Using EHR Information to Using EHR Information to Support Workflows for Support Workflows for Medical Homes: Get the Medical Homes: Get the right tool for the jobright tool for the job

Jeff Hummel, MD, MPHMedical Director for Clinical InformaticsQualis HealthJanuary 26, 2010

ObjectivesIntroduction: Which comes first, accurate reporting, or getting the workflow right?

Workflows necessary for medical homes and the reporting functionality to support them

AttributionCare ManagementTest and Referral TrackingPopulation ManagementPerformance Reporting

Why is this so important

PCMH effort is the only strategy out there for saving primary careEvery system is perfectly designed to give you exactly the outcome you getOur system is broken: we are getting mediocre outcomes despite best effortWe can’t improve what we’re doing without:

Better organized informationMeasuring what we’re doing

Which comes first?

Outcomes measures and workflow are interdependent and inseparableWorkflows depend on information

Reports, dashboards & rules engines are all ways to organize information effectively

Outcomes reporting is completely dependent on workflow:

To deliver the care being measuredTo generate useable data for reporting, through standardized data entry

Information is inseparable from workflow

Target

Chart opened by clinical

team during encounter Rules engine

calculates if immunizations are indicated

Clinical team updates chart information

Clinical team orders needed

immunization

Clinical team gives

immunizationClinical team documents

immunization given

Population outcomes report reflects current

information

Pop Mgr uses action report to identify Pts

needing immunization

Pop Mgr contacts Pt, creates action

plan & updates EHR information

Date5

PneumocoocusTDAP

Diphtheria TetanusVaricella Zoster

Hepatitis BHepatitis A

Date4

Date3

Date2

Date1

Immunization TableReporting Database

The report as change catalystReports expose unstable workflows & performance variationStart with mapping current workflow and creating a future state to:

Standardize workflow & reduce wasteStandardize how data are captured

Only by problem-solving reporting issues can the workflow be fixedOnly by problem-solving unstable workflows can the reporting problems be fixed

4 levels of reporting toolsExcel spreadsheet:

Not scalable

Internal EHR features: Often not very robustUsually require programming

Business Intelligence Query Engines:Complex reporting tools for DB analysts; costlyMay be hard wired to a specific EHRResult is “canned reports”

Custom QI “aftermarket” products:Agile dashboards designed for QI end-userOften a service agreement

The Key Workflows for PCMHAttribution: who is the PCP?Care Management: Dashboards

PreventionChronic illness care

Referral and Test Tracking:Overdue resultsAbnormal results

Population Management:Generating action reports: Pts needing services

Measuring performance: across practices

Attribution: Foundation for Empanelment

Attribution: Defining the goalsData definition: designate the PCP fieldCreate a report for initial attribution:

Define criteria for attribution, e.g.• Provider seen most often• Provider seen most recently

Define mechanism for entering the decision into the PMS/EHRDefine a workflow for Pt to validate & update attribution with each visit

Workflow for Attribution

Scheduler proceeds to appoint Pt

Report writer creates

attribution report

Attribution report is run

Report output populates

PCP field in PMS

Patient makes appt

Scheduler asks Pt to

validate PCP

PMS has correct PCP?

Yes

No

Scheduler corrects the

PCP field entry in PMS

Pt has office visit

EHRPMS

Reporting Database

PMS updates PCP field in EHR

What IT Tools Did We Use?

Report from Reporting Data Base (or PMS)

For each active PtFor each office visit in past x months

• OV Date• Encounter Provider

Apply agreed upon rulesProgramming to auto load output into designated fieldMaintenance: Workflow only

Care Management: GoalsNo one leaves the clinic without it being addressed

The power of physician recommendationIf we can’t deal reliably with patients who are already in the clinic, it makes little sense to ask people to come in for preventive care

Strategy: standardized workflows, integrated with information, that involve the entire team, to guarantee results

The Care Mgmt Workflow

Patient makes appointment

Day of visit team huddle

to review charts & plan

Pt arrives at clinic and is given Pre-

visit summary

MA rooms Pt and updates HM data from

PVS

MA discusses with Pt, orders and pends HM interventions

Provider sees Pt and signs

pended orders

Pt leaves with HM issues

addressed & info updated

The clinical decision-making information assembly line

Care Mgmt: Chronic Illness

Identical workflow strategy for gathering the information during a visit:Plan for today’s patients in the HuddlePre-visit summary to help activate PtGather and organize as much info as possible before provider enters room

What IT Tools Did We Use?

