1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Alabama Practice Name: Partners in Pediatrics, LLC

2. Team Members Cheryl A. Outland, MD Rebecca Wilson, RN Robert Troy, Administrator Ashley Dicks, Chronic Care Coordinator

4. Progress Summary Key Driver 1 - Team

5. General staff training and consciousness rising Delegated tasks Added Ashley as Chronic Care Coordinator Nurse: Educational Materials, equipment and work station structure Increased MD participation, meet monthly TEAM and all nurses attended seminar with local allergist

6. Progress Summary Key Driver 2 - Registry  Define Patient Population  Goal: To use our existing EMR  MD & Administrator – Met with EMR vendor to learn capabilities & potential  Design “reports” needed to manage population  Diagnosis code 493.00  ICS prescription to search for asthma children

7. Progress Summary Key Driver 2 - Registry  Nurse reviewed every identified EMR chart  “PLANNING” to track “POST VISIT”  Attach severity (Intermittent, mild, moderate, severe) to 493.00  Severity category defines follow up interval

8. Progress Summary Key Driver 3 – Planned Care Asthma History Form incorporates ACT and correlate with EMR complaint Asthma history note in EMR is clearly readable Gradually increased staff and patient participation 5 EQIPP encounters per month/MD EMR screen order changed to alert nurse & nurse enters history Front desk gives Asthma history form at check-in

9. Progress Summary Key Driver 3 – Planned Care  ACT score = use of encounter form  CCC collects history form with ACT score  ACT score as a vital sign

10. Progress Summary Key Driver 4 – Protocols  Flu shot ordered for every 493.00 for September 1  NO albuterol refills  Physicians – discussing preferred meds for our group  Spirometry  Follow up plan

11. Progress Summary Key Driver 5 – Self Management Support Nurse owns patient education materials and organization of nurse work station and exam rooms. Collected materials to distribute and books for rooms. Met or spoke with drug companies, allergists and Blue Cross. ACT score – graph to monitor progress (with next EMR update) Written instructions Asthma Action Plan – red, yellow, green light Detailed taper plan for acute attack visits. Spacer, Diskus, Nebulizer how-to

12. EQIPP Graph 1 % of patients with 1 or more asthma-related ED or Urgent Care Visits within the past 12 months. ED or Urgent Care Visits

13. EQIPP Graph 2 % of patients with 1 or more asthma-related hospitalizations within the past 12 months. Asthma-Related Hospitalizations

14. EQIPP Graph 3 % of patients with asthma ages 6 months and older who have received a flu shot or flu shot recommended within the past 12 months. Flu Shot Given or Recommended

15. EQIPP Graph 4 % of patients in which reasons for lack of control is identified when asthma is “not well controlled” or “very poorly controlled” Reasons for Lack of Control

16. EQIPP Graph 5 % of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis. Spirometry used for Diagnosis

17. TEST 1 What: Who (population): Who (executes): Where: When: PD SA TEST 2 What: Who (population): Who (executes): Where: When: 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: Who (population): Who (executes): Where: When: PD SA TEST 2 What: Who (population): Who (executes): Where: When: 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: Who (population): Who (executes): Where: When: PD SA TEST 2 What: Who (population): Who (executes): Where: When: PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA PDSA Title PDSA Ramps

18. PDSA: Encounter Form and Asthma history No. 1  Plan: Utilize CQN parent history  Do: Photo Copy Ask physicians/nurses to use with 5 patients/month. Note in chart.  Study: one MD/Nurse team kept forgetting difficult to use in EMR history not patient friendly  Act: Revise form teach nurses basics of 2007 guidelines integrate with EMR

19. PDSA: Encounter Form and Asthma history No. 2  Plan: Revise order of encounter form to match EMR history  Do: assign “questions” to category in our EMR (symptoms, severity, timing, context) enter “answers” into EMR history asthma tree create training plan/manual for nurses demo at a staff lunch  Study: text reads very awkward nurses forget to initiate MD’s doing 5 only Too much too fast  Act: revise encounter form to look friendlier revise template to read easier with good English construction devise means so nurse with “notice” Asthma make it faster

20. PDSA: Encounter Form and Asthma history No. 3  Plan: Make encounter sheet friendly and fast for patient and nurse  Do: ask team to revise preview with staff and our friends who have asthma kids ask several nurses to use on Mickey Mouse and Donald Duck  Study: “ED” confusing, other complaints need more hints on when to go to next category  Act: some wording changes clean up form, mark EMR section on form for nurses

