Tips for Using EHRs to Improve Quality of Care and Health Outcomes

Tips for Using EHRs to Improve Quality of Care and Health Outcomes


Thank you very much. We will now be privileged to hear from Ms. Bainbridge. Hello. I’m going to start this presentation out by talking about some basic concepts I think are really important for us as we bring electronic health records into healthcare. And then the presenters who follow me are going to talk about specific examples and experiences that they have had in the use of electronic health records. So, probably some of the most important meaningful use that will come out of the advancement of the EHR will be our ability to advance quality. And I think it’s extremely important as we bring electronic health records into the industry and into our individual organizations, we stay very focused on how those electronic health records can help us to achieve that. Right now, healthcare is in a very reactionary state. Right now, we got a lot of stuff coming at our providers, and it’s very easy to react to those things than to plan for those things. And because of the role the electronic health record has the potential to play in helping us to drive for a higher level of quality and safety in our environments, it’s going to be extremely important that we plan for that. Quality wins in healthcare when we, as providers, maximize the chances that we get patient care in operations right the first time. We minimize the risk that an error will make it all the way to the patient or into critical operations. And we ensure that care and operations are consistent with the most current standards that evidence based medicine and current knowledge can provide to us. And the electronic health record has the potential to play very valuable roles in making all three of these happen for our patients and for our providers. This is just an example of what some of the things that are happening inside healthcare that makes the introduction of electronics, and particularly tools like electronic health records so important for us. This is an example of the growth in scientific citations that have occurred between the years 1995 and 2006 in healthcare. And that number continues to escalate, as we are constantly gaining new knowledge and learning how to advance the care we deliver to our patients. And so one of the things that’s very hard on healthcare right now is that our old manual ways of trying to manage all this information and make sure all these things are happening for our patients is very, very difficult on our providers, and it’s very, very difficult on our organizations. And so the electronic health record has the potential to be that powerful tool that will help us to manage some of these things and hopefully, with time, take the burden off our caregivers. One of the other things, as I work with hospitals and other providers around the country to retool their quality programs and to interface their electronic health records with their quality program, that I believe is important for us to remember is what meaningful use means to the provider, or to the patient. It’s real easy these days for us to get so caught up in the processes of making this happen or that happen, that sometimes it’s easy for us to forget that the person who needs to benefit the most from these electronic health records is the patient. And so, meaningful use for the patient is eventually having easy access to health information and to know that all their providers have easy access to their health information. It’s to make sure hat they’re receiving the right care the first time. And our systems and our practices minimize the risk of error and harm for those individuals. And then they want to know that we’re allowing them to access the best care known to medicine at that time. And, as technology continues to change medicine almost on a daily basis, what we can offer patients, the ability to extend their lives and to allow them to live a higher quality of life, it’s going to be extremely important that all our systems, electronic and traditional systems interface well to make that happen for them. The provider that’s caring for those patients need to be able to deliver all of the above to the patients in an environment that supports the workforce in a user friendly way. And then, from an organizational perspective, we need to know as leaders that we’re delivering all these things for our patients and providers. And we have systems that give us very timely access to important leadership information. And it allows us to begin to automate quality control. Possibly one of the most important rules in healthcare reform is going to be the 110/100 rule. This is a business rule that’s been around for other industries for about four decades. And basically what it says is that for every dollar or every hour we spend getting something right the first time, we will spend $10 or 10 hours making mid-course corrections and $100 or 100 hours fixing it after the fact. And one of the problems we have in healthcare is that, as a technologically advancing industry, that last figure, that $100, has actually grown to be something more like 1,000, 10,000 and 100,000 for a healthcare provider. And so it’s really important that we begin to look at how to retool our approaches to quality to allow us to now manage quality to the left, with the goal of always getting it right the first time for the patient and for us. Many of our traditional approaches to quality, because they’re manually driven, have forced healthcare into a position of having to manage quality to the right. We collect data after the fact, we do studies after the fact to try and figure out how often we got something right. And one of the most powerful features of the electronic health record from the quality perspective is to begin to hardwire quality control on the front-end side so the electronic health record will help us maximize the chances of getting it right the first time. This is another important point that was made by a gentleman by the name of James Reason back in the early 1990s, that also the electronic health record will have a