Using a Registry to Manage Asthma Population James Wiley, MD Physician Leader, Alabama AAP Chapter Stephen Pleatman, MD Pediatrician, Suburban Pediatric Associates, Inc. Board Member, Ohio Valley Primary Care Associates, L.L.C. Cincinnati, Ohio AAP Chapter Quality Network Asthma Initiative Alabama Chapter-Learning Session 1 September 17, 2009

What is a registry? A registry is a list of patients and their relevant clinical data that can be sorted by a condition or set of conditions in order to improve and monitor the care of the population Some may view a registry as an intermediate step between the paper chart and an EMR. It is a necessary step. Waiting for the perfect EMR is not the solution. D.K. McCulloch, M.J. Price, M. Hindmarsh and E.H. Wagner, "A population-based approach to diabetes management in a primary care setting: early results and lessons learned," Effective Clinical Practice 1 (1998):12-22 Adapted from Improving Chronic Illness Care; www.improvingchroniccare.org

Importance of Registry to CQN Asthma Initiative (insert key messages/bullet points from national AAP and Alabama chapter leadership) (Alabama/AAP leadership may want to use the following “fear vs. fact” slides to reinforce value/importance of registries to improvement)

Registries: Facts vs. Fears Fear: “Why is a registry vital to quality improvement efforts?” Fact: Planned, population-based care cannot be done without knowing your patient population and related key clinical data. Fact: Primary care teams that implement registries are more likely to improve processes of care and outcomes for populations with chronic conditions. Fact: Teams with registries are less likely to lose patients to follow-up, and more likely to improve patient satisfaction as care improves. The next few slides address fears your audience will likely have. The first being resistance to doing anything new. In this slide you want highlight the benefits of using registries. You want to appeal to your audiences’ desire to be doing better quality care, and registries are a way to get there. There is good evidence that using a registry with reminder capabilities improves processes of care, and facilitates improved clinical outcomes if the practice is addressing disease control through planned care. See: Montori et al. The Impact of Planned Care and a Diabetes Electronic Management System on Community-based Diabetes Care. Diabetes Care v25 n11 Nov 2002. For observational data on the impact of registries on patient care see McCulloch’s follow-up article: McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. Improvement in Diabetes Care Using an Integrated Population-Based Approach in a primary Care setting. Disease Management. 2000; 3(2): 75-82. Adapted from Improving Chronic Illness Care; www.improvingchroniccare.org

Registries: Facts vs. Fears Fear: “I don’t need anyone telling me how to practice! I’m doing just fine with my patients!” Fact:Surveys show that providers consistently under- estimate the number of patients with chronic disease in their practice. Fact:Surveys show that providers consistently over- estimate their performance on quality measures for chronically ill patients. Fact: Knowing your population of patients will help address this disparity. While this fear may present itself in an angry fashion, it really is based in the fear that patients are slipping through the cracks of the hectic acute care day. The surveys referred to in the slides were conducted at Group Health Cooperative of Puget Sound by David McCulloch et al. When asked how many patients with diabetes are in your practice, the randomly sampled group of 80 physicians consistently under estimated the number by 50% when compared to billing, lab and pharmacy data. When asked about their patient process outcomes (A1c testing, renal screening,etc) they consistently overestimated by as much as double the rates. This is because they remembered that patients they have seen, and typically remember positive outcomes versus negative ones. When shown their actual data, this provided strong motivation to seek out way to improve care….that is the initial power of the registry….motivation to improve. Adapted from Improving Chronic Illness Care; www.improvingchroniccare.org

Registries: Facts vs. Fears Fear: “It’s just more work during our already hectic day!” Fact: Using a patient summary form from a registry will actually reduce charting time and make the visit run more smoothly. Fact: The form gives a snapshot of past care, reminders of needed care and planning for future care, all at the time of the visit. Fact: Teams with registries feel better prepared for visits since they have the patient information when they need it. A legitimate fear! Quell it by pointing out that registry implementation while involving some up front work will reduce workloads by providing patient summaries at the time of visit that can be used as flowsheets, reminder for care, and if chart ready reduce charting time. Address the data entry issue head on by pointing out that the patient summary can be key-punched in less than one minute for the typical patient. This is borne out by numerous practice teams around the country that have implemented registries. Adapted from Improving Chronic Illness Care; www.improvingchroniccare.org

Registries: Facts vs. Fears Fear: “This will cost me a fortune and there’s no return on investment!” Fact: Implementing a registry is simple, and there are economies of scale as you add more patients. Fact: Registries facilitate population-based care, which improves outcomes and patient satisfaction. Fact: Planned care via the registry generates visits that are typically of higher intensity, while reducing unexpected visits for acute exacerbations. While there is no research evidence on this question, experience from teams implementing registries suggest that once a registry is in place, it is easy to add new patients and conditions. Evidence presented earlier shows the connection between registries and improved process outcomes as well as demonstrating the critical role registries play in individual patient care. Those using registries find they can plan care for disease populations which generate visits with higher RVUs versus trying to squeeze disease care into an unexpected visit for an acute (often minor) exacerbation. Adapted from Improving Chronic Illness Care; www.improvingchroniccare.org

Ideal Features of a Registry Guides clinical care first, measurement second! Quick to implement Simple to use Data entry simple and efficient Incorporates other automated data sources Stratifies patients by complexity/severity Highlight ease of implementation and use. Point out that disease registries are not the way to go since many patients have multiple chronic conditions. The registry is organized by patient that can have one or more conditions associated with their care. While data for registries should be used to assist in performance reporting, emphasize that their main function is to drive clinical care in an organized fashion by sorting population of patients and their common needs and delivering services proactively to meet multiple population needs. Adapted from Improving Chronic Illness Care; www.improvingchroniccare.org

Registry Strategy (insert key messages/bullet points from national AAP and Alabama chapter leadership)

Cincinnati Case Study: Using PHO Asthma Registry/ Data to Drive Improvement Stephen Pleatman, MD Pediatrician, Suburban Pediatric Associates, Inc. Board Member, Ohio Valley Primary Care Associates Cincinnati, Ohio

Log In Screen

Dashboard Process Dashboard (Year End 2008 Results) Outcomes Dashboard (Year End 2008 Results)

State of Asthma Care

Key Outcome Statistics

View existing patient’s demographics, encounter dates, and flu history

Asthma Encounters Demographics Section

Visit Planner

High Risk Patient List

Utilization Report

Improving Influenza Immunization Rates

Work List Patients who have not had a Flu Shot

Improving Influenza Immunization Rates

Improving Influenza Immunization Rates HL Flu Shot % 2008/2009 Flu Season

Web-based Asthma Reconfirmation

Reconfirmation Progress by Practice Type here

Asthma Reconfirmation Work List