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Beyond Meaningful Use -- Multi- disciplinary Team Integration of Customized Smoking Cessation Patient Education Into EMR Clinical Decision Support

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Beyond Meaningful Use

Beyond Meaningful Use

--

--

Multi

Multi

-

-disciplinary Team Integration of

disciplinary Team Integration of

Customized Smoking Cessation

Customized Smoking Cessation

Patient Education Into EMR

Patient Education Into EMR

Clinical Decision Support

Clinical Decision Support

Wendy Angelo, MD

Wendy Angelo, MD

Capital Region Healthcare

(2)

Learning Objectives

Learning Objectives

By the end of the hour, you will be able to: ¾ Give examples of how an EMR can

educate both providers and patients.

¾ Identify strategic steps that increase the chances for success of a community-wide education program.

¾ Describe at least two advantages of a team approach to patient education.

(3)

My Background

My Background

¾ Wendy Angelo, MD

z Family physician for 15 years

z Physician advisor and clinical Informatician for

Capital Region Healthcare / Concord Hospital

z Proponent of using technology to make it

(4)

Located in Central NH

Located in Central NH

Hot Bed of Medical informatics

(5)

Concord Hospital

Concord Hospital

• Second busiest acute care hospital in NH • 205 beds • Regional referral area 275,000 • 15,000+ admissions annually

(6)

170 Providers Accessing >125,000

Electronic Patient Records

95% of Primary Care

95% of Primary Care Breast Care Center

100% Pulmonary Lipid Management

100% Surgery Diabetes Education

100%

Gastroenterology

Wound Healing Center 66% Dermatology Nutrition Counseling

60% OB/Gyn Sleep Center

(7)

For a Rural Community We

For a Rural Community We

Are Fortunate to Have a

Are Fortunate to Have a

Depth of EMR Penetration

Depth of EMR Penetration

and a Culture of

and a Culture of

Collaborative Practice That

Collaborative Practice That

Enhances Our Ability to

Enhances Our Ability to

Take on Quality

Take on Quality

Improvement at a

Improvement at a

Community Level.

Community Level.

(8)

Triennial Community Needs

Triennial Community Needs

Survey 2004

Survey 2004

Identified smoking cessation

support as one of the most

pressing needs of

communities served by the

hospital.

(9)

Why Focus on Smoking

Cessation

¾ The human cost of tobacco use is devastating

¾ The financial burden of tobacco use is staggering

¾ Systematizing the identification and

treatment of every tobacco user in a health care setting leads to substantial

improvements in cessation rates

Treating tobacco use and dependence – a systems approach. US public health service

(10)

Our Smoking Cessation

Our Smoking Cessation

Program

Program

¾

Traditional methods such as smoking

cessation classes @ Concord

Hospital’s Center for Health

Promotion

z Experienced steadily declining

enrollment figures over the last several years

z

Had no enrollees for a period of 15

(11)

We Were Not Meeting

We Were Not Meeting

Our Patient

Our Patient

s Needs

s Needs

We Needed to Do Some Quality

We Needed to Do Some Quality

Improvement

(12)

First Principles

First Principles

of Quality Improvement

of Quality Improvement

¾

¾ Quality is a system propertyQuality is a system property

Institute of medicine Institute of medicine

¾

¾ Every system is perfectly designed to Every system is perfectly designed to

get exactly the results it gets

get exactly the results it gets

Dr. Berwick

Dr. Berwick’’s 1s 1st st law of improvementlaw of improvement

¾

¾

LetLet’’s collaborate to design systemss collaborate to design systems that get our patients the services they

that get our patients the services they

need

(13)

Our System

Our System

Needed a Redesign !

(14)

System Approach

System Approach

¾

¾ Form a multi Form a multi –– disciplinary teamdisciplinary team

¾

¾ Review current evidence around smoking Review current evidence around smoking

cessation

cessation

¾

¾ Create an EMR based tool incorporating Create an EMR based tool incorporating

the best evidence

the best evidence

¾

(15)

Formation of a

Multi-disciplinary Team

¾ Enlistment of representative members z Health educator z PCP champion z EMR champions z IT specialists z Administrator ¾ Weekly meetings

(16)

Job #1

Job #1

Review the Evidence

(17)
(18)

The Evidence Behind

The Evidence Behind

the PHS Recommendations

the PHS Recommendations

¾

¾ Systems that increase the documentation and Systems that increase the documentation and

assessment of tobacco use markedly increase

assessment of tobacco use markedly increase

rates @ which clinicians counsel smokers to quit

rates @ which clinicians counsel smokers to quit

¾

¾ Clinician counseling markedly increases rates of Clinician counseling markedly increases rates of

successful smoking cessation

successful smoking cessation

¾

¾ Smoking cessation treatment is costSmoking cessation treatment is cost--effective: effective: average cost per smoker for effective cessation

average cost per smoker for effective cessation

treatment is ~ $166

treatment is ~ $166

Treating tobacco use and dependence Treating tobacco use and dependence – – a systems a systems approach.

(19)

The Evidence (Cont.)

¾ Systematic reviews showed that brief

counseling by a provider improves the rate of patients who quit smoking and don’t

relapse for 1 year.

¾ 4 RCT’s found that antismoking advice

improves smoking cessation for people at high risk of smoking-related disease.

