Planned Visits Part II: Order Sets & Flowsheets

1. Planned Visits Part II: Order Sets & Flowsheets October 2010 Bryan L. Goddard, M.D.

2. Improving Quality: Starting with the end in mind • Computers are stupid – GIGO • How will we know when/if we improve quality? • Building data input so the computer can “find” • Making “standard of care” easier than alternatives • Finding your Order Set(s) when you need them • Patient Education finally! • Flowsheets pull it all together

3. Garbage In – Garbage Out (GIGO) • If I put it in, the computer should be able to find it! • For the computer to “find it,” there must be a label for the computer to look for, e.g. if you want to report on A1Cs, you can pull it from the lab section, or you have to define a place that will be the only place you put it (and the format it will be in!) • When you “run a report,” the computer will report on everything in the addresses specified in the query, but nowhere else! • The computer cannot interpret incorrectly formatted data, e.g. if you are looking for date of last A1C in MM/DD/YYYY format, and someone entered it in DD/MM/YYYY format, it will be invisible!

4. Defining Quality • “I know it when I see it!” doesn’t pass muster for insurance companies. • In “multivariate analysis,” the empowered patient is usually a more robust predictor of good POEM outcomes than any lab value. • Medical Schools have never taught us to document our progress in empowering patients. • Surrogate measures are starting to get paid for • PCMH hypothesizes that we can improve on many surrogate measures simultaneously – but the evidence is still inconclusive!

5. Chart Audits are cost prohibitive! • How much time did it take to do the Go Diabetes! chart audits? • How often did you find the information you were looking for in “the wrong place?” • EMRs intuitively should help, but . . . ! • Templates can prompt putting information in the right places • Order Sets can make it easier to • do the right things & • get reports in an easy format to search

6. Why we built GTFC Order Sets • Too much is too much • Similar formats/standards make easier to use • Meds all as generics, cheaper preferred • Category A-C testing, excluded Category D & I • We should be offering more Patient Education

7. Order Sets start with the diagnosis • ICD-9-CM codes are often either more or less specific than we need to think about • Insurers will base quality incentives on their expectations for specific ICD codes, e.g. UHS had a higher admission rate for hypertensive patients until we stopped billing everyone as 401.X • Insurers will deny necessary services if the code doesn’t match, e.g. 401.1 will pay for an ECG, but not an echocardiogram, but 402.10 will!

8. Making it easy to find good Patient Education handouts • We often don’t give out patient education materials because it takes too long to find it, what we find doesn’t match the patient before us, is copy protected, etc.! • We placed .pdf files 1-3 pages of “public domain” information, frequently from the AAFP website • We put links to longer documents, e.g. we have a 3-page AAFP .pdf file on the DASH diet, but a link to a 64-page NIH site for the patient who wants details!

9. Flowsheets – Why bother? • Bring together in one place everything you need to know to prioritize your care • Measure data that you need to report, but which is not usually entered into progress notes, e.g. diabetic retinal exams • They should not be a bother to maintain!

10. The GTFC Diabetes Flowsheet – Ta da! • We kept the rows down so we wouldn’t have to scroll! • Everything we have to include in our Quality Reports shows up • Most rows are auto-populated – Mapping accurately where the data came from took many back-and-forth e-mails! • Your diabetic patients already have their Flowsheets partially filled in! • (Now would be a good time to say “Cool!”)