significant impact on. And that is that every industry, particularly the technologically advancing industries, have a very fine line they’re constantly trying to manage. And that fine line is between safety, innovation and production. And when our quality systems aren’t as strong as they need to be, what we tend to do is bounce back and forth across this line. And periodically we have it that events play out that actually create catastrophic harm for the patient. And so, one of the points that James Reason made in his work is the fact that we need our systems to be strong enough and tight enough in our organizations to help us manage this line to minimize the risk that will come across the line and also to minimize the risk that an error will ever make it all the way to the patient. And the electronic health records has the tremendous potential to help us begin to hardwire those systems that will help us to do that. And the reason I talk about it now with providers is because we’re in the infancy stages of designing and implementing our electronic health records. We’re going to go through several iterations of those records before they have the potential to be the kind of powerful tool for quality that we need them to be and that they can be. But, as we’re going through those iterations, we need to constantly be stepping back and saying, “How in this next iteration can we make this electronic health record serve quality better?” And then we need to work with our vendors to make sure that those modifications play out so that, with time, the electronic health record will become that quality tool that it has the potential to become. The electronic health record has the potential to do two things for us as we’re retooling our quality programs to create an environment where we can achieve those goals I talked about in the beginning. One has the potential to close the gaps that live in the safety innovation equilibrium for healthcare right now. Right now, because of the pace of the industry, the manual-ness of many of our systems and the old way we do quality, the retrospective way we do quality, it’s very easy for things to cross the line. And so, the electronic health record has the potential for us to beginning to close the gaps in that line. And then it also has the potential to help us build a safety zone around that line so when we do have incidences or events that make it across the line, the safety zone traps them before they make it all the way to the patient. The flag for the electronic health records will be able to provide us the reminders and things like that are those things that will help us to build that safety zone. So, if we have something playing out with a patient, a flag may come up in the chart and say, “Are you really sure you want to do that” or “This patient’s lab work is this, is this drug truly indicated for this patient?” See, it’s going to be [timeful] before we have that kind of safety control inside our electronic health records, but we need to start planning for it today if we’re going to make sure we have it for tomorrow. The electronic health record will be the greatest enabler we may introduce into healthcare in my lifetime because what will happen is we are going to be able to align the electronic system with our existing patient care practices and allow that enabler to let those practices be stronger. So, many of the systems we’ve been implementing in the last decade such as the electronic MAR and some of the bar coding for medications, all of those are enablers. They’re electronic systems or processes that we marry to an existing practices inside one of our existing procedures, and with that enabler that process becomes much stronger and much safer for the patient. And so, as we’re retooling our electronic health records, what we’re constantly looking for is how to use it to create an enabler that will better support our staff and better serve our patients. The thing that this is a quote that I think is very appropriate for where healthcare is right now. Chance favors a prepared mind. But one of the concerns that I have, as I travel the country and I work with providers to retool quality programs and integrate their EHRs, is that the stress right now that lives in healthcare is prompting people to not think ahead and not be prepared. And so, it places our electronic health records at risk of not ultimately becoming what they have to the potential to be for us. And so, as we’re bringing them into our environment, it’s very important that we step back, we say, “How can this tool help us to advanced quality and control quality and be exactly what we need to be for our patients and then work with our vendors to make sure that those pieces are being incorporated into each of those iterations that will come out over the next decade.” And, on that note, I’m going to turn my presentation over. Thank you. Well, I’ll start the with this. Rich Kalish, and a pleasure to talk about Boston HealthNet. I want to thank our hosts, the folks in Norfolk for organizing this. What I’m going to be focusing on is the- I’ll give you some of my perspectives. Boston HealthNet is a vertically integrated network with a hospital and a medical school and 15 health centers. And we really are able to enjoy the advantages of being both to sort of share our work together, celebrate our accomplishments and commiserate sometimes. But we’re also able to leverage resources with the Boston Medical Center. I’ll try to speak up a little bit. So, the real main issue here – and I also wanted to be able to thank HRSA. I’ll be talking about some of the resources that they’ve been able to give us. And then I’ll be leading to a further discussion of how we stand with respect to meaningful use criteria, some selected meaningful use criteria and to the medical home criteria. So, we’re about 15 years old right now. We started with about eight health centers in 1995, we’ve grown to 15 right now with a- working with Boston Medical Center, the largest safety net in New England, and the Boston University School of Medicine, which has a real urban health focus. So, 200,000 patients are served by us, and