts

• Mayo Health System• Quality Dept Leadership • MHS Expert Teams• Diabetic Registry programmers & AQM programmers• Ambulatory Care Committee • Site Quality Coordinators

• HICS/Design Council as the oversight body

HCDM Project Metrics• AMB, ED, IP Summaries - ~ 6200 users (providers/nurses)

• Condition Management Rules: 435 MHS Providers (Primary Care)

• Populations Evaluated - Current• Hypertension              51,777 patients• Asthma                  7,696 patients• Depression                19,130 patients• Diabetes                21,903 patients• Vascular Care            9,412 patients

• Records reviewed nightly - 30-35,000 patient records per topic

• The total for all topics ~ 180,000-210,000

• Largest population monitoring of any Cerner client

HCDM

MHS Quality

MHS CDR

Site Quality Directors

ASYST Site Liaisons

ASYST Clinicals

MHS Expert Teams

Mayo-JAX Technical Team

ASYST Technical

Team

ASYST Reporting Team

HICS

PWG

MHS EMR User Groups – FirstNet,

Ambulatory, IP

ASYST Leadership

Cerner Engagement

Cerner Development – Discern ABU

MHS Ambulatory Care Committee

HCDM Interaction

ASYST Learning Team

Determines “what” we build & deploy

Determines “how” we

build & deploy & integrate

into MHS EMR

“Does” majority of

HCDM Build

Oversight

HCDM Components

• 10 Algorithms

• 1 Patient Summary Page

• 4 Condition Summaries w/ Performance Measures

• MPage 2.0 Summaries – AMB, ED, IP

• Reminder Letter functionality

• Team tools (provider schedule icons and scheduling solution integration)

October 2009

July 19, 2010

Q4 2011

Algorithms included:

• Asthma (Adult & Ped)• Depression• Diabetes• (Diabetic Hypertension)• CAD• Hypertension• Hyperlipidemia• Heart Failure• (Diastolic Heart Failure)

Link

Algorithms

Launchable from:• desktop• intranet • condition summary• EMR link

Functionality Goals• Improve data capture (Tool: Ambulatory Summary)

• More efficient documentation of quality metrics at point of care (foot exam, eye exam, PHQ-9, recheck BP, Asthma Control Test)

• Advances ability to have responsive reporting• Educational (data to help support adoption – i.e. PHQ-9 utilization)• Aids in data collection for 3rd party submission (MNCM - DDS)

• Point of care patient metrics (Tool: Condition Summary)• Displays to provider/nurse how the patient is performing on quality

targets

• Population Reporting (Tool: Discern Analytics)• Care-Coordinator/Quality Analyst focus• All measures, all conditions, all patients – updated nightly• “Show all patients with HgbA1c not done in past 6 months for Dr.

Fleming”

Improve data capture (Tool: Ambulatory Summary)

Condition SummaryLINK

Population Reporting (Tool: Discern Analytics)

Invitations & other .20 functionsInvitations & other .20 functions

Reminder letters

Health Maintenance displays

HM: Lipids, Mammo

Top half shows health maintenance overdue and coming due in defined time

frame

Scheduler ability to see HM due items

HM brought into Depart SummaryHealth Maintenance

Invitations for Asthma Depression Diabetes(10) Vascular Hypertension Cervical CA Breast CA Colon CA Lead Screen

HCDM Project TimelineHCDM Project TimelineQ4Q3Q2Q1 Q4Q3Q2Q1 Q3Q2Q1

2011 2012 2011Q4Q4Q3Q2Q1 Q4Q3Q2Q1 Q3Q2Q1

2008 2009 2010Q4

Phase 2 Design

Phase 3 Algorithms

Phase 4 Patient & Condition Summaries, Performance Reports

Phase 6Invitations/.20 functions

Phase 7Refinement/update

Project year 4Project year 3Project year 2Project year 1

Phase 1Feasibility

HCDM Programmer/Analysts (2.0 FTE)

Next 4 sites go-live Last 4 sites go-live ASYST code upgrade

Physician Lead and Project Manager (0.4 FTE & 1.0 FTE x 4 yrs)

Cerner Programmers (contract)

= Functionality Rollout

This timeline is reflected in the current ASYST Roadmap

Up to 60 Clicks … 5 minutes

Provider adoption and efficiencyProvider adoption and efficiencylocate 10 elements on a diabetic patientlocate 10 elements on a diabetic patient

… 2 Clicks< 1 minute

Customizable – by MayoCustomizable – by Mayo

Open Source Sharing - http://mpagescommons.org/

New Summary Pages

New Analytics Reports

MPage 2.0 Development – via MPage 2.0 Development – via BedrockBedrock

IP Discharge Process

Nursing Communication

Utilizes more of the Care Team to deliver Health Maint and Disease

Mgmt

Care Coordinator Patient List

Reminder Letters

Scheduler Notification of due items

Thank you!