1. EHR Implementation for Quality Improvement in California Rural Indian Health Clinics Linda Aranaydo MD Director of Medical Services California Rural Indian Health Board

2.  The California Rural Indian Heath Board, Inc., (CRIHB) was formed in 1969 to enable the provision of health care to member Tribes in California. It is devoted to the needs and interests of the Indians of rural California and is a network of Tribal Health Programs which are controlled and sanctioned by Indian people and their Tribal Governments.  CRIHB develops and delivers policies, plans, programs and services that elevate the health status and social conditions of our People; that develop capabilities within local programs; that communicate, educate, and advocate on our shared interests; and that organizes support for our common goals.  CRIHB does this through program development, legislation and advocacy, organization development, financial resources management, training and technical assistance, and networking and consensus-building.

3. Facilitate EHR Implementation in member clinics  IT Systems for Rural Indian Clinic Healthcare- AHRQ 9/20/2004-8/31/2007 Goal: Facilitate Electronic Health Record Implementation through assessment, selection, group purchasing, implementation and assistance in evaluation and production of IHS reports with clinic member programs. Goal: Facilitate Electronic Health Record Implementation through assessment, selection, group purchasing, implementation and assistance in evaluation and production of IHS reports with clinic member programs.  Tides 8 Strategic Investment Grant 7/1/2004-9/30/07 Goal: Facilitate EMR implementation through leadership, coordination of interdisciplinary clinic teams, planning, training, coaching, managing technical /organizational consultants, resources and evaluation. NG Indian clinic Users Group Workshop 6/07 Goal: Facilitate EMR implementation through leadership, coordination of interdisciplinary clinic teams, planning, training, coaching, managing technical /organizational consultants, resources and evaluation. NG Indian clinic Users Group Workshop 6/07  Tides Technical Assistance Grant 7/1/2005-6/30/06 Goal: Build capacity at CRIHB central to provide self-assessment, financial management, organizational management and change management tools, curriculum and trainings for EMR implementation. QI Data Quality Workshop 6/06, EMR implementation Workshop 6/07 Goal: Build capacity at CRIHB central to provide self-assessment, financial management, organizational management and change management tools, curriculum and trainings for EMR implementation. QI Data Quality Workshop 6/06, EMR implementation Workshop 6/07

4. CRIHB EHR implementation sites Rural California Counties, Multiple sites CRIHB EHR implementation sites Rural California Counties, Multiple sites  Next Gen EPM&EMR Warner Mountain Tribal Health (Alpine Co) Warner Mountain Tribal Health (Alpine Co) 1 site remote, serves 200 Indian patients1 site remote, serves 200 Indian patients United Indian Health Services (Humboldt, Del Norte Co) United Indian Health Services (Humboldt, Del Norte Co) 5 clinic sites, serves 6,000 Indian patients5 clinic sites, serves 6,000 Indian patients MACT Health Board (Mariposa, Amador, Calaveras, Tuolumne Co) MACT Health Board (Mariposa, Amador, Calaveras, Tuolumne Co) 2 of 5 clinic sites in 2 counties implemented, serves 2,2002 of 5 clinic sites in 2 counties implemented, serves 2,200  IHS EHR Feather River (Butte, Yolo Co) Feather River (Butte, Yolo Co) 2 sites, serves 3,500 Indian patients2 sites, serves 3,500 Indian patients

5. “Health Information Technology for Improving Quality of Care in Primary Care Settings” Jerry Langley, Carol Beasley, IHI AHRQ publication No. 07-0079-EF July 2007  “..Most current health IT systems have a long way to go before they encompass the functionality that would support robust ongoing improvement of care.” EPM systems mature, EMR systems not EPM systems mature, EMR systems not  “…The success of health IT-enabled improvement depends critically on the skills of clinical and administrative staff in primary care settings to understand and use solid improvement methods - methods that need not rely solely on health IT to be effective.”