21. PDSA: Encounter Form and Asthma history No. 4  Plan: Engage nurses to initiate encounters consistently  Do: Revise EMR screen order so summary page with problem list is always viewed first team nurse (who works with backup MD) and team physician’s nurse trained on new EMR encounter sheet and EMR plan. other nurses to be trained in small groups supervised with Mickey or Donald encounter written copy of encounter form/prompts and text  Study: Nurses comfortable, only getting some patients  Act: Review at staff meeting begin every checkup and recheck Asthma over 2 years

22. PDSA: Encounter Form and Asthma history No.5  Plan: Engage front office staff to initiate Encounter History learn how to flag office computer  Do: Assign front staff to flag with an ALERT all Asthma children on registry list provide encounter history form and clip board at front desk to give to “Alert” parents on arrival Instruct staff to give form to all visits except traumas  Study: Sometimes missing “Alert”  Act: Put colored sticky note at edge of computer screen

23. Office Flow Document

24. CQN Asthma Encounter Form Partners in Pediatrics, LLC Asthma History Form Please help our practice improve the care we provide your child with asthma. Our goal is for your child to be symptom free, sleep well and participate in all activities. Your nurse or doctor will review these questions with you. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Visit Date _____/_____/______Severity Score: _________________ Patient Name _____________________________ Date of Birth ____/____/____ Med Record # ____________ Name of person completing history________________________ Relationship to child ____________________ Type of Visit: ( ) Well visit( ) Asthma Check ( ) Sick today SY-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------SY In the past 4 weeks how frequently has your child: a) Experienced cough, shortness of breath, wheezing or reduced activity (asthma symptoms) during the DAY? (5) None (4) < 2 days/week (3) 3 to 6 days/week (2) daily (1) throughout the day b) Experienced cough, shortness of breath, wheezing or reduced activity (asthma symptoms) at NIGHT? (5) None (4) once /week (1) most nights c) Needed a QUICK RELIEF MEDICINE for symptoms? Examples: Albuterol, Xopenex, Proair, Proventil, Ventolin) (5) not at all (4) once a week or less (3) few times a week (2) more than once any day (1) 3 or more any day Q--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Q In the past 4 weeks has asthma limited your child’s ACTIVITIES at home or school? (5) not at all (4) a little of the time (3) some of the time (2) most of the time (1)) all of the time In the past 4 weeks my child’s asthma CONTROL is: (5) Completely controlled (4) well controlled (3) somewhat controlled (2) poorly controlled (1) not at all controlled SV-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------SV In the past 12 months was your child: a) Admitted to a hospital for asthma? ( ) yes ( ) nob) Treated at an ED or Urgent Care Center for asthma or breathing problems? ( ) yes ( ) no c) Prescribed an Oral Steroid medicine (Prednisone, Orapred) for Asthma? ( ) yes ( ) no d) Evaluated by an Allergist or pulmonologist? ( ) yes ( ) no T---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------T How many days of school/daycare has your child missed due to asthma in the past 6 months? _________days How many work days did an adult missed due to your child’s asthma in the past 6 months? _________days C--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------C Do you have a written Asthma Action Plan? ( ) yes ( ) no During the past month is your child taking any DAILY control medicines for Asthma or Allergic Rhinitis (Atopy)? Please List ____________________________________ Do you have a spacer? ( ) yes ( ) no M-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------M When are Asthma symptoms worse? Check all that apply ( ) winter( ) spring ( ) summer ( ) fall ( ) during exercise – Used inhaler? ( ) yes ( ) no Do you notice any triggers that start the cough or seem to make the Asthma worse? ( ) tobacco smoke ( ) animals ( ) change in weather ( ) perfumes ( ) mold or dust ( ) certain places ( ) viral respiratory infections, a cold ( ) allergic rhinitis, “sinus”

25. Other – Training Asthma Encounter History in EMR Asthma Encounter History for EMR (The following EMR entries directly correlate to the Parent History Form. A dotted line will separate the sections on the parent history. The chart text will read best if you tap the tree in this order. The left hand column below is an exact copy of the tree choices in the Asthma Encounter. The right hand column is the text that will print in the chart note. The first 5 questions are The ACT-asthma control test. Please tabulate the score, record it in the complaint section (top section in EMR complaints) then record it on the top right hand corner of the Parent history form. Chief complaint Asthma History Form *Well checkAsthma encounter form at Checkup *Asthma recheckAsthma encounter form at Asthma Recheck *Sick VisitAsthma encounter form during sick visit more times on any day.

