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2013 AAP NCE MOC QI and Your EHR

The document discusses the Maintenance of Certification (MOC) for pediatricians, detailing its components and requirements for professional competency, including quality improvement (QI) initiatives and the use of electronic health records (EHRs). It outlines the history and evolution of MOC, including the ongoing need for continuous professional development and the integration of healthcare technology to enhance patient care. The objectives include understanding how MOC, QI, and EHRs can be utilized collectively to improve pediatric practice and patient outcomes.

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Donna M. D’Alessandro, M.D. Professor of Pediatrics University of Iowa
Disclosures and Disclaimer  “I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.”  AAP’s Pedialink - editorial board member  I know a little bit about each– so before you do something, please recheck with the appropriate group to make sure doing the activity will get you what you want/need
Overview  MOC  QI  EHR  Putting it all together
Objectives  Learn about MOC and EHRs and how they can be used to develop quality improvement programs  I hope to show you that  MOC – is a continuous process to maintain your professional competency  QI – is a continuous process to improve the care you provide  EHRs – are continually advancing tools for us to use in our practice  Together they form a stalwart trio to help us provide the best care possible and continue to improve our mastery of pediatrics.
Alphabet Soup  ABP – American Board of Pediatrics, “The Board”  AAP – American Academy of Pediatrics, “The      Academy” CME – Continuing Medical Education MOC – Maintenance of Certification QI – Quality Improvement EHR – Electronic Health Records MU – Meaningful Use
Maintenance of Certification (MOC)
Professional Development: Recent History  Late 1980s – change from time unlimited ABP eligibility to time-limited ABP eligibility (or periodic recertification)  Initially activities included CME, and take-home knowledge and decision-making computer programs  Proctored test
Professional Development: Recent History  1990s and early 2000s  Inconsistencies among practitioners  Competency movement  Patient safety movement  American Board of Medical Specialties - governing board of all medical specialties developed the idea of MOC  Goals  Improved professionalism  Improve patient care including more consistency of practice among providers  Improved accountability to the public
What is MOC?  Program of activities to “maintain” professional competency  There is no expiration date as long as the physician is enrolled in the program
MOC Key Facts  ABP is requiring MOC to maintain board certification  State Boards are moving toward requirements to:  Require MOC  Require board certification MOC
Basic Plan of MOC  4 parts like Puzzle Pieces, not chronologically ordered  Part 1 Professional Standing and Licensure: unrestricted license to practice  Part 2 Life-long Learning Self Assessment: participating in knowledge self assessment tools  Part 3 Cognitive Expertise: passing a secure examination  Part 4 Performance in Practice: participating in quality improvement projects
Basic Plan of MOC  5-year cycle with 100 points for activities  40 points each Part 2 and Part 4  20 points either Part 2 or Part 4  Part 3 – one test every 10 years (every 2 cycles)
Basic Plan of MOC  Pediatricians with unlimited time eligibility  May choose not to enroll  May choose to enroll  May need to enroll  If enroll, pay fee, enter the MOC 5-year cycle
Basic Plan of MOC  Pediatricians coming out of residency  Will pay fee and enter right into the MOC 5-year cycle
Basic Plan of MOC  Everyone else (time-limited eligibility) is in the transition zone  Have different requirements depending on the date of last certification  On next date of next certification, will pay fee and enter the MOC 5-year cycle
Actually Doing MOC  Check the ABP website to see your personal requirements – www.abp.org  If you don’t understand contact the ABP  Pay fee ($1185 in 2013, $1230 in 2014) and enter the MOC 5-year cycle  Website has lists of activities that qualify for each part  All activities     Have a “sell by” date Have a different MOC point value May be free or have an additional cost in addition the MOC fee May or may not award CME
Part 1 – Profession Standing and Licensure  Submit a copy of your current state license every 5 years
Part 2 – Lifelong Learning Self-Assessment  ABP – has a variety of knowledge tests  FREE, most with CME  General knowledge test, decision skills or subspecialty tests  FREE, CME, 10-20 points/year/test  AAP  PREP questions – $213-226 in 2013, gives CME, 20 points  NeoReviews - $110/year, gives CME, 20 points  Pedialink Learning Plan – cost = FREE, but for MOC must have PREP subscription, can link to CME almost seamlessly, 20 points
Pedialink Learning Plan (for MOC2)
iPOC ( for CME)
Part 3 – Cognitive Expertise  Secure examination   Take once every 10 years (i.e. 1 time during 2 cycles of MOC) Fee for one test included in price of MOC
Part 4 - Performance in Practice  ABP  Practice Improvement Modules – FREE, get CME, 20 points  AAP    EQiPP – $199/individual, has group discounts, get CME, 20 points Pedialink- MyQiPP – approved, but details are being worked out Other programs  CAQI – Chapter Alliance for Quality Improvement  QuINN – Quality Improvement Innovation Network
Today We Still Need CME  CME at Point of Care  Cincinnati - Internet Point of Care Credit– FREE, 0.5 CME/?, receive one CME certificate, No MOC  Pedialink iPOC – FREE, 0.5 CME/?, can collate questions to receive one CME certificate, questions link to the Learning Plan for Part 2 MOC
http://www.cincinnatichildrens.org/ed /cme/cme/ipcc.htm www.pedialink.org
Questions about MOC?
