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Comprehensive Overview of Health and Chronic Disease Management Project (HCDM)

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otylia
19 diapositives · 343 Views · Aug 21, 2014

The Health and Chronic Disease Management (HCDM) project, initiated in 2010, aims to enhance ambulatory quality care by leveraging the MHS EMR system. This four-year initiative focuses on providing point-of-care tools for healthcare providers and care teams, developing detailed reporting to advance disease management and prevention. Collaborating with Mayo Clinic and Cerner, the project incorporates multiple components including algorithms for various health conditions and systems to monitor patient populations. Key metrics show significant patient engagement across diverse health issues.

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  1. Health and Chronic Disease Management (HCDM) BEACON 9.8.2010

  2. Overview • 4 year project • Purpose: • Leverage the MHS EMR to deliver point-of-care tools to providers and care teams • Develop detailed provider level reporting to advance ambulatory quality care in areas of prevention and disease management • Collaboration between Cerner and Mayo • 3 components – separate rollouts

  3. HCDM Resources • Project Team • Dr. Rick Fleming – Physician Lead – ISJ Primary Care Provider • Jason Buckmeier – Project Manager • Divya Pathak – Senior Analyst/Programmer • Lakshmi Kharidehal - Senior Analyst/Programmer • Cerner • Engagement Team • Discern ABU • ASYST • Leadership • Analysts • Mayo Health System • Quality Dept Leadership • MHS Expert Teams • Diabetic Registry programmers & AQM programmers • Ambulatory Care Committee • Site Quality Coordinators • HICS/Design Council as the oversight body

  4. HCDM Project Metrics • AMB, ED, IP Summaries - ~ 6200 users (providers/nurses) • Condition Management Rules: 435 MHS Providers (Primary Care) • Populations Evaluated - Current • Hypertension              51,777 patients • Asthma                  7,696 patients • Depression                19,130 patients • Diabetes                21,903 patients • Vascular Care            9,412 patients • Records reviewed nightly - 30-35,000 patient records per topic • The total for all topics ~ 180,000-210,000 • Largest population monitoring of any Cerner client

  5. HCDM Interaction Site Quality Directors MHS Expert Teams MHS CDR ASYST Site Liaisons MHS Quality Determines “what” we build & deploy ASYST Leadership MHS Ambulatory Care Committee ASYST Clinicals MHS EMR User Groups – FirstNet, Ambulatory, IP HCDM Determines “how” we build & deploy & integrate into MHS EMR Cerner Engagement Oversight ASYST Reporting Team HICS ASYST Learning Team Mayo-JAX Technical Team “Does” majority of HCDM Build Cerner Development – Discern ABU ASYST Technical Team PWG

  6. HCDM Components • 10 Algorithms • 1 Patient Summary Page • 4 Condition Summaries w/ Performance Measures • MPage 2.0 Summaries – AMB, ED, IP • Reminder Letter functionality • Team tools (provider schedule icons and scheduling solution integration) October 2009 July 19, 2010 Q4 2011

  7. Algorithms • Algorithms included: • Asthma (Adult & Ped) • Depression • Diabetes • (Diabetic Hypertension) • CAD • Hypertension • Hyperlipidemia • Heart Failure • (Diastolic Heart Failure) Link • Launchable from: • desktop • intranet • condition summary • EMR link

  8. Functionality Goals • Improve data capture (Tool: Ambulatory Summary) • More efficient documentation of quality metrics at point of care (foot exam, eye exam, PHQ-9, recheck BP, Asthma Control Test) • Advances ability to have responsive reporting • Educational (data to help support adoption – i.e. PHQ-9 utilization) • Aids in data collection for 3rd party submission (MNCM - DDS) • Point of care patient metrics (Tool: Condition Summary) • Displays to provider/nurse how the patient is performing on quality targets • Population Reporting (Tool: Discern Analytics) • Care-Coordinator/Quality Analyst focus • All measures, all conditions, all patients – updated nightly • “Show all patients with HgbA1c not done in past 6 months for Dr. Fleming”

  9. Improve data capture (Tool: Ambulatory Summary)

  10. Condition Summary LINK

  11. Population Reporting (Tool: Discern Analytics)

  12. Invitations for Asthma Depression Diabetes(10) Vascular Hypertension Cervical CA Breast CA Colon CA Lead Screen Invitations & other .20 functions Scheduler ability to see HM due items Reminder letters HM: Lipids, Mammo Health Maintenance displays Top half shows health maintenance overdue and coming due in defined time frame HM brought into Depart Summary Health Maintenance

  13. Up to 60 Clicks …5 minutes Provider adoption and efficiencylocate 10 elements on a diabetic patient … 2 Clicks<1 minute

  14. Customizable – by Mayo New Summary Pages New Analytics Reports Open Source Sharing - http://mpagescommons.org/

  15. MPage 2.0 Development – via Bedrock IP Discharge Process Nursing Communication

  16. Utilizes more of the Care Team to deliver Health Maint and Disease Mgmt Reminder Letters Care Coordinator Patient List Scheduler Notification of due items

  17. Thank you!