Improving Quality Improvement with an EHR

Working Smarter, not Harder to Provide Better Care

TEPR+ 2009Donald T. Stewart, MD FAAFP

DonS@SammamishDiabetesAndLipid.Org

Your Background?

• Physicians• NP or PA providers• Administrators• Nursing staff• Quality improvement facilitators• IT staff• Vendors

2

My Background

04/21/23 Sammamish Diabetes and Lipid Clinic, PLLC 3

• Family Practice, started solo from scratch in 1983 after residency in a semi-rural Seattle suburb

• Grew to 6 provider practice which was sold to Swedish Hospital in 2003

• Medical Director of 7-provider clinic in 12-clinic system 2003 - 2007

• First EMR 1997 on Newton Message Pad. Migrated to Practice Partner in 2001. Paperless since 2002

My Background

• Participant in Practice Partner Research Network since 2003

• Participant in Washington State Diabetes Collaborative 2006-2007

• NCQA Recognized Diabetes Physician• Solo in a Micropractice since July 2007 focusing on

primary care for patients with diabetes and lipid disorders

04/21/23 Sammamish Diabetes and Lipid Clinic, PLLC 4

My Patient Centered Medical Home: Sammamish Diabetes and Lipid Clinic

in Sammamish Washington

View from the Street, via Google

Patient Entrance

Reception Area

What is Quality Improvement?

The Institute for Healthcare Improvement http://www.ihi.org

provides a tremendous resource for these issues

Model for Improvement - 3 Questions(developed by Associates in Process Improvement)

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in improvement?

• Setting Aims– Time specific, defined

population, measurable

• Establishing Measures– Quantitative measures

of things that matter

• Selecting Changes– Which changes will

actually lead to the improvement we desire?

Plan-Do-Study-Act(W. Edwards Deming)

• Testing ChangesThe PDSA cycle is a description of the process of testing and implementing changes, assessing the results, and then acting upon them.

Traditional GoalsWhat is the matter?

• Process goals– Patients seen on time– All patients have vital signs– Medication Lists reviewed every visit

• Outcome goals– BP < 130/80– HgbA1c < 7.0

Patient-Centered Goals: What Matters to the Patient?

• “I receive exactly the care I want and need exactly when and how I want and need it.”

Only 25% of adult Americans strongly agree Only 12% of low-income Americans strongly agree

– Respondents are aged 19-69 years, Sept 2005 – April 2006. From HowsYourHealth.org

Patient-Centered Goals:What Matters to the Patient

When patients strongly agree that “I receive exactly the care I want and need

exactly when and how I want and need it.” They have these attributes of care:

Attributes of Carein Satisfied Patients

I have one person I think of as my personal doctor or nurse. Yes: 95% No: 60%

It is very easy for me to get medical care when I need it . Yes: 85% No: 10%

Most of the time, when I visit my doctor’s office, it is well-organized, efficient, and does not waste my time.

Yes: 80% No: 20%

The information given to me about health problems is very good. Yes: 80% No: 25%

I am confident that I can manage and control most of my health problems. Yes: 75% No: 15%

Patient-Centered, Collaborative Care

• Patient-centered vs doctor-centered care: the essence of professionalism is putting the patient’s (not the doctor’s) needs at the center.

• Collaborative care: when members of the health-care team work with patients to provide professional, often “evidence-based” support, to address problems that matter to the patient, resulting in “activated patients” who have the tools and confidence to deal effectively with their problems.

How does this relate to technology?

No practice can afford to achieve high levels of quality care within the traditional, non-technological model

of medical care.

Daily Time Required for Quality• 2500 patient panel Grade A & B Preventive Services: 7.4 hours Chronic Disease Management: 10.2 hours Acute Care: 4.6 hours Total time/day: 22.2 hours

• Optimal Panel Size for an 8-hour work day: 2500*8/22.2 = 901 patients

How can Technology Help?