that’s an excess of 1.2 million visits over the 15 health centers. There’s about 62 percent of the patients come from public payers. That’s Medicaid, Medicare and Commonwealth Care. Some of you are familiar with that, that’s the Massachusetts health center reform product around here about four years now. And 64 percent are race and ethnic minorities. We’re throughout Boston, and we’re throughout Boston, and going down to Quincy and the south shore in the area of eastern Massachusetts. I want to tell a little bit about the evolution of IT over within Boston HealthNet. We’re very fortunate that back in 2001 we got an anonymous foundation grant of almost $6 million to enable eight of the health centers to adopt what was Logician and now Centricity. Boston Medical Center already had it at that time. Our information technology has expanded greatly with our initial EMR award with two one-line connections. We had our second ISDI grant, that’s a HRSA grant, an integrated systems delivery initiative grant in 2002 – 2005 was very helpful. We had a lot of lessons learned, and I’m going to get to that in a little bit. We interface with EMR and other applications, and we have electronic prescribing. Like Ms. Bainbridge said, we have a strategic plan, and I think that’s really connected with what she was saying about meaningful use, which is that the- for providers it really means it’s our strategic goal here that means having an echart tool at each site that functions well and it’s satisfying providers. And the way I used to like to say is that it helps us make sort of the right thing to do the easiest thing to do. And I think we are getting closer to that, though not in every case. And we wanted our partners to be able to track our fills, focus on patient safety issues and be able to work on reporting and some research. And to do what I call- have reflective care so we will have a sense of how we’re doing on any healthcare indicator. So, our vision is a community of care. It was at the hospital, health centers really one through 15. It’s a community information exchange, or an HIE as a lot of you know that. We have information we exchange, we have different transaction services basically from practice management systems. We want to be able to have clinical decision support, analytics and some surveillance work in public health, patient information and medication reconciliation, we’re working hard on that, health and wellness alerts, and then tying everything in with sort of more far-reaching transaction services, and then really connecting with families and patients and then ultimately with other HIEs. You know, patients that come into our system from other systems, we want to be able to cull that information easily. We can put transmitting in our system where if our patients are going somewhere else, that’s where we really want to be. So another big grant that we got in 2007, just a few months ago, was a quarter of a million dollar grant from HRSA again. This connected the EMR at Boston Medical Center and the CHCs. It’s compiled about standards, it’s really the cornerstone of the whole strategy. And while initially we felt we were just going to be able to get labs sort of up at the first pass. And that’s how we sort of designed the grant when we wrote that. Ultimately, we were able to get medication lists, problem lists, allergies, lab results, consult notes. And I’ll go through an exercise on how we’re able to get innovation information exchanged out on H1N1 last year and seasonal flu and pneumo vacs. So, we went live with this about a year and a half ago, and now the 11 health centers, which the Centricity electronic health records as well as Boston Medical Center are using it. Ultimately, we want to have all CHCs using it for the health centers that are electronic records other than Centricity. The CIE was designed to improve patient safety. And again, because at first we could just get lab information, our quality indicators of risk, a lot of the clinicians out there will know that the diabetes drug Metformin and Glucophage, you need to install and kidney function as measured by creatinine. So we want to build some quality indications around that. That would be patient safety. Similarly, patients on statins should have liver function tests, at least an ALT drawn where we have a quality indicator around that. We want to improve diabetes control as measured by hemoglobin A1c’s in the appropriate range. And we want to make sure that people are measuring A1c’s and LDL’s in patients with diabetes and heart disease. So, and then the other piece of this, of course, is that there has to be sort of the human side of this, that there has to be a collaboration with quality people that are using the tool and needing improvement. And so how do we do that? We do that with the dashboard. And the dashboard here, this is just an example of the original eight health center grant on this particular grant, and measuring their A1c’s, the diabetic patients that A1c’s within the 12 months, diabetic patients with at least one LDL within the last 12 months. You’ll see we have an asterisk there on sites that- months that had some technical problems. But you know, health centers three through six really use this leverage of data, being able do this reflective care that I referenced, and there was lots of very rich discussions between sites that weren’t doing as well and others that were. We really used the chronic care model and rapid cycle quality improvement activities. So, I mentioned before that in the early 2000s, we had a HRSA grant where we tried to work on the referral and consultation module to improve the referrals. This is, again, is a very integrated network. The level of intensity just between health centers, you know, predominantly PCPs trying to send patients to the hospital or to specialists that mostly are in the hospital, I should say, and specialists not always having all the information, the information that the specialists not only is giving back to the PCP in that kind of a way, this is as critical as anything that we have. So, and it didn’t out at the very beginning. It was very