Chronic Disease Management

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Chronic Disease Management

• Co-facilitated by
• Frank Egan, Fiona Manning,
• Edwina Ingle, Sarah Lupton,
• Dela Wilkins

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Welcome

• Thursday
• August 23, 2007

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Before we start

• Facilities, breaks
• Review/adapt ground rules
• Group/partner work format
• BCMA payment forms
• Evaluation forms?

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Payment for session
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Agenda

• Introductions (name, where you work)
• Learning session format
• Assumptions and Approaches
• Plan for action

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Agenda LS1A
  1330-1345 Welcome and Introduction to
the CDM Pathway   1345-1400 Fresh Ideas
Enhancing Health Care (video)  
1400-1430 Expanded Chronic Care Model and
Planned Care       Whats in it for
physicians, patients, and practices  
1430-1450 Quality Improvement and the PDSA
Cycle (group work)   14501510 Preview of
CDM Toolkit   1510-1530 Nutrition Break  
1530-1600 Business Case for CDM  
1600- 1700 Introduction to Action Plans (group
work)
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Agenda LS1B
1700-1730 Introduction to Patient Registries
  1730-1800 DINNER Break   1800-1830 Create
an Action Plan for Patient Registries   1830-19
30 Introduction to CDM Toolkit   1930-2015 Creat
e an Action Plan for adopting the CDM
Toolkit   2015-2045 Closing QA
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Purpose

• This module has three sections
• Develop patient registries
• Adopt CDM Toolkit
• Implement planned recall

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Objectives Patient Registry

• Clinical practices will be able to
• Identify patients with a particular chronic
  condition
• Create a patient registry
• Measure improvement in care management

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Objectives CDM Toolkit

• Clinical practices will be able to
• Use flow sheets to provide evidence-based,
  guideline directed care
• Use tools to identify and monitor gaps in care
• Generate reports to profile your practice

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Objectives Planned Recall

• Clinical practices will be able to
• Implement an effective recall system
• Establish a planned, proactive recall system
• Generate reports
• Recall, Key Measures and Data Extremes

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Pathway for CDM Module
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Funding for CDM Module

• Learning Sessions
• 8 sessions
• Recommended 2 x full days 4 x ½ day
• GP Session x 8 3,074.78
• MOA 32 hrs 640.00
• Action Periods
• Potential 4,946.94

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CDM Action Periods
Potential Totals (including LS) 8,661.72
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Dates for Learning Sessions

• 7 hours
• August 23
• October 18
• Evenings
• December 13
• January 10
• February 7
• March 6

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Video

• Fresh Ideas
• Enhancing Health Care

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ECCM and Planned Care

• Art Macgregor

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Quality Improvement and PDSA cycles
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Plan-Do-Study-Act (PDSA)
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• Plan
• The purpose of this stage in the PDSA cycle is to
  help you analyze your current situation, and
  identify the goals and outcomes you want to
  achieve

• Do
• This stage of the PDSA cycle is designed to help
  you implement changes in small chunks to see how
  it works for you.

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• Act
• This is the stage in the PDSA cycle where you
  measure and evaluate the changes you have
  implemented to see if you have achieved your
  goals.

• Study
• This is the stage in the PDSA cycle where you
  measure and evaluate the changes you have
  implemented to see if you have achieved your
  goals.

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• CDM Toolkit
• What is it?

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CDM Toolkit

• What is it?
• Benefits (Why should I use it?)
• How does it impact me?
• What data can I see?
• How secure is it?
• Sample Reports

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What is the CDM Toolkit?

• A secure website for licensed BC physicians, and
  their delegates, to support General Practitioners
  and Collaboratives with
• Secure, Clinical Guideline (Flowsheet) -based
  data capture
• Collaborative reports performance indicators
  and quality improvement measures
• Direct data imports from office based EMR
  software (no more duplicate data entry)

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Current Flowsheets?

• COPD
• CHF
• CKD
• Depression
• Diabetes
• Hypertension/CVD/CKD Prevention
• CD Prevention (ages 50-70)

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CDM Toolkit Contextual Overview
HA/MOHSupport
Recall notices, provider stats,summary stats
Firewall
Input data
Input Data
ToolkitDataBase
Recall notices, Provider stats,Summary stats
Summarystats
Register Updates
MSP CDM Registers
Input data
Web browser
Recall notices, provider stats,summary stats
Input data
HNFTP(file transfer)
Registers(Future)
Input data
File extract (from clinic EMR)
Registers(Future)
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Benefits of the Toolkit

• Easy identification of CDM patients
• Access to current Guidelines and Protocols
• Standardized clinical and quality improvement
  reporting
• Provides peer comparisons individual to group
  comparisons
• Tracks changes in processes and patient outcomes
  over time
• Provides Guideline-based Patient Recall reports
• Supports multiple chronic conditions per patient
  without data duplication
• Supports interdisciplinary care teams and shared
  patient care
• Direct updates to correct MSPs probabilistic CDM
  Registers
• Supports GPSC CDM incentive fee data collection
  requirements

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Benefits (contd)

• .. irrespective of an individual GPs level of
  office automation Internet access and a web
  browser are all that are required

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How does it impact me?

