1. The Michigan Primary Care Transformation (MiPCT) Project Transition of Care Using an EMR (Epic) Diane McLeod BSN,RN, CCP

2. Disclosure I have no conflict of interest to declare I do not have any relevant financial relationships with any commercial interests 2

3. Objective Describe IT tools which facilitate clinician communication across the continuum for optimal patient care 3

4. Sparrow Health System Using EPIC EMR Ambulatory has been live since Aug 2010 Inpatient has been live since Dec 2012 4

5. Transition of Care (TOC) - Pre-EMR Care Facilitators had to rely on paper discharge summaries, ED reports or patient self reporting Inconsistent receipt of reports 50% of the time we did not know that the patient had been admitted Missed TOC opportunities 5

6. Non-Epic facilities TOC for non-Epic facilities still on paper D/C summaries scanned into the chart 6

7. TOC with Hospital on EMR Easily identify MiPCT patients PCP and Care Facilitator receive notification in “real time” of patient admission/ED visit and follow the inpatient/ED course Allows Care Facilitator to coordinate with inpatient care managers PRIOR to discharge Able to run reports and monitor in real time:  Inpatient stay/ED visits  Elective surgery/Procedures  Sparrow Urgent Care clinic 7

8. Identify MiPCT patients How do we determine if the patient is on our MiPCT list? 8

9. MiPCT Problem Created “MiPCT Eligible” problem using a dummy code Clearly visible on the problem list Can create an overview indicating when the case was opened and complex or moderate level IT automated monthly import of MiPCT problem 9

10. 10 How is “Real Time” notification possible?

11. 11 Care Team navigator section In-basket alert received when the patient is admitted to a Sparrow inpatient unit

12. 12 Caseload Tracking

13. Chief Complaint Chief complaint section of navigator - facilitates tracking of discrete data ▫ Ambulatory Complex OR Moderate Care Management ▫ Distinguish from Inpatient Case Management Problem list – adding problem “MiPCT Eligible” Episode create/link 13

14. Epic Reports Each Care Facilitator has a report formatted for their clinics/providers. Run the report several times a week to identify patients appropriate for care management services Displays: MRN/Name/DOB/Age/Gender Admit/Discharge date/Department Admission Reason/DX 14

15. Episode Initial contact create a MiPCT episode Follow up visits link today’s note to the episode Able to see all care facilitator activity/notes in one defined printable report Deactivate episode when patient discharged from care facilitator caseload 15

16. Follow Documentation If the patient is at a Sparrow facility we can monitor documentation in “real time” 16

17. Advantage of “real time” alerts Allows care facilitators to monitor the progress of inpatient or ED in “real time” Notes, orders, imaging and lab results readily available Able to communicate with inpatient/ED providers or care managers PRIOR to discharge Increased coordination of care and TOC 17

18. ED/Inpatient Documentation 18

19. Communication Send in-basket messages to Sparrow PCP/Specialists Send in-basket reminders to yourself and future date them, i.e. “call the patient for a status report” Patient portal: MySparrow ▫ Secure email from/to patient ▫ Patient flow sheet glucose and blood pressure Route documentation 19

20. In-basket/MySparrow message 20

21. Route your documentation 21

22. EMR Improves Documentation Legible Easy to retrieve Use Epic tools to chart faster 22

23. Ambulatory CF Documentation I hate hand writing out my notes! Not so fond of having to type out EVERY word either Sparrow utilized Epic’s smart tool options and created new/return patient note templates Self-management care plans 23

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26. Case Study Provided for your information to demonstrate how an EMR improves TOC Bolding indicates outcome or information directly related to use of EMR 26

27. Complex Case Study Problem List – “MiPCT Eligible” provider saw and referred patient PCP requested I work with 91 y/o male due to HgbA1c of 9.1 (last result 7.8) Called patient to introduce myself. Said he was not feeing “so good” Glucose in the past 3 days had been in the 400’s Facilitated CM and PCP visit now as I could see providers schedule 27

28. Findings Glucose in clinic was 425 Lantus vial empty – he thought he had at least one week of insulin left Novolog: giving incorrectly only at breakfast Glucose testing: only fasting HOH: often cannot hear the phone Lives alone: no life line/did not carry cell phone 28

29. Actions Facilitated PCP visit that day Determined he had previously been seen by Sparrow Endocrine specialty Electronic communication with Sparrow Endocrine. Coordinate care and receive suggested insulin dose changes Facilitated sooner Endocrine follow up apt Communicated with patients son - Demographics Home care referral 29

30. Actions – cont’d Son agrees to family home care insulin teaching I Accompanied patient and son to Endocrine appointment the following week Weekly calls to patient and son Patient chose to continue to live independently Son visited patient at least every other day and called twice a day 30

31. Follow up All was going well for a while………. 31

32. Two Months Later Accompanied patient and son to Endocrine apt Glucose running in the 500’s (I had just called patient 3 days ago –was told levels were 200) Insulin vial empty again! Insulin dose increased and patient sent home with new dose and monitoring instructions Another home care referral Family re-educated importance of medication safety 32

33. The EMR Advantage for TOC Next day I received an electronic alert - patient had been seen at Sparrow ED Able to follow up immediately with family and facilitate a PCP visit Home care updated Patient was firm that he wanted to continue to live alone independently The family did explore alternative living options and had a plan in place 33

34. 34 Fast forward ONE MONTH LATER…

35. Epic Electronic Alert Received Patient currently in the ED - hypoglycemia Notes indicated the plan was to send patient home Facilitated doctor –to-doctor call and discussed “the rest of the story” Patient was admitted to monitor hypo/hyperglycemia episodes and address safety concerns Social work involved In-patient CM communication 35

36. Currently Patient continues to live at home alone Son checks on him twice a day: before and after work Patient now carries cell phone with him Home care has just discharged him 36

37. 37 D IANE M C L EOD BSN, RN CCP C ARE F ACILITATOR SMG WEST 517-622-2788 SMG POTTERVILLE 517-645-0000 D IANE.M C L EOD @S PARROW. ORG D IANE.M C L EOD @S PARROW. ORG