Using the Clinical Registries Health Maintenance Report (CRHMR ) June 2019

1. Defense Health Agency Using the Clinical Registries Health Maintenance Report (CRHMR)June 2019 “Medically Ready Force…Ready Medical Force”

2. Overview • Overview of CRHMR • Description, features and summary of element details • Using the CRHMR • Prepare for the encounter • Access the CRHMR • Copy information into TSWF form • Additional Background • Contact for questions

3. CRHMR Description • Compiles an individual patient’s most current Preventive Services data into a consolidated summary report; only age >18 years at this time • See back-up slides for time lag of clinical data • Facilitates documentation of Preventive Services field in TSWF form • Copy-paste appropriate elements into TSWF form • Avoids need to search multiple sources for patient’s information • Patient’s age and sex determine the report content; based on USPSTF • Preventive services are flagged as DUE/OVERDUE when appropriate • Focuses on general population screenings, not disease specific needs • Available within CarePoint’s familiar Clinical Registries (locations may change) • Accessible by anyone with a PHI-enabled CarePoint account • A column in PCMH Huddle and Appointments registries, also patient details summary tab (right-click patient row in any registry or Patient Lookup)

4. CRHMR features • Computerized collation of most current patient-specific data • Age/sex specific elements • Includes, among others • Date of report • 10-yr CVD risk estimate • Parameters used for CVD risk • Due/overdue logic mirrors MHSPHP • Standard screening elements as in the TSWF template Report copied from MHSPHP Clinical Registries - 06/11/2019 Lipids- 03/01/2016: LDL=142 HDL=40 TOTAL=285 10-yr CVD Risk Other Race/Ethnicity (ACC/AHA)- 3% 10-yr CVD Risk African American (ACC/AHA)- 4% 10-yr CVD Risk Components- Age: 55, Gender: F, Race: UNK, Chol: 285, HDL C: 40, Syst BP: 114, Htn Rx: No, Smoke: No, Diabetes: No 10-yr CVD Risk Current as of- 2018-12-31 Diabetes Screening- HgbA1c: 09/26/2018: 5.0 HIV Screening- 07/02/2012 HCV Screening- 06/28/2012 Colorectal Cancer Screening- Colonoscopy: 03/22/2018 Td/Tdap/Dtap vax- OVERDUE 10/16/2008 Influenza vax- 10/23/2018 Zostavax ZVL- None Recorded Shringrix RZV- 03/04/2019, DUE Mammogram- 02/28/2019 Chlamydia Screening- NOTE: Screening still recommended if at risk, but not routinely GC Screening- NOTE: Screening still recommended if at risk, but not routinely Consider for Aspirin Prophylaxis if 10 year CVD Risk is > 10% 1 2 3 • Advantages: • Avoids need to search other modules for most recent values • Improved accuracy over manually typed data • Improved completeness • Easily readable output 4 • Sample CRHMR (not a real patient)

5. TSWF CORE form Preventive Services field and CRHMR • CRHMR: computerized aggregate of patient-specific data including 10-yr CVD risk estimate; copy-paste selections into TSWF form (screenshot example) • Current: pre-populated empty template, manually updated by support staff using various AHLTA modules Report copied from MHSPHP Clinical Registries - 06/11/2019 Lipids- 01/07/2019: LDL=0 HDL=31 TOTAL=210 10-yr CVD Risk Other Race/Ethnicity (ACC/AHA)- Unable to calculate … 10-yr CVD Risk African American (ACC/AHA)- Unable to calculate CVD … 10-yr CVD Risk Components- Age: 54, Gender: M, Race: WH, Chol: 229, HDL C: 35, Syst BP: Missing, Htn Rx: Yes, Smoke: No, Diabetes: No 10-yr CVD Risk Current as of- 2018-12-31 Diabetes Screening- None Recorded HIV Screening- 01/22/2016 HCV Screening- DUE because birth year between 1945-1965 Colorectal Cancer Screening-OVER DUE Td/Tdap/Dtap vax- 07/19/2010 Influenza vax- 11/06/2018 Zostavax ZVL- None Recorded Shringrix RZV- DUE, DUE Consider for Aspirin Prophylaxis if 10 year CVD Risk is > 10% • (not a real patient)

6. Comparison (May 19 form version) (not a real patient)

7. Additional Information about CRHMR CRHMR… • includes this statement at the top: “Report copied from MHSPHP Clinical Registries [date]” • includes a calculated 10-year CVD risk estimate • with lab parameters used, their date, and risk calculation date. • uses published ACC/AHA Pooled Risk estimation equations. • emits both “African American” and “Other race/ethnicity” estimates because existing demographic data can’t reliably determine race/ethnicity; providers will choose which is applicable for a patient • Is currently calculated on a monthly schedule with some lag; lab values used for the calculation may be different from the most recent lipid values shown • emits “not available” or other similar text if needed data are not available within MHS data systems • accommodates standard cancer screening options but cannot account for special cases or circumstances

8. Additional Information about CRHMR cont’d • Information copied into the TSWF form is simple text and can be edited like any other text field within AHLTA; remember the 2,000 character limit for an AHLTA text field • The text count from a patient’s CRHMR varies, but even the largest reports have no more than 950 characters. • Users must thoughtfully determine if data already entered into the TSWF Preventive Services field should be retained rather than be replaced with CRHMR data.