6. Two Types of Improvement with EHR  1. Direct benefit of the technology a. Operational Efficiencya. Operational Efficiency b. Safety through the reduction of administrative or clinical errorb. Safety through the reduction of administrative or clinical error CRIHB NG clinics wanted a better billing, scheduling, reporting system with capacity for multiple interfaces CRIHB NG clinics wanted a better billing, scheduling, reporting system with capacity for multiple interfaces  2. Use of technology to bring improvements to the system of care a. Proactive Planning for population carea. Proactive Planning for population care b. Whole patient view for planned careb. Whole patient view for planned care CRIHB NG clinics wanted customizable office visits templates, customizable reports for more chronic conditions, CRIHB NG clinics wanted customizable office visits templates, customizable reports for more chronic conditions,

7. Direct Improvement: Operational Efficiency  Billing (faster than paper/legacy software,increased income) Same day billing electronicallySame day billing electronically Faster turn around for first refusalFaster turn around for first refusal Contract Health Services Module (IHS fund tracking)Contract Health Services Module (IHS fund tracking)  Scheduling (easier, faster than paper/legacy software) User friendly for front office, providerUser friendly for front office, provider Supports same day/open accessSupports same day/open access  Financial Reporting (more timely data on accounts and productivity indicators for management) Canned reports easily, directly available to admin, finance staffCanned reports easily, directly available to admin, finance staff

8. Direct Improvement: Safety through reduction of administrative or clinical error Missing information Missing information We improved provider access to clinical information. Current chart accessible from multiple locations (within clinic with multiple providers, multiple clinic sites 2-3hrs away, from hospital or home for doc on call)We improved provider access to clinical information. Current chart accessible from multiple locations (within clinic with multiple providers, multiple clinic sites 2-3hrs away, from hospital or home for doc on call) Computerized Physician Order Entry Computerized Physician Order Entry Legible prescriptions to in-house/outside pharmacy with up to date medication lists in chartLegible prescriptions to in-house/outside pharmacy with up to date medication lists in chart Legible nursing ordersLegible nursing orders Drug interactions/allergies Drug interactions/allergies Allergy alert on every office visit templateAllergy alert on every office visit template Drug interaction standard pop-ups often overridden, should be redesigned to carry more pt specific alertsDrug interaction standard pop-ups often overridden, should be redesigned to carry more pt specific alerts

9. Use of Technology to Bring Improvements to the System of Care  Quality in California Indian Clinics Prior to EHR Tribal/Intertribal Health Board leadershipTribal/Intertribal Health Board leadership Healthcare governance and accountability Healthcare governance and accountability Six years+ of building QI capabilities (with paper/legacy software)Six years+ of building QI capabilities (with paper/legacy software) State IHS diabetic registry training on RPMS State IHS diabetic registry training on RPMS CRIHB initiatives to fund/train clinic staff in QI CRIHB initiatives to fund/train clinic staff in QI annual quality improvement, redesign training (resources: NAAHC, IHI and ANMC consultants & coachesannual quality improvement, redesign training (resources: NAAHC, IHI and ANMC consultants & coaches Clinics achieved open access, some redesignClinics achieved open access, some redesign IHS National Dashboard of Health IndicatorsIHS National Dashboard of Health Indicators Annual and Quarterly reporting requirements for: Clinic users, visits, DM audit, Immunizations, GPRA Indicators Annual and Quarterly reporting requirements for: Clinic users, visits, DM audit, Immunizations, GPRA Indicators Some CRIHB clinics found RPMS legacy hard to use, maintain Some CRIHB clinics found RPMS legacy hard to use, maintain

10. Indian Health Service GPRA indicators  Diabetes indicators Prevalence documented A1c Prevalence documented A1c Poor Glycemic control Poor Glycemic control Ideal Glycemic control Ideal Glycemic control Blood Pressure Control Blood Pressure Control Dyslipidemia Assessment Dyslipidemia Assessment Nephropathy Assessment Nephropathy Assessment Retinopathy Exam Retinopathy Exam  Immunizations Influenza Influenza Pneumococcal vaccine Pneumococcal vaccine Childhood (19-35 months) Childhood (19-35 months)  Dental indicators Fluoride Fluoride General Access General Access Sealants SealantsPrevention:  Cancer Screening Cervical (Pap Smear) Breast (Mammogram) Colorectal  Fetal Alcohol Syndrome Prevention  Domestic/Intimate Partner violence screening  Childhood weight control  Tobacco Cessation Intervention  Depression Screening  Prenatal HIV Screening  CVD Prevention Cholesterol Screening

