EHR-peds

EHRs &

Care Management:

Mandates & Opportunities

MICHAEL NEWELL, RN, MSN

PRESIDENT

LIFESPAN CARE MANAGEMENTPersonal Healthcare Concierge Service www.LifeSpanCM.com

Presented to Case Management Department

Children’s Hospital of Philadelphia

Objectives•Describe the critical components of the

Electronic Heath Record Evolution

•Explain how “Meaningful Use” will

enhance the standard of medical care

as Electronic health records are

implemented

•Describe How Case Managers can use

these innovations to improve transitions

of care and avoid adverse events.

Personal Healthcare Concierge Service www.LifeSpanCM.com

© Copyright 2010. LifeSpan Care Management, LLC. All rights reserved.

The First

Electronic Medical Record

Willem Einthoven first demonstrated electrical heart

conduction using an electrocardiograph in 1906, winning

the Nobel Prize for this invention in 1924

What does the data mean?

68%

16% 16%

Why

Who

What

When

Where

How

Who

• Office of the National Coordinator (ONC)

for Health Information Technology

• Health Information Technology for

Economic and Clinical Health Act

(HITECH Act) of 2009

• $20B Funded by the American Recovery

and Reinvestment Act of 2009 (ARRA)

What + Where

• Primary Care Providers taking Medicare

offered $44,000 each to purchase and use

an EMR

• Eligible providers for Medicaid may apply

for up to $63,750 per clinician

• A base payment of $2 million for eligible

hospitals and critical access hospitals,

depending on certain criteria

• All must show “Meaningful Use”

WhenMeaningful Use Stages

Clinical Information System(s)

Business Process

System(s)

= EMR +PHR

=EHR

+

Clinical

Decision Support

Outcomes

Care coordination

Client satisfaction

Errors

Costs

MU

• Updates to face sheet

• New diagnoses get free text box to enable

details

• Once appropriate details about the diagnosis

or problem are recorded, such as quality,

duration, timing, and complicating factors,

the provider clicks a box marked “add to the

problem list.”

MU-2

• Medication reconciliation

• Summary of encounter provided to patient at

time of discharge, including:

– Chief complaint/reason for visit

– Findings/diagnosis

– Plan of Care

– Meds, diagnostics, treatments ordered

• Notification of care transitions to pertinent

providers

• Summary of care at transition points

Population Health

Management

Defined as:

• Intensive care management for

individuals at the highest level of risk

• Personal health management for those at

lower levels of predicted health risk

H.I.E.

HIE solutions

• Achieving health goals through health

information exchange

• Improving long-term and post-acute care

transitions

• Consumer-mediated information exchange

• Enabling enhanced query for patient care

• Fostering distributed population-level

analytics

HIE To-Do List

• Create and implement up-to-date privacy

and security requirements for HIE

• Coordinate with Medicaid and state public

health programs to establish an integrated

approach

• Monitor and track meaningful use HIE

capabilities in their state

Summary Of Care Record

• Patient name.

• Referring or transitioning provider's name and office

contact information (EP only).

• Procedures.

• Encounter diagnosis

• Immunizations.

• Laboratory test results.

• Vital signs (height, weight, blood pressure, BMI).

• Smoking status.

• Functional status, including activities of daily living,

cognitive and disability status

SoC list…

• Demographic information (preferred language, sex, race,

ethnicity, date of birth).

• Care plan field, including goals and instructions.

• Care team including the primary care provider of record

and any additional known care team members beyond

the referring or transitioning provider and the receiving

provider.

• Reason for referral

• Current problem list (EPs may also include historical

problems at their discretion).

• Current medication list, and

• Current medication allergy list.

SoC List…

• Problem List – At a minimum a list of current, active and

historical diagnoses. The EP is not limited to just include

diagnoses on the problem list.

• Active/current medication list – A list of medications

that a given patient is currently taking.

• Active/current medication allergy list – A list of

medications to which a given patient has known allergies

& any exaggerated immune response or reaction to

substances that are generally not harmful.

• Care Plan …

PoCThe structure used to define the management

actions for the various conditions, problems, or

issues. A care plan must include at a minimum the

following components:

• problem (the focus of the care plan),

• goal (the target outcome) and any

• instructions that the provider has given to the

patient.

A goal is a defined target or measure to be

achieved in the process of patient care (an

expected outcome).

Functional Independence

Measures (FIM--WeeFIM)

Self-Care

• Grooming

• Bathing

• Dressing Upper

• Eating

• Dressing Lower

• Toileting

– Sphincter Control

• Bladder Management

• Bowel Management

Motor– Transfers

• Chair, Wheelchair

• Toilet

• Tub, Shower

– Locomotion

• Walk, Wheelchair

• Stairs

COGNITIVE

• Comprehension

• Expression

• Social Interaction

• Problem Solving

• Memory

FIM Decision Tree

7: Complete Independence Client completes activitywithout help, assistive device,in a reasonable time andwithout safety concerns

6: Modified Independence Needs more time or assistdevice

5: Supervision Needs set-up, cueing or contactguarding

4: Minimal Assistance Completes 75-100% of task

3: Moderate Assist Completes 50-75% of task

2: Maximal Assist Completes 25-50% of task

1: Total Assist Completes little or none by self

WeeFIM Polar Graph

MOS SF-36

• Self/phone/interview administered in 10 minutes

• Uses Likert scale, acute, chronic & disease-

specific versions

• Correlates .70 to .80 with actual health exams

• Discriminates stages, severity of disease and

moderate size treatment effects

SF-36 Health Domains

• General health

perceptions

• Physical functioning

• Role limitations due to

physical and

emotional problems

• Social functioning

• Pain

• Emotional well-being

• Vitality

• Changes in health

HSQ adds 3 question

depression screener

Working with HSQ Data

0

20

40

60

80

100

Phys

Func

Role

/Phy

sPai

n

Mntl

Hlth

Role

-Em

ot

Soc

FxVita

l

Gen

Hlth

Baseline 2nd Visit 1st F/U Adj Norms

Clinical Quality Measures

• Appropriate testing for children with Pharyngitis

• Weight assessment & counseling for nutrition & physical

activity for children & adolescents

• Use of appropriate medication for Asthma

• Childhood immunization status

• Preventive care & screening: influenza immunization

• HA1c test for pediatric patients

• Appropriate Tx for children with URIs

• ADHD: f/u care for children prescribed ADHD meds

• Children who had dental decay or cavities

• +HIV testing f/u

Goals for the

U.S. Healthcare

SystemAs per the Institute of Medicine

of the

National Academy of Science

A Continuously Learning System

References:

Best Care at Lower Cost: The Path to Continuously Learning

Health Care in America (2102) Mark Smith, Robert Saunders, Leigh

Stuckhardt, J. Michael McGinnis, Editors; Committee on the Learning

Health Care System in America; Institute of Medicine, National

Academies Press, Washington DC.

Blumenthal, D., Tavenner, M. (2010). The “Meaningful Use” Regulation

for Electronic Health Records. The New England Journal of Medicine,

363, 501-504.

Halamka, John D. (2009). Making Smart Investments in Health

Information Technology: Core Principles. Health Affairs. 385-289.

DOI: 10.1377/hlthaff.28.2.w385

McBride, S., Delaney, J. Tietze, M. (2012). Health Information

Technology and Nursing. American Journal of Nursing. 112;8. 36-42.

DOI: 10.1097/01.NAJ.0000418095.31317.1b

http://www.cms.gov/regulations-and-

guidance/legislation/ehrincentiveprograms/stage_2.html