20141122 chfht infoway webinar
TRANSCRIPT
©Canada Health Infoway 2014
Central Hastings Family Health Team
1
Harnessing the Power of the EMR to
Improve Work Flow
Adam Stewart MD CCFPJulie Page RN MSc MHS PMP
©Canada Health Infoway 2014
• Who are we?
• How are we set up technology-wise?
• What is our current digital workflow?• Throughout a patient visit• From a population and programming perspective
• How did we get here?
• Challenges & Successes
Today’s Outline:
©Canada Health Infoway 2014
Central Hastings Family Health Team
3
©Canada Health Infoway 2014
Our Patient Population
Rural
Isolated
Elderly
Low Education
Low Socioeconomic Status
Minimal Private Coverage
High Health Care Needs
©Canada Health Infoway 2014
• Relatively small FHT
• Multi-Site
• 8000 patients
• Comprehensive primary care
• Chronic Disease Programs
• 6 Physicians (plus their staff 10+)
• 3 Nurse Practitioners• 0.5 FTE RN• 0.5 FTE RPN• 1.0 Program
Coordinator/System Navigator (RN)
• 0.5 Registered Dietitian• 1.0 Social Worker• 2.5 IHP Clerical Support
Our Team
©Canada Health Infoway 2014
Patient charts Marmora Server
Patient charts Madoc Server
Gilmour
Fax Server
Fax Server
Other Reports
Labs & HRM
Our NetworkPresent Day Our EMR is:
Telus PS Suite
©Canada Health Infoway 2014
The Workflow of a Patient Visit
7
Patient Register
Usher & Prep
The Encounter
Referrals & Tests
Follow Up
©Canada Health Infoway 2014
The Workflow of a Patient Visit
8
Patient Register
Usher & Prep
The Encounter
Referrals & Tests
Follow Up
©Canada Health Infoway 2014
The Patient Visit: Patient Registers• Arrows & symbols on appt schedule everyone the the status
of the patient’s visit.
– As soon as pt arrives and swipes health card, the “UP” arrow tells everyone pt has arrived.
9
©Canada Health Infoway 2014
The Patient Visit: Patient Registers
• Reception has patient complete pre-visit necessities, if applicable.
i.e.• Nipissing Screens for well child visits• Brief Pain Inventory for chronic pain visits• Urine dips, if applicable
• Exciting future role for:
• Instant Messages for rapid communication“Do you want a urine preg for Minnie Mouse?”
10
©Canada Health Infoway 2014
The Workflow of a Patient Visit
11
Patient Register
Usher & Prep
The Encounter
Referrals & Tests
Follow Up
©Canada Health Infoway 2014
The Patient Visit: Usher & Prep• Usher preps pt with BP
– Temp, Height, weight, vision, etc as necessary
• Standard stamps/templates for data entry
12
©Canada Health Infoway 2014
A special example: DM Visit Prep
13
Stamp in chart is started by the usher:
©Canada Health Infoway 2014
The Workflow of a Patient Visit
14
Patient Register
Usher & Prep
The Encounter
Referrals & Tests
Follow Up
©Canada Health Infoway 2014
The Patient Visit: The Encounter
• There is always a role for flexible, free-style, typed notes.
• Not everything fits into a classic pattern or ‘box’
15
©Canada Health Infoway 2014
The Patient Visit: The Encounter• Many presentations do follow patterns, though.• Opportunities for Stamps (“templates”) are
endless!
16
©Canada Health Infoway 2014
The Patient Visit: The Encounter• Stamps aren’t just for SOAP notes …
17
©Canada Health Infoway 2014
The Patient Visit: The Encounter• Towards the end of visit, take time for
opportunistic REMINDERS.
• There are endless possibilities for REMINDERS
18
* Note: the “COPD L1 Screen” reminder
©Canada Health Infoway 2014
A special aside: COPD Screening• As part of our Lung Health Program, we screen for COPD
• Level 1 (L1) screen for:• No COPD already diagnosed• 40 year or older• Past or present smoker• No spirometry or PFTs in 3 years• No previous L1 screen in 3 years
• Result is stamped into chart.
