1. Improving Quality Improvement with an EHR Working Smarter, not Harder to Provide Better Care TEPR+ 2009 Donald T. Stewart, MD FAAFP DonS@SammamishDiabetesAndLipid.Org

2. Your Background? Physicians NP or PA providers Administrators Nursing staff Quality improvement facilitators IT staff Vendors 2

3. My Background 9/13/2015Sammamish Diabetes and Lipid Clinic, PLLC3 Family Practice, started solo from scratch in 1983 after residency in a semi-rural Seattle suburb Grew to 6 provider practice which was sold to Swedish Hospital in 2003 Medical Director of 7-provider clinic in 12-clinic system 2003 - 2007 First EMR 1997 on Newton Message Pad. Migrated to Practice Partner in 2001. Paperless since 2002

4. My Background Participant in Practice Partner Research Network since 2003 Participant in Washington State Diabetes Collaborative 2006-2007 NCQA Recognized Diabetes Physician Solo in a Micropractice since July 2007 focusing on primary care for patients with diabetes and lipid disorders 9/13/2015Sammamish Diabetes and Lipid Clinic, PLLC4

5. My Patient Centered Medical Home: Sammamish Diabetes and Lipid Clinic in Sammamish Washington

6. View from the Street, via Google

7. Patient Entrance

8. Reception Area

9. What is Quality Improvement? The Institute for Healthcare Improvement http://www.ihi.orghttp://www.ihi.org provides a tremendous resource for these issues

10. Model for Improvement - 3 Questions (developed by Associates in Process Improvement) What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Setting Aims – Time specific, defined population, measurable Establishing Measures – Quantitative measures of things that matter Selecting Changes – Which changes will actually lead to the improvement we desire?

11. Plan-Do-Study-Act (W. Edwards Deming) Testing Changes The PDSA cycle is a description of the process of testing and implementing changes, assessing the results, and then acting upon them.

12. Traditional Goals What is the matter? Process goals – Patients seen on time – All patients have vital signs – Medication Lists reviewed every visit Outcome goals – BP < 130/80 – HgbA1c < 7.0

13. Patient-Centered Goals: What Matters to the Patient? “I receive exactly the care I want and need exactly when and how I want and need it.” Only 25% of adult Americans strongly agree Only 12% of low-income Americans strongly agree – Respondents are aged 19-69 years, Sept 2005 – April 2006. From HowsYourHealth.org

14. Patient-Centered Goals: What Matters to the Patient When patients strongly agree that “I receive exactly the care I want and need exactly when and how I want and need it.” They have these attributes of care:

15. Attributes of Care in Satisfied Patients I have one person I think of as my personal doctor or nurse. Yes: 95% No: 60% It is very easy for me to get medical care when I need it. Yes: 85% No: 10% Most of the time, when I visit my doctor’s office, it is well-organized, efficient, and does not waste my time. Yes: 80% No: 20% The information given to me about health problems is very good. Yes: 80% No: 25% I am confident that I can manage and control most of my health problems. Yes: 75% No: 15%

17. Patient-Centered, Collaborative Care Patient-centered vs doctor-centered care: the essence of professionalism is putting the patient’s (not the doctor’s) needs at the center. Collaborative care: when members of the health- care team work with patients to provide professional, often “evidence-based” support, to address problems that matter to the patient, resulting in “activated patients” who have the tools and confidence to deal effectively with their problems.

19. How does this relate to technology? No practice can afford to achieve high levels of quality care within the traditional, non-technological model of medical care.