Prevention and Chronic Illness CareRules EnginesDashboardsFlow Sheets

Workflow designed to gather and organize the information so the correct clinical decision was obvious

Test and Referral Tracking

Workflow goal: Have a process to detect when Pts are lost to follow-upWhat is the workflow?

Whose job is it to track down overdue results?How do they do it, and when?

What tools support the workflowOverdue results rules engineReport showing name & date of orders that need attention

Overdue results workflow

High priority test activates pre-set ODR

timer

Test is ordered

Pt given instructions

on how to get test done

Pt calls and is scheduled for

test

Pt goes to the facility and has the test performed

Results sent to ordering

provider

Ordering provider uses information to make

clinical decision

Option 1: Non-resulted test triggers alert to ODR in-basket

Option 2: Weekly report: Denominator is all Pts who have had the test ordered > set interval; Numerator is all of the denominator Pts with tests not resulted

ODR Mgr contacts Pt to

see what happened

Process is un-stuck and timer reset

Don’t over-do over-due results

Don’t overload the workflowPick only high priority tests to track

Don’t over-build it: Automate the tedious tasks Leave clinical decision-making to humansKeep the action burden low

• Set up standardized responses to ODRs• Use automated messaging where it makes

sense

Abnormal resultsWorkflow goal: Abnormal results won’t slip through the cracksWhat is the workflow?

Who does it? When? What tools do they need to do it?

Example: All women with abnormal paps

A workflow for abnormal paps

Result returns to provider Normal?

Yes

Patient notified

NoProvider

selects abnl tracking interval

Provider makes clinical

decision(s)

Usual care including follow-up

After tracking interval is

elapsed, chart is reviewed

Pt on track?

Yes

No Pt contacted to assure not

lost to f/u

Pap smear done

Var 5

Patient 6Patient 5Patient 4Patient 3Patient 2Patient 1

Var 4Var 3Var 2Var 1

Abnl Paps

Reporting Database

What does the report need?

Patient name, IDDate of last papThe f/u interval Some way to resolve or turn it off when Pt no longer needs tracking

Reset f/u interval to a new valueDelete f/u interval

Population Management

What is the workflow? Goals:

• Automate monitoring• Early recognition of complications• Assure systematic interventions• Risk factor reduction• Empowering patients

• Self-management support• Patient education

Whose job is it?

Workflow steps

Chronic Disease Manager runs & reviews action reportChronic Disease Manager contacts Pt

Orders testsAdjusts treatmentAssesses patient self-management needs

Coordinates with PCP forInformation flowClinic visitsGroup visits

Information flow in Population Mmgt

Anatomy of an action reportDenominators

Careful definition of the populationAccurate attribution is essential

Numerators: All the patients needing action

• Orders & results • Custom data entry fields

All the Population Manager needs to see is the patients in the numerator

Outcomes ReportsSame principle as action reports except the numerator is reversed

Denominator: entire populationNumerator: Those meeting criteria

Must be able to drill down to clinic & provider but not to patient level

Attribution must be reliableTrending to monitor progress

External and external for incentivesAll you may need is percents

Getting StartedIdentify a topic where success is likely

A clear planWidely shared motivation for changeOrganizational capability

Redesigning the workflow (another whole topic for discussion)Creating and maintaining the report

Whose job is it?Do they have the right tools?Do they have the right skills?

Conclusion:Reports/Dashboards & workflow are inseparable, so build them togetherMedical Homes requires new workflows and new information management

EmpanelmentCare managementResults trackingPopulation managementOutcomes reporting

Get the right tool for the job

Questions?