EMR Tools to Support the Planned Care Model

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EMR Tools to Support the Planned Care Model

• Jeffrey Hummel, MD, MPH
• Qualis Health Medical Director for Clinical
  Informatics
• Director for Clinical Improvement, UW Medicine
• Neighborhood Clinics
• March 26, 2007

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Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Decision Support
Self-Management Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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The Big Question

• We did what Don Berwick told us to do, Dont
  wait for the technology.
• We built stand alone registries to support
  chronic illness care
• Now the technology is here, and were installing
  1st generation EMRs
• Designed for acute episodic care
• Few specific tools for chronic illness care
• Double entry is unsustainable
• So, what happens to the registry?

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We Thought a Registry was a Thing

• Thing 1 1995 GHC - spreadsheet
• Thing 2 2000 CDEMS - Access Database
• The planned care model said Clinical information
  systems
• Think of registry functionality, as a set of
  reporting and information display tools
• Disease/risk dashboard for individual patient
• Assorted tools for improving quality
• Population dashboard for a practice
• Reporting dashboard for outcomes monitoring

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Information Management

• In paper record - not enough information
• In EMR - too much information
• Information organization is the challenge
• Just the important information
• All the important information
• Physicians are trying to do the right thing
• Present the information so the answer to, What
  do I do? is obvious
• Push a button to make the right thing happen
• No booby traps

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Mission Stop flying blind by
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adding data-driven guidance
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EMR tools to support QI workflow

• Individual Patient Care Tools
• Overdue results
• Custom data entry forms
• Embedded Decision Support
• Chart note templates
• Order sets
• Health maintenance reminders
• Med-Med/Med-Allergy Alerts
• Flow sheets
• Patient Dashboards
• Population Care Tools
• Registry Functionality
• Back end reporting
• EMR production reporting functionality

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Over-due Results

• Electronic tickler file
• Message sent when an ordered test has no result
  after specified time interval to
• Ordering provider
• Designated support staff
• If there is no associated workflow, ODRs become
  cluttered with tests of limited importance

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Overdue Results Folder
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Custom Data Entry Forms

• EMRs have a limited number of places for entering
  data in categorical format, e.g. Foot exam
• Some useful data like PHQ-9 or asthma symptom
  severity score, etc, may not have a place to be
  entered
• Data entered into progress notes cannot be
  searched
• Custom forms allow providers to enter data in a
  format that can be stored and used for reporting
  or presented in a useful format such as in flow
  sheets

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Order Sets

• Mechanism for visually organizing orders
  pertaining to specific situations
• Diseases e.g. diabetes,
• Types of visits e.g. physical examinations
• Types of intervention e.g. immunizations
• Decision support
• Specific treatments e.g. helicobacter pylori
• Complex changing therapy e.g HIV

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Embedded Decision Support

• Directions for complex orders
• Useful for consultation
• Make sure ordering provider includes relevant
  information for consultant
• Make sure ordering provider gets needed tests
  prior to patient seeing consultant
• Useful for imaging
• Prompt for recent creatinine when ordering tests
  that may include contrast

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Health Maintenance Reminders

• Alerts for tests or interventions that need to be
  done at intervals
• Screening tests pap smears, CRC
• Immunizations
• Alerts visible when chart is opened
• List of HM reminders set to be delivered
• to in-basket of provider
• Delegated support staff

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Pop-up Med-interactions Allergy Alerts

• These are the only pop-ups that always arrive at
  the right time
• Need to balance severity of reaction against
  alert fatigue
• If sensitivity is set correctly they can prevent
  serious patient safety errors
• If set wrong they are frequently over-ridden by
  providers

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Med-Med Med-Allergy Interaction
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Flowsheets

• A way of presenting data on one or more
  parameters for a single patient to enhance
  informational content
• Trends
• Presenting information to patients BP, Wt, LDL
• Seeing pattern in subtle change Creatinine
• Getting all the information in one place anemia
  work-up, hypercalcemia workup

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Flow Sheets
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Flow sheet Graphs
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Chart Note Templates

• Mechanism for embedding decision support
• reminding provider to include specific elements
  in Hx and Exam
• Standardizing workflow for specific intervention
• Can be versatile
• E.g. modular soap note
• Disease specific
• Anticoagulation visit
• Planned diabetes visit
• Low back pain evalaluation

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Patient Lists

• Set criteria for inclusion of patients in a
  registry
• Problem list,
• Set of other criteria including meds ordered and
  lab tests ordered
• Must have way of removing people from registry
• No longer a patient here
• Receives care for this problem elsewhere
• Display set of data fields with each patient
• Date e.g. date of last lab test, last BP, last
  visit
• Value value of last lab or last BP
• Medication Active rx by pharmacologic sub class
  e.g. inhaled corticosteroids
• Status e.g. smoking status

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Patient List Registry in Production
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Backend Reporting
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Conclusion

• We are quickly moving to the age of EHRs
• 1st Generation EHRs have tools to support chronic
  illness care
• But you have to find them
• And they are improving
• On the Horizon Real-time applications for
  decision support
• longitudinally,
• including population management,
• across the range of complex situations

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Questions?