Health Care Homes: Learning
Community Disease Prevention
August 15, 2014
Grant/Contract # 73081
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Overview
Learning Communities can serve as a powerful forum for dialogue and
sharing of tools and best practices among clinic teams for improving
the care of patients and families. The goal of the Learning Community
(LC) is to improve the delivery of care by increasing competencies in
key areas.
We are historically great at collecting data in healthcare, but we are
not as good with using the data for quality and cost improvement. The
purpose of this LC is to introduce participants to techniques for
analyzing health care data for quality improvement.
In this LC, Key Health Alliance (KHA) facilitated clinic discussions and
focused their skills in increasing competencies surrounding the
measurement and reporting of electronic health record data to show
measurable improvement in the areas of tobacco cessation,
hypertension and hyperlipidemia. The LC included an introduction to
basic analytical methods and statistical techniques; introduction to
open source analytical tools and demonstrations for how these tools
can be used to exhibit health improvements by analyzing health data;
examination of effective use of clinical decision support, clinical quality
improvement and tracking and improving population health.
Objectives
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Identify organizational needs as related to data analytics
Develop use cases related to specific organizational needs
Extract meaningful data to measure outcomes
Analyze health care data to measure outcomes
Utilize analytic tools for analyzing health care data and
conducting statistical analysis
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Recruitment Goals and Outcomes
During the planning sessions for the LC, it was decided that KHA would
focus our outreach to clinics all using the same Electronic Health
Record (EHR) platform. Stratis Health, a partner of Key Health
Alliance, supports a user group that focuses its attention of users for
the GE Centricity EHR platform. Focusing the curriculum to a specific
EHR platform allows support and learning opportunities geared
towards that specific application.
The goal for clinic recruitment was four to five clinics from a variety of
communities and diverse populations with each clinic providing a team
of three to four participants. Refer to attachment A for the recruitment
flyer. Specifically, we set out to enlist:
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One
One
One
One
urban Federal Qualified Health Clinic (FQHC)
Rural Health Clinic (RHC)
small (or small group) of independent clinics
clinic that serves an underserved population
At the onset of the LC, five clinics confirmed and submitted participant
registration information.
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Lakewood Health System – six participants
Migrant Health Services, INC – one participant
Native American Community Clinic – three participants
Neighborhood HealthSource – five participants
Sawtooth Mountain Clinic – two participants
The clinic goals were met, however the attendees per community were
not. This may be due in part that in smaller clinics, workers
responsibilities cover more than one specific skills area or role.
After hosting and describing the LC format, curriculum and
expectations as part of the Kick-off Webinar, Neighborhood
HealthSource withdrew its registration.
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Participation in Learning Events
At the completion of this LC there were six learning events.
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The first webinar titled, “Kick-off Webinar: Introduction to Health
Improvement through Data Analytics” was well attended by all
five clinics.
The face-to-face workshop, “Introduction to EHR Data Collection
and Quality Improvement” was attended by all four clinics.
The third learning event, a webinar titled, “Using EHR Data” was
attended only by Lakewood Health System.
“Introduction to Basic Data Analysis for Quality Improvement”,
the fourth webinar learning event, was attended by three of the
four clinics. Native American Community Clinic did not
participate.
The second face-to-face workshop, “Advanced Data Analytics for
Health Improvement” was attended by all four clinics.
The sixth and final webinar, “Lessons Learned/Wrap-up” was
attended by two of the clinics. Native American Community Clinic
and Migrant Health Services did not attend.
Observations, Curriculum Development, Feedback and
Evaluation for each Learning Event
Kick-off Webinar: Introduction to Health Improvement
through Data Analytics
This webinar allowed KHA team members and clinic participants to
introduce themselves and describe what each person was hoping to
achieve by joining in this LC. Below is a summary of anticipated
outcomes:
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Hoping to see some direct application of Health Care Home
principles and utilizing the EHR
To see how other clinics were using their EHR to meet
Meaningful Use and how it ties to the three disease states
outlined in this LC
Looking for greater collaboration and ideas and how other clinics
are using GE Centricity
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Would like to review how data is collected, stored and how the
data is extracted or mined to improve data integrity
Refer to attachment B for the final agenda and presentation curriculum
that assisted in guiding the conversation during the webinar.