Quality Improvement (QI)
What is Quality?  Meeting the needs and exceeding the expectations of the patients and families that healthcare providers serve  Delivering all and only the care that the patient and family needs It is NOT…  Telling at people to work harder, faster, or safer  Creating protocols and order sets and then failing to monitor their use or effect  Quality Assurance - The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled (ie. the standards are met each time)  Research (but they can co-exist nicely) - Modified from Institute for Healthcare Improvement
Improving Quality  Requires change - every system is designed perfectly to achieve exactly the results it gets  Needs to be kept simple  if you don’t you destroy productivity, and unintended consequences results in too big a disruption
Delivering Care and Making Changes Structure Inputs •Patients •Equipment •Supplies •Environment •Training Processes and People* Steps •Physician orders •Nursing care •Ancillary staff •Coordination •Business practice Outcomes of Care Outputs •Physiologic parameters •Functional status •Satisfaction •Cost *Has the greatest chance to improve care, also the closest to the care - Modified from Institute for Healthcare Improvement
The Personnel Team  One person (rarely) can make the changes necessary. It is a system of processes and personnel that is delivering care  Team – can be small or large, with everyone involved in some way.  It is the actual people doing the work, not a representative for others
Planning Steps for the Change What do we want to achieve? What changes will drive our progress? How will we measure our progress? How should we modify our latest changes? modified from: The Foundation of Improvement by Thomas W. Nolan et. al
What do we want to achieve?  Set a SMART goal      Specific Measure Achievable Relevant and reliable Time limited  “Increase the screening rates for dental caries in 5- year olds within 6 months”  May have more than 1 goal, so discuss options and chose one goal to work on with the team modified from: The Foundation of Improvement by Thomas W. Nolan et. al
What changes will drive our progress ?    Select changes that are the most likely to improve outcomes Recognize that not all changes improve outcomes – “Just because you can, doesn’t mean you should” and conversely, “Just because you think you can’t, doesn’t mean you shouldn’t try.” “Changing the EHR to include discrete structured data to improve reporting” modified from: The Foundation of Improvement by Thomas W. Nolan et. al
How will we measure our progress?  How will you know how far you have come to realizing your goal? Need more than 1 measure It doesn’t have to be perfect You be able to answer the journalistic 5Ws and H? Who, What, Where, When, Why & How        Pilot test Collect data Evaluate the data and compare it– overtime, to benchmarks, to end aim Evaluate regularly not just at the end modified from: The Foundation of Improvement by Thomas W. Nolan et. al
PDSA Cycles - How should we modify our latest changes?  Run PDSA cycles to implement your changes and see your results  Can you answer the 5Ws and H?  The analysis phase is imbedded in the planning modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Questions about Quality Improvement?
Electronic Health Records (EHRs)  Computers that store health information that then health care personnel (and patient/family) can access and utilize to provide care, and hopefully improve health  Healthcare provider controlled EHR  Computerized patient record  Electronic medical record  Electronic health record  Patient controlled EHR  Patient health record  Personal health record
EHRs are Not New  Depending on how you want to define an EHR, first ones go back to late 60s  Probably even earlier to help with accounting/billing that then could be used for epidemiological work  Holy grail – integration – getting computers to talk to each other
Fast Forward to Today  Have computers that reasonably (sort of, maybe) talk to each other  Have Internet where information is easily/constantly available  Shouldn’t everyone have an EHR and use it to provide quality care to patients and families?
History of EHRs and Meaningful Use (MU)  American Recovery and Reinvestment Act of 2009 (Recovery Act) signed into law  Within the Recovery Act lies the Health Information Technology for Economic and Clinical Health Act, or the "HITECH Act”  HITECH caused CMS to set criteria for :  “Certified” EHRs  For “meaningful use” of the EHRs  Reporting quality measures  Create an incentive system for providers to acquire, use and report using EHRs
Meaningful Use (MU)  Goal: to promote the spread of electronic health records to improve health care in the United States.  Improve quality, safety, efficiency, and reduce health disparities  Engage patients and families  Improve care coordination, and population and public health  Maintain privacy and security of patient health information
MU  Criteria that defines  Eligible professionals  Eligible hospitals and critical access hospitals  Implementation that is rolling out….
