Asthma Encounter Form Asthma Encounter Form Development Development

Eastern Maine Medical Center’s Eastern Maine Medical Center’s Outpatient Pediatric Practice Outpatient Pediatric Practice

(Husson Pediatrics)(Husson Pediatrics)

Michael A. Ross, MD FAAPMichael A. Ross, MD FAAP

American Academy of Pediatrics American Academy of Pediatrics CAQI:CAQI:

Asthma Quality Improvement ProgramAsthma Quality Improvement Program

The IssuesThe Issues Multiple metrics need to be tracked in order to improve Multiple metrics need to be tracked in order to improve

asthma quality and report data for the AAP’s Asthma asthma quality and report data for the AAP’s Asthma Quality program (and for the Maine PCMH pilot)Quality program (and for the Maine PCMH pilot)

Physicians need to use an encounter form that Physicians need to use an encounter form that promotes implementation of 2007 asthma guidelines.promotes implementation of 2007 asthma guidelines.

The form needs to be user friendly towards a variety of The form needs to be user friendly towards a variety of individual documentation styles.individual documentation styles.

The form needs to be linked to online reference for up-The form needs to be linked to online reference for up-to-the-minute evidence-based practiceto-the-minute evidence-based practice

Data collection needs to be exported to existing Registry Data collection needs to be exported to existing Registry (Meridios) - Current metrics are limited to manual (Meridios) - Current metrics are limited to manual EQUIP entryEQUIP entry

The form needs to be plastic, to reflect medicine’s The form needs to be plastic, to reflect medicine’s evolutionary natureevolutionary nature

The form needs to work with our existing QA structure The form needs to work with our existing QA structure at Husson Pediatricsat Husson Pediatrics

Current system at Husson Current system at Husson Pediatrics:Pediatrics:

GE-Centricity EMR, Based GE-Centricity EMR, Based Largely on CCC-formsLargely on CCC-forms

Protocols: Reminder system Protocols: Reminder system that promotes delivery of that promotes delivery of care by non-provider staff care by non-provider staff (MA, RN, receptionist) for (MA, RN, receptionist) for physician review.physician review.

Current Protocols: Current Protocols: Flu Shots Flu Shots Smoking StatusSmoking Status Asthma Management PlansAsthma Management Plans

Populated from medication Populated from medication listlist

Asthma Control TestAsthma Control Test

No asthma-specific encounter No asthma-specific encounter form exists: most provider form exists: most provider documentation is entered via documentation is entered via an open “HPI” field (and thus an open “HPI” field (and thus untrackable)untrackable)

Could we use an existing Could we use an existing encounter form?encounter form?

Multiple Asthma forms Multiple Asthma forms are available: are available: Maine’s Ah!Asthma FormMaine’s Ah!Asthma Form Cincinnati Children’s Cincinnati Children’s

asthma management formasthma management form AAP’s CQN-encounter formAAP’s CQN-encounter form GE-Centricity “CCC” GE-Centricity “CCC”

asthma management formasthma management form Each form was analyzed Each form was analyzed

– could they work with – could they work with our current setup?our current setup?

AAP’s CAQI AAP’s CAQI Asthma Encounter form:Asthma Encounter form:

What worked: What worked: Promoted use of Promoted use of

2007 guidelines2007 guidelines Captured all AAP’s Captured all AAP’s

metricsmetrics What didn’t: What didn’t:

Paper basedPaper based ACT was “built in”ACT was “built in” Some PCMH Some PCMH

Metrics were Metrics were missingmissing

Ah!Asthma form: :Ah!Asthma form: :

What worked: What worked: Promoted use of 2007 Promoted use of 2007

guidelinesguidelines Allowed for “external” Allowed for “external”

ACT administrationACT administration Captures other metrics Captures other metrics

not available as part of not available as part of AAP’s current program, AAP’s current program, but part of PCMHbut part of PCMH

What didn’t: What didn’t: Paper basedPaper based

GE/CCC-Asthma Form GE/CCC-Asthma Form v8.3.7.2 (cutting edge v8.3.7.2 (cutting edge

version)version) What worked:What worked:

Promoted use of 2007 Asthma Promoted use of 2007 Asthma guidelinesguidelines

Obs terms for registry captureObs terms for registry capture Auto-Populated Management PlansAuto-Populated Management Plans Linked to online/onboard asthma Linked to online/onboard asthma

resourcesresources Incorporated data into Asthma Incorporated data into Asthma

Management handout Management handout What didn’t:What didn’t:

Interface did not allow for addition Interface did not allow for addition of AAP/PCMH metricsof AAP/PCMH metrics

Could not incorporate Asthma Could not incorporate Asthma Control Test or other tools into Control Test or other tools into clinical decision makingclinical decision making

Interface was confusing to Interface was confusing to physicians - resistant to usephysicians - resistant to use

No area for Asthma past historyNo area for Asthma past history Needed to re-assign an new obs Needed to re-assign an new obs

term to every asthmatic in practice term to every asthmatic in practice (“severity” term)(“severity” term)

Unable to alter/add to existing Unable to alter/add to existing form for future.form for future.

