20141122 CHFHT Infoway Webinar

©Canada Health Infoway 2014

Central Hastings Family Health Team

Harnessing the Power of the EMR to

Improve Work Flow

Adam Stewart MD CCFPJulie Page RN MSc MHS PMP

• Who are we?

• How are we set up technology-wise?

• What is our current digital workflow?• Throughout a patient visit• From a population and programming perspective

• How did we get here?

• Challenges & Successes

Today’s Outline:

Central Hastings Family Health Team

Our Patient Population

Isolated

Elderly

Low Education

Low Socioeconomic Status

Minimal Private Coverage

High Health Care Needs

• Relatively small FHT

• Multi-Site

• 8000 patients

• Comprehensive primary care

• Chronic Disease Programs

• 6 Physicians (plus their staff 10+)

• 3 Nurse Practitioners• 0.5 FTE RN• 0.5 FTE RPN• 1.0 Program

Coordinator/System Navigator (RN)

• 0.5 Registered Dietitian• 1.0 Social Worker• 2.5 IHP Clerical Support

Our Team

Patient charts Marmora Server

Patient charts Madoc Server

Gilmour

Fax Server

Other Reports

Labs & HRM

Our NetworkPresent Day Our EMR is:

Telus PS Suite

The Workflow of a Patient Visit

Patient Register

Usher & Prep

The Encounter

Referrals & Tests

Follow Up

Patient Register

Usher & Prep

The Encounter

Referrals & Tests

Follow Up

The Patient Visit: Patient Registers• Arrows & symbols on appt schedule everyone the the status

of the patient’s visit.

– As soon as pt arrives and swipes health card, the “UP” arrow tells everyone pt has arrived.

The Patient Visit: Patient Registers

• Reception has patient complete pre-visit necessities, if applicable.

i.e.• Nipissing Screens for well child visits• Brief Pain Inventory for chronic pain visits• Urine dips, if applicable

• Exciting future role for:

• Instant Messages for rapid communication“Do you want a urine preg for Minnie Mouse?”

Patient Register

Usher & Prep

The Encounter

Referrals & Tests

Follow Up

The Patient Visit: Usher & Prep• Usher preps pt with BP

– Temp, Height, weight, vision, etc as necessary

• Standard stamps/templates for data entry

A special example: DM Visit Prep

Stamp in chart is started by the usher:

Patient Register

Usher & Prep

The Encounter

Referrals & Tests

Follow Up

The Patient Visit: The Encounter

• There is always a role for flexible, free-style, typed notes.

• Not everything fits into a classic pattern or ‘box’

The Patient Visit: The Encounter• Many presentations do follow patterns, though.• Opportunities for Stamps (“templates”) are

endless!

The Patient Visit: The Encounter• Stamps aren’t just for SOAP notes …

The Patient Visit: The Encounter• Towards the end of visit, take time for

opportunistic REMINDERS.

• There are endless possibilities for REMINDERS

* Note: the “COPD L1 Screen” reminder

A special aside: COPD Screening• As part of our Lung Health Program, we screen for COPD

• Level 1 (L1) screen for:• No COPD already diagnosed• 40 year or older• Past or present smoker• No spirometry or PFTs in 3 years• No previous L1 screen in 3 years

• Result is stamped into chart.

• This is done by any team member at any time

EMR Searches can then pull out those pts who need L2 screening (spirometry)

A special aside: COPD Screening• Once Level 2 (L2) screening is complete, the

spirometry results are stamped in to chart:

Standardized entry format allows for further data analysis

Now back to: … The Encounter

• A special example: The Diabetes Visit

• Our use of technology in our Diabetes Program has earned CHFHT two widely recognized awards!

– Canada Health Infoway’s“LEADing Practice Award”

– AFHTO’s“Bright Light Award”

Harnessing the EMR

• Telus Health EMR• aka “Practice Solutions”

• DM visits utilize the power of the “Encounter Assistant” feature.

•Fully customizable

•Data mainly entered in check-box or pull-down menu format, but the output is a typed text note when finished.

The Encounter Assistant

The final result of an EA is a tidy, stamped progress note.

Harnessing the EMR

Data is automatically imported

Harnessing the EMRClicking on this, opens a graph of A1C

Harnessing the EMRClicking on this, opens your web browser to the new CDA interactive guideline tool.

Harnessing the EMR

Clicking on these items opens a patient HANDOUT for quick and easy printing.

Report Card – Patient GOALS

• At the end of the report card, there is a section to enter the patient’s self-management goal(s).

• At the next visit, the form (and visit stamp) automatically populates with the last visit goals, making it readily available to reassess

• Eliminates the need to be scrolling back through the chart to dig up last visits notes.

