Primary Care Providers Using Their EHR to Improve Quality: Lessons Learned

Practical solutions to typical practice problems

Presented by:Tashara Milligan, MA, PCMH CCE

Kelly Wiseman, BSN, RN, PCMH CCEWake AHEC Practice Support Services

Primary Care Practices – Where they are

What is PCMH?Paper? Or change to EHR?Maybe I should just

retire?

?Am I getting left behind?

I cannot afford all this change.

What is PQRS? Where do I

start?

What is the best EHR? Portal?

What is

health

information

exchange?

How can I get paid for my Medicare physical exam claims?

Why is Medicare paying me less?

Why am I printing visit summaries when the point is to be all electronic? Paper and ink is expensive.

Will I get a penalty?Am I required

to have a portal? People out here do not have home computers.

Objectives

• Identify the following obstacles faced by practices implementing EHRs – Obtaining population data from your electronic health record in order to

improve patient outcomes– Providing patients with patient health information (clinical summaries

and portals)– Managing resources when there are so many different quality programs

in which to participate– Interfacing– Security risk assessment

• Describe one solution to resolve each issue• Describe one problem providers will face as they implement the

2014 ONC-ACB certified electronic health records and continue to improve quality.

Meaningful Use and Quality –First you must have …

Certified EHR

• How do you know your EHR is certified?CHPL list http://

oncchpl.force.com/ehrcert?q=chplCHPL = Certified Health IT Product List

• Need the EHR to be ONC-ACB certified • ONC-ACB = Office of the National Coordinator

Authorized Certification Body – only 4 right now• CCHIT, Drummond, InfoGard, ICSA Laboratories• http://www.healthit.gov/policy-researchers-implemen

ters/certification-bodies-testing-laboratories

Problem 1EHR Quality Reporting

1. National Quality Forum (NQF) Measures are often used to report quality initiatives.

2. Practices want to use their EHRs to capture data to show improvement from their quality efforts.

3. Interpretation of NQF criteria for EHRs is based on each EHR vendor and their developer’s understanding of clinical structured data and the quality measure

4. Practices are limited by the functionality their EHR provides (NQF reports available, usability, evidence-based practice).

Problem 1EHR Quality Reporting

NQF Quality Reporting Myths

1. NQF reports from any ONC-ATCB Certified EHR provide the same results.

2. Only active patients will be included in any NQF report.3. Patient demographics will be consistent for any ONC-

ACB certified EHR and will be reported as delineated by the NQF guidelines.

4. Only current, evidenced-based practice is reflected in the NQF quality reports.

Resolution for Problem 1EHR Quality Reporting

1. Determine if the canned NQF report is accurate. Drill down to what patients are included and what conditions are met or not met.

2. Create your own quality report using the data captured in another field a. Review current workflowb. Where is it charted now? Is it structured?c. Can you build a report based on a procedure code,

historical data or other structured data?d. Test it!!!

Problem 1Documenting by

Entering Accurate Structured Data Charting to your EHR

• Text fields • Workflows within the EHR• Terms and structured data fields• Data location for quality reporting• Caution in charting by exception – functionality

depends on EHR• Must chart the negatives• Identifying patients in a certain group (e.g., referrals)

• Labs• LOINC codes!!

Resolution for Problem 1Documenting by Entering Accurate Structured Data

Charting to your EHR• Contact vendor and determine location for structured

data which will count for quality reporting

• Labs• Contact the lab to determine if they use

LOINC codes.• Enter a support ticket with the EHR vendor to

have LOINC codes established.

Problem 2Providing Patients with Patient Health Information

• Clinical Summaries• Patient Electronic Communication

Problem 2Clinical Summaries

• Cost • Workflow• Patient Questions• Not Customizable

Resolution for Problem 2Clinical Summaries

1. Print clinical summaries and provide them at check out.

2. Print clinical summaries for the nurse or provider to review with the patient.

3. Add a portal and make the clinical summaries available to the patient electronically.

Problem 2Patient Electronic Communication

1. Rural Areas with little broadband access2. Adolescents’ privacy3. Patient engagement (e.g., mobile device access,

computer availability, education level, interest) 4. Patient having access to information provider has

charted that the provider may not want the patient to read (e.g., suspected ETOH, appearance)

Resolution of Problem 2Patient Electronic Communication

Functionality1. Provider controls what is seen by patient2. Provider can add text explaining patient results 3. Privacy settings for adolescents

Patient Engagement4. Consider incentives for patients to engage – gift cards,etc5. Prompting patients to access portal by making lab results and clinical

summaries available 6. Adding prescription refills and appointment requests to the portal for patient

convenience

Accessibility7. Explore grants for increased broadband access8. Provide kiosk for patients in waiting rooms

Resolution of Problem 3Managing Resources During Transformation

1. How does a practice choose where to begin with transformation?a. Meaningful Useb. PCMHc. PQRSd. BQPPe. ICD-10

2. What should a practice consider when selecting?a. Practice prioritiesb. Time to completec. Cost to completed. Incentive to participate based on payerse. Penaltiesf. Staff Resource availability and burnoutg. Government/Organizational Mandates

Problem 3Managing Resources During Transformation

1. Practice Goals – undefined, unrealistic, competing

2. Not finishing one program before starting another

3. Starting more than one program at once

Problem 4Interfacing – Providers Sharing DataWhich to choose?

a. State and local health information exchange (WNCHN, NCHIE, CCHIE)

b. Direct Messaging c. EHR Provider Portal (e.g., eCW P2P)d. Encrypted emaile. Encrypted clinical care document sent via

regular email without encryptionf. Referral portal associated with Accountable

Care Organization

Resolution for Problem 4Interfacing – Providers Sharing Data

1. NCHIE is the only organization at this time with a connection to NCIR. You must connect to NCIR for MU compliance.

2. Determine what solution your ONC-ACB certified EHR has available. 2014 versions should have secure messaging.

3. Referral software and exchange with other members of their Accountable Care Organization

4. Exchange through the provider portal within the EHR 5. Email an encrypted clinical care document6. Disease registries7. Hospitals for diagnostic testing

Problem 5Risk Assessment of Patient Privacy

1. Expert consultation is expensive and unavailable

2. Office staff have difficulty completing the assessment because of terminology and skill level

3. System is hosted and vendor refuses to guarantee compliance

4. Limited resources to address security deficiencies

Resolution for Problem 5Risk Assessment of Patient Privacy

1. Office staff addresses checklist to the best of his/her ability and addresses deficiencies as they are able

2. Practice contacts IT support or another practice for assistance

3. Example security policies are adopted to the practice and implemented in the practice

Bibliography

• http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events.html

• http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf

• http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html