11. Diabetic Audit Measures Demographics, vitals,exams,labs,IZs,procedures,meds,education DM Registry: total, gender, age, type I or II, duration of dx BMIHgbA1C Mean Blood Pressure Tobacco Use DM Treatment: diet/exercise insulin insulin oral med, combination oral med, combination insulin+oral Anti platelet therapy Ace inhibitor or ARB use Lipid Lowering Agent Annual Foot exam Annual Eye exam Annual Dental exam Immunizations: annual flu, pneumovax, Td Urinalysis: microalbuminuria screen, if neg proteinuria screen Serum Creatinine Lipid Tests: Total Chol, HDL, LDL, TG EKG TB status Diabetes Education Depression Screen

12. Using Technology to Improve Systems of Care  1. Proactive planning for population care: Queries and follow-up with sub-populations Queries and follow-up with sub-populations *Next Gen population based queries for Indian Clinic indicators require a SQL programmer or the funds to have a custom report written! Our software has a long way to go to improve queries We provided technical assistance to the clinics to query the software for reports required by Indian Health Service. We provided technical assistance to the clinics to query the software for reports required by Indian Health Service. IHS tribal clinics are not exactly the same as community clinics and vendor reports provided to community clinics do not meet our requirements. IHS tribal clinics are not exactly the same as community clinics and vendor reports provided to community clinics do not meet our requirements.

13. Using Technology to bring and maintain improvements in systems of care (UIHS Warner Mtn)  We improved Report Data Quality The EHR implementation was a catalyst for improving clinic workflow, data entry. Organizational attention and resources were focused on data quality and report accuracy. The EHR implementation was a catalyst for improving clinic workflow, data entry. Organizational attention and resources were focused on data quality and report accuracy. Bring accurate data from paper/legacy system to Preload EHR Bring accurate data from paper/legacy system to Preload EHR Train all staff at point of data entry Train all staff at point of data entry Coding training for providers Coding training for providers IHS indicators defined, mapped verified in Next Gen IHS indicators defined, mapped verified in Next Gen (Indicator definitions (codes, lab values, etc.) Identify data fields or create new fields, write report, test report, verify data,(Indicator definitions (codes, lab values, etc.) Identify data fields or create new fields, write report, test report, verify data,  We created Custom SQL Next Gen Reports to maintain existing reporting capabilities. Registration, Visit, Workload, Diabetic Audit, Immunization Report, GPRA report Registration, Visit, Workload, Diabetic Audit, Immunization Report, GPRA report Individual Diabetic Audit Flow Sheet, NG Diabetic Audit monthly report in use by diabetes case management team has already resulted in improvement of diabetes indicators at UIHS Individual Diabetic Audit Flow Sheet, NG Diabetic Audit monthly report in use by diabetes case management team has already resulted in improvement of diabetes indicators at UIHS UIHS OB report EDCs, prenatal care in multiple facilities, deliveries in two hospitals UIHS OB report EDCs, prenatal care in multiple facilities, deliveries in two hospitals

14. Using Technology to Improve Systems of care  Whole patient view for planned care: all pertinent information in one place (all providers over time) Our software has a long way to go. NG EMR beginning to create denser displays in upgrades NG EMR beginning to create denser displays in upgrades EHR Templates –Standard office visit templates have been improved to include more information on one scroll down template (less clicks) including allergies, HCM, vitals, labs, chronic condition list, assessment, plan, medication, nursing orders, pt educationEHR Templates –Standard office visit templates have been improved to include more information on one scroll down template (less clicks) including allergies, HCM, vitals, labs, chronic condition list, assessment, plan, medication, nursing orders, pt education NG Chronic disease management flow charts need customization for Indian clinic indicators NG Chronic disease management flow charts need customization for Indian clinic indicators must be constructed to automatically update lab, pharmacy, vitals etc. must be constructed to automatically update lab, pharmacy, vitals etc. WE HAVE A LONG WAY TO GO Rural Indian QI/ChronicDM/HIT: ->CVD, COPD, Asthma, Behavioral Health-Depression, Dental WE HAVE A LONG WAY TO GO Rural Indian QI/ChronicDM/HIT: ->CVD, COPD, Asthma, Behavioral Health-Depression, Dental