Download Menu Item: Population Management

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Menu Item: Population
Management
Name of Applicant Organization: Fremont Family Care
Organization’s Address: 2540 N Healthy Way, Fremont,
NE 68025
Submitter’s Name: Elizabeth Belmont
Submitter’s Title: Advanced Practice Registered Nurse,
Director of Primary Care Clinics
Submitter’s E-mail: [email protected]
Executive Summary
Fremont Family Care is part of Health Care Professionals which is a wholly owned 501(c) -3
subsidiary of Fremont Area Medical Center (FAMC). The mission of our organization is to
improve the health and wellness of the people in the communities we serve. Fremont Family
Care implemented eClinicalWorks electronic medical record in October of 2010 and shortly after
the initial implementation and go live began tracking and improving population health in our
communities. This case study will describe the steps we took as a clinic to implement the
electronic medical record, track our patients, and improve the health of the population we serve.
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Background Knowledge
In October of 2010 Fremont Family Care implemented eClinicalWorks electronic medical record
with the help of a EMR support team and Curas our support/vendor. The goal was to improve the
care of the patients in the population we served. With the innovative forward thinking leadership
team we embarked on EMR implementation to achieve this goal. The team began to develop
population management and quality improvement goals. Within a year of implementation of the
EMR we felt that we had enough data entered in to the EMR to begin this process.
Population management has been something that Fremont Family Care has desired to accomplish
for many years however without the technology it was virtually impossible. After the initial
implementation and go live period was complete we began to embark on a process of population
management. Initially our goal was to promote preventive health care knowing that frequently in
health care our treatment is reactive, once a disease process has started, rather than preventive.
Fremont Family Care felt we could make a difference by preventing disease processes if
possible. Our goals were to increase the percentage of patients who had age appropriate
screening testing including mammogram, colonoscopy, and pneumonia vaccine.
The Nebraska Cancer Registry report from 2006-2010 indicated that cancers of the prostate,
breast, lung, and colon accounted for more than half of the deaths in our state. Among women,
breast cancer was the most common cancer diagnosis in Nebraska. The Centers for Disease
Control report that if everyone age 50 and older had appropriate colon cancer screening we could
prevent 60% of colon cancer. With this knowledge we felt that by promoting preventive health
care we could hopefully prevent some of these cancer deaths or at least identify cancer at a stage
where it would be treatable.
Given this data we as a practice embarked on a mission to improve the health and wellness of the
people in the communities we serve. We decided we would notify each patient that they were
due for one of these screening tests and recommend they contact us to schedule an appointment.
Local Problem and Intended Improvement
The most recent data in Nebraska indicates that cancer is the leading cause of death surpassing
heart disease. Our goal was to prevent as many cases of preventable cancer as possible. Our
practice knew the best way to accomplish this goal was to get our patients age appropriate cancer
screening. The problem was how do we contact those patients we don’t see frequently or who do
not have a scheduled follow up to remind them that they are due for cancer screening. Engaging
our patients in their health care had been something that was difficult utilizing the paper chart.
Patients were lost to follow up as we had no reliable method of tracking or following up with
these patients. With the implementation of eClinicalWorks we had tools that allowed us to track,
monitor, and contact these patients that were reliable and accurate. The EMR allowed us to
search using the registry feature a list of patients who were part of a specific age group who had
not had specific cancer screening or immunizations in the appropriate time frame. We were then
able to develop a letter that could be sent to the patients by mail or electronically using the
patient portal indicating they are due for cancer screening and asking them to contact our
practice to schedule.
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Design and Implementation
After our initial go live in October of 2010 the providers now had instant access to the patient’s
past results, all tests following go live were ordered within the EMR and could be tracked. We
scanned in past results so they were available for review during the patient’s appointment.
Ordering tests in the EMR made them searchable and we were able to begin to build our
database indicating where we were missing opportunities for scheduling or recommending
cancer screening.
The practice also implemented education process for providers and staff on Clinical Decision
Support System (CDSS). This tool alerts providers and staff if the patient is due for age
appropriate preventive screening as well as certain chronic care management items. We began to
have nursing staff check the CDSS and implemented standing orders based on CDSS alerts. This
process was completed during each morning and afternoon team huddle. The clinical staff would
then write in the chief complaint what the patient was due for to remind the provider to discuss
this with the patient. We also implemented standing orders using the CDSS allowing the clinical
staff to order a mammogram, discuss colonoscopy, or administer pneumonia vaccine if it was
indicated that they were due by CDSS. This eliminated barriers for clinical staff members
waiting for an order from the provider and increased efficiency within our practice.