3 Stages of MU Stage 1 Data Capturing and Sharing •Began 2011, use for 2 years •Use an EHR •Set of Criteria •Core Objectives •Menu Objectives •Reports Obtain an EHR and start to use it -Modified from Meaningful Use Overview, AAP
3 Stages of MU Stage 1 Data Capturing and Sharing •Began 2011, use for 2 years •Use an EHR •Set of Criteria •Core Objectives •Menu Objectives •Reports Obtain an EHR and start to use it Stage 2 Advance Clinical Processes •Begins 2014, use for 2 years •Use a “Certified EHR” •Set of Criteria •Core Objectives (many were menu obj. in MU1) •Menu Objectives •Some new objectives •All have higher standards or measures •Reports Clinical Quality Measures •Improved definitions/close loop holes •Medicaid definitions •Reporting periods Increase standards and start to use for quality improvement -Modified from Meaningful Use Overview, AAP
3 Stages of MU Stage 1 Data Capturing and Sharing •Began 2011, use for 2 years •Use an EHR •Set of Criteria •Core Objectives •Menu Objectives •Reports Obtain an EHR and start to use it Stage 2 Advance Clinical Processes Stage 3 Improve Health Outcomes •Began 2016, use for 2 years •Being Developed •Begins 2014, use for 2 years •Use a “Certified EHR” by ONC •Set of Criteria •Core Objectives (many were menu obj. in MU1) •Menu Objectives •Some new objectives •All have higher standards or measures • Reports Clinical Quality Measures •Improved definitions Increase standards and Use the EHR for real QI start to use for quality -Modified from Meaningful Use Overview, AAP improvement
Other Key Changes in MU2  Patients have to actually sign-up and use the Certified EHR  > 5% must send secure messages, >5% must access their information  Changes the definition of what constitutes a Medicaid encounter  Extends eligibility to hospital based providers (NICU, radiology groups who are independent of the hospital but practice within a hospital)  Increased information exchange  New pediatric specific clinical quality measures
Core Objectives (must report all) 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders >60 percent of medication, 30% laboratory, and 30% radiology orders are recorded using CPOE. 2.Generate and transmit permissible prescriptions electronically (eRx) >50 percent of prescriptions transmitted electronically 3.Record demographic information >80 percent of all unique patients seen have demographics recorded as structured data 4.Record and chart changes in vital signs 5.Record smoking status for patients 13 years old or older 6.Use clinical decision support to improve performance on highpriority health conditions
Core Objectives 7.Provide patients the ability to view online, download and transmit their health information 8.Provide clinical summaries for patients for each office visit 9.Protect electronic health information created or maintained by the Certified EHR Technology 10. Incorporate clinical lab-test results into Certified EHR Technology 11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care
Core Objectives 13. Use certified EHR technology to identify patientspecific education resources 14. Perform medication reconciliation 15. Provide summary of care record for each transition of care or referral 16. Submit electronic data to immunization registries 17. Use secure electronic messaging to communicate with patients on relevant health information
Menu Objectives (must report 3 out of 6) 1. Submit electronic syndromic surveillance data to public health agencies 2.Record electronic notes in patient records 3.Imaging results accessible 4.Record patient family health history 5.Identify and report cancer cases to a State cancer registry 6.Identify and report specific cases to a specialized registry (other than a cancer registry)
Pediatric Clinical Quality Measures (must report 9 of 64)  Immunization status – rates for certain vaccines by age 2  URI treatment – rates for URI not given an antibiotic at visit or within 3        days afterwards ADHD – rates of initial follow-up visit within 30 days of med initiation, rates of 2 additional visits within 9 months after initial follow-up visit Depression – rates for screening for > 13 year olds, and follow-up if positive Dental caries - % of children with caries/decay Asthma – rates of persistent asthmatics on chronic medication Chlamydia screening – rates of >16 year old sex-active teens screened Weight, activity and nutrition counseling – rates of Ht, Wt, BMI documents, documented counseling for nutrition and activity Pharyngitis – rates of appropriate testing and treatment for Group A streptococcus
Questions about EHR and MU?
Three Examples  Dental caries  Persistent asthma  Chlamydia screening
Basic Process – Your Very Own PDSA Cycle         1. Background information search – CME, MOC2 2. Look for MOC 4 QI availability - MOC 4 3. Plan QI and Use EHR - EHR/MU What do we want to achieve? What changes will drive the process? How will progress be measured? How should we modify our latest changes? Run reports for QI and MU 4. Use Questions that arise in #3 to do other searches
Dental Caries 1. Background Information Search – Get CME, MOC2  What are the overall rates in my state/location?  What are some of the local problems with dental caries prevention?  What do caries look like? 2. Look for MOC 4 QI availability  My search of the ABP for MOC2 and MOC4 yielded no specific programs
Dental Caries 3. Plan QI and Use EHR  In Iowa, all 5 year olds must have a dental screening for school entry and if have caries should be referred  Problem: EHR doesn’t have to say whether caries are present or not (and we often don’t do this)  Problem: Screening for dental home is good, but referral to dentist doesn’t say whether for dental home or for caries  Problem: No discrete data elements in EHR
Dental Caries  What do we want to achieve?  Screening all 5 year olds for dental caries  Improved screening for dental home  Improved documentation of dental caries present or not  Improved rates of going to dental home
Dental Caries  What will drive the process?  Screening documents will ask about dental caries, presence of dental home and last visit to dental home  MA will review/ask these questions of parents  Physician will document presence of caries and dental home, last visit to dental home, and reason for referral if made  At check out, front desk will ask parent if they would like them to make appointment with dental home, give instructions on hours/how to get there, insurance for the referral  Use a structured data element in EHR to help make reporting easier?
