Use of Computerized Clinical Decision Support System and

Use of Computerized Clinical Decision Support System and Registry Functions to Track and Improve Clinical Outcomes Pamela Ferrari RN Director of Performance Improvement and Clinical Knowledge Support Open Door Family Medical Center Inc

What is CDSS? (Clinical Decision Support) "Clinical decision support (CDSS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. " AMIA, A Roadmap for National Action on Clinical Decision Support, June 13, 2006.

Goal and Aims of CDSS o 1. 2. To bring relevant knowledge to bear on the health care and well being of a patient or a population of patients. To make data about the patient easier to access or more apparent to a provider. To foster optimal problem solving, decision making and action by a provider “Clinical Decision Support-The Road Ahead” edited by Robert Greenes

Types of CDSS o Pop-ups and out of range alerts in the EMRn o Templates n o Recommend treatment of specific conditions CDSS/Alerts n o Structured data collection Order sets n o Example out of range vital signs, and labs. Based on preventive guidelines and medical history Provider reference n Up-to-date, Epocrates

Pop-up alerts: Red Font Identifies Elevated Blood Pressure

Templates: Structured data collection

Order Sets: Hypertension

CDSS/Alerts: Based on preventive guidelines and medical history

CDSS Alerts: Trigger an Order Set for BP control

Provider Buy-in o Good ideas are not adopted automatically. They must be driven into practice with courageous patience. n Hyman Rickover US (Polish-born) admiral (1900 - 1986)

The Importance of Provider Panel Integrity

Provider feedback needs to be applicable to their patients o o o We use Rendering Provider/Primary Caregiver for most reporting, We expect each patient to be seen by Primary Caregiver at least annually. We set a goal that 80% of our patients should be seen by PCG annually.

PI Project for 2009

Examples of CDSS that have improved care o o Diabetes A 1 c screening lab alerts Hypertension EKG Order sets Self management. Structured data templates. Asthma Action Plans. Structured data templates.

Improving A 1 c screening for diabetic patients

The CDSS Alerts remind Providers to get an A 1 c

Order Sets tell Provider when the last A 1 c was performed

Provider/Site Feedback Reports

Self-management template, increased compliance with documentation of goals

Structured text is inserted into progress note

Examples of structured data we collect o o o o Diabetes and hypertension control Medication adherence Diet and exercise assessment Last eye exam and result Last foot exam and result Self-management goals Results of autism screen Asthma control and Asthma Action Plan

Examples of templates we use o o Well-baby visits--include all anticipatory guidance as well as developmental screening Chronic Disease Templates--Asthma, Hypertension and Diabetes Acute Disease Templates Pregnancy test templates encourage enrollment in prenatal care

Diabetic foot exam

Structured data flows to Chronic Care Outcome reports and Flow sheets

Diabetes Flow sheet

Hypertension order set increased the number of patients with ECG.

Asthma Template documents both underlying severity and current control

Using data to improve care o o o List all diabetic patients whose last A 1 c was >9 and call them to come in for diabetes education. List all patients without an Asthma Action Plan and invite them to an Asthma Night List all hypertensive patients who said that they were not watching their diet and invite them to a presentation on the Dash Diet.

Improved Outcomes for the Practice

Clinical Performance Indicator Goal/National Benchmark 2006 2007 2008 YTD 2009 Percent of patients who have had more than one visit in the reporting year and have seen their PCG at least once Goal 80% Not Collected 29% 75% Percent of adult women screened for cervical cancer according to standard of care. Medicaid 64% 63% 21% 59% 54. 34% Percent of women >42 years of age who have had a mammogram in the past two years. Medicaid >50% 335 12% 26% 33. 66% Percent of Patients with asthma who’s current level of control is assessed * measure changed in 2008 Goal 80% unknown 42% Percent of Patients with asthma who’s current level of control is well controlled * measure changed in 2008 Goal 80% unknown 32% Percent of Patients with asthma with a current Asthma Action Plan Goal 50% 0% 2% 10% 25% Percent of patients who initiate their prenatal care in the first trimester. Medicaid 81% 80% 52% 72% Average last A 1 c for all Diabetic patients with an A 1 c measured in the reporting year. Goal <7 8. 2 8. 0 8. 2 Percent of Diabetic patients with HBA 1 C in past year Medicaid 78% 60% 73% 89% 96% Percent of Diabetic patients with A 1 c <7. 0 Percent of Diabetic patients with A 1 c>7 and <9. 0 Percent of Diabetic patients with A 1 c < 9 Medicaid 51. 2 * lower is better Not Collected 42% 32% 24% 35% 33% 32% Percent of Hypertensive Patients ( no Diabetes) with Blood pressure control <140/90 Medicaid 53. 4 Not Collected 45. 44% Percent of Hypertensive Patients with Diabetes with Blood pressure control <130/80 Medicaid 29. 5 Not Collected 26. 85%

Provider Report Card for Diabetes Provider Clinical Report Card May 2009 Provider/Measure DG VK PM MRP SR AR LR DW TY Total #Diabetics 76 117 72 139 15 21 83 70 217 1111 # A 1 c 75 117 71 139 14 21 83 70 214 1058 % with A 1 c in past 6 months Average A 1 c 99% 100% 93% 100% 99% 95% 8. 2% 8. 4% 7. 9% 7. 7% 8. 2% 8. 6% 8. 4% 7. 8% 8. 0% # A 1 c <7 26 44 23 58 1 7 25 37 91 409 %A 1 c <7 34. 2% # Lipid 47 % Lipid 61. 8% 37. 6% 61 52. 1% 31. 9% 61 84. 7% 41. 7% 106 76. 3% 6. 7% 33. 3% 12 80. 0% 16 76. 2% 30. 1% 49 59. 0% 52. 9% 48 68. 6% 41. 9% 140 64. 5% 36. 8% 686 61. 7% # Microalbumin 26 % Microalbumin 34. 2% 45. 3% 44. 4% 54. 0% 26. 7% 23. 8% 68. 7% 62. 9% 61. 8% 48. 6% % DM BP Controlled <130/80 29. 0% 16. 0% 21. 0% 34. 0% 57. 0% 25. 0% 23. 0% 55. 0% 25. 0% 37. 0% 53 32 75 4 5 57 44 134 540