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H ealth and C hronic D isease M anagement (HCDM). BEACON 9.8.2010. Overview. 4 year project Purpose: Leverage the MHS EMR to deliver point-of-care tools to providers and care teams
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Health and Chronic Disease Management (HCDM) BEACON 9.8.2010
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
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
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
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
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
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
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”
Condition Summary LINK
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
Up to 60 Clicks …5 minutes Provider adoption and efficiencylocate 10 elements on a diabetic patient … 2 Clicks<1 minute
Customizable – by Mayo New Summary Pages New Analytics Reports Open Source Sharing - http://mpagescommons.org/
MPage 2.0 Development – via Bedrock IP Discharge Process Nursing Communication
Utilizes more of the Care Team to deliver Health Maint and Disease Mgmt Reminder Letters Care Coordinator Patient List Scheduler Notification of due items