Dental Caries  How will progress be measured?  Rates of screening for dental caries  Rates of documentation of caries present or not  Rates of screening for a dental home  Number of families assisted in making appointments, brochures distributed  Rates of dental home visit within past year?  Use EHR to run reports for this, or at least to identify all 5 year olds that should have been screened, or should be screened coming up in the schedule  Use EHR to report MU
Dental Caries  How should we modify what we are doing?  Move to screening all kids with teeth  Improved rate of dental caries identification  Close the loop – within the next year, do the families go to dental home  What new questions have arisen that should be researched? Remember its your own PDSA – go back to the start and get CME, MOC2
Asthma  1. Background Information Search - Get CME, MOC2  What are the categories of asthma?  How do you define persistent asthma?  What CPT codes can be used for persistent asthma?  What medications are appropriate to treat persistent asthma?  Should influenza vaccine be considered a chronic medication also even though it is a biologic medication?  2. Look for MOC 4 QI availability  My search of the ABP for MOC2 yielded 1-10 potential programs and MOC4 yielded 36 specific programs
Asthma  Problem – inconsistent use of various terms for asthma  Problem – don’t know if patients are receiving appropriate medication  Problem – not clear who is primarily managing the asthma
Asthma  3. Plan QI and Use EHR - EHR/MU  What do we want to achieve?  Improved rates of accurately recorded asthma status  Improved rates of persistent asthmatics on controller medication  Improved rates of persistent asthmatics receiving an influenza vaccine  Clarifying who is primarily managing the asthma
Asthma  What changes will drive the process?  EHR will run a report for certain CPT codes (asthma, bronchiolitis, reactive airway disease) and charts flagged  As patients come to office, MA will review all medications asking specifically about asthma medication, Will review immunizations including influenza  Physician will review and refine the diagnoses, entering accurate diagnosis into problem list  Physician will review medications and appropriately renew or prescribe controller medication  Physician will review with family who is primarily responsible for the asthma management and record this in the problem list
Asthma  How will progress be measured?  Run reports with EHR for these CPT codes to identify patients  Rates of generic asthma and asthma modifiers  Cross reference those that are persistent asthmatics with medications  Rates of 1,2,3, medications use  Cross reference with those that received influenza vaccine within past year  Rates for all asthmatics, persistent asthmatics, entire practice  Rates for recording in problem list who is managing the asthma  Run reports with the EHR and report MU
Asthma  How should we modify our latest changes?  How many persistent asthmatics have asthma action plans  How many actually know they have them, and can identify what to do  How could we work closer with the allergist/pulmonologist to manage the persistent asthmatics?  What new questions have arisen that should be researched? Your own PDSA cycle again - CME, MOC2
Chlamydia  1. Background Information Search - Get CME, MOC2  What are the guidelines for Chlamydia screening, treatment and other STI screening/treatment?  Who should be screened and when?  2. Look for MOC 4 QI availability  My search of the ABP for MOC2 yielded 1+ potential programs and MOC4 yielded 3 specific programs
Chlamydia  Problem – best to have this as a discrete data element  Problem – problems with confidentiality, accurate reporting by patients and recording by health care providers  Problem – appropriate providers being conveniently available to adolescents
Chlamydia  3. Plan QI and Use EHR - EHR/MU  What do we want to achieve?  Screen all sexually active teenagers (13+) for Chlamydia  Screen all sexually active teenagers (13+) for other STIs
Chlamydia  What changes will drive the process?  Identify all sexually active teens using confidential forms/computers, MA verbal screening and physician screening.  Physician will document presence of sexual activity and previous screening, review appropriate results and treatment  Physician will offer screening and will document results or if teen declines screening  Provide resources for other sexual health providers in area  Front desk will ask teen if they want help making appointment with another provider, give instructions on hours/how to get there and insurance
Chlamydia  How will progress be measured?  Rates of screening for Chlamydia and other STI or declination  Rates of documentation of sexual activity or not (probably will need to do chart review because no discrete data element in EHR currently)  Rates of referral to other sexual health provider  Rates of referral sexual health provider visits within past year  Number of teens assisted in making appointments, brochures distributed  Run reports with the EHR and report MU
Chlamydia  How should we modify our latest changes?  Move to screening all teens (if did a subset before)  Improved documentation rate for sexual activity  Close the loop – within the next year, do the teens go to the referral provider  Distribute condoms in office?  Work with schools and pharmacists to assist teens locally?  What new questions have arisen that should be researched? Your own PDSA again - CME, MOC2
Summary  The objective of this session was to learn about MOC and EHRs and how they can be used to develop quality improvement programs  I hope your can see how  MOC – is a continuous process to maintain your professional competency  QI – is a continuous process to improve the care you provide  EHRs – are continually advancing tools for us to use in our practice  Together they form a stalwart trio to help us provide the best care possible and continue to improve our mastery of our pediatrics.
Donna M. D’Alessandro, M.D. donna-dalessandro@uiowa.edu

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2013 AAP NCE MOC QI and Your EHR

  • 1.
    Donna M. D’Alessandro,M.D. Professor of Pediatrics University of Iowa
  • 2.
    Disclosures and Disclaimer “I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.”  AAP’s Pedialink - editorial board member  I know a little bit about each– so before you do something, please recheck with the appropriate group to make sure doing the activity will get you what you want/need
  • 3.
