1. Population Health: Doing work for multiple patients simultaneously September 2015 Updates: 1.Use of recommended My Panel Metrics Dashboard if available 2.Include new Mychart Inactive outreach workflow (telephone) 3.Exclude Provider workflow (to be done at enterprise level) 4.Adding patients to Do Not Contact List

2. Agenda Primary Care Health Maintenance Nursing Protocol Protocol Document Protocol Order Yearly Training (Learning Management Systems) What’s new with Reporting Workbench Bulk Orders Reports Changes to filtering Telephone Workflow for Patients Not Active in MyChart Bulk Communication New Bulk order reports from the My Panel Metrics Dashboard What to do if I make a mistake How to add a Do not contact flag

3. Why should we use bulk activities for our patients? 3

4. THE HEALTH OF OUR PATIENTS “We miss opportunities every day to help our patients achieve health and wellness. Registry, workbench, and population health tools provide us with ways to find our patients and help them stay well.” – Sitapati, MD Health.ucsd.edu

5. Overview of the places that you can run Bulk Ordering and Communication: Nurses expected to run these monthly Bulk Orders Requires HM Protocol Order Reporting Workbench Report Dashboard Report OrdersCommunication SmartText Diabetes LDL (Control and Testing) X Lipid Panel Bulk Multi Test Diabetes A1C (Control and Testing) X HGB A1C Bulk Multi Test Diabetes Microalbumin X Urine MicroAlbumin Bulk Multi Test CAD LDL (Control and Testing) X Lipid Panel Bulk Multi Test OsteoporosisXXray DexaBulk Multi Test ChlamydiaXChlamydia/G C Urine Bulk Chlamydia GC Ordering Breast Cancer Screening XScreening Mammo Bilat Bulk Mammo Ordering Colon Cancer Screening XFIT TestBulk Colorectal Cancer FIT Test

6. In order to get started, all patients getting the intervention need an active HM Protocol Order Nursing Protocol (Bulk Ordering/Bulk Communication) (refer to UCSD Ambulatory Care – Health Maintenance Screening Order Protocol) Diabetes (LDL, A1C, Microalbumin) CVD (LDL) Osteoporosis Chlamydia Breast Cancer Screen Persistent Meds - reports coming soon Colon Cancer Screening FIT test – reports coming soon Bulk Communication Only Pneumovax Cervical Cancer Screen Influenza Requires HM Protocol Order before Nurse can place the order Image: gameanalytics.com

7. Protocol Batch Ordering Trainer Nurses FM: LWC: Ashley Rollins SR: Barb Fennessey IM: LJ: Heather Hansen LWC IM – April Estacio Concierge: Downtown: Barb Fennessey Training Audience: Primary Care Nurses, Managed Care Nurses, Cardiology Nurses (include Cardio Slides) Bulk Ordering Trainer Nurses in Department:

8. What is the old way that patients were found? 8

9. Search for Registry and Find your report within the UC Patient Disease Registry Template

10. Access your My Reports from the Epic Dropdown Menu (Old Reports) Note: You can add the My Reports to your top toolbar for quicker access by using the Wrench

11. Run a disease specific report Available Bulk Ordering Workflows are: Cardio Vascular disease by site, Diabetes by site, Pneumonia by site, Breast cancer by site, Cervical cancer by site, Chlamydia by site, and Osteoporosis screening by site. Note: These reports are already filtered for patients missing orders and that already have an HM protocol order placed. 1.Choose the specific report you would like to run. (Select additional reports if not immediately available) 2.Click Run

12. Reporting Workbench Note: the team is working to convert reports from UC Patient Disease Registry (old template) to UC My Panel Metrics which are accessible from the Dashboard.

13. What are the NEW ways to run reports? 13

14. New Dashboard Based Template New Template Your Panel metrics Dashboard shows you measures for your department and specific providers. Also gives you access to the My Panel Metrics Reports to run and follow-up with patients to improve your department’s measures.

15. Accessing your Dashboard Reports (New Reports) Open your Dashboard tab from your Epic Dropdown Menu Access the Reports Folder Open My Dashboards Remember to “Wrench It” for quick access

16. Accessing your Dashboard Reports Once Prompted Select the Panel Metrics Dashboard and Accept.

17. Panel Metrics Dashboard Your Panel metrics Dashboard shows you measures for your department and specific providers. Also gives you access to the My Panel Metrics Reports to run and follow-up with patients to improve your department’s measures.