After the webinar concluded, it was requested that participants
complete an evaluation of the webinar’s effectiveness in meeting
expectations and objectives. There were nine questions specific to
these areas. A scale of 1-5 was used, 5 being the highest. Seven
people responded. Below are the average results:
Effectiveness in meeting expectations and
objectives
Average
Score
The presentation was well organized.
4.29
The presenters were knowledgeable about the specific
subject.
4.43
The presentation content was appropriate.
4.14
The webinar technology and instructions were easy to
use.
4.43
The presentation was relevant to my position.
4.29
The presentation increased my knowledge on this topic.
3.86
Please rate the overall teaching effectiveness of the
presenters.
3.71
The objectives of the presentation were met.
6-Met
1 – Not
Sure
Overall, I had a positive experience with today’s webinar.
4.14
Overall, the feedback was positive in nature. Since this LC is data and
quality-based and we requested that the data and quality subject
matter experts attend, it was suggested that Quality Improvement 101
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is not needed. The KHA team members learned through the discussion
and the evaluation that the LC really wants hands on, peer discussion
and facilitation on what each clinic is doing, how they overcome
barriers and struggles and how to improve data integrity.
Face to Face Workshop: Introduction to EHR Data
Collection and Quality Improvement
Based off the discussion and feedback during the Kick-Off webinar, it
was decided to change the format of the face to face discussion from
mainly a class room or presentation style workshop to a guided
discussion on obtaining the problem areas or barriers of data
collection, what clinics are currently doing to fix the identified barriers
and how can this LC can aid in the process. We provided the
curriculum as support but it was provided mainly as a resource for
participants. Refer to attachments C and D for the curriculum.
It was a great learning and information gathering session. A summary
of identified problems and current solutions follows:
Identified Problems:
1. Data Capture Issues
a. Unstructured data is captured too frequently
b. Custom forms are constructed which result in the storage
of varied data terms/formats (e.g., different observation
terms may be used for one problem)
c. Providers are unable to document efficiently
d. SuiteRomeo is a documentation application but is not used
consistently or in the same manner by all providers
e. SuiteRomeo does not have all the necessary forms
therefore providers are forced to document in more than
one application
2. Data Use Issues
a. Inconsistent data storage (i.e. Oracle vs SQL)
b. InQuery has numerous issues
i. Unable to combine and/or statements
ii. To maximize use, one must have knowledge of
Crystal reports
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iii. The accuracy of the reports is questionable leading
to trust issues
3. Provider Buy-in
a. Providers have not fully bought into standardized
documentation practices
Current Solutions:
1. Data Capture Solutions with SuiteRomeo
i. Do not make use optional
ii. Schedule one-on-one time with providers
2. Data Use Solutions
a. Create a data warehouse (data cube) to pull data out of
the EMR to meet the demands of the organization
3. Buy-in of SuiteRomeo has been improved using the following
strategies
a. Demonstrate the importance of standardized
documentation
i. If you don’t document correctly you don’t get paid
ii. Show how the data can be used to improve
patient/provider communication
b. Show the provider their performance on CQMs (maybe
even share performance with their peers)
c. Assign a physician champion
d. Adopt a Care Team Approach for care coordination
i. RNs are scribing
What can the Learning Community do to help your organization?
1. Help was requested in the following areas:
a. How should we use GE Centricity, in general?
b. How do we foster standardized use among providers? Are
there best practices?
i. The role of a team-based care approach
c. How do we use standardized reports within GE Centricity?
i. What aren’t we doing that we can be doing? What
are others doing?
2. Explore these applications:
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a. Cloud-based reporting for Meaningful Use (GE Centricity
12.1)
The second half of the face-to-face workshop was focused on
reviewing the Plan/Do/Study/Act (PDSA) process and cycle and how it
will help the clinics improve data quality in one of the disease focus
areas of this LC. Refer to attachment E and F for the curriculum and
the PDSA tool.