    Overview  MOC  QI EHR  Putting it all together
  • 4.
    Objectives  Learn aboutMOC and EHRs and how they can be used to develop quality improvement programs  I hope to show you that  MOC – is a continuous process to maintain your professional competency  QI – is a continuous process to improve the care you provide  EHRs – are continually advancing tools for us to use in our practice  Together they form a stalwart trio to help us provide the best care possible and continue to improve our mastery of pediatrics.
  • 5.
    Alphabet Soup  ABP– American Board of Pediatrics, “The Board”  AAP – American Academy of Pediatrics, “The      Academy” CME – Continuing Medical Education MOC – Maintenance of Certification QI – Quality Improvement EHR – Electronic Health Records MU – Meaningful Use
  • 6.
  • 7.
    Professional Development: Recent History Late 1980s – change from time unlimited ABP eligibility to time-limited ABP eligibility (or periodic recertification)  Initially activities included CME, and take-home knowledge and decision-making computer programs  Proctored test
  • 8.
    Professional Development: Recent History 1990s and early 2000s  Inconsistencies among practitioners  Competency movement  Patient safety movement  American Board of Medical Specialties - governing board of all medical specialties developed the idea of MOC  Goals  Improved professionalism  Improve patient care including more consistency of practice among providers  Improved accountability to the public
  • 9.
    What is MOC? Program of activities to “maintain” professional competency  There is no expiration date as long as the physician is enrolled in the program
  • 10.
    MOC Key Facts ABP is requiring MOC to maintain board certification  State Boards are moving toward requirements to:  Require MOC  Require board certification MOC
  • 11.
    Basic Plan ofMOC  4 parts like Puzzle Pieces, not chronologically ordered  Part 1 Professional Standing and Licensure: unrestricted license to practice  Part 2 Life-long Learning Self Assessment: participating in knowledge self assessment tools  Part 3 Cognitive Expertise: passing a secure examination  Part 4 Performance in Practice: participating in quality improvement projects
  • 12.
    Basic Plan ofMOC  5-year cycle with 100 points for activities  40 points each Part 2 and Part 4  20 points either Part 2 or Part 4  Part 3 – one test every 10 years (every 2 cycles)
  • 13.
    Basic Plan ofMOC  Pediatricians with unlimited time eligibility  May choose not to enroll  May choose to enroll  May need to enroll  If enroll, pay fee, enter the MOC 5-year cycle
  • 14.
    Basic Plan ofMOC  Pediatricians coming out of residency  Will pay fee and enter right into the MOC 5-year cycle
  • 15.
    Basic Plan ofMOC  Everyone else (time-limited eligibility) is in the transition zone  Have different requirements depending on the date of last certification  On next date of next certification, will pay fee and enter the MOC 5-year cycle
  • 16.
    Actually Doing MOC Check the ABP website to see your personal requirements – www.abp.org  If you don’t understand contact the ABP  Pay fee ($1185 in 2013, $1230 in 2014) and enter the MOC 5-year cycle  Website has lists of activities that qualify for each part  All activities     Have a “sell by” date Have a different MOC point value May be free or have an additional cost in addition the MOC fee May or may not award CME
  • 17.
    Part 1 –Profession Standing and Licensure  Submit a copy of your current state license every 5 years
  • 18.
    Part 2 –Lifelong Learning Self-Assessment  ABP – has a variety of knowledge tests  FREE, most with CME  General knowledge test, decision skills or subspecialty tests  FREE, CME, 10-20 points/year/test  AAP  PREP questions – $213-226 in 2013, gives CME, 20 points  NeoReviews - $110/year, gives CME, 20 points  Pedialink Learning Plan – cost = FREE, but for MOC must have PREP subscription, can link to CME almost seamlessly, 20 points
  • 19.
  • 20.
  • 21.
    Part 3 –Cognitive Expertise  Secure examination   Take once every 10 years (i.e. 1 time during 2 cycles of MOC) Fee for one test included in price of MOC
  • 22.
    Part 4 -Performance in Practice  ABP  Practice Improvement Modules – FREE, get CME, 20 points  AAP    EQiPP – $199/individual, has group discounts, get CME, 20 points Pedialink- MyQiPP – approved, but details are being worked out Other programs  CAQI – Chapter Alliance for Quality Improvement  QuINN – Quality Improvement Innovation Network
  • 23.
    Today We StillNeed CME  CME at Point of Care  Cincinnati - Internet Point of Care Credit– FREE, 0.5 CME/?, receive one CME certificate, No MOC  Pedialink iPOC – FREE, 0.5 CME/?, can collate questions to receive one CME certificate, questions link to the Learning Plan for Part 2 MOC
  • 24.
  • 25.
  • 26.
  • 27.
    What is Quality? Meeting the needs and exceeding the expectations of the patients and families that healthcare providers serve  Delivering all and only the care that the patient and family needs It is NOT…  Telling at people to work harder, faster, or safer  Creating protocols and order sets and then failing to monitor their use or effect  Quality Assurance - The planned and systematic activities implemented in a quality system so that quality requirements for a product or service will be fulfilled (ie. the standards are met each time)  Research (but they can co-exist nicely) - Modified from Institute for Healthcare Improvement
  • 28.
