1. Development of Effective Screening for Osteoporosis Lisa Ray, MD, CCD MAHEC Family Medicine Faculty, Asheville Assistant Professor of Family Medicine UNC Chapel Hill

2. Objectives Define CQI process Describe how we used CQI to develop osteoporosis screening system and collaborative care clinic Identify ways that EMR can be used to develop screening protocol and track efficacy of screening and treatment

4. MAHEC Residencies MAHEC Family Practice residency MAHEC OB GYN residency MAHEC Geriatric Fellowship

5. MAHEC Family Health Clinic Asheville, North Carolina Population 75,000 9041 active patients 10% women > 65, 3% men > 70 17% Medicare DXA on site Multidisciplinary Osteoporosis Clinic IV bisphosphonates available on site

6. CQI Continuous Quality Improvement Multidisciplinary Team Identifies a clinical problem Proposes solutions to address problem Tests if those solutions works

7. The clinical challenge USPSTF guidelines recommends screening DXA for all women over 65 Nelson H, et al. Screening for postmenopausal osteoporosis. Systematic Evidence Review No. 17. Rockville, MD: Agency for Healthcare Research and Quality. September 2002.

8. Baseline at Our clinic We purchased a DXA machine in 2001 Dr. Ray went through additional training in osteoporosis management and interpretation of DXA Osteoporosis lecture became core lecture Dr. Ray hounded residents mercilessly during clinic consulting to get appropriate screening DXA

9. Which intervention was most effective in improving screening? 1. Dr. Ray’s incessant hounding during consulting 2. Dr. Ray’s lectures 3. Having the DXA machine in the office

10. 2005 Rate of Screening (DXA in Office 4 Years)

11. What was the problem? Physicians know the screening recommendations Physicians and patients don’t think of screening for silent disease? Patients don’t perceive osteoporosis as a deadly disease? Physicians get too busy? Patients don’t have time? Office visits are complex with multiple competing agendas?

12. Team MD faculty PharmD faculty Residents Radiology Tech Clinical Secretary Computer Tech

13. The Plan Try to target patients who are physically in clinic Systematically identify patients to screen using EMR Automatically order the test using protocol Set up a system that automatically checks itself

14. The Plan – Targeting Patients A report is run from the EMR of female patients over 65 who have an appt the next week and the date of their last DXA (Computer Tech) Radiology Tech reviews report. If less than 2 years – do nothing If > 2 years and < 5yrs and was normal do nothing. If no DXA then patient is targeted If DXA > than 5 years then patient targeted If > 2 years and T score < -1.0 patient is targeted

15. Flag for the Chart Dr___Preston____________________ Your scheduled patient: Mrs Bones____ needs a DXA. Indication___Age > 65__ Lisa Ray, MD Appt.Time____2:30_____________

16. The Plan - Automatically Order DXA Targeted patient has Flag attached to their billing sheet as they arrive reminding physician that patient needs DXA DXA is ordered on the encounter form using menopause as diagnosis code (Clinical Secretary) When the patient is done with office visit and is checking out The patient is asked if they received their DXA If not they are asked if they want it today If not they are scheduled later. (Front Desk)

17. The Plan – Self Checking System Patients who are scheduled for DXA who do not come enter a call back loop that continues until they come in or they refuse DXA (Radiology Tech) If they refuse DXA a message is sent back to primary physician to address (Physician)

18. Results

19. Pearls Knowledge does not necessarily improve screening It takes a village to screen a patient If you want screening done well ask the staff to do it and automate When the clinicians agree to a protocol you can use the EMR very effectively to identify patients for screening EMR prompts are not enough Screen the patients when they are already in the office This works because we have a ICD-9 code which works for screening women (627.8 menopause) We systematically ignore men –no ICD9 code

20. The Multidisciplinary Osteoporosis Clinic

21. Nurse Physician Pharmacist

22. Collaborative Osteoporosis Clinic Interdisciplinary clinic with a physician, pharmacist, and a nurse All patients with abnormal DEXA are offered an appointment Nurse completes “get up and go test”, performs vitals including orthostatics, and updates medications Physician performs physical examination and work-up

23. The Pharmacist’s Role Dietary history for calcium intake Recommends calcium and vitamin D products Educates on bisphosphonate use Conducts falls risk assessment Coordinates care for smoking cessation Facilitates entry into teriparitide (Forteo) classes Recommends bone strengthening exercise Ensures access to medications

24. How Effective is Multidisciplinary Osteoporosis Clinic Retrospective study in 2005 61 patients at baseline 70% Osteoporosis, 30% Osteopenia Sub-optimal calcium dose in 28% of patients Only 50% of patients were on osteoporosis medications

25. How Effective is Multidisciplinary Osteoporosis Clinic

26. Learners in Osteoporosis Clinic Physician and Pharmacist are always joined by An MD learner (FP resident, OB GYN intern or geriatric fellow) A pharmacist learner (pharmacy student or pharmacy resident)

27. Learners in Osteoporosis Clinic MD learners are encouraged to shadow then evaluate patients independently using MD faculty as consultant MD learners also shadow Pharmacist Vice Versa for the pharmacy students

28. Unique Learning in OC Clinic starts with short presentation by one member on new issue or paper about osteoporosis MD learner sees multidisciplinary clinic modeled MD learner benefits from the complimentary skill sets of MD and PharmD faculty for a greater depth of experience MD learner observes the power of partnering with pharmacists for comprehensive management of chronic disease Multidisciplinary clinic is fun!

29. Where We Are Headed Screening and treatment initiative in high risk men Baseline needs assessment for women receiving depo-medroxyprogesterone acetate (DPMA)

30. Conclusions A continuous quality improvement approach can improve osteoporosis screening and care Collaborative care increases the quality of care provided Collaborative care clinics create unique teaching opportunities