• This is done by any team member at any time
19
EMR Searches can then pull out those pts who need L2 screening (spirometry)
©Canada Health Infoway 2014
A special aside: COPD Screening• Once Level 2 (L2) screening is complete, the
spirometry results are stamped in to chart:
20
Standardized entry format allows for further data analysis
©Canada Health Infoway 2014
Now back to: … The Encounter
21
• A special example: The Diabetes Visit
• Our use of technology in our Diabetes Program has earned CHFHT two widely recognized awards!
– Canada Health Infoway’s“LEADing Practice Award”
– AFHTO’s“Bright Light Award”
©Canada Health Infoway 2014
Harnessing the EMR
• Telus Health EMR• aka “Practice Solutions”
• DM visits utilize the power of the “Encounter Assistant” feature.
•Fully customizable
•Data mainly entered in check-box or pull-down menu format, but the output is a typed text note when finished.
©Canada Health Infoway 2014
The Encounter Assistant
The final result of an EA is a tidy, stamped progress note.
©Canada Health Infoway 2014
Harnessing the EMR
Data is automatically imported
©Canada Health Infoway 2014
Harnessing the EMRClicking on this, opens a graph of A1C
©Canada Health Infoway 2014
Harnessing the EMRClicking on this, opens your web browser to the new CDA interactive guideline tool.
©Canada Health Infoway 2014
Harnessing the EMR
Clicking on these items opens a patient HANDOUT for quick and easy printing.
©Canada Health Infoway 2014
©Canada Health Infoway 2014
Report Card – Patient GOALS
• At the end of the report card, there is a section to enter the patient’s self-management goal(s).
• At the next visit, the form (and visit stamp) automatically populates with the last visit goals, making it readily available to reassess
• Eliminates the need to be scrolling back through the chart to dig up last visits notes.
©Canada Health Infoway 2014
Report Card – Patient GOALSReport Card from the visit 3 months ago:
Report Card at THIS visit:
This data is automatically imported to the current custom form
Patient picks a new goal and it is typed in here
Patient picked a goal and it was typed in here
… AND THE CYCLE CONTINUES …
©Canada Health Infoway 2014
The Patient Visit: The Encounter
• At the end of a patient encounter,
• Prescriptions are generally e-Faxed
• Handouts for pts are saved within the EMR to given to patients
• Referrals & Tests are completed and faxed electronically
31
©Canada Health Infoway 2014
The Workflow of a Patient Visit
32
Patient Register
Usher & Prep
The Encounter
Referrals & Tests
Follow Up
©Canada Health Infoway 2014
The Patient Visit: Referrals & Tests• INTRA-Team referrals:
• Mental Health Counseling• Dietician• Foot Care nurse• NPs for expertise roles in DM, insulin, HTN, Lung
Health
• All done quickly and efficiently within the EMR• Using ‘Custom Form’ referral forms• Using EMR messages
33
Trackable Data !
©Canada Health Infoway 2014
The Patient Visit: Referrals & Tests
34
• When the patient sees a Interdisciplinary Health Professional,
• All notes in the same pt chart for review by the primary care provider
• Messages back and forth, when applicable
• A “Discharge” Custom Form can be used (again for tracking purposes)
©Canada Health Infoway 2014
The Patient Visit: Referrals & Tests
• Referral Letters are e-Faxed
• Requisitions for tests are done digitally within with pt’s chart and are also e-Faxed
• All pending statuses are tracked with the EMR
35
©Canada Health Infoway 2014
The Patient Visit: Referrals & Tests
• Because we are remote and rural, most blood work is drawn on site by our hired phlebotomist.
• The Lab Req therefore stays in the chart until the patient is ready for it.
36
©Canada Health Infoway 2014 37
Custom Lab Req with “Buttons” that auto-populates preset options.
(The buttons are not visible when the req is printed)
©Canada Health Infoway 2014
The Workflow of a Patient Visit
38
Patient Register
Usher & Prep
The Encounter
Referrals & Tests
Follow Up
©Canada Health Infoway 2014
The Patient Visit: Follow Up• For important issues, can post-date messages to
self or front staff
39
©Canada Health Infoway 2014
The Patient Visit: Follow Up• i.e. DM recalls• Remember, the Diabetic Stamp note?