Cincinnati Children's Cincinnati Children's asthma encounter formasthma encounter form

What worked:What worked: Excellent overall template for Excellent overall template for

asthma careasthma care Promoted use of 2007 guidelinesPromoted use of 2007 guidelines Past Asthma history Past Asthma history

documentation documentation Lots of educational opportunities Lots of educational opportunities

(Mask-Mouthpiece add-on)(Mask-Mouthpiece add-on) What didn’t:What didn’t:

““On-board” ACT did not work with On-board” ACT did not work with our existing system our existing system

““On-Board” Asthma Management On-Board” Asthma Management handout did not work with our handout did not work with our systemsystem

Minimal room for free-typing was Minimal room for free-typing was bothersome to some providersbothersome to some providers

Entire form is an encounter: Entire form is an encounter: cannot be used with our hospital’s cannot be used with our hospital’s current “CCC-CPOE” system.current “CCC-CPOE” system.

Some obs terms not in our system, Some obs terms not in our system, or already used in other areas or already used in other areas (Custom made for Cincinnati)(Custom made for Cincinnati)

Solution?Solution?

““Steal Shamelessly” – Steal Shamelessly” –

Peter Margolis, MD, PhDPeter Margolis, MD, PhD

Professor of Pediatrics, Cincinnati Professor of Pediatrics, Cincinnati Children’sChildren’s

Choose what worked from Choose what worked from each to make our owneach to make our own

Used Cincinnati Children’s for a physical Used Cincinnati Children’s for a physical templatetemplate

Added aspects from Ah!Asthma form, CAQI Added aspects from Ah!Asthma form, CAQI encounter form, and GE-CCC-asthma.encounter form, and GE-CCC-asthma.

Added specific obs terms to interface with Added specific obs terms to interface with our registryour registry

2-tabbed form:2-tabbed form: Asthma follow-upAsthma follow-up Asthma diagnosis.Asthma diagnosis.

The First Tab: The First Tab: Emphasizing the Acute Emphasizing the Acute

historyhistory

Moving down the First Tab: Moving down the First Tab: Decision supportDecision support

Questions shift based on age of patientQuestions shift based on age of patient Prompts provider to assign a category Prompts provider to assign a category

based on 2007 guidelines of controlbased on 2007 guidelines of control

Auto-Populates the Asthma Control Test Auto-Populates the Asthma Control Test scored from the last visit and from Today’s scored from the last visit and from Today’s visitvisit

Encourages the Provider to assign a level Encourages the Provider to assign a level of baseline controlof baseline control

Brief reference material directly on formBrief reference material directly on form

Tracks step-wise approach, and provides Tracks step-wise approach, and provides quick access to Maine’s Ah!Asthma online quick access to Maine’s Ah!Asthma online asthma management resourceasthma management resource

Online Resource:Online Resource:

Bottom of First Tab: More Bottom of First Tab: More MetricsMetrics

Prompts provider to investigate other aspects of control (ER Prompts provider to investigate other aspects of control (ER visits, school days missed, hospitalizations, spirometry)visits, school days missed, hospitalizations, spirometry)

Investigates family’s degree of comfort with asthmaInvestigates family’s degree of comfort with asthma Encourages provider to provide further patient education Encourages provider to provide further patient education

Quick-link to asthma-related patient educational materials/handoutsQuick-link to asthma-related patient educational materials/handouts

Second Tab: Second Tab: New diagnosis/New patient with New diagnosis/New patient with

AsthmaAsthma

Moving down the Second Moving down the Second Tab: Diagnosing Initial Tab: Diagnosing Initial

Degree of SeverityDegree of Severity Questions shift automatically based Questions shift automatically based

on age of patienton age of patient

Severity Assessment based on 2007 Severity Assessment based on 2007 guidelinesguidelines

Allows for a diagnosis to be assigned Allows for a diagnosis to be assigned directly from the formdirectly from the form

Utilizes Cincinnati Children’s Utilizes Cincinnati Children’s mask/mouthpiece educational mask/mouthpiece educational checklistchecklist

Current Form StatusCurrent Form Status

Some minor tweaks still pending (typos, Some minor tweaks still pending (typos, links to order spirometry and asthma links to order spirometry and asthma education referrals from form, etc).education referrals from form, etc).

Rolled out to Providers at Husson Rolled out to Providers at Husson Pediatrics of 12/23/2009.Pediatrics of 12/23/2009.

To be incorporated into Pediatric To be incorporated into Pediatric Encounter Documents in the near Encounter Documents in the near future.future.

Meridios (Registry) terms assigned, Meridios (Registry) terms assigned, registry programming in near future.registry programming in near future.

SharingSharing

In the Spirit of the Collaborative, we In the Spirit of the Collaborative, we are happy to share this encounter are happy to share this encounter form with any who would benefit form with any who would benefit from it’s use. Please contact me at from it’s use. Please contact me at mross@emh.orgmross@emh.org for details: for details:

Michael Ross, MD FAAPMichael Ross, MD FAAP

Husson Pediatrics, EMMCHusson Pediatrics, EMMC