advancing team-based care:data driven dashboards to support team based care

WelcomeThe National Cooperative Agreement on

Advancing Team-Based Care

WEBINAR 4: Data Driven Dashboards to Support Team-Based Care

April 7th, 2016

Presented by the the Community Health Center, Inc. & the MacColl Center for Health Care

Innovation

SpeakersFrom MacColl Center for Health Care Innovation, Group Health Research Institute:Ed Wagner, MD, MPH, Director Emeritus Brian Austin, Deputy DirectorKatie Coleman, MSPH, Research Associate

From Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program Manager Veena Channamsetty, MD, Chief Medical OfficerNicholas Ciaburri, BS, Director of Business IntelligenceTierney Giannotti, MPA, Quality Improvement Data AnalystLori Clavette, RDH, Mobile Dental Program ManagerRamon Clark, Medical Assistant

From Community Health Partners:Lander Cooney, MS, Chief Executive OfficerHannah Pulaski, MSN, RN, Nursing DirectorAmber Traxinger, Data Analyst

Community Health Center, Inc.

Foundational Pillars1. Clinical Excellence- fully Integrated teams,

fully integrated EMR, PCMH Level 3

2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students

CHC Profile:•Founding Year - 1972•200+ delivery sites•130k patients

The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training

to interested health centers in: Transforming Teams• National Webinars on advancing team based care• Invited participation in Learning Collaboratives to advance team

based care at your health center

Training the Next Generation• Two National Webinar series on developing Nurse Practitioner

and Clinical Psychology residency programs and successfully hosting health professions students within health centers

• Invited participation in Learning Collaboratives to implement these programs at your health center

Email your contact information to [email protected] and visit www.chc1.com/NCA.

mailto:[email protected]

Learning Objectives:1. Participants will be able to identify how two different

members of the team can utilize data driven dashboards.

2. Participants will be able to identify two potential impacts of using clinical dashboards on UDS outcomes.

Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and

#HRSAnca • Recording and slides are available after the presentation on our

website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca

http://www.chc1.com/nca

CHC’s Timeline in Using Data-Driven Dashboards• 1970s: Participated in

initiatives around data collection using computers

• 2006: First fully integrated electronic health record system• eClinicalWorks

• 2010: Built our own data warehouse, for reporting and data analysis• Covers clinical, financial,

and Human Resources• Currently: Integrating data and

process involvement with the goal of better patient outcomes

Creating Effective Dashboards and Reports• Team Based approach

• Each team member uses different sets of data, and gets a different dashboard

• Work with clinical leadership to identify the goal of the dashboard• Work with care teams and clinical microsystems to determine what data is

useful to them and how it best fits in with their workflows• Work with EHR staff to determine the best way to input the data

• Actionable Data• Distributing the data to the team members that can take action on it• Only include the data that is actionable – Too much data can be a bad thing!

Why develop my own reporting environment?• Control

• Buying vs. Renting• More transparent access to your

data• Flexibility

• Customize your dashboards and reports as you see fit

• Combine your data with data from other sources (payers, EHX’s, finance, HR, etc.)

• Workflows• Design your dashboards around

your workflows rather than your workflows around your reporting tools

BI Data Environment• Having Useful data starts with the EHR

• Structured Data• Reformat the data to make reporting

easier• Include business rules• Connect to data from other sources• Format for easier reporting

• EHR’s are designed for inputting data, not reporting

• Clean the data• Exclude non-valid values • Map data to categories

• Analytics Cube allows for drag-and-drop high level data analytics

Utilizing Data Starts on the Front LinesOur phone script

includes data on which appointments the patient is due for so that we can schedule all of their appointments at once.

Planned Care Dashboard

Complex Care Management Dashboard

Behavioral Health Dashboard

Dental Dashboard

Dental Dashboard (continued)

Strategies for Success:Using Measurement to Guide

Improvement

Chronic Opioid Dashboard: Background• One example of using data to improve quality

of care• Developed to support care teams in

management of patients using chronic opioids• November 2015: Grand Rounds on the

management of patients on chronic opioid therapy (COT)• New and improved Opioid Dashboard unveiled• Didactic information about managing COT

patients• Provider-specific report distributed• Panel management time to review cases on

the Opioid Dashboard

Chronic Opioid Dashboard

Control Charts: ExplanationLines on graphs:• Solid line = average

• Dashed lines = 3 std dev limits

Patterns to Look For:• Point(s) outside limits

• Shift (8 or more consecutive points on same side of average)

• Trend (7 or more points with consecutive increase or decrease)

Interpretation:• Pattern absent = random

variation• Pattern present = significant

∆

Mar-15 Jun-15 Jul-15 Aug-15 Sep-15 Nov-15 Dec-15 Jan-16 Feb-160

102030405060708090

100Urine Toxicology Screening (past 6 months)


20

40

60

80

100

Pain Assessment (past 3 months)

statistically significant increase for one month

Opioid Measures: % Patients Meeting Measure


102030405060708090

100Opioid Agreement (ever)


20

40

60

80

100Urine Toxicology Screening (past 6 months)


20

40

60

80

100Patients Receiving Behavioral Health

(past 3 months)


20

40

60

80

100Pain Assessment (past 3 months)



20

40

60

80

100 Prescription Monitoring Drug Website Queried (12 months)

statistically significant increase for two months

p Chart: Checking Rx Drug Monitoring Website – Site I

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-160%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UCLpPercentp-barLCLp

Month

% o

f pati

ents

on

COT

who

se p

rovi

der c

heck

ed

the

CT P

MP

in th

e la

st 1

2 m

onth

s


p Chart: Checking Rx Drug Monitoring Website – Provider I

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-160%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UCLpPercentp-barLCLp

Month

% o

f pati

ents

on

COT

who

se p

rovi

der c

heck

ed th

e CT

PM

P in

the

last

12

mon

ths

Resource Spotlight #1

Resource Spotlight #2

www.improvingprimarycare.org

Community Health Partners, Inc.• FQHC started in 1997, rural/frontier, ~130

employees, 6 sites• Medical, dental, behavioral health, pharmacy,

and educational programming• 12,000 patients during 45,000 visits in 2015• NCQA-recognized Level 3 PCMH since 2012• Live on NextGen EHR since April 2009, added

integrated EDR June 2012

Open Space for Discussion

RemindersSign up for our next webinar in this series:

A Team Approach to Prevention and Chronic Illness Management

Thurs., April 21st, 3–4 p.m. EST

Complete our survey!

Sign up at www.chc1.com/NCA

advancing team-based care:data driven dashboards to support team based care

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