epic ugm 2014 presentation
TRANSCRIPT
Milking Epic in a PCMH Family
Residency
Community Hospital East Family Medicine
ResidencyIndianapolis, IN
Barb Kirk, RN Nurse Care Manager
With CHNw 28 years
With FMC Residency
8 years
Experience
Larissa Davids, RN Clinical
Nurse Manager
With CHNw 2 years
With FMC Residency
2 years
Experience
• Community-based network of healthcare providers• Serving Central Indiana since 1956• More than 2 million patient encounters each year• Over 1 million outpatient visits per year• Eight hospitals and more than 200 sites of care • 700,000 annual patient encounters• EPIC Go-Live June 2012• First Hospital in Indiana to meet Meaningful Use
Stage 2
From Seed to Stalk• Started 1974
• 38 Resident Classes Graduated
• Expanding Resident Class Size
• Current Class Size 8-10-10
• Future Class Goal 12-12-12
Home Front
Part of a Health PavilionState-of-the-art
16,000 sq. ft30 Exam rooms
Two procedure roomsOMT/Therapy room
Patient Demographics
• 226,000 Patient clinic visits annually
• Approximately 7600 patients
• 60% Medicaid
• 20% Medicare
• 20% Private Insurance or uninsured
Who’s Bailing Our Hay?
ProvidersEducation Staff
Support StaffAdditional Students
OB Pediatrics Home Visit
On-site Nursing Home Visits Ambulatory Clinic
Inpatient Rotation(ICU, Pediatrics, Service Team)
Emergency Care (ED) Specialty Rotations
Preparing to take Family Practice
Boards
Resident Education Focus
What is NCQA?What is PCMH?What is Hedis?
Before PCMH Journey
• “This is the way we have always done it”
• Lack of teamwork• No clinical team structure• No population health
management• Poor patient follow-up care
Our PCMH Journey
Goals• Clinical transformation• CULTURE transformation• Optimal patient
experience• Comprehensive patient
care
Level 3 PCMH Recognition
Residency Process Improvement
Requirement of FMC Residency Curriculum
Standardization CommitteePatient Advisory Group
Nurse Care Managers
Preventative Health
Maintenance
Chronic Disease
Management
High Risk Patient
Intervention
• Development
• Responsibilities
• Evolving position
Multidisciplinary Approach to
Care
• Diabetes IVR• Group Visits
• Transition of Care
• Office Visits• Team Time• Metrics
Winter Leah R, MA
Fac Fisher Fac Callahan
R3 Shaver R2 Gelatt R1 Jaeger
Katie, RN
Snow Kaylee, MA
Fac ShockleyR3 Holland
R2 Grindstaff R2 Tran
R1 Pohlman
Katie, RN
Autumn Emmy, MA
Fac Arrizabalaga Fac DaRosa
R3 Baig R2 Jones
R1 Pittman
Cindy, RN/Karen, RN
Wind Kaylee, MAFac MathewFac WheelerR3 Abratigue
R2 Land R1 Bachman
R1 King
Cindy, RN/Karen, RN
Summer Amber, LPN
Fac Cashman R3 Polly
R2 FogelsongR2 Malicay R1 Morris
Nancy, RN
Sun Kellie, MA
Fac Clark R3 Walcott 347R2 Burns 277
R1 Sanderson 109807
Nancy, RN
Spring Leah CFac Lisby
R3 Auman R2 Nimmagadda
R1 Brackett
Barb, RN
Rain Sonia
Fac Hern Fac EglenR3 Hunt
R2 Mohammadi R1 Schmoll
Barb, RN
Weekly RN/LPN/MA/Tech
MondayMammograms
WednesdayImmunizations/
WCC
FMC TeamsEffective 3/1/2014
RN=Care Coordinator
Education*Smoking Cessation
*Diabetes*Asthma
*Hypertension*Obesity
*Medication Adherence*Group Sessions
*Diabetes IVR*Patient Appointments
Health Maintenance*ED/Inpatient Follow-up
*Wellness Visits*Follow-up*Reports
*Workques*Telephone Triage
*Telephone Encounters*Prior Authorizations
High Risk Population*Routine and Frequent
Follow-Up and Education*Proactive
Communication*Frequent NCM Appointments
*Address Social/Economical/Behavioral
Barriers
TuesdayPap Smear/
GCHL
ThursdayHTN, DM,
Hyperlipidemia
FridayPneumovax/
Zostavax/Tdap
Weekly RN/LPN/MA
MondayMammograms
TuesdayPap Smear/
GCHL
WednesdayImmunizations
/WCC
ThursdayHTN, DM,
HLD
FridayPneumovax/
Zostavax/Tdap
RN=Care Coordinator
Education*Smoking Cessation
*Diabetes*Asthma
*Hypertension*Obesity
*Medication Adherence*Group Sessions
*Diabetes IVR*Patient Appointments
Health Maintenance*ED/Inpatient Follow-up
*Wellness Visits*Follow-up*Reports
*Workques*Telephone Triage
*Telephone Encounters*Prior Authorizations
High Risk Population*Routine and Frequent
Follow-Up and Education*Proactive Communication
*Frequent NCM Appointments
*Address Social/Economical/Behavioral
Barriers
DailyMA/LPN
Medication Refills
Telephone Encounters/
Mychart
Abstracting
DiannePA’s
Provider Forms Paperwork
Pre-visitPlanning
PhaseII
6/1/14
PhaseIII
9/1/14
Daily RN
ED/InpatientFollow-up
Lab/ImagingWorkque-
Mammograms/DXA Scan focus
Chronic Care/High Risk Patient Reports
and Management
Lab/Imaging Workque (MA/LPN)
Phase IV
11/1/14
ALL RN’s prepared for Care Coordinator (Manager) Role
Phase V
1/1/15
*RN’s Team Pools/ED, Inpatient follow-up --introducing
Milking EPIC• Maintain PCP
Panels• Pre-Visit• ED and Inpatient• Chronic Disease• Population Health• Follow-up• Pilot Projects• Audits• Reminders• Referrals
Basic Provider Report
Maintaining Provider Panels
How?
