1. CQN Team Presentation Kim Giuliano, MD Sharon O’Brien, MA Ivana Wilson, Medical Secretary

3. Progress Since Learning Session 1 Adaptation of CQN form into EMR Policy for incorporation of CQN form at every visit for patients with asthma Simplified process for generating asthma action plans in EMR Multiple revisions of office flow diagram to improve reliability Monthly reliability reports given to MDs and nursing staff Designed asthma education sheet to be given to all asthma patients at every visit EMR report generated by IT department of all patients in practice who have been prescribed a controller medication for asthma EMR report requested from IT department of all patients in practice who have a diagnosis of asthma

4. Optimal Care

5. Use of Validated Tool

6. Asthma Action Plan

7. Asthma Education

8. TEST 1 What: CQN paper form Who (population): 5 pts Who (executes): Giuliano When: 2 clinic sessions in Oct PD SA TEST 2 What: EMR form Who (population): Giuliano pts Who (executes): Sharon O. When: week of 10/19/09 PD SA TEST 3 What:: Expansion of EMR form Who (population): all asthma pts Who (executes): entire office staff When: week of 10/26/09 PD SA TEST 1 What: EMR Asthma Action Plan using letter template Who (population): Giuliano pts Who (executes): Giuliano When: week of 10/26/09 PD SA TEST 2 What:: EMR Asthma Action Plan using “dot phrase” Who (population): Giuliano pts Who (executes): Giuliano When: 10/30/09 PD SA TEST 3 What:: EMR Asthma Action Plan using “dot phrase” Who (population): all asthma pts Who (executes): all MDs When: 11/6/09 PD SA TEST 1 What:: Handouts given when verbal teaching not done Who (population): Giuliano pts Who (executes): Giuliano When: 12/1409 PD SA TEST 2 What:: Handouts given during rooming process Who (population): Giuliano pts Who (executes): Sharon and Carmen When: week of 12/21/09 PD SA TEST 3 What:: Handouts given during rooming process Who (population): all patients Who (executes): RNs and MAs, MDs if not completed prior When: week of 1/11/10 PD SA CQN FormAsthma Action PlanEducation Handout PDSA Ramps

9. MA/RN puts revised CQN form with provider only questions on top of patient identification sheet Patient is ready to be seen by Physician During the visit the physician fills out the provider form while having Informed clinical Discussion Questions 11-27 Patient with new diagnosis of Asthma, form is pulled and filled out concurrently Completed form returned to asthma form collection tray Physician completes the form immediately after the visit NO YES During Office Visit Post Visit Activities Nurse Leader removes encounter form and verifies for completeness If necessary circle back with physician or patient family by phone to obtain missing information NO All necessary information on the form is entered into EQIPP by medical secretary Paper copy kept on file at secretary’s desk Pull list of asthma patients from EMR every 3 months. If no form on file, letter sent to home to schedule asthma appointment. OFFICE FLOW DIAGRAM MA/RN rooms pt. If asthma med noted during medication reconciliation, MA/RN asks parents questions #1-10 and enters responses into medical record Patients ID by signal lights in EMR, stickers that ID patients (go on the sheets, physician questions) Parent/patient education handout given PFT/ spirormetry ordered if needed YES Nurse Leader checks form to see if f/u appt recommended NO YES Nurse Leader checks EMR to see appt was scheduled YES NO Nurse leader gives name to PSR to call and schedule appt Pre Visit

10. CQN Encounter Form Parent 1. Has your child visited the ER or urgent care due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"} 2. Has your child been admitted to the hospital due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"} 3. How many days of school/daycare has your child missed due to asthma in the past 6 months? {NUMBER:30898} 4. How may work days have you or your spouse missed due to your child's asthma in the past 6 months? {NUMBER:30898} 5. How comfortable are you in managing your child's asthma, rated on a scale of 1-10 (1=not comfortable, 10=very comfortable)? {NUMBER:29773} 6. During the past week, how often did your child use a fast acting or quick relief medication at times other than before exercise? {ALBUTEROL USE:70290} 7. When are your child's asthma symptoms the worst (select all that apply)? {TIMING- ASTHMASX:70291} 8. How often does asthma limit your child's activities? {ACTIVITY IMPACT:70292} 9. Over the previous 2-4 weeks, how frequently has your child experienced episodes of cough, SOB, wheezing or reduced activity due to asthma during the DAY? {FREQUENCY DAY SX:70293} 10. Over the previous 2-4 weeks, how frequently has y our child experienced episodes of cough, SOB, wheezing or waking up due to asthma at NIGHT? {FREQUENCY NIGHT SX:70295} 11. How would you rate your child's asthma control during the past month? {ASTHMA CONTROL:70296}

11. CQN Encounter Form Provider Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months?  Yes  No Has your child been admitted to the hospital due to asthma in the past 12 months?  Yes  NoIf yes, how many times? ________ Were one or more asthma key indicators present when considering the diagnosis of asthma?  Yes  No  Not documented Were lung function measures by spirometry used to establish the asthma diagnosis?  Yes  No  Age inappropriate, younger than 5 years Was a validated instrument used to determine the current level of asthma control?  Yes  No What is the patient’s current level of control during the past month?  Well controlled  Not well controlled  Very poorly controlled 6b:If “not well controlled” or “very poorly controlled”: Did you identify reason(s) for lack of control? (Examples: exposure to allergens, tobacco smoke, indoor or outdoor pollutants and irritants, non- adherence to medication regimen)  Yes  No Is spirometry currently scheduled or have results been obtained within the last 1 or 2 years?  Yes  No  Age inappropriate, younger than 5 years Have you used the age-appropriated NHLBI stepwise table used to identify treatment options or to adjust therapy based on asthma control?  Yes  No Has a flu shot been administered or recommended within the past 12 months?  Yes  No  Patient younger than 6 months or contraindications Does the patient have a written asthma action plan?  Yes  No 10b. If yes, was the plan updated as needed and reviewed at this visit?  Yes  No Were asthma self-management education and materials (other than or in addition to the asthma action plan) provided and explained to the patient and family at any visit?  Yes  No Was a follow-up appointment scheduled to monitor asthma control?  Yes  No _____ Needs to schedule in ______ months _____ Already has upcoming appt scheduled

12. EMR Patient Lists In Feb, IT Department pulled list of all asthma patients who had been prescribed controller medications Letter sent to patients’ home requesting them to schedule asthma visit Utilizing list as tool in absence of availability/feasibility of registry

13. EMR Patient List

14. Letter to Asthma Patients

15. Key Learnings  Testing on small scale first helps with group “buy- in”  Measures that are simple and do not involve significant increase in office visit time are implemented most successfully  Incorporation of nursing in more active roles in patient encounter has positive impacts in nursing attitudes and patient satisfaction

16. Barriers and Successes Barriers –Registry creation requires involvement of IT department that is responsible for entire institution. Priority is low. –Time Successes –Physician and nursing participation –Improved care for our patients

17. Future Plans Continue monthly audits to improve physician and nursing reliability Follow up letters or phone calls to patients on controller medications who did not respond to initial mailing re: asthma follow up appointment Letters to be sent to all asthma patients in September for flu vaccine Follow up letters to asthma patients 1 st week of December if has not had flu vaccine Continue to use EMR generated lists for identification of asthma patients if unable to utilize registry function within EMR