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Kim Giuliano, MD Sharon O’Brien, MA Ivana Wilson, Medical Secretary. CQN Team Presentation. Progress Since Learning Session 1. Adaptation of CQN form into EMR Policy for incorporation of CQN form at every visit for patients with asthma
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Kim Giuliano, MD Sharon O’Brien, MA Ivana Wilson, Medical Secretary CQN Team Presentation
Progress Since Learning Session 1 • Adaptation of CQN form into EMR • Policy for incorporation of CQN form at every visit for patients with asthma • Simplified process for generating asthma action plans in EMR • Multiple revisions of office flow diagram to improve reliability • Monthly reliability reports given to MDs and nursing staff • Designed asthma education sheet to be given to all asthma patients at every visit • EMR report generated by IT department of all patients in practice who have been prescribed a controller medication for asthma • EMR report requested from IT department of all patients in practice who have a diagnosis of asthma
P P P P P P P P P D D D D D D D D D S S S S S S S S S A A A A A A A A A PDSA Ramps TEST 3 What:: Handouts given during rooming process Who (population): all patients Who (executes): RNs and MAs, MDs if not completed prior When: week of 1/11/10 TEST 3 What:: EMR Asthma Action Plan using “dot phrase” Who (population): all asthma pts Who (executes): all MDs When: 11/6/09 TEST 3 What:: Expansion of EMR form Who (population): all asthma pts Who (executes): entire office staff When: week of 10/26/09 TEST 2 What:: Handouts given during rooming process Who (population): Giuliano pts Who (executes): Sharon and Carmen When: week of 12/21/09 TEST 2 What:: EMR Asthma Action Plan using “dot phrase” Who (population): Giuliano pts Who (executes): Giuliano When: 10/30/09 TEST 2 What: EMR form Who (population): Giuliano pts Who (executes): Sharon O. When: week of 10/19/09 TEST 1 What: EMR Asthma Action Plan using letter template Who (population): Giuliano pts Who (executes): Giuliano When: week of 10/26/09 TEST 1 What:: Handouts given when verbal teaching not done Who (population): Giuliano pts Who (executes): Giuliano When: 12/1409 TEST 1 What: CQN paper form Who (population): 5 pts Who (executes): Giuliano When: 2 clinic sessions in Oct CQN Form Asthma Action Plan Education Handout
OFFICE FLOW DIAGRAM Pre Visit Patients ID by signal lights in EMR, stickers that ID patients (go on the sheets, physician questions) MA/RN rooms pt. If asthma med noted during medication reconciliation, MA/RN asks parents questions #1-10 and enters responses into medical record During the visit the physician fills out the provider form while having Informed clinical Discussion Questions 11-27 Patient with new diagnosis of Asthma, form is pulled and filled out concurrently Completed form returned to asthma form collection tray MA/RN puts revised CQN form with provider only questions on top of patient identification sheet Patient is ready to be seen by Physician During Office Visit YES Physician completes the form immediately after the visit NO PFT/ spirormetry ordered if needed Parent/patient education handout given YES Nurse Leader removes encounter form and verifies for completeness All necessary information on the form is entered into EQIPP by medical secretary Paper copy kept on file at secretary’s desk If necessary circle back with physician or patient family by phone to obtain missing information Post Visit Activities Pull list of asthma patients from EMR every 3 months. If no form on file, letter sent to home to schedule asthma appointment. NO YES NO Nurse Leader checks form to see if f/u appt recommended Nurse Leader checks EMR to see appt was scheduled Nurse leader gives name to PSR to call and schedule appt NO YES
CQN Encounter FormParent • 1. Has your child visited the ER or urgent care due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"} • 2. Has your child been admitted to the hospital due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"} • 3. How many days of school/daycare has your child missed due to asthma in the past 6 months? {NUMBER:30898} • 4. How may work days have you or your spouse missed due to your child's asthma in the past 6 months? {NUMBER:30898} • 5. How comfortable are you in managing your child's asthma, rated on a scale of 1-10 (1=not comfortable, 10=very comfortable)? {NUMBER:29773} • 6. During the past week, how often did your child use a fast acting or quick relief medication at times other than before exercise? {ALBUTEROL USE:70290} • 7. When are your child's asthma symptoms the worst (select all that apply)? {TIMING-ASTHMASX:70291} • 8. How often does asthma limit your child's activities? {ACTIVITY IMPACT:70292} • 9. Over the previous 2-4 weeks, how frequently has your child experienced episodes of cough, SOB, wheezing or reduced activity due to asthma during the DAY? {FREQUENCY DAY SX:70293} • 10. Over the previous 2-4 weeks, how frequently has y our child experienced episodes of cough, SOB, wheezing or waking up due to asthma at NIGHT? {FREQUENCY NIGHT SX:70295} • 11. How would you rate your child's asthma control during the past month? {ASTHMA CONTROL:70296}
CQN Encounter FormProvider • Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months? Yes No • Has your child been admitted to the hospital due to asthma in the past 12 months? Yes No If yes, how many times? ________ • Were one or more asthma key indicators present when considering the diagnosis of asthma? Yes No Not documented • Were lung function measures by spirometry used to establish the asthma diagnosis? Yes No Age inappropriate, younger than 5 years • Was a validated instrument used to determine the current level of asthma control? Yes No • What is the patient’s current level of control during the past month? Well controlled Not well controlled Very poorly controlled 6b: If “not well controlled” or “very poorly controlled”: • Did you identify reason(s) for lack of control? (Examples: exposure to allergens, tobacco smoke, indoor or outdoor pollutants and irritants, non-adherence to medication regimen) Yes No • Is spirometry currently scheduled or have results been obtained within the last 1 or 2 years? Yes No Age inappropriate, younger than 5 years • Have you used the age-appropriated NHLBI stepwise table used to identify treatment options or to adjust therapy based on asthma control? Yes No • Has a flu shot been administered or recommended within the past 12 months? Yes No Patient younger than 6 months or contraindications • Does the patient have a written asthma action plan? Yes No • 10b. If yes, was the plan updated as needed and reviewed at this visit? Yes No • Were asthma self-management education and materials (other than or in addition to the asthma action plan) provided and explained to the patient and family at any visit? Yes No • Was a follow-up appointment scheduled to monitor asthma control? Yes No _____ Needs to schedule in ______ months _____ Already has upcoming appt scheduled
EMR Patient Lists • In Feb, IT Department pulled list of all asthma patients who had been prescribed controller medications • Letter sent to patients’ home requesting them to schedule asthma visit • Utilizing list as tool in absence of availability/feasibility of registry
Testing on small scale first helps with group “buy-in” Measures that are simple and do not involve significant increase in office visit time are implemented most successfully Incorporation of nursing in more active roles in patient encounter has positive impacts in nursing attitudes and patient satisfaction Key Learnings
Barriers and Successes • Barriers • Registry creation requires involvement of IT department that is responsible for entire institution. Priority is low. • Time • Successes • Physician and nursing participation • Improved care for our patients
Future Plans • Continue monthly audits to improve physician and nursing reliability • Follow up letters or phone calls to patients on controller medications who did not respond to initial mailing re: asthma follow up appointment • Letters to be sent to all asthma patients in September for flu vaccine • Follow up letters to asthma patients 1st week of December if has not had flu vaccine • Continue to use EMR generated lists for identification of asthma patients if unable to utilize registry function within EMR