    Improving Quality  Requireschange - every system is designed perfectly to achieve exactly the results it gets  Needs to be kept simple  if you don’t you destroy productivity, and unintended consequences results in too big a disruption
  • 29.
    Delivering Care andMaking Changes Structure Inputs •Patients •Equipment •Supplies •Environment •Training Processes and People* Steps •Physician orders •Nursing care •Ancillary staff •Coordination •Business practice Outcomes of Care Outputs •Physiologic parameters •Functional status •Satisfaction •Cost *Has the greatest chance to improve care, also the closest to the care - Modified from Institute for Healthcare Improvement
  • 30.
    The Personnel Team One person (rarely) can make the changes necessary. It is a system of processes and personnel that is delivering care  Team – can be small or large, with everyone involved in some way.  It is the actual people doing the work, not a representative for others
  • 31.
    Planning Steps forthe Change What do we want to achieve? What changes will drive our progress? How will we measure our progress? How should we modify our latest changes? modified from: The Foundation of Improvement by Thomas W. Nolan et. al
  • 32.
    What do wewant to achieve?  Set a SMART goal      Specific Measure Achievable Relevant and reliable Time limited  “Increase the screening rates for dental caries in 5- year olds within 6 months”  May have more than 1 goal, so discuss options and chose one goal to work on with the team modified from: The Foundation of Improvement by Thomas W. Nolan et. al
  • 33.
    What changes willdrive our progress ?    Select changes that are the most likely to improve outcomes Recognize that not all changes improve outcomes – “Just because you can, doesn’t mean you should” and conversely, “Just because you think you can’t, doesn’t mean you shouldn’t try.” “Changing the EHR to include discrete structured data to improve reporting” modified from: The Foundation of Improvement by Thomas W. Nolan et. al
  • 34.
    How will wemeasure our progress?  How will you know how far you have come to realizing your goal? Need more than 1 measure It doesn’t have to be perfect You be able to answer the journalistic 5Ws and H? Who, What, Where, When, Why & How        Pilot test Collect data Evaluate the data and compare it– overtime, to benchmarks, to end aim Evaluate regularly not just at the end modified from: The Foundation of Improvement by Thomas W. Nolan et. al
  • 35.
    PDSA Cycles -How should we modify our latest changes?  Run PDSA cycles to implement your changes and see your results  Can you answer the 5Ws and H?  The analysis phase is imbedded in the planning modified from: The Foundation of Improvement by Thomas W. Nolan et. al
  • 36.
  • 37.
    Electronic Health Records(EHRs)  Computers that store health information that then health care personnel (and patient/family) can access and utilize to provide care, and hopefully improve health  Healthcare provider controlled EHR  Computerized patient record  Electronic medical record  Electronic health record  Patient controlled EHR  Patient health record  Personal health record
  • 38.
    EHRs are NotNew  Depending on how you want to define an EHR, first ones go back to late 60s  Probably even earlier to help with accounting/billing that then could be used for epidemiological work  Holy grail – integration – getting computers to talk to each other
  • 39.
    Fast Forward toToday  Have computers that reasonably (sort of, maybe) talk to each other  Have Internet where information is easily/constantly available  Shouldn’t everyone have an EHR and use it to provide quality care to patients and families?
  • 40.
    History of EHRsand Meaningful Use (MU)  American Recovery and Reinvestment Act of 2009 (Recovery Act) signed into law  Within the Recovery Act lies the Health Information Technology for Economic and Clinical Health Act, or the "HITECH Act”  HITECH caused CMS to set criteria for :  “Certified” EHRs  For “meaningful use” of the EHRs  Reporting quality measures  Create an incentive system for providers to acquire, use and report using EHRs
  • 41.
    Meaningful Use (MU) Goal: to promote the spread of electronic health records to improve health care in the United States.  Improve quality, safety, efficiency, and reduce health disparities  Engage patients and families  Improve care coordination, and population and public health  Maintain privacy and security of patient health information
  • 42.
    MU  Criteria thatdefines  Eligible professionals  Eligible hospitals and critical access hospitals  Implementation that is rolling out….
  • 43.
    3 Stages ofMU Stage 1 Data Capturing and Sharing •Began 2011, use for 2 years •Use an EHR •Set of Criteria •Core Objectives •Menu Objectives •Reports Obtain an EHR and start to use it -Modified from Meaningful Use Overview, AAP
  • 44.
    3 Stages ofMU Stage 1 Data Capturing and Sharing •Began 2011, use for 2 years •Use an EHR •Set of Criteria •Core Objectives •Menu Objectives •Reports Obtain an EHR and start to use it Stage 2 Advance Clinical Processes •Begins 2014, use for 2 years •Use a “Certified EHR” •Set of Criteria •Core Objectives (many were menu obj. in MU1) •Menu Objectives •Some new objectives •All have higher standards or measures •Reports Clinical Quality Measures •Improved definitions/close loop holes •Medicaid definitions •Reporting periods Increase standards and start to use for quality improvement -Modified from Meaningful Use Overview, AAP
  • 45.