Clinic participants identified barriers, problems and solutions to correct
data integrity issues that have hampered quality reporting to improve
the outcome of the specific disease focus area they chose. Below are
the PDSA projects each clinic focused on during this LC:
Lakewood Health System
• Aim –Motely Clinic – Diabetes (DM) patients to achieve 38%
optimal care rate by December 31, 2014
• Goal - 100% of patients with DM to have had an LDL test
ordered by December 31, 2014
• Plan - Determine DM patients who have had LDL tests ordered
o Using Minnesota Community Measurement data
specifications as the denominator and the percentage
of patients who had the test ordered and completed as
the numerator
o Then break down by provider and then by patient
o Use that data to fine tune next action steps to target
improvement
Native American Community Clinic
• AIM – Increasing A1cs drawn when Diabetes (DM) patients are
present at the clinic for any reason
• Goal – Not defined yet
• Plan o Utilizing an alert system
o Pre day huddle to review patients being seen that day
and if they have DM flagging them some how
o Developing the roles of each team member and their
function in the overall care plan
Migrant Health Workers
• AIM – Currently asking ‘Do you smoke?” for patients 18 and
older
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Goal - Change the age to 13 and older and obtaining the goal of
100% of patients, who fit this age requirement, being asked
Plan – Staff training to explain the need
Sawtooth Mountain Clinic
• AIM – Smoking cessation
• Goal - Decrease patients in practice who spoke by five percent
• Plan o 30% referred to Call It Quits practice referral system
o Have it is set up in the EHR
o Monitor the feedback from the Call It Quits call back
program to see if they are being reached and
participating
o Based on that feedback, next steps will be planned to
help achieve the goal
Overall, the evaluation of the face-to-face workshop indicated that the
effectiveness in meeting expectations and objectives were met. In
addition, there was an increase in scores by attendees’ in content
appropriateness and increased knowledge of this topic. The evaluation
used a scale of 1-5, 5 being the highest. There were 10 questions
and seven people responded. Below are the average results:
Effectiveness in meeting expectations and
objectives
Average
Score
The workshop was well organized.
The presenters were knowledgeable about the specific
subject.
The workshop content was appropriate.
The workshop content was relevant to my position.
The workshop increased my knowledge on this topic.
Please rate the overall teaching effectiveness of the
presenters.
The objectives of the workshop were met.
The meeting space was suitable for today’s learning
experience.
The refreshments provided were adequate.
Overall, I had a positive experience with the workshop.
4.29
4.29
4.43
4.14
4.29
3.57
7 (all)
4.57
4.57
4.57
The feedback and comments were supportive and encouraging that
this LC is focused on the right areas and in a style that is compatible
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with the participants. Participants were very appreciative of the time,
patience and assistance of the team walking them through the day’s
work.
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Webinar: Using EHR Data
The focus and style of this webinar was set up in a presentation
format. The material focused on many different aspects of using EHR
data. Areas included, health terminologies, data dictionaries, reviewing
quality clinical measures for the focus areas of this LC and some
suggestions in processes to increase data integrity and tools for data
analysis. Refer to attachment G for the final curriculum presentation.
Since the LC is focused for users of the GE Centricity platform, Stratis
Health provided an update from a conference recently attended on an
EHR upgrade for GE Centricity. Refer to attachment G for the final
curriculum presentation.
An evaluation of the session was conducted, however, being as only
one clinic participated, there was limited feedback provided. Two
people from that clinic responded. Due to the low numbers, a
numerical value was not computed. In summary, the objectives were
met. One person was a registered nurse and commented that this
particular teaching was not in her area of expertise, but felt the
presentation was well organized and well presented.
As participation dropped for this webinar, an email was sent with a link
to the recording and the message outlined the next steps or homework
for each clinic in preparation for the next learning event.
Webinar: Introduction to Basic Data Analysis for Quality
Improvement
The outline for the fourth learning event was framed into two parts.
The first half of the event was focused on each clinic providing
information in the following areas of their PDSA cycle project:
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Questions and/or barriers encountered
Solutions found
These updates were provided in a round robin style with Stratis Health
facilitating the discussion. Each clinic provided a brief reminder of their
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focus area. Please refer to attachment H for a copy of the
presentation.
Lakewood
Identified by provider, the number of diabetes patients that did not
have a LDL test in the previous year.
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Two barriers identified, reviewed for and addressed:
o The report identified patients who were misdiagnosed with
diabetes
o Breakdown in communication with some of the physicians.