As a practice we then began to identify patients who had abnormal testing and needed more
frequent follow up. We struggled with a process of identifying this specific patient population
and contacting them for follow up. The EMR leadership team developed a process of using the
action feature in the EMR to bridge this gap. The EMR leadership team educated staff and
providers on this process and implemented the use of actions to follow up on those patients who
needed more frequent cancer screening. The actions are created for each specific patient
indicating the abnormality and when follow up is due, they then remind providers/staff when the
timeframe for follow up has lapsed. The provider or clinical staff member will start a new action
for example if the patient has an abnormal mammogram that needs repeat in 6 months. This
action would be dated 6 months from the abnormal mammogram date and assigned to the
clinical staff member who would then get an order to repeat mammogram from the provider.
This process was very beneficial in tracking and keeping follow up with those patients. This
process the paper chart was nearly impossible and we relied heavily on the patient to come back
or call to schedule appointments. This was an inefficient process and erroneous process. The
actions allowed us a reliable feature to track and manage our patients efficiently and effectively.
Our practice then began to use the registry feature to create lists of patients who were due for
cancer screening, create letters, and send them to the patient’s home indicating they should call
for an appointment. We started with preventive care but then this grew to include chronic care
reminders as well. We began to remind patients who were due for hemoglobin A1C,
hypertensive’s due for blood pressure check, and patients who had not been seen in more than a
year. This was highly successful. We would send these letters initially through the mail and
people would create appointments or contact the office to schedule the appointment or test. This
was a successful way for us to implement change by tracking patients who may have otherwise
been lost to follow up. The number of letters initially was large and our practice saw an
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opportunity to communicate with our patients electronically. In 2012 we implemented patient
portal where we could communicate with our patients electronically. The patients were also able
to see preventive care reminders on the patient portal. We were able to then send their reminder
letters electronically.
As a practice we began to measure the results of our efforts by tracking the percentage of
patients who had the age appropriate screening. We reported this data at the provider level.
These results were shared across the clinic with the staff and providers regularly. This helped
remind providers and clinical staff of the need to offer cancer screening to their patients. This
initiative was a success and we began to see steady improvement in the percentage of our patient
population who had obtained cancer screening.
Utilization of Health IT
The EMR was essential in us developing and executing population management using these
quality goals. Tracking improvement or even developing a patient list was impossible in the
paper chart. We used the EMR to compile data to create our patient list and the EMR to create
patient letters. The addition of the patient portal to electronically communicate with the patients
was also beneficial in increasing patient engagement and reminding the patient in real time of
preventive health care they may be due for. The EMR was also used to determine numerator and
denominator of those patients who have had screening. This data is then reported across the
practice and among the providers. This has been helpful in keeping cancer screening top of mind
for our employees and helped to allow our staff to celebrate the success of improving their
scores. All of this data would not have been available in the paper chart. The EMR has truly
allowed us to provide better care to our patients in the community we serve.
Value Derived
The implementation of eClinicalWorks EMR has been invaluable to us as a practice. Our
practice has used the EMR to manage our populations. See Core Case Study: Clinical Value for
additional details. We have seen an improvement in the percentage of our patients who have
received cancer screening by sending registry letters and electronic communications and
reminding providers and clinical staff of the importance of cancer screening. We have also seen
great benefit in use of the actions within the EMR. This allows us to remind ourselves when the
patient is due for repeat mammogram or colonoscopy if it is before the regular timeframe due to
polyps or other abnormality. This has been very helpful and popular among our staff and
providers. This has also increased patient satisfaction as we are now being more proactive in
their care rather than reactive. We have seen a substantial benefit in implementation of the EMR.
We have continued to demonstrate increased percentage of our patients being screened for
cancer. We also track and follow up on chronic care quality initiatives which has been very
beneficial to our practice. We have currently been tracking diabetes, hypertension, and
preventive care as outlined above.
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These results are reported to the providers and across the practice which has also been helpful in
tracking and identifying gaps between our goals and our performance.
Lessons Learned
Implementation of an EMR system is a challenge across the practice however it is a much better
way to care for our patients. Starting from paper charts and converting to electronic medical
record is a challenge for staff and providers. It is essential to have a strong EMR leadership team
with clinical background. This team can lead the initiatives you develop. At our practice a nurse
practitioner along with the administrator and community EMR specialist (RN) developed and
tracked improvement as well as created and implemented improvement plans. The
implementation of quality goals are extremely important in improving the care of your patient
population. Provider/physician buy-in to improving care is also essential. Ensure that you are
able to accurately extract the data you need to report on the goals and to send the letters. Initially
this process was burdensome for us as we created the list of patients who were due for preventive
health care however as not all of the data was in the EMR as structured data yet we went through
each electronic chart on this list to ensure that the patient was in fact due for the testing. There
were still cases where a patient received a letter and wasn’t due for the testing. Our practice took
the approach that it would be better to remind the patient twice rather than not at all. We then
were able to develop a numerator and denominator for the entire practice and per provider.