18. Radar My Panel Metrics Note: If the My Panel Metrics are available, users should launch the bulk ordering reports from the Dashboard. Only use the old (UC Patient Disease Registry Search) when the reports are not available on the Dashboard. Future development will make all reports available in the new Dashboard format. This will replace you having to find your department within the list of available reports. To access these reports expand the measure by selecting the arrow and run the last report on the list.

19. The Quality Improvement Chair is hoping that our clinic can be the best in A1C testing. We are hoping that the testing will help find patients that are not well from diabetes. 19 Goredforwomen.org

20. Let’s start by finding the patients that need to have their A1C checked. 20 A1C – and Diabetes Outsideinclinic.wikispaces.com

21. Filter to patients with a protocol order and no test result within specified timeframe (looking at A1C’s in this example) FIRST: When choosing Filters, if prompted, be sure to load all 1.Filter on patients with a HM Protocol Order Date within the last 5 years 2.who Filter on patients with Last test result as blank (ie. A1c) or outside specified timeframe > 3.Verify that filtering is done correctly so that only appropriate patients have labs ordered 4.Select multiple patients by holding down the > or > key 5.Click Bulk Orders to place orders for multiple patients

22. Now it’s time to place the order Photo: rsna.org

23. 1.Check “Use PCP as Authorizing Provider” 2.Select order(s) 3.Click Add Communication if you need/want to send a communication or Click “Sign Without Communication.

24. 1.Enter Subject and template > 2.Select the test that will be ordered and appropriate instructions for the test 3.Enter Patient Outreach Tracking info 4.Click “Sign with communication” Route Communication to MyUCSDChart Active Patients

25. What about the patients who do not have MyUCSDChart? 25 Image: Digium.com

26. Route Call List Via Inbasket (all MyChart Inactive) Can use DotPhrases or SmartTexts (all start with “bulk”) in system to quickly generate explanation to people making the calls on why they are contacting the patient. Enter in person/group of people (May be yourself) into the InBasket Recipient area.

27. After you click Sign, you may see this pop up Click “Continue”

28. After Signing Depending on how many patient’s orders are being processed this can take a while. You can move on and work on other things, an In Basket message will be sent to you when it is all done. Look in “Bulk Action Results” folder and verify all actions were successful If any actions failed review and place individual orders as necessary

29. Completing Calls to MyUCSDChart Inactive Patients Find the Initiate Call folder in the InBasket Single select of the patient will show you instructions entered by the person who placed the bulk order(s) To Initiate the call, Select Tel Call or Double Click on the patient from the InBasket Report

30. Outreach Calls to Patients A Telephone Call Encounter will open (Open with PCP as the Provider). Complete Contact information and document your attempt to outreach with the patient in the documentation section. Close the encounter once outreach has been completed.

31. What about bulk messaging – where the work only needs communication without the order? 31 Image: telegraph.co.uk

32. Bulk Communication Only Bulk Orders Requires HM Protocol Order Reporting Workbench Report Dashboard Report Communication SmartText Pneumonia VaccinationXBulk Pneumonia Vaccine Message Cervical Cancer Screening XBulk Cervical Cancer Hypertension (BP Control) XXBulk BP Control Note: Influenza handled at Enterprise Level N/A

33. Bulk Communication Only example: Pneumonia Vaccination Registry Patients – LJ IM 1.Select multiple patients by holding down > or > key. 2.Click Send Bulk Communication

34. Bulk Communication to MyUCSDChart Inactive Patients (Phone Call) Enter a person or pool within InBasket Recipients who you want to complete the outgoing calls (It may be yourself). Use DotPhrases or SmartTexts (all start with “bulk”) to quickly generate message on why patients are being contacted. Explain here that patients are to be called to schedule a Vaccination/Test appointment

35. Completing Calls to MyUCSDChart Inactive Patients (Same as Bulk Ordering) Find the Initiate Call folder in the InBasket Single select of the patient will show you instructions entered by the person who placed the bulk order(s) To Initiate the call, Select Tel Call or Double Click on the patient from the InBasket Report

36. 1.Enter Subject and template/smart phrase (see Registry Patients Instruction). Note: this is important to keep the subject line exactly as it is in the document. 2.Complete the message 3.Enter Patient Outreach Tracking Info 4.“Click Accept” Bulk Communication to MyChart active Patients

37. What about patients that do not want to have messages and calls? Clipartbest.com

38. Adding a Do Not Contact Flag When patients state they do not want to be contacted for outreach, use the following steps to mark the patient as do not contact. Access the Demographics on the patient Under the Additional Information screen check the “Do not contact” checkbox

39. Do Not Contact Patients Do not contact patients will be flagged as “unable to receive messages” when users attempt to send a bulk communication.