Some did not understand why LDL tests were ordered and
then canceled the order
Next step – Adding a care coordinator/navigator to assist in this
coordination
Migrant Health Services
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One main barrier identified:
o How to find time to create approach and get the initiative
going
Next Steps
o Hired a full time HIT professional
o Stratis Health and College of The College of St. Scholastica
offered a conference call to help prioritize and strategize
Sawtooth Mountain Clinic
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Three barriers identified, reviewed for and addressed:
o It is a slow referral process
o Keeping this process on the nurse’s and physician’s radar.
o How the nurses and physicians approach patients
Next steps
o Advertise in local paper, posters – in conjunction with
great American smoke out
o Train nurses and physicians in motivational speaking
The second part of the learning event focused on presenting different
resources for analyzing electronic health record data and incorporating
what was discussed in each clinic’s updates and how these resources
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could help them. Please refer to attachment I for a copy of the
presentation.
Upon completion of the webinar, it was requested that participants
complete an evaluation of the webinar’s effectiveness in meeting
expectations and objectives. There were nine questions specific to
these areas. A scale of 1-5 was used, 5 being the highest. Four
people responded. Below are the average results:
Effectiveness in meeting expectations and
objectives
Average
Score
The presenters were knowledgeable about the specific
subject.
4.0
The presentation content was appropriate.
4.0
The webinar technology and instructions were easy to
use.
3.75
The presentation was relevant to my position.
4.0
The presentation increased my knowledge on this topic.
3.75
Please rate the overall teaching effectiveness of the
presenters.
3.0
The objectives of the presentation were met.
3-Met
1 – Not
Sure
Overall, I had a positive experience with today’s webinar.
4.0
There were limited comments or suggestions provided in this
evaluation, but overall, the tone of the webinar was positive and
interactive in nature. The general value of the scores decreased a
small amount, however fewer people responded and objectives
seemed to be met.
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Scheduled Phone Discussions with Clinics
In response to lack progression with some clinics we added to the
curriculum a one-on-one call to each clinic to offer additional targeted
support. Phone calls were scheduled with each clinic to answer any
questions or address any concerns they might have around the PDSA
cycles. Four calls were scheduled over the course of a month and here
is a summary of some of the information captured or areas discussed:
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In general discussed PDSA progress
Challenges faced
Next steps
Wanted to learn more about the type of flow sheets others were
using to capture smoking status
Experiencing difficulties in chart audits as they were unable to
determine the accuracy of the data that was being pulled
Interested further in discussing capturing smoking status with
other facilities
Wanted to gain further insight into how other facilities are
reaching out to providers to maintain their involvement in the
project
Others revealed they are facing very few problems and are
progressing
Face-to-Face Workshop: Advanced Data Analytics for
Health Improvement
This face-to-face workshop was interactive and participants were
engaged. Following the successful format of the first face-to-face
workshop, it began with each clinic providing an update on their PDSA
cycle project. There was meaningful discussion, support and assistance
provided by the clinics all helping and sharing best practices when
questions or problem areas were identified. Focus areas of assistance
and peer sharing included:
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Storage of forms in the GE Centricity EHR
How to capture and pull a patient’s smoking status and
document education
Increasing provider engagement by introducing friendly
competition via provider reporting
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Definition of ‘Ops’ terms and how to pull quality data
Reviewed actual GE Centricity forms and how they were being
used
Plans of sustainability for each project were shared by all clinics. They
reported that they were integrating the processes outlined in each of
their projects as a normal part of how they provide patient care.
However, some adjustments were being made to processes and/or
steps being taken to help activities and expectations become more
sustainable.
Lakewood Health System
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Review of utilizing call back nurse more efficiently
Hiring a certified medical assistant to be a navigator to help
coordinate the flow of the care team
Migrant Health Services
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Identifying how to use the MN Network to support this project
This is new to all the clinics in their health care system therefore
are working diligently in hopes that it will become part of their
everyday patient care
Native American Community Clinic
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Removed some of the educational pieces from the call back and
follow up as well as changed duties to scheduling. Are focusing
on better access for patients
Certified medical assistants are calling to schedule follow up
clinic visits. Registered nurses are performing the calls for
inpatient follow up.
Sawtooth Mountain Clinic
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Their project is a focus area for two different arenas
They review and discuss at every staff and nursing meeting and
it is also on the quality improvement work plan
Assuring that processes are building and supporting on each
other
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After clinic updates and sustainability efforts reporting, the learning
transitioned to the need for data analytics and actual hands on
activities. Refer to attachment J for a copy of the presentation.
