Use of Computerized Clinical Decision Support System and Registry Functions to Track and Improve Clinical Outcomes

Pamela Ferrari RNDirector of Performance Improvement and Clinical Knowledge SupportOpen Door Family Medical Center Inc

What is CDSS?(Clinical Decision Support)

"Clinical decision support (CDSS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care." AMIA, A Roadmap for National Action on Clinical Decision Support, June 13, 2006.

Goal and Aims of CDSS To bring relevant knowledge to bear on the

health care and well being of a patient or a population of patients.

1. To make data about the patient easier to access or more apparent to a provider.

2. To foster optimal problem solving, decision making and action by a provider

“Clinical Decision Support-The Road Ahead”

edited by Robert Greenes

Types of CDSS Pop-ups and out of range alerts in the EMR-

Example out of range vital signs, and labs. Templates

Structured data collection Order sets

Recommend treatment of specific conditions CDSS/Alerts

Based on preventive guidelines and medical history

Provider reference Up-to-date, Epocrates

Pop-up alerts: Red Font Identifies Elevated Blood Pressure

Templates:Structured data collection

Order Sets: Hypertension

CDSS/Alerts: Based on preventive guidelines and medical history

CDSS Alerts: Trigger an Order Set for BP control

Provider Buy-in

Good ideas are not adopted automatically. They must be driven into practice with courageous patience. Hyman Rickover

US (Polish-born) admiral (1900 - 1986)

The Importance of Provider Panel Integrity

Provider feedback needs to be applicable to their patients

We use Rendering Provider/Primary Caregiver for most reporting,

We expect each patient to be seen by Primary Caregiver at least annually.

We set a goal that 80% of our patients should be seen by PCG annually.

PI Project for 2009

Patients w ho have seen their Assigned PCG w ithin the past year

80%

29%

75%

0%10%20%30%40%50%60%70%80%90%

Goal Baseline 2008 Present

Examples of CDSS that have improved care

Diabetes A1c screening lab alerts Hypertension EKG Order sets Self management. Structured data

templates. Asthma Action Plans. Structured data

templates.

Improving A1c screening for diabetic patients

The CDSS Alerts remind Providers to get an A1c

Order Sets tell Provider when the last A1c was performed

Provider/Site Feedback Reports

Self-management template, increased compliance with documentation of goals

Structured text is inserted into progress note

Examples of structured data we collect

Diabetes and hypertension control Medication adherence Diet and exercise assessment Last eye exam and result Last foot exam and result Self-management goals Results of autism screen Asthma control and Asthma Action Plan

Examples of templates we use

Well-baby visits--include all anticipatory guidance as well as developmental screening

Chronic Disease Templates--Asthma, Hypertension and Diabetes

Acute Disease Templates Pregnancy test templates encourage

enrollment in prenatal care

Diabetic foot exam

Structured data flows to Chronic Care Outcome reports and Flow sheets

Diabetes Flow sheet

Hypertension order set increased the number of patients with ECG.

Asthma Template documents both underlying severity and current control

Using data to improve care List all diabetic patients whose last A1c was

>9 and call them to come in for diabetes education.

List all patients without an Asthma Action Plan and invite them to an Asthma Night

List all hypertensive patients who said that they were not watching their diet and invite them to a presentation on the Dash Diet.

29%

52%

80%

10%

75% 75%

98%

25%

0%

20%

40%

60%

80%

100%

120%

Percent of patients w ho have had more thanone visit in the reporting year and have seen

their PCG at least once

Women w ho enter prenatal care in the f irsttrimester

% Diabetic patients w ith A1c in past 12months

% of Asthma patient w ith an Asthma ActionPlan

2008

2009

Improved Outcomes for the Practice

Clinical Performance Indicator Goal/National Benchmark

2006 2007 2008 YTD 2009

Percent of patients who have had more than one visit in the reporting year and have seen their PCG at least once

Goal80%

Not Collected

Not Collected

29% 75%

Percent of adult women screened for cervical cancer according to standard of care.

Medicaid 64%

63% 21% 59% 54.34%

Percent of women >42 years of age who have had a mammogram in the past two years.

Medicaid >50% 335 12% 26% 33.66%

Percent of Patients with asthma who’s current level of control is assessed * measure changed in 2008

Goal 80% unknown unknown unknown 42%

Percent of Patients with asthma who’s current level of control is well controlled * measure changed in 2008

Goal 80% unknown unknown unknown 32%

Percent of Patients with asthma with a current Asthma Action Plan Goal 50% 0% 2% 10% 25%

Percent of patients who initiate their prenatal care in the first trimester.

Medicaid 81% 80% 80% 52% 72%

Average last A1c for all Diabetic patients with an A1c measured in the reporting year.

Goal <7 8.2 8.0 8.0 8.2

Percent of Diabetic patients with HBA1C in past year Medicaid78%

60% 73% 89% 96%

Percent of Diabetic patients with A1c <7 .0Percent of Diabetic patients with A1c>7 and <9.0Percent of Diabetic patients with A1c < 9

Medicaid 51.2* lower is better

Not Collected

Not Collected

42%32%24%

35%33%32%

Percent of Hypertensive Patients ( no Diabetes) with Blood pressure control <140/90

Medicaid 53.4

Not Collected

Not Collected

Not Collected

45.44%

Percent of Hypertensive Patients with Diabetes with Blood pressure control <130/80

Medicaid29.5

Not Collected

Not Collected

Not Collected

26.85%

Provider Report Card for DiabetesProvider Clinical

Report Card May 2009

                   

Provider/Measure DG VK PM MRP SR AR LR DW TY Total

#Diabetics 76 117 72 139 15 21 83 70 217 1111

# A1c 75 117 71 139 14 21 83 70 214 1058

% with A1c in past 6 months

99% 100% 99% 100% 93% 100% 100% 100% 99% 95%

Average A1c 8.2% 8.4% 7.9% 7.7% 8.2% 8.6% 8.4% 7.4% 7.8% 8.0%

# A1c <7 26 44 23 58 1 7 25 37 91 409

%A1c <7 34.2% 37.6% 31.9% 41.7% 6.7% 33.3% 30.1% 52.9% 41.9% 36.8%

# Lipid 47 61 61 106 12 16 49 48 140 686

% Lipid 61.8% 52.1% 84.7% 76.3% 80.0% 76.2% 59.0% 68.6% 64.5% 61.7%

# Microalbumin 26 53 32 75 4 5 57 44 134 540

% Microalbumin 34.2% 45.3% 44.4% 54.0% 26.7% 23.8% 68.7% 62.9% 61.8% 48.6%

% DM BP Controlled <130/80

29.0% 16.0% 21.0% 34.0% 57.0% 25.0% 23.0% 55.0% 25.0% 37.0%