Download - Increasing screening for osteoporosis Team 1 - 10/2013 Thanks to Georgia Carlson and N Topeka staff
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Increasing screening for osteoporosis
Team 1 - 10/2013
Thanks to Georgia Carlson and N Topeka staff
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Increasing screening for osteoporosis
• Increase parsable documentation of fulfillment of patient choice for screening by USPSTF osteoporosis guidelines by 25% within 3 months • This is your operationalized
version• The elevator version is the
project title
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Baseline data
• Made by QI Tools at OpenCPU
• Sometimes only a single baseline measurement is available
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Baseline: Fishbone or Ishikawa diagram (cause and effect diagram)
• Made by QI Tools at OpenCPU
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Baseline flow chart
• Made by LucidCharts• PNG file downloaded from Lucid
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Process map: baseline (optional)
• Made by QI Tools at OpenCPU
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Stakeholder analysis• Stakeholder’s impression of barriers
– Doctor.: Clarity of evidence-based guidelines for f/u– Nurse:
• Hassle to input dx of tobaccoism in EHR=multiple clicks• Reluctance to persistently ask about smoking cessation• Lack of knowledge regarding billing for counseling
• Stakeholder’s impression of benefits from improvement
– Doctor: Better cessation rates/counseling=more $$– Nurse: More likely to ask and document if aware of $$
• Stakeholder’s impression of solutions– Doctor: All interventions seem reasonable and appropriate.– Nurse: Willing to try new EHR documentation, concern that “not willing to
quit, not counseled” will not be used
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Chart review
• We manually reviewed 50 charts for– Presence of asthma in promoted Problem lists
• Criterion: ICD9• Criterion: Excluded free text
– Parsable documentation in Health Maintenance of• PFTs/spiro with pre/post testing or methacholine challenge
– Criterion: Excluded free-text entries
– Scanned documents• PFTs/spiro • Presence of hyper-reactivity by pre/post testing or
methacholine challenge
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Pareto chart
• Made by QI Tools at OpenCPU
• Sometimes sorted bar-chart is better
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Interventions
• March 2011– All anticoag patients cared for by residents
• Single provider receives all results
– Cypress patients• Nurses verify doses when pt arrives for lab draw
• May 15, 2011– All anticoag patients cared for by residents
• Registry for identified late patients
• June 8, 2011– Cypress patients
• Point of care testing
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Flow chart: revised
Result is sent to Cypress Clinic
PA contacts the patient
Patient reports warfarin use and factors such as diet, medications, etc
Warfarin dose adjusted
INR f/u scheduled
Blood is drawn POC for INR by lab or home health or other
EHR queried weekly for pts without INR > 30d
Patient contacted > 30 d
Result entered into
EHR
Clinician & patient make decisions:Use Warfarin by Wichita nomogram
Nurse enters results into EHR
Nurse forwards results to PA
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Lit search: Clinical Evidence
• USPSTF Guidelines (http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm)
• Comparison of different screening tools (FRAX®, OST, ORAI, OSIRIS, SCORE and age alone) to identify women with increased risk of fracture. A population-based prospective study (PMID: 23669650)
• Bone-Density Testing Interval and Transition to Osteoporosis in Older Women (PMID: 22256806)
• Better would be to include a quantitative estimate of benefit
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Lit search: Implementation Evidence
• Mailed intervention and self-scheduling improves osteoporosis screening compliance• Control group: 5%• Mailed letters: 17%
o J Bone Miner Res. 2013. PMID: 22836812• Electronic Standing Orders Highlight Care Gaps and Allow
Nonphysicians to Address Themo DEXA rose from 45% to 52%o http://innovations.ahrq.gov/content.aspx?id=3140
• Try to quantify benefit
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Intervention 1:Improved Documentation
• 4 main categories• Concise• RN-approved
• Star: automatic drop-down to A/P
• ICD-9 code and G-billing code for appropriate counseling• Bill code every time,
but will not be billed after max allowable
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Intervention #2: Patient Information
Information to be sent by PCP Resident
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Results: projected monthly income
Unit price Before intervention@ 100 Pts/month
After intervention@ 100 Pts/month
Revenue 264.90 829.20
INR 8.83 264.90 264.90
Encounter billing 18.81 0.00 564.30
Expense 0.00 212.19
Staff time(who, how much)
$0.3/minute 0.00 0.00
Supplies for machine
207.18 per box which provides 48 tests
($4.32 per test)
0.00 129.49
Machine 496.20 0.00 82.70*
Net income per month
617.01
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Results:
• Made by QI Tools at OpenCPU
• Unusual to have this slide
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Summary
• Initial results suggest an improvement occurred
• Revenue positive
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Recommendations for future teams
• Can G-code be used for quarterly billing for anticoagulation?