Technology can improve efficiencies in a medical practice, and can reduce overhead expenses, but we need to go “outside the box” for a quantum

leap in progress

The Conundrums

• Not enough PCPs in the pipeline to allow for one provider for every 901 patients

• No payment structures available to pay for quality at a rate that incentivizes it

• Patients not motivated to get preventive services

• Infrastructure that is necessary, without technology, is quite unaffordable

Technological Aids For Efficiency• Electronic Health Records

– Once implemented, increase office efficiency and decrease overhead costs

• Secure Patient Portals– Ideally built into the EHR, for communication and education

• Registries (best if included in EHR)– Track patients with targeted illnesses and aid population management

• Automated Patient Recall and Reminders– To increase the probability that patients will follow-up

• E-prescribing– Reduce errors, automate refills, automatically document

Technological Aids For Efficiency

• Are all expensive, all require provider and staff resources, and are all valuable.

• But, they do not solve the problem of how to provide care that matters to the patient in a cost-effective way.

• We need use technology to involve the patients themselves in the process

Automated History Taking

• Instant Medical History: – a commercial software which integrates with most

if not all EMRs, and which allows the patient to enter the history, ideally before the visit from home, in an unhurried way. It can also be run from a kiosk in the reception area.

– IMH can automatically run research-validated screenings on the patient triggered by the answers given to the questions it asks.

Advantages of Instant Medical History

• Low cost• High levels of patient satisfaction• More compulsive and thorough than most

providers have the time to be• Collects not only the history, but also what

matters to the patient using validated tools• No staff time or provider time necessary – all

the work is done by the patient

Now, imagine a way to provide:

• patients with the information they want in real time

• providers with patient data that matters to the patient summarized for their care

• stratified in behaviorally sophisticated categories (e.g. confidence)

• cumulated patient-centered data to improve all patient care and your office practice processes

Imagine the patient doing that for you and also loading a simple registry for you to sort your patients based on:

• Demographics: name, age group, gender, financial status

• What matters: pain, emotion, confidence, meds that make the patients ill, more than one MD,

• What is the matter: high BP, diabetes, angina, CHF, history of stroke, respiratory disease, last BP, last cholesterol if 50+, last sugar if diabetes

• Prevention: mammogram, bowel cancer screening, Pneumovax

HowsYourHealth.org

20+ Years of research/testing pedigree

Dartmouth Medical School (John Wasson MD)

HowsYourHealth.org• Free for patients; nominal charge for clinicians

when customized• Collects information on general health status

but also information on what matters to the patient using validated tools

• Perhaps the best over-all measure of Quality of Care yet developed

• No staff time or provider time necessary – all the work is done by the patient

Action Form

Generated for each individual patient providing summary of issues that

matter to the patient as well as issues that should be addressed

Population Summary Report

Advantages of HowsYourHealth.org

• Patient assessment and feedback system– Unmask the true patient needs and agenda that might

undercut your best efforts– Automatically tailors information to your patient’s needs

and chronic conditions– Additional versions for hospitalized and very sick/frail

patients– Meets or supports many requirements for CMS/NCQA

Medical Home designation

Advantages of HowsYourHealth.org

• Patient Portal for Best Information, Links, Problem-Solving and Shared Decision-Making– Non-commercial, well-tested tools and information that saves

you time while you better inform your patients– Behaviorally Sophisticated Methods to Improve Patient

Outcomes

• Portable Personal Health Record for Your Patients and Your Records– Minimize risks and frustrations of fragmented information

Advantages of HowsYourHealth.org

• Patient Registry that Your Patients Complete for You– With one click list your patients/addresses by condition,

abnormal lab, functional limit, screening not done– Sort and contact patients by behaviorally useful

categories such as lack of confidence with self management

• self management

Advantages of HowsYourHealth.org

• Practice Improvement System that Instantly and Automatically Gives You Performance Data– Patient experiences and bio-clinical measures offered with

several national standards

• Customization options so that HowsYourHealth fits what you and your patients need– Add questions, change reports, import format for Electronic

Health Record

• Patient Pre-Visit Planner and “Reviewer of Systems” for Your Patients and Payer– Makes an office visit more efficient and your billing more

complete

Model for Improvement :a new look

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in improvement?

• Setting Aims– Based on What Matters

to the Patients

• Establishing Measures– Through web-based

assessments like Hows YourHealth? and IMH

• Selecting Changes– PDSA cycles with prompts

in EHR, web portals and even visit scheduling.

Questions?

04/21/23 51 Sammamish Diabetes and Lipid Clinic, PLLC