When?
Building a Basic Report
Reconcile Health Maintenance
PCP Panels
Pre-visit
MA Clinic
ED/Inpatient
Chronic Disease
Monthly Audits
Transition of Care
Preventative
Health Maintenance
Group Visits
IVR
TOC
Reports
Identify Needs• Preventative/Maintenance
Labs• Diabetic Foot Exams• ACT• SPO2• Immunizations• Controlled Medications• Preventative Procedures• Preventative Imaging• Appointments
Report identifies patients with Diabetes and Hypertension with scheduled appointments.
Report is run weekly. EMR is reviewed for missing or due health maintenance.
Protocoled orders are placed and patient is notified.
Goal: Patient completes orders prior to upcoming appointment.
Pre-Visit Planning
Diabetes:HgbA1c 6 months HgbA1c > 7 3 monthsLipid Panel-fasting 12 monthsMicro albumin/Creatinine Urine Ratio 12 monthsCMP-fasting 12 monthsDiabetic Eye Exam 12 monthsDiabetic Foot Exam 12 months
Hypertension:BMP-fasting 12 months
Hyperlipidemia:Lipid Panel-fasting 12 monthsCMP-fasting 12 months
Hypothyroidism:TSH 12 months
Pre-Visit Protocol
Establish criteria
identifying High Risk Patients
Run Report daily
Assess care plan and
interventions
Review EMR
Discuss plan with patient
and identify barriers
Contact patient by
phone, MyChart or letter
Update or develop
care plan
High Risk Patients
Health Maintenance Reports
Identifies patients with upcoming appointments with health maintenance needs
MA/LPN runs report every 3 days
Comment is placed on the ‘Appointment Notes’ designating a need
Clinical staff rooming the patient has information easily available
Health Maintenance Reports
Fruits of our Labors
10/1/
2012
12/1/
2012
2/1/20
13
4/1/20
13
6/1/20
13
8/1/20
13
10/1/
2013
12/1/
2013
2/1/20
14
4/1/20
14
6/1/20
14
8/1/20
1405
101520253035
Date
% of Patients
Diabetic Patients w/o HgbA1c in 6 Months
February 1, 2013 28% of Diabetic
patients had not had a HgbA1c in 6
months.
2/1/20
13
3/1/20
13
4/1/20
13
5/1/20
13
6/1/20
13
7/1/20
13
8/1/20
13
9/1/20
13
10/1/
2013
11/1/
2013
12/1/
2013
1/1/20
14
2/1/20
14
3/1/20
14
4/1/20
14
5/1/20
14
6/1/20
14
7/1/20
14
8/1/20
140
10
20
30
40
50
60
70
80
90
Patients with Diabetes w/o a Foot Exam in 1 year
January 2013 2% of our patients with Diabetes had
a filament test
Percentage of Pediatric Patients with Overdue Immunizations
7/1/20
13
8/1/20
13
9/1/20
13
10/1/
2013
11/12
013
12/1/
2013
1/1/20
1405
101520253035
July 2013 32.6% of our pediatric patients 0-13 had overdue state mandated
immunizations
Patients overdue for Well Visit
Diabetes IVR Pilot
EDand
Inpatient
Transition of Care ProgramSocial WorkPharmacist
Nurse Care Manager
Provider
• Round on inpatients• Facilitates transition
home• Coordinates
Provider, Nurse Care Manager, Pharmacist
• Follow-up• Weekly TOC ClinicGoals
Additional Uses• Smart Phases
• Workques• Triage• Letters• Photos• Reminders• Billing• Referrals• Call Backs
FeedbackPatients• “I feel like a queen when I come here, everyone really
cares.”• “I like having my labs done before my appointment. It
saves a step, I have more time with my Doctor.”• “Never had a foot exam done before.”• Voiced appreciation that clinical staff was providing the
foot exams • Parents voiced appreciation for less trips to the office for
immunization catch-up.
FeedbackMAs’ feedback
• More efficient utilization of time• “Do not have to research patient’s chart to provide
care.”• “I like knowing what the patient needs before I get
them.”
Providers’ feedback• Foot exams consistently performed before provider sees
the patient.• Not doing minimal tasks; filling out paperwork for Health
Department• Detecting and treating Asthma patients outside of the
green zone before an exacerbation occurs.• “My colleagues didn’t believe my Nurses could order the
labs ahead of time. It saves me so much time.”
Feedback
Outcomes
• Elevate quality of care• Improve patients’
outcomes• Efficiency• Motivate clinical staff• Decrease ED/hospital
admissions• Decrease health care
spending• Policies and protocols• Healthier work
environment
• Patient Centered Comprehensive Care
What Have We Learned?
Question
s