9. Element details:CVD and Diabetes • Lipids screening date and results for most recently available, otherwise: • Males: “Due at age 35” if < 35 yrs or “Due” if >35 yrs • Females: “Due at age 45” if < 45 yrs or “Due” if >45 yrs • 10-year CVD risk estimate calculation and parameters • Uses AHA/ACC calculator when parameters are available • Emits “Unable to calculate” if parameters are missing • May be a 3 month lag due to issues related to collating equation parameters • Result for both race groups displayed because of unreliable EHR race data; provider decides which to retain/utilize • Diabetes screening date and result • If BMI >25, emits result or “Diabetes screening: None recorded” • If BMI <25, emits “Diabetes screening: Not applicable” • If diagnosed diabetic, emits “Diabetes testing: [Date], [result]” (or “none recorded”)

10. Element details:Cancer screening • Breast cancer screening • Women <39 years of age: nothing emits • Women 39-40 years of age: “Consider/discuss at age 40” • Women >40 years of age: utilizes MHS Pop Health Portal algorithms including date of last test or “DUE”/“OVERDUE” • Cervical (Pap or Pap/HPV): utilizes MHS Pop Health Portal algorithms • Emits date and type of last test or “DUE” or “OVERDUE” • Women <21 years of age: emits “Not applicable due to age” • Colorectal: utilizes MHS Pop Health Portal algorithms, accounting for colonoscopy, flex sig, fecal occult blood, FIT DNA, and Colon CT and their appropriate standard intervals • Emits date and type of last test or “DUE” or “OVERDUE”

11. Element details:Infectious diseases • HCV screening: only for those born 1945-1965 • Date of test, “DUE because birth year between 1945-1965”, or “None recorded” • Chlamydia screening: (same as GC) • Females >17 and <25 years of age: date of test or “None recorded” • Females >24 years of age: “NOTE: Screening still recommended if at risk, but not routinely” • GC screening: (same as chlamydia) • Females >17 and <25 years of age: date of test or “None recorded” • Females >24 years of age: “NOTE: Screening still recommended if at risk, but not routinely” • HIV screening: • Date only, or “None recorded” if no result is on file

12. Element details:Immunizations • Influenza: last vaccination or “None recorded” • Due/Overdue not included because it’s due for everyone annually • Td/Tdap/Dtap: date of last vaccination, “OVERDUE”, or “None recorded” • Shingles: 2 separate lines, one for Shingrix and one for Zostavax • “Zostavax ZVL”: starting at age >60 yrs: date or “none recorded” • “Shingrix RZV”: starting at age >50 yrs: date or “Due”, i.e. “Date/Date”, “Date/Due”, or “Due/Due” (see comments on slide 19) • Pneumococcal: uses MHS Pop Health Portal algorithms to emit dates, “Due”, or “None recorded” • HPV: 3 placeholders for date or “Due” for ages 15 through 26. ie. “Date/Date/Date” or “Date/Date/Due” or “Date/Due/Due” or “Due/Due/Due”

13. Element details:Others • Folic acid: • Age 15 through 45 emits “Recommended for Folic Acid” • Aspirin prophylaxis: • If age 50 through 59: “Consider for Aspirin prophylaxis if 10-year CVD risk is >10%” • AAA screening: • Age 65 through 75 and male emits “Consider for AAA screening if ever smoked tobacco” • (Can’t be more definitive due to uncertain history of tobacco use in EHR.) • Lung Cancer screening: no report because unable to calculate pack-year history or quit duration • Osteoporosis screen: currently researching a patient-specific methodology

14. Shingrix: additional details • ACIP recommends a 2-dose series 2-6 months apart • Fine print allows 2nd dose if not less than 28 days from 1st dose • Additional fine print allows +/- 4 days around a stated interval for actual immunization delivery • Including various existing data sources, some patients have >2 Shingrix CPT dates, most of which are within a few (1-7) days, indicating differences in administrative factors such as billing • Administrative factors are not expected to “echo” dates beyond 7 days • Therefore, the Shingrix algorithm was designed as follows: • Find a patient’s first recorded date and assign that date as the 1st dose • Find the next date that is > 24 days after that first date and assign that date as the 2nd dose. • If no Shingrix CPT codes for a patient, emit “Due, Due” • If one date or >1 date but all within 24 days of a first date, emit “DATE, Due” • If a 2nd date is > 24 days from the first date, emit “DATE, DATE”

15. Using the CRHMR

16. Using the CRHMR Overview of steps: • Prepare the TSWF form for the encounter • Access the CRHMR in MHS Pop Health Portal • Copy-paste information as needed

17. 1. Prepare the TSWF form for the encounter • These instructions focus on preventive services documentation, not other steps in the encounter prep process; fit or adjust these steps as best suits your workflow. • Typically during “open not checked in” or “copy forward” process, may be any time • Team should coordinate on procedures for updating preventive services content • Open the patient’s encounter, S/O module, TSWF form (CORE family of forms). • Briefly orient as to the status of the existing Preventive Services field contents: • Do any expected elements require updated information or dates?