40. Known Issues Break the Glass – Bulk Ordering will not prompt you to Break the Glass. However, Bulk Communication, will require users to Break the Glass on applicable patients. Use normal Break-the-Glass workflow. Bulk Communication  MyChart encounters that get created do not auto close even though patients can’t reply to these messages. These will show up in “My Open Encounters” folder of In-basket of the user that sent the bulk communication. These will autoclose after 10 days You can manually close these MyChart encounters from your in-basket or wait for the auto close

41. What if I make a mistake? Try to do this work when you can be focused and take time without being rushed. Thelatestnews.com

42. What if I placed orders in error? First notify the authorizing physician Bulk orders can be found within your InBasket folder Labeled “Bulk Action Results”

43. Cancelling Bulk Orders Find the group of orders you need to cancel and review the date and time of the order that is intended to be removed and confirm accuracy. IF there are less than 100 orders and less than 24 hours time period you can use the Cancel Bulk Orders button while highlighted on the desired order group to be removed.

44. More than 100 Bulk Orders? If a Nurse following the protocol places bulk orders or communication and identifies an error more than 24 hours following the bulk order or communication OR if the bulk activity involves more than 100 patients, the best practice advised would be to notify the Population Health team in Clinical Systems for analysis, communication plan, and management. The goal of the notification would be to identify methods to minimize patient impact as well as to prevent future errors. Use one of the following to report these errors: 1)Send electronically a help message (in Epic) including the error description, type of order, time, and affected number of patients estimated 2)By telephone contact directly the 77EMR to open a ticket for the episode with the detail in (1) Why let the team know if the mistake is large? They want to help make Sure that patients are not impacted as well as think about how to prevent Future mistakes?

45. What if the report is inaccurate or has errors? 1)Ensure that the patient’s chart is up to date (ie. Has the right orders placed, has the correct health maintenance triggers, etc.) 2)If you just changed information in the patient’s chart, the report can take a day or two to update itself. 3)Finally if the information is still inaccurate contact the Population Health team in Clinical Systems for analysis, communication plan, and management by one of the following methods. 1.Send electronically a help message (in Epic) including the error description, type of order, time, and affected number of patients estimated 2.By telephone contact directly the 77EMR to open a ticket for the episode with the detail in (1)

46. Summary Nurses expected to run these reports monthly Continue using Reporting Workbench reports – with new phone contact Transition to My Panel Metric reports as they become available (results should be the same for Reporting workbench and corresponding dashboard reports) Nurses will receive yearly training notices from the UC Learning System Yearly refresher training and assessment is required Train the trainer responsibilities Know what to do if you make a mistake Patients are allowed to “opt out”. Honor their requests using the do not contact flag in demographics

47. Reference Documents Training will be posted on http://emr.ucsd.edu/resourcelibrary/Pages/Ambulatory.aspx Nurses are to complete a yearly refresher course as well as completion of competency exam by a trainer.

48. Other Service Lines

49. Cardiology Bulk Ordering Access the Cardiology Specific Bulk Order reports

50. Cardiology Bulk Ordering Filter the reports on the last cardiologist seen Send Bulk orders one provider at a time

51. Follow the same process as above sending bulk communication and bulk ordering SmartText for Cardiology Specific is labelled as “Bulk LDL CARDIOLOGY ORDERING” Cardiology Bulk Ordering

52. Enterprise Protocol Ordering Run the All UC Patients with no HM Protocol order Report

53. Enterprise Protocol Ordering All patients who have not had a HM Protocol Order placed within the past 5 years are displayed. Select all the patients (Shift + Click) and choose bulk orders

54. Enterprise Protocol Ordering Sign the Health Maintenance Protocol Order for all patients