• For physicians joining the PSP CDM module and for
  other new users
• The Toolkit can be pre-populated with MSP CDM
  probabilistic Patient Registers
• Physicians can then edit their registers online
  rather than starting from scratch
• Saves data entry time
• Saves chart review time

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B
CDM Toolkit Loading Patient Registers
PHC Physician requests PSP Physician Profile
Report
PHC Branch, MOH processesrequest
Physician submits signed request letter by fax or
mail
Physicians report generated, in secure
environment, from MSP administrative databases
Physician/MOA load register (from Report CD) to
Toolkit
CD and print version of report mailed to physician
MSP CDM Registers
CDM Toolkit (web browser)
Available soon June 2007
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What data can I see?

• Physicians (MRPs)
• Patient data for your own patients
• Patient data for other providers patients if
  they have granted you access to one or more of
  their patients
• Detailed, patient-specific reports for all
  patients for whom you have access
• Summary reports for all patients and providers
  for whom you have access
• MOAs, Nurses, other non-physician provider
  Delegates
• Patient data for patients to whom a physician has
  granted you access
• Detailed, patient-specific reports for all
  patients for whom you have access
• Summary reports for all patients and providers
  for whom you have access

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What data can I see? (contd)

• Health Authority PSP Teams
• Summary reports for providers within their HA or
  Collaborative
• No access to individual patient data
• Ministry of Health Administrators
• Summary reports for all providers within the CDM
  Toolkit
• Automatic updates to the probabilistic CDM
  registers (no human access to the data)
• No access to individual patient data
• Access Administration for all users (who has
  access to which patients, which providers data)

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How secure is the data?

• 128-bit SSL Encryption
• The same strength used for online banking
• PLUS
• Client-Side Certificates
• A second factor of authentication to ensure the
  user is entitled to use his/her user id (i.e. are
  you who you say you are?)
• Role-Based data access
• Only physicians or their authorized delegates can
  see patient-specific data
• Other users can only see aggregate reports

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CDM Toolkit Report Samples

• Advanced Search
• Reporting
• Recall Report
• Patient Education
• Profile Report
• Run Charts
• Patient List
• Data Extremes
• Key Measures
• Patient History
• Data Entry Summary

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Nutrition Break

• 20 minutes

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Business Case for CDM
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• Reimbursement process and criteria
• Incentive billing
• CDM
• Prevention fee codes
• Complex care

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Introduction to Action Plans

• Group work

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Patient Registries
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CDM eligibility guidelines

• Eligible chronic conditions must
• Be in the priority list (PHC Charter)
• Have a guideline
• Have a flowsheet in the Toolkit
• Therefore
• DM
• CHF
• Hypertension (HTN)
• CKD
• COPD

Effective May 2007. Eligible condition list
is subject to change over time
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CDM eligibility guidelines (contd)

• Choose an eligible condition
• Aim to develop your register for all of your
  patients with that condition
• If you have lt20 patients, add a second condition
  (and aim to add all of your patients with that
  condition)

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CDM Module Payments

• Are weighted higher than other modules because
  CDM is more work
• Do not affect your ability to bill the CDM
  incentive fees (e.g., HTN, CHF, DM)
• Do pay for data collection and analysis to
  support QI work
• CDM Toolkit is the only current option for this
• Direct data entry or through an EMR

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DINNER BREAK

• PLEASE BE BACK HERE
• AT 6 P.M.

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Create Action Plan

• For Patient Registries

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CDM Toolkit
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CDM ToolkitHow to Register
May 2007
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What do I need to use the Toolkit?

• Internet access
• Preferably high speed, but dial-up is possible
• An email address
• A current web browser
• E.g., Internet Explorer v6 or better, Firefox,
  Mac browser
• CDM Secure Website User ID and Password

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How do I Apply for Access?

• If you havent already signed up for the CDM
  Secure Website
• Complete the Registration Agreement online at
  http//healthnet.hnet.bc.ca/has/regagree/4614fil.p
  df
• Read the agreement and print a copy of the form
  for your files
• Hit Submit

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Request an ID for your MOA too

• Use the Access Administrator spot on the form
  to request an ID for your medical office
  assistant (MOA)
• This will make your MOA your delegate for the
  CDM Toolkit
• It will let your MOA
• Request new/reset passwords for you
• Call the helpdesk on your behalf
• Manage your patient registers
• Enter data
• Run reports

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List of Tools and Resources

• Practice Guides
• http//www.practicesupport.bc.ca
• Guidelines protocols
• http//www.health.gov.bc.ca/gpac/newsite.html
• CDM Toolkit
• http//www1.hlth.gov.bc.ca/phc/resource_secure_pra
  ctitioner.html

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Your Clinic Name, or Dr John X Lee Inc
Should be an email you can pick up at the office
MOA Email can be the same as the Drs
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Adding Other Delegates to your CDM Account

• Physicians can email Connections/Access Services
  at the MOH
• hlth.hnetconnection_at_gov.bc.ca
• Include your user ID and Organization ID
• Include the name, email address, phone and fax
  numbers for each individual you would like to
  permit access to your account

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What if I have an EMR

• GOAL Minimize duplication of effort for
  practices using EMR software
• There is an XML schema that permits EMRs to
  send data to the CDM Toolkit
• Vendors modify their software to extract
  flowsheet data into a standard XML file format
• Users then log on to the Toolkit and submit the
  file
• This eliminates data entry in two places
• Users benefit from the Toolkit reports
• All PITO approved EMR vendors will have this
  feature
• Some vendors already have this for some flowsheets

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Evaluation

• Please complete evaluation form at the end of the
  session

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Payment for session

• BCMA invoice form for todays session for GP and
  MOA
• BCMA invoice form for completion of In-Depth
  Practice Assessment Form (pre-work)

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CME Info

• CME is available through

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Getting Started