    3 Stages ofMU Stage 1 Data Capturing and Sharing •Began 2011, use for 2 years •Use an EHR •Set of Criteria •Core Objectives •Menu Objectives •Reports Obtain an EHR and start to use it Stage 2 Advance Clinical Processes Stage 3 Improve Health Outcomes •Began 2016, use for 2 years •Being Developed •Begins 2014, use for 2 years •Use a “Certified EHR” by ONC •Set of Criteria •Core Objectives (many were menu obj. in MU1) •Menu Objectives •Some new objectives •All have higher standards or measures • Reports Clinical Quality Measures •Improved definitions Increase standards and Use the EHR for real QI start to use for quality -Modified from Meaningful Use Overview, AAP improvement
  • 46.
    Other Key Changesin MU2  Patients have to actually sign-up and use the Certified EHR  > 5% must send secure messages, >5% must access their information  Changes the definition of what constitutes a Medicaid encounter  Extends eligibility to hospital based providers (NICU, radiology groups who are independent of the hospital but practice within a hospital)  Increased information exchange  New pediatric specific clinical quality measures
  • 47.
    Core Objectives (mustreport all) 1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders >60 percent of medication, 30% laboratory, and 30% radiology orders are recorded using CPOE. 2.Generate and transmit permissible prescriptions electronically (eRx) >50 percent of prescriptions transmitted electronically 3.Record demographic information >80 percent of all unique patients seen have demographics recorded as structured data 4.Record and chart changes in vital signs 5.Record smoking status for patients 13 years old or older 6.Use clinical decision support to improve performance on highpriority health conditions
  • 48.
    Core Objectives 7.Provide patientsthe ability to view online, download and transmit their health information 8.Provide clinical summaries for patients for each office visit 9.Protect electronic health information created or maintained by the Certified EHR Technology 10. Incorporate clinical lab-test results into Certified EHR Technology 11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach 12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care
  • 49.
    Core Objectives 13. Usecertified EHR technology to identify patientspecific education resources 14. Perform medication reconciliation 15. Provide summary of care record for each transition of care or referral 16. Submit electronic data to immunization registries 17. Use secure electronic messaging to communicate with patients on relevant health information
  • 50.
    Menu Objectives (must report3 out of 6) 1. Submit electronic syndromic surveillance data to public health agencies 2.Record electronic notes in patient records 3.Imaging results accessible 4.Record patient family health history 5.Identify and report cancer cases to a State cancer registry 6.Identify and report specific cases to a specialized registry (other than a cancer registry)
  • 51.
    Pediatric Clinical QualityMeasures (must report 9 of 64)  Immunization status – rates for certain vaccines by age 2  URI treatment – rates for URI not given an antibiotic at visit or within 3        days afterwards ADHD – rates of initial follow-up visit within 30 days of med initiation, rates of 2 additional visits within 9 months after initial follow-up visit Depression – rates for screening for > 13 year olds, and follow-up if positive Dental caries - % of children with caries/decay Asthma – rates of persistent asthmatics on chronic medication Chlamydia screening – rates of >16 year old sex-active teens screened Weight, activity and nutrition counseling – rates of Ht, Wt, BMI documents, documented counseling for nutrition and activity Pharyngitis – rates of appropriate testing and treatment for Group A streptococcus
  • 52.
  • 53.
    Three Examples  Dentalcaries  Persistent asthma  Chlamydia screening
  • 54.
    Basic Process – YourVery Own PDSA Cycle         1. Background information search – CME, MOC2 2. Look for MOC 4 QI availability - MOC 4 3. Plan QI and Use EHR - EHR/MU What do we want to achieve? What changes will drive the process? How will progress be measured? How should we modify our latest changes? Run reports for QI and MU 4. Use Questions that arise in #3 to do other searches
  • 55.
    Dental Caries 1. BackgroundInformation Search – Get CME, MOC2  What are the overall rates in my state/location?  What are some of the local problems with dental caries prevention?  What do caries look like? 2. Look for MOC 4 QI availability  My search of the ABP for MOC2 and MOC4 yielded no specific programs
  • 56.
    Dental Caries 3. PlanQI and Use EHR  In Iowa, all 5 year olds must have a dental screening for school entry and if have caries should be referred  Problem: EHR doesn’t have to say whether caries are present or not (and we often don’t do this)  Problem: Screening for dental home is good, but referral to dentist doesn’t say whether for dental home or for caries  Problem: No discrete data elements in EHR
  • 57.
    Dental Caries  Whatdo we want to achieve?  Screening all 5 year olds for dental caries  Improved screening for dental home  Improved documentation of dental caries present or not  Improved rates of going to dental home
  • 58.
    Dental Caries  Whatwill drive the process?  Screening documents will ask about dental caries, presence of dental home and last visit to dental home  MA will review/ask these questions of parents  Physician will document presence of caries and dental home, last visit to dental home, and reason for referral if made  At check out, front desk will ask parent if they would like them to make appointment with dental home, give instructions on hours/how to get there, insurance for the referral  Use a structured data element in EHR to help make reporting easier?
  • 59.
