application of a primary headache diagnosis algorithm to emr · professor of child neurology and...
TRANSCRIPT
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Application of a Primary Headache Diagnosis
Algorithm to EMR
Marielle Kabbouche, MD, FAHS
Professor of Child Neurology and Headache Medicine
Cincinnati Children’s Hospital Medical Center
Headache Center
Rationale for the algorithm : Standardization
� Variation amongst providers in diagnosing primary HA disorders: • 41% of patients coming to ED were diagnosed with: Non-specific Headache disorder
• 58%: received Migraine Diagnosis
Dr. Vinson et. al: Annal of Emergency Med: 41(1): 90-97.2003
� Variation amongst providers in regards to treatment:• Affects care delivery and cost:
• Physician use of higher resources in the ED was associated with increased LOS and did not reduce return visits to ED
Practice variation such as this may represent an opportunity to improve health care quality and decrease costs!!
Jain Stabnam &al.: Physician practice variation In Pediatric ED and it’s impact on resources use and quality of care : Dec2010, volue26 Issue12: 902-908
Diagnosis Standardization is an essential first step to improve headache treatment, outcomes, as well as
controlling costs!
Measurement: How Success is Defined
Clinical outcomes:
�More then 80% of encounters with appropriate diagnosis of migraines using the ICHD-3 criteria was assigned
�More then 80% of encounters where appropriate imaging and labs were ordered based on diagnosis.
Process outcome:
�More then 80 % of encounters where algorithm was correctly followed
�Process is sustainable
Financial outcome:
�Direct effect: • Less then 20% of patients receiving unnecessary tests & procedures
�Long term effect: • Evaluating cost of HA care in pediatrics (NV vs. FU, chronic vs. intermittent)
• Showing cost control (this may take time)
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% Algorithm Followed
83%
94.10%100%
75%
83.30% 82%
94%
0%
20%
40%
60%
80%
100%
120%
March April June July August September November
Algo followed
4 Pts
New Neuro residents?
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Appropriate Tests Ordered
83%
94.10%100%
87%
100% 100%
90%
0%
20%
40%
60%
80%
100%
120%
March April June July August September November
Appropriate Tests
Correct Diagnosis
72.20%
82.30%
100%
65%
83.30%90% 89.20%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
March April June July August September November
Correct Diagnosis
N:4
Outpatient Headache Evaluation cost :
long term evaluation needed to show cost effectiveness
$462.28
$524.35 $533.00
$660.00
$678.00
$400.00
$450.00
$500.00
$550.00
$600.00
$650.00
$700.00
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17
Headache Diagnosis
Charge Per Case (OP only)
More Chronic patients seen In
the fall: HA seasonal Disease
Pkalanis &al.: Seasonal variation in ED referral among pediatric headache patients.
Headache Sept2016:56/8:1344-7
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Application of the headache diagnostic algorithm into
EMR ( EPIC )
2 entry points:
1- Patient entry: tablet given at registration with questionnaire. Questions answered are automatically syncing to the patient’s EPIC visit
2- Flowsheet in EPIC visit for that day where provider can review the entry and make changes if necessary when interviewing the patient
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• 1- Full Description of headache with severity mild –moderate to severe, frequency, worsening with exercise, ?waking up from sleep
• 2- Questions about acute treatments, preventive treatments
• 3- frequency of use of acute medications
• 4- PedMIDAS/MIDAS
• 5-Review of system, past medical history, family history
48 Questions for new visit . Takes 10-15 minutes to fill up
•Click on Flowsheets section > "Headache New Visit Questionnaire" or "Headache Follow-up Visit Questionnaire".
Review unvalidated patient answers, make changes to answers as necessary, file flowsheet rows to validate a
Click on Flowsheets section > "Headache New Visit Questionnaire" or "Headache
Follow-up Visit Questionnaire".
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Review unvalidated patient answers: unvalidated patient answers have an icon and are cross hatched.
Make changes to patient answers as necessary:
File flowsheet: When all rows are reviewed and any changes made, hover near the
date/time at top of flowsheet, left-click and select from the drop down "File Selected".
This will highlight all rows and file the flowsheet.
If the information in validated flowsheet rows for the Headache New Visit Questionnaire is
answered according to the headache diagnosis algorithm, alerts may fire to help provide best
practice diagnosis or ordering guidelines. These will vary depending on the patient answers.
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Populate your note with validated flowsheet answers using newly created .neunew (new visit)
and .neufu (follow up visit) headache templates.
Type .neunew (or .neufu)
OR : Select the headache with links version
These templates have been enhanced to populate the note with validated
flowsheet information.
Historical Average charges adjusted to current pricing
3/1/15-2/29/16
Adjusted for Price Increases
Clinic 141.25 $148.83
Labs 557.5 $587.44
Radiology 3030 $3,192.70
Total 3728.75 $3,928.97
Current Average charges
3/1/16-6/30/17
Clinic $153.24
Labs $597.25
Radiology $2,934.25
Total $3,684.74 $3,684.74
Decrease $244.23
% Decrease 6.22%