Clinical Information Systems
Chronic Care Learning Communities
California Association of Public Hospitals
Lisa Johnson, M.D.
David Ofman, M.D.
Oakland, California
November 2, 2004
Adapted from Improving Chronic Illness Care
www.improvingchroniccare.org
The Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Delivery
System
Design
Informed,
Productive
Empowered Interactions
Patient
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
You are
here
If a productive patient-clinician
interaction is at the heart of good
visit, then information
is the life blood flowing throughout
that interaction
Currently: Information Available
During the Interaction Tends to Be:
• focused on the paper record
• disorganized
• disease/procedure-centered
versus patient-centered
• responsive to the past interaction
versus forward looking
What would be more helpful?
Clinical Information System
System Change Concepts
•Provide timely reminders for providers and patients.
•Identify relevant subpopulations for proactive care.
•Facilitate individual patient care planning.
•Share information with patients and providers to
coordinate care.
•Monitor performance of practice team and care
system
What is needed in terms of technology?
The technology is not the issue!
It could be a :
•
•
•
•
•
•
shoebox full of 3x5 cards
a paper log of patient data
spreadsheet
simple database
web or LAN-based repository
electronic medical record
What is the Issue?
Functionality!
Whatever you use must be able to
deliver information that supports the
practice team in the delivery of
individual and population-based care
For many of us,
it will be a registry.
A registry is a list of patients and their
relevant clinical data that can be sorted
by a condition or set of conditions in order
to improve and monitor the care of the
population
What a Registry Should Be
• be quick to implement and simple to use
• be organized by patient; not disease, but
responsive to disease populations
• contain only data relevant to clinical practice
• make data entry simple and efficient
• be easy to update from automated data sources
• assist internal and external performance reporting
• guide clinical care first, measurement second!
Can I use my EMR for what I
need to do? Yes, if…
• It provides access to lab data, dx test
results, and across settings in your
system.
• Guidelines and prompts are included for
needed services
• You can identify populations and
subpopulations of patients
Can I…(cont.)
If…
• Allows stratification of patients
(complexity, disease severity for case
management services)
• Captures outcomes by provider
• Captures all critical clinical information
Reminders
Timely reminders for providers and patients
Prompts to deliver evidencebased care.
They can be delivered :
• At the time of visit
• Through population reports
• Via exception reports
Use of Exception Reports
Focus on subgroups: EXAMPLES:
Patients not seen in > 6 months:
Sort: “not followed at this clinic any longer - delete
PCP designation ”, or “needs reminder letter”.
Send standardized outreach reminder letter.
Patients with HgA1C of > 9.5: Providers and DM
Team have focused diabetes case conference
on these patients – Goal is to make Care Plan
for high risk patients - may need increased
multidisciplinary team work
Use of Exception Reports
Examples (Diabetic Patients) of Other Exception
Reports that can be used to improve care:
Patients with no HgA1C within 6 months
Patients with no LDL within 12 months
Patients with LDL over 130 (or over 100)
Patients without documented Pneumovax
Populations and subpopulations
Relevant for proactive care.
Populations and subpopulations
Relevant for proactive care.
Population-Based Care
• Goal: Maximize the health outcomes of a
defined population (all patients for one
clinic, a provider panel, patients at risk)
• Efforts are made to assure that all
relevant members of a population receive
needed services
• Use info systems, planning and outreach
Individual Patient Care
Planning
Individual Care Planning
• Having the right information readily
available at the time of the encounter
(patient summaries)
• Having the right tools to create and track
treatment plans, both clinical and selfmanagement
• Ensuring that all routine care is delivered
at the appropriate time
Manifestations of care planning
• Summaries provided to patients
• Description of patient actions and
provider actions
• Shared care plan
Share information
To coordinate care
Avoiding miscommunication
Ensure understanding of the care
processes across all parties
Reduce duplication of effort by care
providers
Eliminate frustration caused by
uncertainty of who is delivering what
care when!
Monitoring performance
Of the provider and system
Use the CIS to:
1. Create population-specific reports
2. Facilitate external reporting
requirements
3. Create dashboard reports of the
practice as a whole
CIS: Facts vs. Fears
Fear: Why do we have to have a registry?
Fact: Planned population-based care cannot be done
without knowing your patient population and its
key clinical data
Fact: Primary care teams that implement registries
are more likely to improve processes of care for
all chronic conditions
Fact: Teams with registries are less likely to lose
patients to follow-up, and more likely to improve
patient satisfaction as care improves
CIS: Facts vs. Fears
Fear: I don’t need anyone telling me how to practice!
I’m doing just fine with my patients!
Fact: Surveys show that providers consistently under
estimate the numbers of patients with chronic
disease in their practice
Fact: Surveys show that provider consistently over
estimate their performance measures on
process and clinical outcomes for chronically ill
patients.
Fact: The two are interdependent.
Fact: Knowing you population of patients will help
rectify this disparity.
CIS: Facts vs. Fears
Fear: It’s just more work during our already hectic
day!
