Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Oregon Practice Name:PHMG-Barger Pediatrics Team Members: Lorna Wong, MD, Paul Benda, MD, Tammy Barstow, MD, Heather Rutherford, CMA, Tonja Wells, RN, Michelle Dimitri, CMA, Jamie Brownlee, Cheryl Ivey, and Sandy Campbell, RN

Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Oregon Practice Name:PHMG-Downtown EugenePediatrics Team Members: Jeff Joehnk, MD, Chris Hammond, MD, Mary Miller, MD, Richard Hansen, RN, Debra Ard, RN, Dayle Martinez, CMA, Linda Himber, Blanca Quintero, and Sandy Campbell, RN

Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Oregon Practice Name:PHMG-Riverbend Pavilion Pediatrics Team Members: Christine McKee, MD, Lauren Herbert, MD, Leslie Pelinka, MD, Fay Sunada, MD, Diane Citti, RN, Veronica Hernandez, LPN, Katie Salinas, CMA, Linda Brigleb, Gilma Vergara, and Sandy Campbell, RN

Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Oregon Practice Name:PHMG-South Eugene Pediatrics Team Members: Jimmy Unger, MD, Debbie Fuerth, MD, Eileen Hanna, RN, Irina Gidenko, CMA, Sara Stout, RN, Virginia Nelson, Sherri Schor, and Sandy Campbell, RN

PeaceHealth Medical Group Pediatrics We will establish and use sustainable quality improvement tools within our practices to achieve measurable improvements in asthma outcomes. From fall 2009 to fall 2010 we will achieve measurable improvements in asthma outcomes by implementing appropriate NHLBI guidelines, making CQN Asthma Pilot Project’s key practice changes, and with the goal of potential incorporation into the EMR.

PHMG QI Measurement points at 1 year, 2 years, and 3 years Asthma Action Plan in the EMR: 75% year one, 85% year two, and 90% year three. Flu vaccine given or recommended each year: 75% year one, 85% year two, 90% year three. Annual asthma checkup with evaluation using accepted asthma encounter form: 75% year one, 85% year two, 90% year three Asthma diagnosis marked appropriately on the problem list in the EMR: 75% year one, 85% year two, 90% year three

Asthma Action Plan in the EMR Goal 75% year one, 85% year two, 90% year three Baseline to now changes  Barger: 35% to 63%  Downtown Eugene: 100% to 90%  RiverBend Pavilion: 20% to 94%  South: 75% to 100%

% of patients who have a current written asthma action plan explained to them at this visit – PHMG Barger Pediatrics

% of patients who have a current written asthma action plan explained to them at this visit - PHMG Downtown Eugene Pediatrics

% of patients who have a current written asthma action plan explained to them at this visit PHMG RiverBend Pavilion Pediatrics

% of patients who have a current written asthma action plan explained to them at this visit - PHMG South Eugene Pediatrics

Flu vaccine given or recommended each year: 75% year one, 85% year two, 90% year three. Baseline to Now Changes  Barger: 78% to 60%  Downtown Eugene: 100% to 100%  RiverBend Pavilion: 100% to 94%  South: 83% to 100%

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot recommendation within the past 12 months – Barger Pediatrics

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot recommendation within the past 12 months – Downtown Eugene Pediatrics

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot recommendation within the past 12 months – RiverBend Pavilion Pediatrics

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot recommendation within the past 12 months – South Eugene Pediatrics

Annual asthma checkup with evaluation using accepted asthma encounter form 75% year one, 85% year two, 90% year three Using our excel registry we will be able to monitor this in the coming years based on the patients we are seeing for asthma encounters this year.

Asthma diagnosis marked appropriately on the problem list in the EMR 75% year one, 85% year two, 90% year three We began measuring this in January of this year Our baseline and current measurements are: Barger: 76% and 100% Downtown: 73% and 100% RiverBend: 67% and 100% South: 52% and 100%

Factors considered for optimal asthma care Was the parent/patient questionnaire used to determine the current level of asthma control? Was the age-appropriate NHLBI EPR-3 stepwise table used to identify treatment options or to adjust therapy based on asthma control? Has the patient received, or had recommended, a flu shot during this flu season? Does the patient have a written asthma action plan?

% of patients receiving optimal asthma care PHMG Barger Pediatrics

% of patients receiving optimal asthma care PHMG Downtown Eugene Pediatrics

% of patients receiving optimal asthma care PHMG RiverBend Pediatrics

% of patients receiving optimal asthma care PHMG South Eugene Pediatrics

Spirometry PHMG Percentiles

% of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis – Barger Pediatrics

% of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis – Downtown Eugene Pediatrics

% of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis – RiverBend Pavilion Pediatrics

% of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis – South Eugene Pediatrics

Obstacles to implementing spirometry recommendations Physician’s perception that it rarely alters treatment recommendations Accessibility: for many families it means a separate appointment and another ½ day off work/school Result reliability: highly dependent on technique and age of patient –small offices don’t have the test volume and personnel to guarantee reliability –Reliable results are more difficult to obtain on children less than 8-10 years old Cost of obtaining high quality equipment to perform test

Our Spirometry Dilemma Centralized testing: –Potentially more reliable results –Less expensive, but less accessible for patients Decentralized testing: -More accessible for patients -More expensive -Potentially less reliable results -Disruption of patient flow in busy practice setting

Benefits of Spirometry Objective data Using routinely will promote better use of spirometry tool, more familiarity, and better results Can be an effective tool in distinguishing intermittent asthma from persistent asthma

What we learned from EQIPP data 1.Tipping point with the AAP. 2.Support of the team / meetings, important for practice change 3.Improved formalized use of a step-wise approach to asthma care 4.Shock value of formal data collection. 5.Importance of processes. (refills, capturing patients)