Different software discussed were MS Excel, R and My SQL. It was a
team discussion that focused on the pluses and negatives of each
software package. It was followed by walking participants through data
table structures, commands to pull data, joining tables and running
the actual queries. After the queries were written and data was pulled,
participants were then shown how to export the data to Excel and
create different table formats.
Overall the evaluation was positive. The evaluation used a scale of 15, 5 being the highest. There were 10 questions and three people
responded. Below are the average result averages:
Effectiveness in meeting expectations and
objectives
Average
Score
The presenters were knowledgeable about the specific
subject.
The workshop content was appropriate.
The workshop content was relevant to my position.
The workshop increased my knowledge on this topic.
Please rate the overall teaching effectiveness of the
presenters.
The objectives of the workshop were met.
4.33
The meeting space was suitable for today’s learning
experience.
The refreshments provided were adequate.
Overall, I had a positive experience with the workshop.
3.33
3.67
3.33
3.0
2 met
1 not
sure
4.67
4.67
4.67
One comment was identified in the survey in reference to wanting
more education on actual reporting functionality from GE Centricity. A
clinical participant mentioned that it may have been better to have
breakout sessions so the data people can work together and then the
clinical people can work together, thus enhancing applicable skills for
both positions.
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Webinar: Lessons Learned and Wrap Up
The final webinar focused on three main areas. First, clinics provided
updates and what was accomplished and lessons learned. Second, we
walked through some additional information for R Commander, a data
analytic software, and third, we discussed what Key Health Alliance
could have done differently. Please refer to attachment K for a copy of
the talking points and discussion areas of this webinar. There was not
a formal presentation.
Clinic reporting on what was accomplished and lessons learned:
Lakewood Health System
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Timing of the LC was really good. They were beginning review of
process improvements and using the PDSA cycle helped all
remain on the same track
Having the data analytics staff person as part of the discussion
at the beginning as well as all the way through was beneficial. It
was important to link the IT/data with the clinical upfront. It
helped the analyst to understand the why behind the request
Sawtooth Mountain Clinic
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Connections made with the other clinics were very helpful
Looking at the processes of entering the data into the EHR and
pulling it out was very helpful
Overall, not clinic specific, but generally agreed upon lessons learned:
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Start with a small test group at clinic before beginning with all
providers
Standardize processes when applicable
Communication clinic wide on changes or process, not just to the
specific team
The structure of the PDSA was appreciated
Based on the discussion and feedback from the last face to face
workshop, a resource document was created and reviewed with the
participants. The document included links to data sets, and you tube
videos created by David Marc from The College of St. Scholastica in
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how to use SQL and R, as well as how to write queries and pull data.
Please refer to attachment L.
From the clinic perspective, what could be done
differently for the next LC:
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Actual access to a GE Centricity demo model to review inquiry
mode and access
Clinics stated that the face-to-face workshops were more
effective with the type of conversations we were conducting
o The time and expense of the travel to the face-to-face has
to be weighed to the value of the LC
Check the availability and use of video conferencing
Make the actual in person time of the face-to-face longer to help
offset the burden of travel time
When meeting face-to-face, have separate or break-out sessions
for the clinical people and data/IT people. It will be more
applicable to the subject matter expert in each role
More one-on-one conference calls may be helpful
In closing, both clinics agreed that there is a great deal of potential in
learning communities for many areas moving forward.
Lessons Learned and what can be done differently from
Key Health Alliance’s Perspective
There were two main lessons learned. The first is to assure that each
clinic understands the requirements and expectations of the LC. For
example, although the LC is free, there is an in-kind time expectation
of attendance at each LC event, homework outside of each event and
travel to face-to-face workshops. Two methods were identified to help
improve understanding and comprehension of these areas. One was to
review, over the phone, the expectations when potential clinics call to
inquire about the LC and another was to create a participation
agreement by clearly outlining the expectations of the LC and have it
signed by the appropriate person at each clinic.
The second main lesson learned was the need for several reminders
and follow regarding the completion of homework as well as
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attendance at the upcoming LC events. Clinic staff are busy and often
wear many hats. Multiple email reminders in between events are
needed. A possible solution is have the LC team send out calendar
meeting invites to clinic participants so the event is entered directly on
each participant’s calendar. This can happen in conjunction with the
email reminders.
Additional areas to consider include:
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A travel stipend for clinic participants
Obtain access to a test version of the EHR to develop real life
cases for demonstration
Offer one-on-one calls with clinics in between learning events
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