American Academy of Pediatrics CAQI: Asthma Quality Improvement Program

1. American Academy of Pediatrics CAQI:Asthma Quality Improvement Program EMR Encounter Form Development for Eastern Maine Medical Center’s Outpatient Pediatric Practice (Husson Pediatrics) Michael A. Ross, MD FAAP

2. “I have the following financial relationships with the manufacturers) of any commercial product and/or provider of commercial services discussed in this CME activity:” Speakers’ Bureau: GE Centricity Physician Champion It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for GE Centricity . However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations.”

3. The Issues • Multiple metrics need to be tracked in order to improve asthma quality and report data for the AAP’s Asthma Quality program (and for the Maine PCMH pilot) • Physicians need to use an encounter form that prompts implementation of asthma guidelines. • The form needs to be user friendly towards a variety of individual documentation styles. • The form needs to be linked to online reference for up-to-the-minute evidence-based practice • Data collection needs to be exported to existing Registry (Current metrics are limited to manual EQUIP entry) • The encounter form needs to be plastic, to reflect medicine’s evolutionary nature • The new form needs to work with our existing QA structure at Husson Pediatrics

4. Current system at Husson pediatrics: • Protocols: Reminder system that promotes delivery of care by non-provider staff (MA, RN, receptionist) for physician review. • Current Protocols: • Flu Shot reminders, • Smoking Status • Asthma Management Plans • Populated from medication list • Asthma Control Test • No asthma-specific encounter form exists: most provider documentation is entered via an open “HPI” field (and thus untraceable)

5. Could we use an existing encounter form? • Multiple Asthma forms are available: • Maine’s Ah!Asthma Form • Cincinnati Children’s asthma management form • AAP’s CQN-encounter form • GE-Centricity “CCC” asthma management form • Each form was analyzed – could they work with our current setup?

6. AAP’s CAQI Asthma Encounter form: • What worked: • Promoted use of 2007 guidelines • Captured all AAP’s metrics • What didn’t: • Paper based • ACT was “built in” • Some PCMH Metrics were missing

7. Ah!Asthma form: : • What worked: • Promoted use of 2007 guidelines • Allowed for “external” ACT administration • Captures other metrics not available as part of AAP’s current program, but part of PCMH • What didn’t: • Paper based

8. GE/CCC-Asthma Form v8.3.7.2 (cutting edge version) • What worked: • Promoted use of 2007 Asthma guidelines • Obs terms allow for registry capture • Auto-Populated Asthma-Management Plans • Linked to online and onboard asthma resources • Incorporated into the Asthma Management handout • What didn’t: • Interface did not allow for addition of AAP metrics • Could not incorporate Asthma Control Test into decision making • Interface was somewhat confusing; those who liked to free-text were resistant to use • No area to document Asthma past history • Unable to edit

9. Cincinnati Children's asthma encounter form • What worked: • Excellent overall template for asthma care • Promoted use of 2007 guidelines • Past Asthma history documentation • Lots of educational opportunities (Mask-Mouthpiece add-on) • What didn’t: • “On-board” ACT did not work with our existing system • “On-Board” Asthma Management handout did not work with our system • Minimal room for free-typing was bothersome to some providers • Entire form is an encounter from start to finish: cannot be used with our office’s dedicated “CPOE” system. • Some obs terms not in our system, or already used in other areas

10. Solution? “Steal Shamelessly” – Peter Margolis, MD, PhD Professor of Pediatrics, Cincinnati Children’s

11. Choose what worked from each to make our own • Cincinnati Children’s as a physical template • Added aspects from Ah!Asthma form, CAQI encounter form, and GE-CCC-asthma. • Developed a 2-tabbed form: • Asthma follow-up • Asthma diagnosis.

12. The First Tab: Emphasizing the Acute history

13. Moving down the First Tab: Decision support • Questions shift based on age of patient • Prompts provider to assign a category based on 2007 guidelines of control • Auto-Populates the Asthma Control Test scored from the last visit and from Today’s visit • Encourages the Provider to assign a level of baseline control • Brief reference material directly on form • Tracks step-wise use, and provides quick access to Maine’s Ah!Asthma online asthma management resources

14. Online Resources

15. Bottom of First Tab: More Metrics • Prompts provider to investigate other aspects of control (ER visits, school days missed, hospitalizations, spirometry) • Investigates family’s degree of comfort with asthma • Encourages provider to provide further patient education • Quick-link to asthma-related patient educational materials/handouts

16. Second Tab: New diagnosis/new patient to practice with Asthma(Near-direct lift from Cincinnati Childrens)

17. Moving down the Second Tab: Diagnosing Initial Degree of Severity • Questions shift automatically based on age of patient • Severity Assessment based on 2007 guidelines • Allows for a diagnosis to be assigned directly from the form • Utilizes Cincinnati Children’s mask/mouthpiece educational checklist

18. Current Form Status • Rolled out to Providers at Husson Pediatrics of 12/23/2009 • To be incorporated into Pediatric Encounter Documents in the near future • Meridios (Registry) terms assigned, registry coming online in near future

19. Sharing In the Spirit of the Collaborative, we are happy to share this encounter form with any who would benefit from it’s use. Please contact me at mross@emh.org for details: Michael Ross, MD FAAP Husson Pediatrics, EMMC