1. Team Based Care Combining Team Based Care and Technology to Improve Quality and Transform Healthcare to Improve Blood Pressure Control Wednesday February 12th, 12 Noon Improving Health for Populations & Communities South Dakota Foundation for Medical Care Christopher H. Tashjian, MD, FAAFP HIT fellow using the EHR and practice innovations to increase participation in the Million Hearts Initiative and improve performance on the Million Hearts goal Chief Medical Advisor WHITEC

2. Active Decision to Improve Care We changed our overall thinking from: ◦ It’s a physician problem To ◦ It’s a team challenge

3. What does that mean? Physicians had to give up TOTAL ownership Staff had to be trained to understand the problem ◦ Nurses ◦ Lab ◦ Care Co-ordinators ◦ Front Office

4. What does that mean? (Part II) My patients are my partner’s patients My partner’s patients are my patients Every visit is a hypertension visit!

6. MU and MH built into the patient visit Using basic EHR functionality and performing common tasks can meet MU and Million Hearts goals Continuous Quality improvement Privacy & Security Patient & Family Engagement

7. Stage 1: Data capture and patient access Stage 2: Information exchange and care coordination Stage 3: Improved outcomes Stages of Meaningful Use

8. Million Hearts® National initiative co-led by CDC and CMS Partners across federal and state agencies and private organizations 7 Goal: Prevent 1 million heart attacks and strokes in 5 years Goal: Prevent 1 million heart attacks and strokes in 5 years

9. Heart Disease and Stroke Leading Killers in the United States Cause 1 of every 3 deaths More than 2 million heart attacks and strokes each year –800,000 deaths –Leading cause of preventable death in people <65 –$444B in health care costs and lost productivity –Treatment costs are ~$1 for every $6 spent Greatest contributor to racial disparities in life expectancy Roger VL, et al. Circulation. 2012;125:e2-e220. Heidenriech PA, et al. Circulation. 2011;123:933–4.

10. Key Components of Million Hearts™ COMMUNITY PREVENTION Changing the context CLINICAL PREVENTION Optimizing care Focus on ABCS Health information technology Clinical innovations TRANS FAT

11. Million Hearts – Provider Goals 10

12. Clinical Prevention Optimizing Quality, Access, and Outcomes Focus on the ABCS Simple, uniform set of measures Data collected or extracted in the workflow of care Link performance to incentives NQF#0064Comprehensive Diabetes Care: LDL-C Control <100 mg/dL NQF#0018Controlling High Blood Pressure NQF#0075Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100 mg/dL NQF#0068Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic NQF#0028Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention

13. Getting to Goal InterventionBaselineTarget Clinical target A spirin for those at high risk 47%65%70% B lood pressure control 46%65%70% C holesterol management 33%65%70% S moking cessation 23%65%70% Sodium reduction ~ 3.5 g/day20% reduction Trans fat reduction ~ 1% of calories50% reduction Unpublished estimates from Prevention Impacts Simulation Model (PRISM). 12

14. Low Tech Low Tech

15. HIGH TECH First Take Data from EHR and Export to Excel

16. Excel to Access Database

17. Generate Patient Lists

18. Use of Filters

19. Patient Scorecards

20. Provider Scorecards

21. Results! In just four years, Ellsworth Medical Clinic reported the following improvements in blood pressure control: ◦ Among patients with diabetes, hypertension control increased from 73% to 97% (2007–2011) ◦ Among patients with cardiovascular disease, BP control increased from 68% to 97% (2007– 2011) ◦ Currently as of December 2012 ALL patients with hypertension controlled at 90%

22. Percentage (%) of Patients in Control by Category November 2013 Review CategoryIn ControlTotal PatientsPercent BP9510095.0% Hgb A1c7410074.0% LDL8510085.0% ASA100 100.0% Tobacco8210082.0% Total Patients in Control5210052.0% August 2013 Review CategoryIn ControlTotal PatientsPercent BP9910495.20% Hgb A1c8210478.80% LDL8610482.70% ASA104 100.00% Tobacco8710483.70% Total Patients in Control5710455.00% Current progress

24. Saves 417 Hearts, 72 Legs & 745 Pairs of Eyes Each Year! 32,747 members with diabetes, in one health plan, in 2012 suffered 417 fewer heart attacks, 72 fewer leg amputations and 745 people did not experience eye complications compared to what would have happened to the same 32,747 plus members in 2000. 23

25. For our Patients – We have a Million Hearts

26. This Year River Falls is a Million Hearts Finalist!

27. The Difference it Makes – Ask our Patients!

28. It Takes Teamwork!

30. Join Us: Take the Pledge 29 http://millionhearts.hhs.gov

31. Resources Vital Signs: Where’s the Sodium? www.cdc.gov/VitalSigns/Sodium/index.h®l www.cdc.gov/VitalSigns/Sodium/index.h®l Vital Signs: Getting Blood Pressure Under Control www.cdc.gov/vitalsigns/Hypertension/index.h®l www.cdc.gov/vitalsigns/Hypertension/index.h®l Team Up. Pressure Down. http://millionhearts.hhs.gov/resources/teamuppressuredown.h®l http://millionhearts.hhs.gov/resources/teamuppressuredown.h®l Community Guide: Team-Based Care www.thecommunityguide.org/cvd/teambasedcare.h®l www.thecommunityguide.org/cvd/teambasedcare.h®l SDOH Workbook: Promoting Health Equity, a Resource to Help Communities Address Social Determinants of Health www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf Program Guide for Public Health: Partnering with Pharmacists in the Prevention and Control of Chronic Diseases www.cdc.gov/dhdsp/programs/nhdsp_program/docs/ Pharmacist_Guide.pdf www.cdc.gov/dhdsp/programs/nhdsp_program/docs/ Pharmacist_Guide.pdf Data Trends & Maps http://apps.nccd.cdc.gov/NCVDSS_D® http://apps.nccd.cdc.gov/NCVDSS_D®

32. A Different Way to Look at Quality? Previous simvastatin labelNew simvastatin label Avoid simvastatin with: Itraconazole Ketoconazole Erythromycin Clarithromycin Telithromycin HIV protease inhibitors Nefazodone Contraindicated with simvastatin: Itraconazole Ketoconazole Posaconazole (New) Erythromycin Gemfibrozil Clarithromycin Cyclosporine Telithromycin Danazol HIV protease inhibitors Nefazodone Do not exceed 10 mg simvastatin daily with: Gemfibrozil Cyclosporine Danazol Do not exceed 10 mg simvastatin daily with: Amiodarone Verapamil Diltiazem (Note: These drugs are contraindicated with Simcor as Simcor is only available with 20 mg or 40 mg of simvastatin.) Do not exceed 20 mg simvastatin daily with: Amiodarone Verapamil Do not exceed 20 mg simvastatin daily with: Amlodipine (New) Ranolazine (New) Do not exceed 40 mg simvastatin daily with: Diltiazem Avoid large quantities of grapefruit juice (>1 quart daily)Avoid large quantities of grapefruit juice (>1 quart daily

33. What We Found Simvastatin Dose Total Number 20 95 40 976 80 365 AmiodaroneAmlodipineVerapamilDiltiazem 8 241 13 49 70,000 Total Patients in all 3 clinics OtherItraco nazole Ketoco nazole Posaco nazole Erythro mycin Clarithr omycin Telithro mycin Nefaza done Gemfi brozil Dan azol 0201100230

34. Be BOLD!

35. For More Information contact: Chris Tashjian, MD, FAAFP ctashjian@rfmc.org Ellsworth Medical Clinic 715-273-5041