40
©Canada Health Infoway 2014
DM “Lost to f/u” Recall
• EMR search used to generate list of pts.
A staff member is given responsibility to pull a fresh list and recall pts on a monthly basis.
©Canada Health Infoway 2014
The Workflow of a Program
42
Build it
ONE SMALL STEP
at a time …
©Canada Health Infoway 2014
The Workflow of a Program• Start with a Registry
i.e. a “Diabetic Registry” or “COPD registry”
• Standardize the Data Entry• Every Diabetic has “250” in the problem list.• Everyone uses “COPD” for COPD pts.
• Run searches to clean up the data• Rule in false negatives• Rule out false positives• Ongoing process, repeat periodically
43
©Canada Health Infoway 2014
an example of a DM registry
44
©Canada Health Infoway 2014
Standardize the Documentation• For any variable or statistic that is to be tracked
• Ensure everyone is inputting the data in a standardized manner
• Start small, grow “One Small Step at a Time”
• Ensure engagement and agreement by all!
• The EMR can help make it seamless !– Remember the L1 COPD screening stamp?– Or the Spirometry results stamp?– Or the DM final EA stamped note?
45
©Canada Health Infoway 2014
The Workflow of a Program
• Regular monthly meetings• Report Data• Analyze Data• Set Goals
• Sub-Committees & PDSA’s
46
©Canada Health Infoway 2014
How did we get here?
47
Paper Charts
EMR“The Early Years”
EMR“Now”
©Canada Health Infoway 2014
How did we get here?• Again, “One Small Step at a Time”
• Keys to success:– External Consult: Best Practice in EMR use– PS Suite annual User Conferences– EMR ‘Super-User(s)’– Program Champions– Partnership with Third Party for Data Analysis– Monthly Meetings
» Shared goals, Engagement» PDSAs
• Never settle! Ongoing improvement.48
©Canada Health Infoway 2014
Challenges
49
• Still had a paper burden in the office• “Dirty” data input• Fluctuating engagement levels• Results plateau
©Canada Health Infoway 2014
QIP Monthly Monitoring
50
1/12/2014 Target All CHFHT Current
Total Number 801 Percent of DM pts with A1c<= 7 >60% 446 57% Percent of DM pts with A1c in past six months >90% 746 93% Percent of DM pts with BP <=130/80 >55% 492 64% Percent of DM pts on ACEI or AARB >60% 500 62%
Percent of patient with LDL<= 2.0 nmol/l in past 184 days >65% 292 63%
Percent of DM pts with retinopathy screening in past 24 months >90% 625 78%
Percent of DM pts with comprehensive foot exam in past 12 months >90% 522 65% Percent of DM pts with microabluminuris (ACR) screening in past 12 months >65% 663 83%
©Canada Health Infoway 2014
Successes
©Canada Health Infoway 2014
Successes
©Canada Health Infoway 2014
The Lung Health Program
53
Identification of patient eligible for screening – Level 1 and Level 2 Moving forward with COPD management and Smoking Cessation
Level 1 Screen (Canadian Lung Health Test)
90% of eligible screened to date-
728 positive screens representing 32.6% of Level 1 screens
Level 2 Screen (Spirometry)369 patients have received in house spirometry
57%24%
11%8%
Normal ObstructiveRestrictive Mixed
©Canada Health Infoway 2014
Success !
54
A transparent, interdisciplinary, primary care practice centered on providing quality care based on best practices
Full integration of the EMR into the practice
Custom reminders, stamps, custom forms, encounter assistant all used to document care
Ability to pull data to drive quality improvement plans
Staff satisfaction in using the EMR
Patient satisfaction knowing that their health care record is right at the finger tips of the care providers.
ONE SMALL STEP AT A TIME
©Canada Health Infoway 2014
QUESTIONS ??
55
• Central Hastings Family Health Teamwww.chfht.ca
• Dr. Adam [email protected]
• Julie Page, [email protected]