Implementation OF MU: Hospital based practice

1. Implementation OF MU: Hospital based practice Mark Huang, M.D. Chief Medical Information Officer Rehabilitation Institute of Chicago

2. REHABILITATION Institute of Chicago • Hospital based practice with academic affiliation to Northwestern University • 65 medical staff including mid level providers • 40 residents, 6 fellows • Main hospital outpatient clinic • Cerner EHR (Powerchart) • Offsite clinics on the main EHR • Partnerships not fully on EHR

3. DECISION to pursue MU • Cost analysis: • software costs • incentive payments • impending penalty consideration • Roughly break even for the organization • Overlap with PQRS compliance • Some aspects were “meaningful” • Eprescribe • Problem list • Visit summary for instructions • Patient portal

4. Implementation Strategies • Establish implementation task force • Weekly status updates • Analyze current clinic workflows • Review proposed changes with EHR • Extra tasks needed for MU • Review exactly who does what for each measure to ensure this will be completed • Involve clinical staff in decisions

5. Additional office staff tasks • Invite patients to participate in patient portal (automate registration, encourage use for refills, electronic communication) • Record demographic information (race) • Record vital signs (BP, height and weight) • Record smoking status • Document smoking cessation plan • Record family history • Update allergies and medications • Generate transition of care document

6. What physicians need to do? • Medication reconciliation • Maintain/update problem list • E-prescribe • Generate clinic visit summary • Patient education • Secure messaging with patients via the EHR

7. WORKFLOW IMPACTs • Less clinic efficiency • Clinicians taking longer to complete visits per patient • Office staff duties diverted to meaningful use compliance tasks • Increased after hours catch up work • Information given to patients not relevant to scope of practice

8. VITAL SIGNS • Height, weight, BP, BMI • Growth curves in children 0-20 • Target: 50% of unique patients • Exclusion: < 3yrs • Establish process with office staff that ensures height and weight routinely obtained • Obtain scales for clinic • Height recording • Those in wheelchairs, ask for estimated height • Many EHR uses metric system • Issue quick conversion charts for english to metric

9. SMOKING • Target: < 50% unique patients older than 13 • Smoking • Ensure staff assess for smoking • Can also use documentation to record any interventions (one of the clinical quality measures includes smoking cessation)

10. Problem list • Target: 80% of patients must have a problem documented • Maintain active problem list • Encourage use of problems, often these can be used to create diagnosis for charges • Clinician needs to review PRIOR to printing visit summary • Strategy: • could have clinical staff enter initially and physician review/edit as approp

11. Problem list

12. VISIT Summary • Target: 50% of all office visits • Provide summary within 3 business days • Excludes procedures • Include at minimum following information • Problem List • Diagnostic Test Results • Medication List • Medication Allergy List

13. Visit Summary • Providing clinical summary one of most challenging objectives to meet • How will patient get document? • End of visit • If not done at end of visit who will track visit summary completion and how patient will get document • Mailed to home • Patient portal • Need to ensure process for completion • Can use extender to print document

14. Visit summary Workflows • Physician or designee updates medication list before patient leaves clinic. • Visit Summary replaces patient’s copy of the Med Reconciliation List • Physician or designee will sign visit summary document • Front desk staff will print visit summary and distribute to patient at check out • this was later changed to clinician prints to front desk

15. VIEW Transmit DOWNLOAD • Target 50% of unique patients • Patients are provided online access within 4 business days to their health information • Problems, allergies, medications, vitals instructions • Patients only need to be invited to have access, they do not actually need to view or access the actual online content • Emphasize enrollment with patients • Allows easier access to visit summary if done after the visit

16. Electronic prescriptions • Target: 40% of eligible prescriptions must be sent electronically • Electronic prescription of non controlled substances • Must be sent directly to the pharmacy • Controlled substances • Controlled eprescribe requires 2 levels of authentication

17. E-prescribe • Clinicians route prescription directly to pharmacy

18. Decision support • Create decision support that may assist in other areas (clinical quality measures)

19. Medication reconciliation • Target: 50% of visits must have medication reconciliation performed • At each office visit, review medications patient is taking • Most EHRs offer some method of medication reconciliation (must be able to simultaneously compare 2 different lists of medication)

20. Quality measures • Few measures are applicable to PM & R • Even those that seem applicable may not • Not all measures are built within EHR reporting • Consider group reporting for quality measures and PQRS

21. Quality measures: • Measure #238 (NQF 0022): Drugs to be Avoided in the Elderly • Measure #312 (NQF 0052): Low Back Pain: Use of Imaging Studies • Measure #39 (NQF 0046): Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

22. Quality measures • Measure #48 (NQF 0098): Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older • Measure #154 (NQF 101): Assessment of Fall Risk in the Elderly

23. MU reports • Status reports • Ensure accuracy of reports • Use reports to target providers at risk • Deploy resource to assist with education and support • Early intervention critical to compliance • Identify personnel to review reports • Examine feedback from users in regards to workflow • Observe for best practices that can be applied across users

24. Reports

25. Reports

26. Attestation • Ensure that you have supporting information • Begin registering early • Complete attestation by end of Feb of subsequent year • BE SURE TO KEEP CAREFUL RECORDS OF COMPLIANCE in case of an audit

27. Stage 2 Challenges

28. Transition of cARe • Provide a summary of care document for more than 50% of transitions or referrals to another provider of care • Includes therapy and home health referrals • A further 10% of these summary of care documents need to be sent electronically • Challenge is finding enough referral sources who can receive these • Conduct test with a another separate EHR or conduct successful electronic exchange of information

29. Transition of care • Sometime difficult to determine exactly which provider to send document • Patient has not decided on provider • May not know by end of office visit • Requires process to follow through • Identifying referral sources that can receive the information • Many therapy sites and home health agencies not equipped to receive transition of care electronically

30. Secure Messaging • 5% of patients need to message provider via secure messaging means (patient portal) • Email does not count • Challenging for certain disabled populations • Often requires use of email to enroll • Many clients do not use email or have a computer • Elderly, indigent population, those with language barrier

31. SECURE MESSAGING • Strategies • Automate enrollment in patient portal • Ask patient to review portal information • Message patients who have signed up to get them to respond • Discourage email communication

32. Conclusion • Workflow analysis • EHR usability critical to success and satisfaction • Reports key to measuring progress • Feedback from providers critical