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Increasing the Effective Use of Electronic Standing Orders (SO-TRIP)

Increasing the Effective Use of Electronic Standing Orders (SO-TRIP) . Lynne S. Nemeth, PhD, RN Associate Professor Medical University of South Carolina September 29, 2010. Co-Presenter: SO-TRIP Practice. Steven P. Johnson, MD New London Family Practice New London, CT.

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Increasing the Effective Use of Electronic Standing Orders (SO-TRIP)

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  1. Increasing the Effective Use of Electronic Standing Orders (SO-TRIP) Lynne S. Nemeth, PhD, RN Associate ProfessorMedical University of South Carolina September 29, 2010

  2. Co-Presenter: SO-TRIP Practice Steven P. Johnson, MD New London Family Practice New London, CT

  3. PPRNet SO-TRIP Co-Investigators • Steven M. Ornstein, MD • Ruth G. Jenkins, PhD • Paul J. Nietert, PhD • Andrea M. Wessell, PharmD • Loraine F. Roylance, MA Funded by AHRQ Contract No. HHSA290 2007 10015

  4. Background

  5. Rationale for Study • Time constraints and competing obligations in primary care practice contribute to inadequate delivery of clinical preventive and disease monitoring services. • Standing orders for practice staff using reminder systems embedded in EHR systems may help overcome some of these deficiencies.

  6. SO-TRIP Project Aims 1. Facilitate the adoption of an EHR based standing order protocol for selected preventive services, adult immunizations, and diabetes monitoring measures in 8 primary care practices using a validated quality improvement intervention. 2. Identify effective strategies and barriers to the adoption of this protocol. 3. Document changes in the use of the protocol and delivery of the study measures.

  7. Health Maintenance Table

  8. Health Maintenance Pop-Up Reminder

  9. Chart Summary Screen

  10. Methods

  11. Design: Pilot demonstration project from July 1, 2008 to April 1, 2010 using the framework PPRNet-TRIP QI Model • Setting: 8 primary care practices in 8 states

  12. Intervention • Quarterly audit and feedback on use of Practice Partner ™ Health Maintenance (HM) features and adherence with study measures • 2-3 practice site visits by study investigators (LN, SO) to help adopt HM features and SO protocol • Two annual network meetings with all practice liaisons and study investigators to share “best practice approaches”

  13. Quantitative Methods Data Collection • Quarterly EHR extract Analyses • Presence of study measure on HM template • Entry on HM template for study measure • Percent of patients up to date with each study measure • Pre and post-intervention comparison of summary measure

  14. Qualitative Methods Data Collection • Interviews • Observation • Correspondence Analyses • Identify approaches, facilitators, and barriers to adoption of SO protocol

  15. PPRNet-TRIP Improvement Model Prioritize Performance Involve All Staff Redesign Delivery System Activate the Patient Use EMR Tools JtComm J Qual & Safety, August2004, 30(8):432-441

  16. Practice Development Model Implementation Science 2008, 3:3

  17. Measures *U.S. Preventive Service Task Force recommendation ** Center for Disease Control Advisory Committee on Immunization Practices guideline*** Expert consensus or clinical experience, AHRQ National Healthcare Quality Report and American Diabetes Association current guidelines.

  18. Results

  19. Practice Characteristics

  20. Approaches to Adoption of SO Protocol • Regular meetings to support implementation, reach consensus, and provide feedback • Establish formal policies/protocols approving staff to act upon the electronic SO’s • Adapt EHR tool to include patient and staff in adoption of SO protocol: with significant behind the scenes “tweaking” of templates, rules, and utilities

  21. Health Maintenance Table

  22. New London Family Practice : Office Flow

  23. Patient Flow MA discusses with patient: Need CPE? Mammogram? Flu or Pneumovax? Tetanus? Zostavax? Cholesterol? Urine Microalbumin?

  24. Patient Info Update

  25. Progress Note From Note Template (example)

  26. Personalized Patient Handout

  27. Quantitative Analyses

  28. Outcome: Screening-Monthly Medians

  29. Outcome: Immunizations- Monthly Medians

  30. Outcome: Diabetes-Monthly Medians

  31. Summary Performance

  32. Qualitative Analyses

  33. Staff Quotes from New London Medical Assistants • Better patient care • Overwhelming at first, but becomes very routine after • Patient information sheet a good tool ….patients more in tune with their medications • We feel more involved in patient care • I like how we can have lab slips etc. ready for patient when they come out, so things move more smoothly

  34. Staff Quotes from New London MDs • Helps maximize program potential and make it more powerful • Improves medical care • Realize how many patients with diseases we need to capture • Patient info sheets great for patients to check on bio, HM, and medication information • Some chance for MAs to off load HM items

  35. Staff Quotes from MD’s continued • We definitely improved immunizations and HM items • It would be better if Connecticut MAs could give shots • HM items get done often without me even realizing • More is done because MAs have prepared patients so no long discussions needed during the visit • We have expanded the concept beyond the SO-TRIP parameters to also include pap smears, complete physicals, monofilament testing, and basically all the “red” areas of HM

  36. Facilitators of SO Protocol Adoption • Tech savvy leaders helped create tools that made process easy for staff and helped activate patients • Nursing note templates • Electronic patient update forms • Leaders redesigned systems for efficient patient flow • Practice policies/protocols; education, follow-up • Clinician follow-up; collaboration/communication • Staff that were non-supportive of the changes left practices and were replaced by staff “buying-in”

  37. Barriers to SO Protocol Adoption • Spread • Getting all staff to implement SO’s • Staff selectively implementing only some SO’s • Some providers uncomfortable with SO’s • Staff perceptions • Time management: SO’s slowing patient flow • Need to double check with provider re: SO • Need for decision-making re: screening lipids (fasting or non-fasting) or for additional labs; mammogram without breast exam

  38. Barriers to SO Protocol Adoption • Staff education or follow up on project plans limited • Practice reimbursement, patient funding or lack of availability limits implementing some vaccine SO’s • Patient refusals or disinterest • Technical issues with EHR; use of HM tools/utilities • Legal regulations in some states prohibiting SO’s or immunizations by unlicensed clinical staff • Competing priorities: new facility/merged providers

  39. Discussion

  40. 1) In SO-TRIP 6 of 8 practices were able to successfully adopt an electronic standing order protocol and had meaningful improvement in delivery of the study measures. 2) Staff in successful practices were able to incorporate new activities without significant time burdens and found doing so a source of empowerment

  41. 3) Technical competence/leadership are needed to optimally adapt and use the EHR reminder tools 4) More research is needed to evaluate effectiveness of an EHR based standing order protocol in a broader sample of practices and to identify which clinical measures are best suited for inclusion in such protocols

  42. Questions and Discussion Correspondence: nemethl@musc.edu

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