Making Data Work for You

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Making Data Work for You

• Use of the Registry in Pro-Active Care
• Celeste A. Frangeskou, RN, BSN
• State Collaborative Coordinator
• Texas Association of Community Health Centers
  (TACHC)
• cfrangeskou_at_tachc.org [phone]

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Goal of the Collaboratives

• To close the gap between what we know to do and
  what is actually done for every patient in the
  practice.
• To make planned and deliberate changes to the
  care delivery system so that in the future we can
  do what cannot be done today.
• To ultimately improve patient outcomes and delay
  or prevention complications associated with
  chronic care diseases and improve office
  efficiency.
• To sow the seeds of equity of healthcare for all.
• Source Health Disparities Collaborative Pre-work
  Manual, May 2003 Collaborative Charter Problem
  Statement

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Importance of Measurement

• Not about good or bad its about managing the
  practice in a better way.
• Tracking Population outcomes
• What percentage of our patients are due for an
  HbA1c or have an HbA1c gt9?
• Feedback for any level of clinical quality
• Performance improvement
• Accreditation
• Grant

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Issues in the Organization of Diabetes Care

• The biggest issue in care organization is that
  patients are only seen when they show up with a
  problem.
• They are seen at random times in the middle of
  chaotic days to be seen by providers who are
  stressed out, behind schedule and disorganized.
• Important questions to ask
• Can you identify all (or nearly all) the patients
  with diabetes seen at the practice?
• Do you know what services those patients should
  be offered in any given year?
• Do you have a system for tracking how you are
  doing?

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Clinical Information System

• A registry defines your total population of
  patients. Know who your patients are.
• Provide reminders for care that is due at the
  time of the visit and remind the provider who is
  due for a visit.
• Provides feedback for providers and patients.
• Identify relevant patient subgroups and provide
  proactive care. (Those that are in need of better
  management)
• Facilitate individual patient care planning
  through the registry.

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Clinical Information System Redesign Changes

• Populating PECS for your center.
• Running monthly reports
• Patients who havent been seen in the past year.
• Practice level reports - where is the gap in
  care?
• Improved Patient Care Planning
• PECS encounter notes updated and in the chart
  before the provider sees the patient.
• Reminder reports who is due for care who do
  you want to recall?

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Clinical Information SystemKeys to Success

• Define your clinical data needs
• What do you need to track?
• For the provider
• For the practice
• What do you want to be reminded about?
• For individualized patient care planning
• Patient care summaries for the visit
• Identification of relevant subpopulations of in
  need of proactive care.
• Which Monthly Reports do you need?
• Performance improvement initiatives
• Accreditation
• Grant

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Clinical Information SystemKeys to Success

• Identify the best person on the team to manage
  the CIS and
• Train a back-up person
• Define the roles and responsibilities
• Always, always, always back up your data.
• Incorporate ways to verify data integrity
• Identify 5 patients and do a chart review to see
  if what is in PECS is accurate.

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One Team Overview

• Family Practice Services at 5 sites just south of
  Boston, MA
• Approximately 650 patients with diabetes
• POF 205 patients
• Spread site 45 patients
• Computers used for appointment scheduling and
  patient registration
• No clinical databases before PECS
• In the process of converting to an EMR

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First use of the RegistryWho needs an office
visit?

• Query for patients who havent had an office
  visit gt90 days, check appointment schedule to
  confirm no appointment
• F/U phone call to make an appointment, letter
  sent if unable to reach by phone
• Track appointments in PECS weekly and f/u no show
  and cancelled appointments
• Note placed in chart to follow medication
  protocol Effective for patients who would
  schedule an OV to get med refill then N/S or
  cancel.

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Other Uses

• PECS encounter used as diabetes flow sheet to
  guide adherence to care guidelines with items
  needing attention highlighted
• Query to identify patients
• with HbA1C gt 8.0 for case management and
  referral to diabetes educator or nutrition
• no visit gt 90 days
• no eye exam gt 1 year
• Creating new field in Consults/Education to
  track
• - return to clinic for labs
• - eye exam report forms
• Documenting and follow-up of self-management
  goals
• PECS summaries and graphs to communicate the
  progress of the project to staff, leadership, and
  BOD

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Uses outside the CHC

• We are using the registry data
• To assess status and report on projected outcomes
  for grant projects.
• To describe current efforts, support our ability
  to sustain and spread our improvements, and
  identify needs in care delivery for grant
  applications.
• To complete the application process for Diabetes
  Self-Management Education Recognition.
• To form Community Partnerships.

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Tips and Traps on using the registry for
pro-active care

• Tips
• Secure leadership support to provide funding for
  registry development and maintenance
• Incorporate a system for data entry to keep
  registry database/PECS encounters current/have
  back-up data entry staff
• Highlight needed interventions/easier for
  providers to use
• Utilize the report functions that are built into
  the system
• Continuous education and collaboration with staff
• Traps
• Reliability of data
• -Deletion of referral checks (ex.for eye
  exam)
• -Staff and provider resistance to using form
  at every OV
• Trying to complete every field, only enter data
  you will use

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Plans to use the Registry
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A Clinical Information Systems PDSA

• HDC2005 Learning Session 2
• Atlanta, GA
• May 11-14, 2005

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A Case Study

• Community Health Center in Nebraska participating
  in the CVD collaborative
• Struggling with making improvement with measure
  LDL Cholesterol lt100mg/dl
• The number of CVD patients with CAD, or DM whose
  last fasting LDL value (documented within the
  last 24 months) is less than 100 mg/dlavg
  stagnant at about 33 for 1 years.

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Known relationship between statins and LDL

• From the PECS Data Dictionary
• Statins are medications used to treat
  Dyslipidemia.  They lower LDL and triglycerides
  and raise HDL.  They have been extensively
  studied and shown to prevent cardiovascular
  events.

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In the spirit of the HDC.

• A PDSA was initiated!
• The prediction If the CVD patients not on
  statins can be identified, contacted or
  recalled, and prescribed the medication, then
  LDL Cholesterol levels in these patients -along
  with the population average- will decrease
  (improve).

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Changes to PECS

• A statin reminder was added to the PECS Encounter
  Note which would activate when a patient had DM
  or CAD, was gt40yrs, was not already on a statin,
  and had no contraindications for this particular
  med

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Step 2--

• Use the RSR Drill-down to identify patients with
  LDLgt100
• Find out if those patients are on statins (choose
  a methodie. Run the drill-down for the statins
  item and compare lists)
• If already prescribed statinsschedule
  appointment to take a fasting LDL
• If notschedule visit and/or prescribe med
  (unless contraindicated)

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The RSR Drill-down
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Results of the Case Study

• After only 6 months, the percentage of patients
  who had an LDLlt100 had increased 12 (from 33)
• After 10 months, the percentage increased 39.6
  (to a current 72.6)
• Prescription rate of statins went from lt40 to
  gt75 in 6 months
• After 10 months, the prescription rate for
  statins increased to 96

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This is just one example!

• There are many ways you can use PECS to improve
  the quality of care youre providing to your
  patients.