18. 2. Access CRHMR in MHS Pop Health Portal • Open CarePoint’sMHSPHP. (Assumes familiarity with Clinical Registries; see back-up slides for more information) • If needed, set parameters for the date and provider encounters you are preparing. • Open PCMH Huddle or Appointments registry to find the HM column (or right click in any registry row, select Patient View; HM is in Patient Summary tab) • NOTE: First ensure “Health Maintenance” is selected using column picker. This step is only needed once: use “column picker” to select columns to view & rearrange their position order as desired; settings stay until changed by the user. See backup slides for additional detail. • Ensure the open AHLTA record and the HM entry are for the same patient. • In the patient’s MHSPHP Registry entry, scroll to Health Maintenance column.

19. 3. Copy-paste into TSWF form • Copy an individual element. (e.g. lipid results and date, 10-year CVD risk, etc.) • Paste into the AHLTA TSWF Preventive Services field. (manually typing dates or values is not recommended due to the risk of errors.) • Repeat as needed; clean up any undesired text from TSWF Preventive Services field as needed. • ----Now you’re ready to move to the next patient----

20. BACKUPS Additional details about the CRHMR and MHSPHP (as of June 2019)

21. Establish access to MHSPHP Clinical Registries • Open the MHSPHP home page • If you don’t already have access, click “PHI Access” and follow instructions shown on the page.

22. Open Clinical Registries, “Appointments” or PCMH Huddle

23. Change to view tomorrow’s appointments • Default view is just today. • Click on Options on the far right of page. • Click the dropdown to select tomorrow or other options shown. • Enter start and end date for other days.

24. Selected registry icons Mouse over any icon in MHSPHP for description Document generator DMIS filter Scroll to Grid Column picker • Document generator: shows a list of “canned” reports the user can generate, useful for team huddles • DMIS filter: for selecting which DMIS to view, if you have access to more than one DMIS • Column picker: used to select which data columns are shown and the order they are shown, left to right • Scroll to Grid: snaps to the viewable screen so the scroll bars on the right and bottom are easily found

25. Manipulating Columns Column picker • Uncheck columns to hide (they move to bottom of list) • Rearrange the position of a column by dragging to new position in list of column names or by changing the “Position from left” number • Click Apply

26. My Layouts in Column Picker • Can create multiple views • Can update a previous saved views • Can create a new view by editing a public view • (Only administrators can make public views) • But you can Share

27. Changing Parent/Child DMIS • Click Hospital icon to open “Page Filter”. • If your facility is the only DMIS listed, you can ignore this step. • Selections made in Page Filter apply to all registries. • If you have access to more than one DMIS, the best way to see them all is to leave them all unchecked. This will display all DMISs. • If you check select all, only those listed will be checked. • If new providers or provider groups change names, they will not be included.

28. Sorting Registries • Click on Column header to sort ascending (A-Z, low to high, old to new) • Click on Column header again to reverse order to descending • Click on small arrow in the column header to choose sort on that column • Can sort on multiple columns • In order of how you select the columns

29. MHSPHP Data Sources • Each metric’s and registry’s data sources are described in the methodology documents (top of navigation menu) • Data is captured from: • DEERS: who is enrolled for metric and list criteria • CHCS Enrollment file: for recent enrollment changes • CHCS encounter data • CHCS Lab data • Direct care inpatient coded records • Direct care encounter data (CAPER) • Purchased care claims for inpt and outpt care • All meds dispensed in direct care or purchased care • Limited AHLTA data: vitals, TSWF MHSPHP AIM data, MH Scores

30. Understanding Data Timeliness • CRHMR is updated nightly but uses some sources that update at different intervals • Some underlying data takes ~6 wks to receive and process • CVD risk estimates are updated monthly • Other lab tests should be included within 3 days of completion • Enrollment data/contact data: patients are redistributed on all lists according to nightly CHCS enrollment data • Data entered using the TSWF MHSPHP AIM form updates about one to three weeks after entry • Appointment registry updated every 5-15 minutes

31. General MHSPHP Registry Timeliness

32. QUESTIONS? • For MHSPHP or Clinical Registries access or functionality questions contact: • Judy Rosen: judith.i.rosen.ctr@mail.mil OR • Kevin Palk: kevin.d.palk.ctr@mail.mil OR • Michael Weisenburger: michael.a.weisenburger.ctr@mail.mil • For Health Maintenance Report content questions contact TSWF Team at • www.tswf-mhs.com/support/(scroll to bottom of the page and click on “Contact Us”)