Lauren Veicht, MBA
March 11, 2015
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About Us
Background Information
Approach
Quality Measures & Workflow
Patient Engagement
Q&A
About Us
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Headquarters in Springfield, IL
Second largest private multi-specialty clinic in Illinois
Nearly 400 providers
Practicing in nearly 80 medical specialties and subspecialties
• Serving 20+ locations, and a population of nearly 1 million
patients
• Went live on Allscripts TouchWorks EHR in 2006 using all
modules
Background Information
• Identify patients that can benefit from a disease management program.
• Target patients with specific high risk needs or chronic conditions to help
manage them more closely and effectively.
• Promotes consistency and continuity of care, thereby improving quality of
care and reduce costs.
Approach
• Segment the population into categories for prioritization.
• Prioritize prevention and interventions for patients at highest
risk and subsequently highest cost.
• Shifting from a defensive approach, to an offensive approach
to patient care by utilizing clinical quality measures.
Capturing Measures
• We are currently utilizing primary care measures, in order to
accommodate both Meaningful Use and our MSSP/ACO
programs.
• Some of these quality measures are:
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Preventative Care and Screening: Influenza Immunization
Pneumonia Vaccination Status for Older Adults
Falls: Screening for Future Fall Risk
Tobacco use: Screening and Cessation Intervention
Diabetes Mellitus: Hemoglobin A1c Poor Control
Colorectal Cancer Screening
Hypertension (HTN): Controlling High Blood Pressure
Depression Remission at Twelve Months
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Description: Percentage of patients aged 6 months and
older seen for a visit between October 1 and March 31 who
received an influenza immunization OR who reported
previous receipt of an influenza immunization.
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Workflow: We have QIS hosted by EHR Integration
 For this measure, we document vaccine administration
via the Immunization tab. Historical data is documented
via Immun Hx tab and flows to QIS.
 Description: Percentage of patients 65 years of age and older
who have ever received a pneumococcal vaccine.
 Workflow: Same as for Influenza – active medication
administration is documented via the Immunization tab
 Historical information is documented under Immun Hx tab in
TW. This information then flows to QIS.
• Description: Percentage of patients 65 years of age and
older who were screened for future fall risk during the
measurement period.
• Workflow: We plan to use a series of questions to determine
whether the patient is high risk for falls.
• We will assess whether the patient has:
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A history of falling in the previous year;
Four or more medications per day (dizziness);
Balance and gait problems;
Low blood pressure
• Data will be captured via the vitals panel
• Description: Percentage of patients aged 18 years and
older who were screened for tobacco use one or more times
within 24 months AND who received cessation counseling
intervention if identified as a tobacco user
 Workflow: We utilize an order group to meet this measure,
which includes our individual education orders and
instructions. The patient also receives a pamphlet from the
provider.
• Description: Hemoglobin A1c Poor Control: Percentage of
aged 18—75 years with diabetes mellitus who had most
recent HgbA1c greater than 9.0%
 Workflow: We have an order/result interface - This is data
is captured once the electronic lab result is finalized with an
HgbA1c is greater than 9%.
• Description: Percentage of patients aged 50 through 75
years who received the appropriate colorectal cancer
screening.
 Workflow: Fecal occult blood test (FOBT) lab test flows
automatically into QIS; Flex sig and colonoscopy are a
document, enter into the order that you received the result,
or manual entry into QIS.
• Description: Percentage of patients aged 18 through 85
years of age who had a diagnosis of hypertension (HTN)
and whose BP was adequately controlled (< 140/90 mmHg)
• Workflow: Data captured during intake process via vitals
panel
Description: Adult patients age 18 and older with major
depression and an initial PHQ-9 score > 9 who demonstrate
remission at twelve months defined as PHQ-9 score less than 5.
This measure applies to both patients with newly diagnosed and
existing depression whose current PHQ-9 score indicates a need
for treatment.
Workflow: We are reviewing two possibilities;
• Implementing a paper form for patients to fill-out, scan in, and
pull a query on the scanned documents.
• Or, we are also reviewing an upgraded version of QIS, which
will allow us to build “Depression Remission” and input the
date we had the patient fill out the form.
Patient Engagement
• 90% prefer web-based access to health information and
education
• 72% want to book, change or cancel physician appointments
online
• 88% want to receive email reminders for preventative or
follow-up care
• 76% want the option of email consultations with doctors
Patient Engagement at Springfield Clinic
mySC Mobile App:
FollowMyHealth:
-FMH Achieve
-Utilizing online forms
-Recently implemented
online registration
Photos in TouchWorks:
- Capturing before and
after photos of patient
surgeries
dbMotion:
SC Calcs:
QIS Upgrade:
- Providing patients
electronic forms that can be
completed in the office on
an iPad
- Allow providers to enter
information in QIS, and
have it flow to
appropriate place in
TW.
- Assist with MSSP/ACO
workflows.
-Planning to interface
with 1 MSO, and 3 local
hospitals
-Lincoln Land HIE has
decided to use dbMotion
solution as the EHR
agent for the local
hospitals
- Will provide patients a
visual aid in detailing their
progress
- Forms file directly into TW
after approval
-Symptom Checker
- Disease Prevention
Program
- New Patient Appt.
Requests
- Library of health
articles and
apps
Questions?