Report Card – Patient GOALSReport Card from the visit 3 months ago:

Report Card at THIS visit:

This data is automatically imported to the current custom form

Patient picks a new goal and it is typed in here

Patient picked a goal and it was typed in here

… AND THE CYCLE CONTINUES …

The Patient Visit: The Encounter

• At the end of a patient encounter,

• Prescriptions are generally e-Faxed

• Handouts for pts are saved within the EMR to given to patients

• Referrals & Tests are completed and faxed electronically

Patient Register

Usher & Prep

The Encounter

Referrals & Tests

Follow Up

The Patient Visit: Referrals & Tests• INTRA-Team referrals:

• Mental Health Counseling• Dietician• Foot Care nurse• NPs for expertise roles in DM, insulin, HTN, Lung

Health

• All done quickly and efficiently within the EMR• Using ‘Custom Form’ referral forms• Using EMR messages

Trackable Data !

The Patient Visit: Referrals & Tests

• When the patient sees a Interdisciplinary Health Professional,

• All notes in the same pt chart for review by the primary care provider

• Messages back and forth, when applicable

• A “Discharge” Custom Form can be used (again for tracking purposes)

• Referral Letters are e-Faxed

• Requisitions for tests are done digitally within with pt’s chart and are also e-Faxed

• All pending statuses are tracked with the EMR

• Because we are remote and rural, most blood work is drawn on site by our hired phlebotomist.

• The Lab Req therefore stays in the chart until the patient is ready for it.

©Canada Health Infoway 2014 37

Custom Lab Req with “Buttons” that auto-populates preset options.

(The buttons are not visible when the req is printed)

Patient Register

Usher & Prep

The Encounter

Referrals & Tests

Follow Up

The Patient Visit: Follow Up• For important issues, can post-date messages to

self or front staff

The Patient Visit: Follow Up• i.e. DM recalls• Remember, the Diabetic Stamp note?

DM “Lost to f/u” Recall

• EMR search used to generate list of pts.

A staff member is given responsibility to pull a fresh list and recall pts on a monthly basis.

The Workflow of a Program

Build it

ONE SMALL STEP

at a time …

The Workflow of a Program• Start with a Registry

i.e. a “Diabetic Registry” or “COPD registry”

• Standardize the Data Entry• Every Diabetic has “250” in the problem list.• Everyone uses “COPD” for COPD pts.

• Run searches to clean up the data• Rule in false negatives• Rule out false positives• Ongoing process, repeat periodically

an example of a DM registry

Standardize the Documentation• For any variable or statistic that is to be tracked

• Ensure everyone is inputting the data in a standardized manner

• Start small, grow “One Small Step at a Time”

• Ensure engagement and agreement by all!

• The EMR can help make it seamless !– Remember the L1 COPD screening stamp?– Or the Spirometry results stamp?– Or the DM final EA stamped note?

The Workflow of a Program

• Regular monthly meetings• Report Data• Analyze Data• Set Goals

• Sub-Committees & PDSA’s

How did we get here?

Paper Charts

EMR“The Early Years”

EMR“Now”

How did we get here?• Again, “One Small Step at a Time”

• Keys to success:– External Consult: Best Practice in EMR use– PS Suite annual User Conferences– EMR ‘Super-User(s)’– Program Champions– Partnership with Third Party for Data Analysis– Monthly Meetings

» Shared goals, Engagement» PDSAs

• Never settle! Ongoing improvement.48

Challenges

• Still had a paper burden in the office• “Dirty” data input• Fluctuating engagement levels• Results plateau

QIP Monthly Monitoring

1/12/2014 Target All CHFHT Current

Total Number 801 Percent of DM pts with A1c<= 7 >60% 446 57% Percent of DM pts with A1c in past six months >90% 746 93% Percent of DM pts with BP <=130/80 >55% 492 64% Percent of DM pts on ACEI or AARB >60% 500 62%

Percent of patient with LDL<= 2.0 nmol/l in past 184 days >65% 292 63%

Percent of DM pts with retinopathy screening in past 24 months >90% 625 78%

Percent of DM pts with comprehensive foot exam in past 12 months >90% 522 65% Percent of DM pts with microabluminuris (ACR) screening in past 12 months >65% 663 83%

Successes

The Lung Health Program

Identification of patient eligible for screening – Level 1 and Level 2 Moving forward with COPD management and Smoking Cessation

Level 1 Screen (Canadian Lung Health Test)

90% of eligible screened to date-

728 positive screens representing 32.6% of Level 1 screens

Level 2 Screen (Spirometry)369 patients have received in house spirometry

57%24%

Normal ObstructiveRestrictive Mixed

Success !

A transparent, interdisciplinary, primary care practice centered on providing quality care based on best practices

Full integration of the EMR into the practice

Custom reminders, stamps, custom forms, encounter assistant all used to document care

Ability to pull data to drive quality improvement plans

Staff satisfaction in using the EMR

Patient satisfaction knowing that their health care record is right at the finger tips of the care providers.

ONE SMALL STEP AT A TIME

QUESTIONS ??

• Central Hastings Family Health Teamwww.chfht.ca

• Dr. Adam Stewartadamstewart79@gmail.com

• Julie Page, RNjulie.page@chfht.com

20141122 CHFHT Infoway Webinar

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