    Dental Caries  Howwill progress be measured?  Rates of screening for dental caries  Rates of documentation of caries present or not  Rates of screening for a dental home  Number of families assisted in making appointments, brochures distributed  Rates of dental home visit within past year?  Use EHR to run reports for this, or at least to identify all 5 year olds that should have been screened, or should be screened coming up in the schedule  Use EHR to report MU
  • 60.
    Dental Caries  Howshould we modify what we are doing?  Move to screening all kids with teeth  Improved rate of dental caries identification  Close the loop – within the next year, do the families go to dental home  What new questions have arisen that should be researched? Remember its your own PDSA – go back to the start and get CME, MOC2
  • 61.
    Asthma  1. BackgroundInformation Search - Get CME, MOC2  What are the categories of asthma?  How do you define persistent asthma?  What CPT codes can be used for persistent asthma?  What medications are appropriate to treat persistent asthma?  Should influenza vaccine be considered a chronic medication also even though it is a biologic medication?  2. Look for MOC 4 QI availability  My search of the ABP for MOC2 yielded 1-10 potential programs and MOC4 yielded 36 specific programs
  • 62.
    Asthma  Problem –inconsistent use of various terms for asthma  Problem – don’t know if patients are receiving appropriate medication  Problem – not clear who is primarily managing the asthma
  • 63.
    Asthma  3. PlanQI and Use EHR - EHR/MU  What do we want to achieve?  Improved rates of accurately recorded asthma status  Improved rates of persistent asthmatics on controller medication  Improved rates of persistent asthmatics receiving an influenza vaccine  Clarifying who is primarily managing the asthma
  • 64.
    Asthma  What changeswill drive the process?  EHR will run a report for certain CPT codes (asthma, bronchiolitis, reactive airway disease) and charts flagged  As patients come to office, MA will review all medications asking specifically about asthma medication, Will review immunizations including influenza  Physician will review and refine the diagnoses, entering accurate diagnosis into problem list  Physician will review medications and appropriately renew or prescribe controller medication  Physician will review with family who is primarily responsible for the asthma management and record this in the problem list
  • 65.
    Asthma  How willprogress be measured?  Run reports with EHR for these CPT codes to identify patients  Rates of generic asthma and asthma modifiers  Cross reference those that are persistent asthmatics with medications  Rates of 1,2,3, medications use  Cross reference with those that received influenza vaccine within past year  Rates for all asthmatics, persistent asthmatics, entire practice  Rates for recording in problem list who is managing the asthma  Run reports with the EHR and report MU
  • 66.
    Asthma  How shouldwe modify our latest changes?  How many persistent asthmatics have asthma action plans  How many actually know they have them, and can identify what to do  How could we work closer with the allergist/pulmonologist to manage the persistent asthmatics?  What new questions have arisen that should be researched? Your own PDSA cycle again - CME, MOC2
  • 67.
    Chlamydia  1. BackgroundInformation Search - Get CME, MOC2  What are the guidelines for Chlamydia screening, treatment and other STI screening/treatment?  Who should be screened and when?  2. Look for MOC 4 QI availability  My search of the ABP for MOC2 yielded 1+ potential programs and MOC4 yielded 3 specific programs
  • 68.
    Chlamydia  Problem –best to have this as a discrete data element  Problem – problems with confidentiality, accurate reporting by patients and recording by health care providers  Problem – appropriate providers being conveniently available to adolescents
  • 69.
    Chlamydia  3. PlanQI and Use EHR - EHR/MU  What do we want to achieve?  Screen all sexually active teenagers (13+) for Chlamydia  Screen all sexually active teenagers (13+) for other STIs
  • 70.
    Chlamydia  What changeswill drive the process?  Identify all sexually active teens using confidential forms/computers, MA verbal screening and physician screening.  Physician will document presence of sexual activity and previous screening, review appropriate results and treatment  Physician will offer screening and will document results or if teen declines screening  Provide resources for other sexual health providers in area  Front desk will ask teen if they want help making appointment with another provider, give instructions on hours/how to get there and insurance
  • 71.
    Chlamydia  How willprogress be measured?  Rates of screening for Chlamydia and other STI or declination  Rates of documentation of sexual activity or not (probably will need to do chart review because no discrete data element in EHR currently)  Rates of referral to other sexual health provider  Rates of referral sexual health provider visits within past year  Number of teens assisted in making appointments, brochures distributed  Run reports with the EHR and report MU
  • 72.
    Chlamydia  How shouldwe modify our latest changes?  Move to screening all teens (if did a subset before)  Improved documentation rate for sexual activity  Close the loop – within the next year, do the teens go to the referral provider  Distribute condoms in office?  Work with schools and pharmacists to assist teens locally?  What new questions have arisen that should be researched? Your own PDSA again - CME, MOC2
  • 73.
    Summary  The objectiveof this session was to learn about MOC and EHRs and how they can be used to develop quality improvement programs  I hope your can see how  MOC – is a continuous process to maintain your professional competency  QI – is a continuous process to improve the care you provide  EHRs – are continually advancing tools for us to use in our practice  Together they form a stalwart trio to help us provide the best care possible and continue to improve our mastery of our pediatrics.
  • 74.
    Donna M. D’Alessandro,M.D. donna-dalessandro@uiowa.edu