Reporting performance across the practice by provider and sharing with the staff has been
extremely beneficial to benchmark the clinical teams and improve performance. This allows us
to identify gaps in our performance compared to our goals. The data was reported individually as
well as at the staff and provider meetings. Reporting the data at this venue was helpful in
brainstorming ideas for improved workflows and/or identifying areas for improvement that
would drive better care. Creating clinical teams composed of regular assigned clinical staff and
the provider is beneficial as the they work as a team and improvement in performance can be
directly related back to this team. This allows the clinical staff and providers to celebrate their
successes and take pride in improvements they make. Our teams consist of two clinical staff
members per physician and one clinical staff member per APRN and PA. Our workflow includes
development of strong clinical quality goals, educating staff, creating teams, and sharing the
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data. We have seen improvement in all of our goals and we continue to routinely report on these
goals and modify workflows as necessary.
Financial Considerations
Fremont Family Care’s initial investment in the EMR has been detailed in the ROI core case
study. The additional costs include staff training including paying wages outside of patient care
hours. This time has not been significant as training is typically added in to our monthly staff
meetings. Our nurse practitioner has been the clinical quality leader for our practice. There has
been additional overhead for using her as a resource outside of patient care hours to develop,
implement, train staff, and report on the quality measures. Seeing real time data demonstrating
improvement in clinical measures and population management is something that is invaluable to
the practice and the population we serve.
The financial return on investment for these measures has been in additional revenue from
increasing the number of pneumonia vaccines administered. We also realized a return in
investment by increasing the number of colonoscopies performed by the two physicians within
our practice who perform colonoscopies. We did not see a financial return on investment by
increasing the percentage of our patients who had a mammogram as our practice does not
perform the actual mammography testing. However, our practice felt the benefits of proactively
notifying patients, training staff, and sending letters to patients far outweighed the cost
associated with this.
As a practice we saw a significant increase in the percentage of patients who had received a
colonoscopy. We tracked patients age 50-75 who had a colonoscopy in the last 10 years. Initially
our practice did not do so well with only 37% of our patients having a colonoscopy. Over the last
3 years the percentage of patients who have had a colonoscopy has climbed to 70%.
Percentage of patients age 50-75 who have had colonoscopy
100%
90%
80%
70%
60%
50%
40%
37%
43%
42%
45%
45%
Q2
2011
Q3
2011
Q4
2011
Q1
2012
49%
48%
Q2
2012
Q3
2012
57%
56%
Q4
2012
Q1
2013
63%
64%
66%
65%
Q2
2013
Q3
2013
Q4
2013
Q1
2014
70%
30%
20%
10%
0%
Q1
2011
Q2
2014
Financial Reimbursement for Colonoscopies
Performed
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Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
2011
2012
2013
2014
$
243.00
$
$ 1,542.22
$
720.55
$
592.00
$ 1,032.32
$ 2,972.27
$ 2,850.64
$ 7,731.39
$ 8,819.31
$ 18,048.37
$ 18,146.88
$ 21,923.61
The financial return on investment is detailed
in this table. As a clinic Fremont Family Care
has realized increased revenue each quarter
with a substantial increase from Q1 2011 to
Q1 2014. The financial reimbursement
continues to grow each quarter.
Fremont Family Care also saw an increase in
revenue by increasing the percentage of
pneumonia vaccine given to our patients age
65 and older. Initially the percentage of
patients who had received a pneumonia
vaccine in 2011 was 56%, over the course of
3 years this percentage has risen to 75% as
detailed below.
Patients age 65 and older who have had a pneumovax
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
60% 58%
56% 58% 56% 58% 58%
64%
75%
69% 71% 71% 71% 72%
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014
Financial Reimbursement for Pneumonia Vaccines
Administered
Q1
$ 328.60
Q2
$ 149.19
2011
Q3
$ 859.61
Q4
$ 1,460.76
Q1
$ 114.38
Q2
$ 511.71
2012
Q3
$ 712.03
Q4
$ 3,708.38
Q1
$ 2,831.25
2013
Q2
$ 2,434.04
Q3
$ 3,586.25
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Financial return on investment has been
realized as well by administering more
2014
pneumonia vaccines as detailed here. The
increase is somewhat seasonal as many of these patients were given pneumonia vaccines around
the season for influenza vaccines. We have also noted a decline in reimbursement in the last
quarter which we suspect is partially attributed to the season but may also indicate that as more
of our patients are vaccinated the demand will begin to decrease.
Q4
Q1
$ 2,852.07
$ 583.25
Fremont Family Care did also increase the percentage of patients age 50-74 that had a
mammogram in the last 2 years. These patients were contacted using the same procedure as those
patients who needed colonoscopy and pneumonia vaccine. We did see a return on our investment
in terms of quality with the mammogram measure but not a hard dollars and cents return on our
investment.
Screening Mammogram for Women age 50-74
100%
80%
60%
40%
20%
54% 55% 56%
48% 48% 49% 50%
43%
42%
35% 38% 39%
28% 33%
20%
0%
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014
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