20. Daily Time Required for Quality 2500 patient panel Grade A & B Preventive Services: 7.4 hours Chronic Disease Management: 10.2 hours Acute Care: 4.6 hours Total time/day: 22.2 hours Optimal Panel Size for an 8-hour work day: 2500*8/22.2 = 901 patients

22. How can Technology Help? Technology can improve efficiencies in a medical practice, and can reduce overhead expenses, but we need to go “outside the box” for a quantum leap in progress

23. The Conundrums Not enough PCPs in the pipeline to allow for one provider for every 901 patients No payment structures available to pay for quality at a rate that incentivizes it Patients not motivated to get preventive services Infrastructure that is necessary, without technology, is quite unaffordable

24. Technological Aids For Efficiency Electronic Health Records – Once implemented, increase office efficiency and decrease overhead costs Secure Patient Portals – Ideally built into the EHR, for communication and education Registries (best if included in EHR) – Track patients with targeted illnesses and aid population management Automated Patient Recall and Reminders – To increase the probability that patients will follow-up E-prescribing – Reduce errors, automate refills, automatically document

25. Technological Aids For Efficiency Are all expensive, all require provider and staff resources, and are all valuable. But, they do not solve the problem of how to provide care that matters to the patient in a cost-effective way. We need use technology to involve the patients themselves in the process

26. Automated History Taking Instant Medical History: – a commercial software which integrates with most if not all EMRs, and which allows the patient to enter the history, ideally before the visit from home, in an unhurried way. It can also be run from a kiosk in the reception area. – IMH can automatically run research-validated screenings on the patient triggered by the answers given to the questions it asks.

33. Advantages of Instant Medical History Low cost High levels of patient satisfaction More compulsive and thorough than most providers have the time to be Collects not only the history, but also what matters to the patient using validated tools No staff time or provider time necessary – all the work is done by the patient

34. Now, imagine a way to provide: patients with the information they want in real time providers with patient data that matters to the patient summarized for their care stratified in behaviorally sophisticated categories (e.g. confidence) cumulated patient-centered data to improve all patient care and your office practice processes

35. Imagine the patient doing that for you and also loading a simple registry for you to sort your patients based on: Demographics: name, age group, gender, financial status What matters: pain, emotion, confidence, meds that make the patients ill, more than one MD, What is the matter: high BP, diabetes, angina, CHF, history of stroke, respiratory disease, last BP, last cholesterol if 50+, last sugar if diabetes Prevention: mammogram, bowel cancer screening, Pneumovax

36. HowsYourHealth.org 20+ Years of research/testing pedigree Dartmouth Medical School (John Wasson MD)

37. HowsYourHealth.org Free for patients; nominal charge for clinicians when customized Collects information on general health status but also information on what matters to the patient using validated tools Perhaps the best over-all measure of Quality of Care yet developed No staff time or provider time necessary – all the work is done by the patient

41. Action Form Generated for each individual patient providing summary of issues that matter to the patient as well as issues that should be addressed

44. Population Summary Report

46. Advantages of HowsYourHealth.org Patient assessment and feedback system – Unmask the true patient needs and agenda that might undercut your best efforts – Automatically tailors information to your patient’s needs and chronic conditions – Additional versions for hospitalized and very sick/frail patients – Meets or supports many requirements for CMS/NCQA Medical Home designation

47. Advantages of HowsYourHealth.org Patient Portal for Best Information, Links, Problem-Solving and Shared Decision-Making – Non-commercial, well-tested tools and information that saves you time while you better inform your patients – Behaviorally Sophisticated Methods to Improve Patient Outcomes Portable Personal Health Record for Your Patients and Your Records – Minimize risks and frustrations of fragmented information

48. Advantages of HowsYourHealth.org Patient Registry that Your Patients Complete for You – With one click list your patients/addresses by condition, abnormal lab, functional limit, screening not done – Sort and contact patients by behaviorally useful categories such as lack of confidence with self management self management

49. Advantages of HowsYourHealth.org Practice Improvement System that Instantly and Automatically Gives You Performance Data – Patient experiences and bio-clinical measures offered with several national standards Customization options so that HowsYourHealth fits what you and your patients need – Add questions, change reports, import format for Electronic Health Record Patient Pre-Visit Planner and “Reviewer of Systems” for Your Patients and Payer – Makes an office visit more efficient and your billing more complete

50. Model for Improvement : a new look What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Setting Aims – Based on What Matters to the Patients Establishing Measures – Through web-based assessments like Hows YourHealth? and IMH Selecting Changes – PDSA cycles with prompts in EHR, web portals and even visit scheduling.

51. Questions? 9/13/201551 Sammamish Diabetes and Lipid Clinic, PLLC