26. Other – Training “Quality” Quality *Activities Limited +5--- not at all Activities are Not limited. +4-- once a week or less Activities are limited once a week or less. +3-- few times a week Activities are limited few times a week. +2-- more than once a day Activities are limited more than once a day. +1-- 3 or more any dayActivities are limited 3 or more times on any day. *Parent opinion of control +5--Completely controlled Parent believes asthma is completely controlled. +4-- well controlled Parent believes asthma is well controlled. +3-- somewhat controlled Parent believes asthma is somewhat controlled. +2--poorly controlled Parent believes asthma is poorly controlled. +1-- not at all controlledParent believes asthma is not at all controlled.

27. Other – Training “Severity” Severity (MEMO: CHOOSE ONLY 1 OF THE 1 ST 3 ITEMS) *Admission/ED/ UrgentCareCenter –NO No Asthma admission, ED or Urgent Care Center visit occurred in the last 12 months. *Admission—YESChild was admitted to the hospital for Asthma in the last 12 months. *ED/ Urgent Care Center ---YESChild went to an ED or Urgent Care Center for Asthma in the last 12 months. * Oral Steroid +NoAn oral steroid was not used for Asthma in the last year. +YESAn oral steroid was prescribed for Asthma in the last year. * Allergist/pulmonologist +NO No pulmonologist/Allergist was needed in the last 12 months. +Yes A pulmonologist/Allergist was seen in the last 12 months.

28. Other – Training “Timing” Timing *Missed school/day care during last 6 months +yesChild missed school/daycare during the last 6 months due to asthma +noChild didn’t miss school/daycare during the last 6 months due to asthma *Missed work during last 6 months +yesand parent missed work during the last 6 months due to Child’s asthma. +noand parent didn’t miss work during the last 6 months due to Child’s asthma.

29. Other – Training “Context” Context *Asthma Action Plan +NoChild doesn’t have an Asthma Control Plan. +YESChild uses an Asthma Control Plan. *Long-term control Meds +noLong-term control meds were NOT used most days last month. +YES (click yes and all that apply) Long-term control meds were used most days during the last month: + (LIST OF ANTIHISTAMINES, NASAL SPRAYS AND ASTHMA MEDS) *Spacer +NOChild does NOT use a spacer. +YESChild uses a spacer.

30. Other – Training “Modifying Factors” Modifying factors *Seasonal Symptoms +YES (click yes and all that apply) Asthma seems worse in the winter, spring, summer, fall. +winter +spring +summer +fall *Exercise Induced +NoExercise doesn’t cause symptoms. +YESExercise causes symptoms. +Uses MDI before exerciseA Quick Relief Med is used before exercise. *Triggers +YES (click yes and all that apply)Asthma symptom TRIGGERS are tobacco smoke, animals, change in weather, perfumes, mold or dust, certain locations, URI, allergic rhinitis. +tobacco smoke+animals+change in weather+perfumes +mold or dust+certain locations+URI+allergic rhinitis

31. Key Learnings  Change is difficult  Frequent monitoring until the change is OUR way  Parents and kids like being WELL!  Improvements generalize

32. Barriers and Successes “Barriers” Cost: Time and Money Staff hours = $$ Physician hours EMR Our lack of planning is not their emergency. Physician/practice failure to fully understand EMR potential. Habits Die Hard

33. Barriers and Successes “Successes” Structural Changes The preferred way is the easy way (Reliability theory) Reorganized nurse and physician work station for uniformity and easy availability. Changed order of EMR screen opening. Double Dipping Parent asthma history form becomes the medical history. Part of the Asthma history form is the ACT. ACT score can be tracked to measure improvement. ACT score (1005F) serves as “proxy” for QI monitoring of charts. Asthma Severity – defines follow up protocol Technologically Savvy We’re getting there

34. Future Plans A. Buy printers for each MD computer Implement Spirometry Refine use of patient educational materials by nursing staff Revisable Asthma Action Plan in EMR (when vendor ready) Refine “reports” (vendor must program) Devise work plan for CCC – Chronic Care Coordinator B. Adapt methodology for other chronic disease – i.e. ADHD