(20)

Smoking Cessation

Smoking Cessation

Clinical Decision

Clinical Decision

Support Tool

Support Tool

A New Centricity Form Is Born

(21)

Rule #1

Rule #1

When We Create New Tools in

When We Create New Tools in

the EMR

(22)

How Can We Use Our EHR to

“Make It Easy to Do the Right

Thing”?

Dramatically improve those aspects of quality we can measure

And

And

Preserve and protect the time we need to talk with our patients

(23)

Principles of Effective Decision

Support

¾ Speed is everything.

¾ Anticipate needs and deliver in real time.

¾ Fit into the user’s workflow.

¾ Simple interventions work best.

¾ Little things can make a big difference

(changing “counseled to quit” prompt to red)

¾ Monitor impact, get feedback, and

respond

From ten commandments for

effective decision support

Bates et al, JAMIA Dec 2003

(24)

Old EMR Smoking

Old EMR Smoking

Documentation

Documentation

Mainly Unstructured Data

Mainly Unstructured Data

Consistent With Paper

Consistent With Paper

Documentation Styles

(25)
(26)

Step 1 in EMR Form Development

Step 1 in EMR Form Development

¾

What information do we want the form

to capture as structured (vs.

Unstructured) data?

(27)
(28)
(29)

Step # 2

Step # 2

Embed Dynamic Reminders to

Embed Dynamic Reminders to

Collect the Data Structured

Collect the Data Structured

For Both Providers and Staff

(30)

providers

(31)
(32)

Next, Embed the 5 “A’s” of

Tobacco Counseling

¾

Ask

¾

Advise

¾

Assess

¾

Assist

¾

Arrange follow-up

(33)

Ask

Advise

Assess

Assist Arrange follow-up

(34)

Then, Individualize Educational

Material

to Stage of Readiness

to Stage of Readiness

¾ Create patient education materials that

can be customized to the patient’s stage of change

¾ Make it easy to use

¾ Incorporate it into the normal workflow of the provider

(35)

Handout Types Developed

¾ Smoke free living: thinking about quitting? ¾ Smoking cessation: contemplation

¾ Smoke free living: preparing to quit ¾ Smoking cessation: action

¾ Smoke free living: congratulations! ¾ Smoking cessation: relapse

¾ Smoking cessation: prenatal patient information

(36)

Next, Show Providers

How to Use the Tool

¾ Health educator trains providers to:

z Utilize Prochaska / DiClemente model to

assess stage of readiness to quit

z Employ motivational interviewing

z Invoke “5 R’s” for those not ready to quit

• Relevance

• Risk

• Rewards

• Roadblocks

(37)

What to Do When

(38)
(39)

What to Do When

3 Minutes Is Too Long…

¾ Give healthy plan form as homework

z Reasons to quit:

reasons not to quit:

z My goal for stopping smoking is:

z The steps I will take to achieve my goal are:

z The things that could make it difficult to achieve my goal

include:

z My plan for overcoming these difficulties includes:

z Support/resources I will need to achieve my goal include: z My confidence that I can achieve my goal:__________ z (Scale of 1-10 with 1 being not confident at all, 10 being

(40)

What to Do When

1 Minute Is Too Long…

¾ NH Smoker's Help Line enrollment form

z Prints out with patient demographics and the

patient signs it

z Faxed to the state program

z Program contacts patient by phone

• 2 times prior to quit date

(41)
(42)

Framing and Measuring Our

Framing and Measuring Our

Accomplishments

Accomplishments

¾

¾ Communicating framework for measuring Communicating framework for measuring

success

success

z

z What is the clinical What is the clinical ““casecase”” for our goalsfor our goals

z

z What metrics do we need to measure ?What metrics do we need to measure ?

z

(43)

Clinical Framework … an

Obtainable Goal

¾ Target high-risk populations by incorporating into the NCQA’s

Certification as part of the project ¾ DPRP

(44)

Metrics

Metrics

Create crystal report to measure number of patients >18 whose smoking status

has been identified, and smokers who have been counseled to quit within the last year.

(45)

Create Baseline Metrics

Create Baseline Metrics

Where Is the Starting Line?

(46)

What Would You Estimate the

What Would You Estimate the

Smoking Rates in Your

Smoking Rates in Your

Practices?

Practices?

¾ Less than 20 % ¾ 20-50 % ¾ 50-70 % ¾ Over 70 % ¾ Don’t know

(47)

Concord Baseline Smoking Data

Concord Baseline Smoking Data

0 10 20 30 40 50 60 70 80 90 100 9/1/2004 % smoking status complete % of smokers counseled % smokers

(48)

Communicating to Providers

Communicating to Providers

1. Distribute reports to PCPs, illustrating each PCP’s scores in comparison to colleagues’ scores and to DPRP AND HSRP benchmarks.

(49)
(50)

Our Results

Our Results

Did It Work?

(51)

2 year trend graph 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Sep -04 Mar-0 5 Sep -05 M ar-06 Sep-0 6 M ar-07 Sep -07 M ar-08 Sep-0 8 M ar-09 Se p-09 M ar-10

% with known smoking status % smokers counseled <1y % non-smokers (known status) % smokers (known status)

(52)

Ongoing Challenges

(Remember the Big “AND”)

¾ Encouraging physicians to shift to a team-based approach to smoking cessation.

¾ Aligning incentives with non-clinical staff. ¾ Balancing measurable quality with

non-measurable quality.

¾ Expanding the metrics down to 13 years old for meaningful use

(53)

What Cessation Strategies

Have Worked for You?

(54)

Question and Answers

Question and Answers

Thank You

References

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