Fact: Using a patient summary form from a Registry
will actually reduce charting time and make the
visit run more smoothly
Fact: The form gives a snapshot of past care,
reminders of needed care and planning for
future care all at the time of the visit
Fact: Teams with registries feel better prepared for
visits since they have the patient information
when and where they need it.
CIS: Facts vs. Fears
Fear: This will cost me a fortune and there’s no return
on investment!
Fact: Implementing a registry is simple, and there are
economies of scale as you add more patients.
Fact: Registries facilitate populations-based care
which improves outcomes and patient
satisfaction
Fact: Planned care via the registry generates visits
that are typically of higher intensity while
reducing unexpected visits for acute
exacerbations
Making Clinical Information
Work for You in Clinical
Practice
The Software
• Assess available software for appropriate
functionality
• Install the software.
• Identify training resources.
• Highlight CIS importance to rest of team
for buy-in
The Chronic Illness Data Manager
• Identify best person on team to manage the
disease management information.
• Choose person with computer skills and
interest.
• Define roles and responsibilities for manager.
• Secure training for manager as needed.
• Train a back-up.
Populating a Registry
• Use billing data and ICD9 codes to identify
specific populations or build prospectively.
• Download names and contact information
into registry.
• Establish process for regular population
updates.
Getting Clinical Data into the
Registry
• Define the relevant clinical data needs.
• Use the visit for collecting nonautomated data.
• Develop and test data capture process.
• Use chart audits judiciously.
• Develop and test data entry process
Using Data at Point of Care
• Establish process for producing patient
summary data for use at time of visit (acute or
planned)
• Make sure summary is replacing other data
capture processes to avoid double entry.
• Ensure summary is on chart or in exam room.
• Ensure new data is captured on the summary.
• Develop process for new summary data to be
entered into registry.
Using Data for Care Reminders
• Establish what you want “reminding” about.
• Determine how you want to be reminded.
(i.e, exception reports or individual patient prompts)
• Identify team member responsible for monitoring
reminders.
• Create process for responding to reminders.
(i.e., who calls patient, when. for what purpose)
• Create process for updating/modifying
reminders.
Using Data to Monitor
Performance
• Determine what types of population
reports are needed, and at what reporting
intervals.
• Establish process for creating customized
reports.
• Who will generate reports?
• Who receives reports?
• Do the reports facilitate continued
improvement?
Keys to Success from Those that have
Implemented Registries
• Everyone understands the clinical utility and supports
the time involved in registry upkeep.
• Care management using registry data is a team
approach
• Dedicated time each week for primary team to use data
• Data forms are clear, roles are assigned.
• Data are clinically relevant, used for patient care first,
and measurement second.
• Data can be shared with patient to improve
understanding of treatment plan.
Barriers to CIS use
• Lack of perceived value
• Competing business and productivity
demands
• Lack of office flow expertise
• Lack of information support
• Lack of leadership support
For More Information:
Please visit Improving Chronic Illness
Care’s web site at
www.improvingchroniccare.org
Target Areas for Improvement
Problem: Low levels of Lipid
Profile documentation AND low
levels of self-mgt goal setting.
Idea: Actively find patients
without lipid profile and get
them into the clinic. Combine
visit for free lipid profile with SM
Goal setting.
Purpose of a test cycle: Test
use of free lipid profiles to
improve performance on the key
measures.
Set SM Goals at time of lipid visit
Query run
Free lipid profiles offered
Monitor Impact of Test Cycles of
Change
100%
All Teams
using huddle
to target DM
Marcia is
patient
now part of
needs.
the Huddle
43%
38% 40%
32%
percent
80%
60%
40%
SM PDSA
Implemented
20%
0%
11%
48%
52%
Staff
Training
58%
60%
All care teams
setting SM
goals with pts
14%
1% Feb-00
3% M ar-00 Apr-00 M ay-00 Jun-00 Jul-00 Aug-00 Sep-00 Oct-00 Nov-00 Dec-00 Jan-01
Jan-00
Monitor Impact of Implemented
Changes
100%
percent
80%
Received new DCMS
softw are update
60%
70%
No data
40%
available for a
20% monofilament
foot exam.
0%
Implemented
foot stamp
52%
60% 61%
46%
34% Discussed need for
proper
documentation
75%
80% 82%
S urpassed YR
ur2010 National
Objectives for
Foot Exams
RN’s
doing foot
exams
0% Feb-00
0% M0%
Jan-00
ar-00 Apr-00 M ay-00 Jun-00 Jul-00 Aug-00 Sep-00 Oct-00 Nov-00 Dec-00 Jan-01
Identify Reasons for Lack of
Improvement: Ocean Park Health Center
Brainstorm
Stuck at
53% for
LDL < 100
Decision Support?
Documentation?
Tests not ordered
(missing prompt)
Test not ordered
(no buy-in to guideline)
Test ordered (but not
treating to target)
Data verification –
comparison of registry to
chart and lab records