PDSA Cycles

PDSA Title: Encounter Form Completion  Plan: Encounter form will be completed prior to the provider entering the exam room  Do: engage & educate staff, identify patients, create poster for waiting rooms, get encounter form in Spanish  Study: Small sample to broader group  Act: slightly different at each site

TEST 1 What: form completion Who (population)patient: Who (executes):PAS Staff Where: Waiting room When:at arrival PD SA TEST 2 What:form completion Who (population)patient: Who (executes)PAS or roomer: Where:in waiting room or exam room When:at arrival or if missed, during rooming process PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA TEST 1 What: form completion Who (population):patient Who (executes):PAS staff Where:in waiting room When:at arrival PD SA TEST 2 What:form completion Who (population):patiient Who (executes):PAS or roomier Where:in waiting or iexam room When:at arrival or during rooming PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA TEST 1 What:form completion Who (population)patient: Who (executes):PAS staff Where:in waiting room When:at arrival PD SA TEST 2 What:form completion Who (population):patient Who (executes):rooming nurse Where:in exam room When:during rooming process PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA BargerDowntown & RiverBendSouth Encounter Form Completion prior To MD entering Exam room

PDSA Title: Collection of forms and data entry – test two PLAN: Collect encounter forms and enter data into excel registry, EQIPP, and EMR DO: engage & educate staff, designate a data entry person at each site, designated person collects forms and enters data STUDY: studied and successful ACT: adopted at all sites

PDSA Title: Collection of forms and data entry PLAN: Collect encounter forms and enter data into excel registry, EQIPP, and EMR DO: engage & educate staff, send forms by interdepartmental mail to primary administrator STUDY: forms inadvertently sent to medical records, forms left on provider desks, forms lost to the black hole of interdepartmental mail ACT: adapted

PDSA Title: completion of electronic asthma action plan PLAN: asthma action plan will be completed in the EMR on 75%, 85%, and 90% of patients seen with asthma over the course of the next 3 years DO: Physician will complete the AAP during the visit and give copy to patient STUDY: not enough time to complete this during visits other than asthma recheck appointments - not happening consistently ACT: adapted

PDSA Title: completion of electronic asthma action plan – test two PLAN: asthma action plan will be completed in the EMR on 75%, 85%, and 90% of patients seen with asthma over the course of the next 3 years DO: Physician will either complete AAP electronically at time of visit or dictate AAP into note, give patient a handwritten version, and data entry staff will create electronic version during data entry process STUDY: studied and successful ACT: adopted

PDSA Title: Increased rate of flu vaccine administration PLAN: Flu vaccine will be given or recommended to 75%, 85%, and 90% of patients with an asthma diagnosis in years 1, 2, and 3 DO: flu vaccine clinics, flu vaccine capture with all visit types, call patients from registry or other high risk patient lists and schedule for vaccine STUDY: studied ACT: adopted

PDSA Title: Increase number of patients receiving annual asthma check with use of accepted asthma encounter form PLAN: Increase the number of asthma patients receiving an annual asthma check DO: increase number of patients on registry, appointments triggered by asthma med refill requests, use form during well child checks in patients with known asthma, include patients being seen for an illness visit with wheezing identified by either provider or rooming nurse STUDY: ongoing study being done ACT: adapted encounter form to increase usage by non- participating providers within all groups

PDSA Title: Asthma appropriately documented on the EMR problem list PLAN: 75%, 85%, and 90% of identified asthma patients will have an asthma diagnosis on the EMR Problem list in years 1, 2, and 3 respectively DO: updated by provider, updated by rooming nurse, updated by data entry staff STUDY: ongoing study ACT: currently a combination of the above is happening at each site. Study continues.

Process Maps

The CQN Encounter Form Too lengthy –Revamped form many times to shorten it Not user friendly –Suggestions of colleagues, participating and non- participating Providers wanted a form they could score –incorporated the ACT into the form

Key Learnings page 1  Use of a formalized encounter form improved quality of asthma care (surprise – we thought we did a good job before)  Improved asthma quality of care due to standardization of care  Asthma handouts  AAP in EMR (useful for providers and staff)  Identifying and prevention of asthma triggers  Aerochamber use and education  Increased use of inhaled steroids  Change requires process change and engagement  Continued motivation of the entire team promotes teamwork and improves outcomes

Key Learnings page 2  Ongoing monitoring of any process improvement is important to sustain change  Must set goals and have objective data to support  Implementation of the electronic Asthma Action Plan is easier than previously envisioned  Realization that it is necessary to allow more time to provide optimal asthma care (lengthening office visit time)  Coding appropriately for the visit (most can be 99214)

Other Feedback from all staff on how processes are working (participating and non-participating) Engaging non participating providers and staff in newly developed processes –Revised encounter form (numerous revisions before settling on current form) –Change how form is delivered to patient (done differently at each site)

Barriers Tedious, busy work Registry cost prohibitive Availability of spirometry in the office (cost, office flow, clinical utility, accessibility, trained staff) Time out of the office Inertia to change Difficulty of doing during short illness visits Timing of narrative report makes it difficult to meet with teams to answer questions appropriately Challenges of doing electronic Asthma Action Plan during routine office visit

Future Plans Continued engagement of providers and staff to provide optimal asthma care to our patients Improving feedback loop of data to providers and staff Ongoing monitoring of data for at least 3 years Finalizing education materials Providing all materials in Spanish Continued entry of data into EQIPP

Future Plans Presentation to QC to solicit funding for support of asthma care including formal registry and spirometry Revision of forms for hospital asthma admissions Consideration of online asthma questionnaires to allow automatic entry of information into a database Party for team at the end of project