1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Oregon Practice Name: Childhood Health Associates of Salem Team Members: Carlson, Heggen, Etzel, Dettwiler

2. About Us Clinic of 10 pediatricians plus 2 PA’s and 2 PNP’s. Eight pediatricians, 2 PA’s and one PNP submitting data to EQIPP. 54,340 encounters in 2009 16,000 unique active patients (seen in last 18 months) 3200 (20%) with asthma on their problem list

3. Where we started Only one provider reliably using asthma action plans Very little asthma education materials available Spirometry only when initial diagnostic uncertainty No consistent recheck guidelines with most asthma care delivered at acute visits

4. Encounter form reliability Improvement PDSA Ramp Form was manually attached at front desk for few select patients as initial test of form. First step to automate was to attach CQN form to bookeeping encounters day before visit To improve same day visit identification front desk staff instructed to attach based on cc. Asthma identification added to provider/MA huddle. This has variable reliability based on provider participation in huddle. To improve created reference card attached to workstations

5. Sampling by providers at end of shift. Testing reliability of “automatic” processes Most missed were same day encounters Encounter form reliability

6. Encounter Form Reliability Next Steps Continue to work with front desk to use reference cards Teach MA’s on where asthma reminders are in EHR Encourage providers to bring into room and document while taking history Encourage MA’s to use encounter form to start reason for visit documentation

7. Initial Strengths HospitalizationsFlu shots F/U appt recommended

8. Inital Weaknesses Optimum asthma careSpirometry performed <12m Educational Materials

9. Asthma action plan improvement PDSA Ramp Asthma encounter form already in EHR but needed to agree upon language and make easier to find. Translate to Spanish Teach providers how to generate and print Teach providers and phone nurses on how to find Unify phone protocols with action rescue plan

10. Asthma Action Plan Data Optimal Asthma CareAction Plan Reviewed

11. Asthma action plan Next steps Create short video reinforcing to providers and staff on how to generate and find action plans. Looking forward to learning from other groups on how they’ve hit 90%.

12. Point of Care Spirometry PDSA Ramp Install spirometry software on all nursing floor laptops Train more nurses in how to perform quality spirometry Create trigger for needing spirometry by adding to reason for visit on schedule Provider training on interpretation by Dr. Holger Link visiting us for Friday noon conference Latest EHR update added ability to better add prompt for patient without spirometry updated Trip to OHSU CF clinic to observe

13. Spiometry Done or Scheduled

14. Spirometry next steps Teach providers and staff about new EHR reminder system (“care manager”) Continue to train more nurses Review our apparent high rate of normal spirometry

15. Patient Education Began collecting handouts and placing on internal wiki Collected favorites and bundled into packet that was pre-printed Collected Spanish handouts and translated as needed to create Spanish packet

16. Patient education Next steps Use ACT for nursing follow-up phone calls Improve web site resources Continue to add to list of handouts in our virtual file cabinet and translate as needed

18. Patient Identification

19. Pre-visit Prep

20. Medical Encounter

21. Post-visit data entry Providers are consistently getting 5 per month, with many much more Closing loop back to chart when deficits are identified doesn’t yet occur reliably

22. Near term goals Still working toward 90% on asthma action plans Spread to two providers not involved in project Registry implementation Improve efficiency of point of care spirometry Online educational resources Keep having fun!

23. Ongoing barriers Provider time and willingness to adapt to rapid process changes (“spread”) Language barriers inhibing patient education (“patient self-management”) Cost and time investment needed to implement registry 1440 patients had visit for asthma out of estimated population of 3200. How to define when asthma is an “active” problem versus “resolved”.

24. What we’ve learned We feel we are beginning our journey in learning to integrate quality improvement methodology to facilitate chronic disease management. Specifically... Data collection is hard Provider spread is harder Improvement stories are critical Continual process improvement really works Weekly 15 minute meetings more effective than 1 hour monthly meetings Engaging and improving patient’s health can be fun