Primary Care Providers Using Their EHR to Improve Quality: Lessons Learned

1. Primary Care Providers Using Their EHR to Improve Quality: Lessons Learned Practical solutions to typical practice problems Presented by: Tashara Milligan, MA, PCMH CCE Kelly Wiseman, BSN, RN, PCMH CCE Wake AHEC Practice Support Services

2. Primary Care Practices – Where they are Paper? Or change to EHR? Maybe I should just retire? Why am I printing visit summaries when the point is to be all electronic? Paper and ink is expensive. What is PCMH? ? Where do I start? What is PQRS? Why is Medicare paying me less? Am I getting left behind? What is health information exchange? I cannot afford all this change. Am I required to have a portal? People out here do not have home computers. Will I get a penalty? How can I get paid for my Medicare physical exam claims? What is the best EHR? Portal?

3. Objectives • Identify the following obstacles faced by practices implementing EHRs • Obtaining population data from your electronic health record in order to improve patient outcomes • Providing patients with patient health information (clinical summaries and portals) • Managing resources when there are so many different quality programs in which to participate • Interfacing • Security risk assessment • Describe one solution to resolve each issue • Describe one problem providers will face as they implement the 2014 ONC-ACB certified electronic health records and continue to improve quality.

4. Meaningful Use and Quality –First you must have …Certified EHR • How do you know your EHR is certified? CHPL list http://oncchpl.force.com/ehrcert?q=chpl CHPL = Certified Health IT Product List • Need the EHR to be ONC-ACB certified • ONC-ACB = Office of the National Coordinator Authorized Certification Body – only 4 right now • CCHIT, Drummond, InfoGard, ICSA Laboratories • http://www.healthit.gov/policy-researchers-implementers/certification-bodies-testing-laboratories

5. Problem 1EHR Quality Reporting • National Quality Forum (NQF) Measures are often used to report quality initiatives. • Practices want to use their EHRs to capture data to show improvement from their quality efforts. • Interpretation of NQF criteria for EHRs is based on each EHR vendor and their developer’s understanding of clinical structured data and the quality measure • Practices are limited by the functionality their EHR provides (NQF reports available, usability, evidence-based practice).

6. Problem 1EHR Quality Reporting NQF Quality Reporting Myths • NQF reports from any ONC-ATCB Certified EHR provide the same results. • Only active patients will be included in any NQF report. • Patient demographics will be consistent for any ONC-ACB certified EHR and will be reported as delineated by the NQF guidelines. • Only current, evidenced-based practice is reflected in the NQF quality reports.

7. Resolution for Problem 1EHR Quality Reporting • Determine if the canned NQF report is accurate. Drill down to what patients are included and what conditions are met or not met. • Create your own quality report using the data captured in another field • Review current workflow • Where is it charted now? Is it structured? • Can you build a report based on a procedure code, historical data or other structured data? • Test it!!!

8. Problem 1Documenting by Entering Accurate Structured Data Charting to your EHR • Text fields • Workflows within the EHR • Terms and structured data fields • Data location for quality reporting • Caution in charting by exception – functionality depends on EHR • Must chart the negatives • Identifying patients in a certain group (e.g., referrals) • Labs • LOINC codes!!

9. Resolution for Problem 1Documenting by Entering Accurate Structured Data Charting to your EHR • Contact vendor and determine location for structured data which will count for quality reporting • Labs • Contact the lab to determine if they use LOINC codes. • Enter a support ticket with the EHR vendor to have LOINC codes established.

10. Problem 2Providing Patients with Patient Health Information • Clinical Summaries • Patient Electronic Communication

11. Problem 2Clinical Summaries • Cost • Workflow • Patient Questions • Not Customizable

12. Resolution for Problem 2Clinical Summaries • Print clinical summaries and provide them at check out. • Print clinical summaries for the nurse or provider to review with the patient. • Add a portal and make the clinical summaries available to the patientelectronically.

13. Problem 2Patient Electronic Communication • Rural Areas with little broadband access • Adolescents’ privacy • Patient engagement (e.g., mobile device access, computer availability, education level, interest) • Patient having access to information provider has charted that the provider may not want the patient to read (e.g., suspected ETOH, appearance)

14. Resolution of Problem 2Patient Electronic Communication Functionality • Provider controls what is seen by patient • Provider can add text explaining patient results • Privacy settings for adolescents Patient Engagement • Consider incentives for patients to engage – gift cards,etc • Prompting patients to access portal by making lab results and clinical summaries available • Adding prescription refills and appointment requests to the portal for patient convenience Accessibility • Explore grants for increased broadband access • Provide kiosk for patients in waiting rooms

15. Resolution of Problem 3Managing Resources During Transformation • How does a practice choose where to begin with transformation? • Meaningful Use • PCMH • PQRS • BQPP • ICD-10 • What should a practice consider when selecting? • Practice priorities • Time to complete • Cost to complete • Incentive to participate based on payers • Penalties • Staff Resource availability and burnout • Government/Organizational Mandates

16. Problem 3Managing Resources During Transformation • Practice Goals – undefined, unrealistic, competing • Not finishing one program before starting another • Starting more than one program at once

17. Problem 4Interfacing – Providers Sharing Data Which to choose? • State and local health information exchange (WNCHN, NCHIE, CCHIE) • Direct Messaging • EHR Provider Portal (e.g., eCW P2P) • Encrypted email • Encrypted clinical care document sent via regular email without encryption • Referral portal associated with Accountable Care Organization

18. Resolution for Problem 4Interfacing – Providers Sharing Data • NCHIE is the only organization at this time with a connection to NCIR. You must connect to NCIR for MU compliance. • Determine what solution your ONC-ACB certified EHR has available. 2014 versions should have secure messaging. • Referral software and exchange with other members of their Accountable Care Organization • Exchange through the provider portal within the EHR • Email an encrypted clinical care document • Disease registries • Hospitals for diagnostic testing

19. Problem 5Risk Assessment of Patient Privacy • Expert consultation is expensive and unavailable • Office staff have difficulty completing the assessment because of terminology and skill level • System is hosted and vendor refuses to guarantee compliance • Limited resources to address security deficiencies

20. Resolution for Problem 5Risk Assessment of Patient Privacy • Office staff addresses checklist to the best of his/her ability and addresses deficiencies as they are able • Practice contacts IT support or another practice for assistance • Example security policies are adopted to the practice and implemented in the practice

21. Bibliography • http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events.html • http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf • http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Stage_2.html