cumbersome in that earlier stab that we took at it. So, this time around, leveraging the CIE, we had another grant from HRSA. And we developed a new referral portal with a vendor called [Terra S.] And we’re able to send referrals electronically and short, comprehensive information gathering and it can really tell where in the queue a referral is. So, how is this used? Well, it’s become a very effective management tool because we have a sense of, you know, those specialists that said, Oh, you know, that it’s not such a long wait for them to see me or the referral process doesn’t take so long. So, you can see pretty well that this process began in June of ’09 just over with those five months among a bunch of different specialties, the improvement from the time the referral request came in until the schedule was made and so, from the time the referral request came in until the actual patient visit, and the timeliness of the specialist’s report. You know, look at this. I actually- this is sort of a blended average July of 2009 where we had a 2-1/2 month wait for some specialists to actually get the report back. There were some centers of excellence doing a much better of job getting information there as well. We had two quality indicators. We decided to do it around some risk management, sort of three. But we wanted to reduce the no-show rate for colonoscopy screening and for cardiac testing, specifically echocardiograms and stress tests as well. Then you can see that there was anywhere from a 33 percent to a 67 percent improvement in the no-show rates. And then we decrease the lag time from the scheduling of the visit, we test until the visit actually happens. Some timing, sort of the public health activities flu vaccine tracking, we said we really wanted to make sure that particularly last year, all of the concern about H1N1, is there a way that if a vaccination is given at a health center that it can be transferred to the hospital without the hospital having to make the phone call, “Did you give H1N1, did you give a flu vaccine on a patient that was hospitalized or did they see a specialist?” So specialist was seeing the patient. So, BMC needed to service the community. There was multiple entry points. I can’t get into all this because I actually don’t quite understand all of them. But I knew it was hard to do. We had to connect all the patients, make sure that they were matched, that we- so this is really using a master patient index, and make sure that we could have a real integrated solution. So we leveraged the CIE, the master patient index and what we’re calling that continuity of care document that the medication problem lists allergies and so on. And then we used that TerraS portal, that was the vendor where they had the e-referral. So, this is what a screen shot will look like. And you can tell that whether it’s a flu mist, flu vaccine, H1N1, mist or vaccine or pneumo vac, when and time it was given. And you can actually link it to the site where it was given as well. So there actually is some data, for instance, of giving a second pneumo vac may actually be harmful to patients. And this is also a patient safety issue. You want to get it right where you’re vaccinating the right people and not over-vaccinating. And I tip my hat to the IT dept at Boston Medical Center that was able to do this in three weeks. So, the benefits of the CIE, it was quality and safety applications. We were very mindful of national patient safety goals, effectiveness of the communication and the caregivers and ultimately good patient care. You know, right now some of the things at the facility are a little bit clunky. For instance, the filtering isn’t very good. Sometimes you have to know what you’re looking for. But over time, we know that this is going to develop into something that’s much, much easier to use. And I’m going to get into some areas with reimbursements and- I’m sorry meaningful use criteria that ultimately can lead to higher reimbursements also with the medical home initiatives. We were just awarded a very generous nearly $3 million grant from HRSA to implement another sort of high impact IT grant. This is going to be working on several of the health centers getting a much better practice management system called Centricity practice or community health centers or CPS. We’re going to have much better data warehousing where we’ll be able to blend all the health centers and Boston Medical Center databases to be able to have a richer database. We’re going to have clinical registries with the critical concepting done with child immunizations. So we know we can do it because we just did it with adult immunizations and diabetes of course. But ultimately, having clinical registries with many more chronic conditions. And then making life easier for all the health centers that are, of course, have to do the UVS reporting. So the goals for this latest grant that we are now in the first month of is to increase the number of children fully immunized by age two, to decrease flu immunizations for children up to 24 months, increase adherence to HEDIS indicators in diabetes care, for instance their A1c’s. And the diabetes registry is going to track key clinical conditions and communicate information for care coordination across the whole care continuum. And then we’re going to implement more decision support tools. We do have some. You’ll see a grid I show in a little bit that I think we’re a little bit hard on ourselves but we had some decision support tools, we want to have more and we have a resource to do it. So, just to go over a couple of grids, meaningful use, this is kind of a busy slide. I’m not going to read through every one of them, but sort of the area of quality, safety, efficiency and reducing health disparities. We’re going to have clinicians that — computerized physician order entry for medical orders, drug/drug interactions, we already have that, electronic transmissions, we do e-prescribing. That was the easiest thing in the world. I’ve got to talk to people about that again. I shouldn’t say- that was the biggest win we’ve ever had in terms of making things easier for physicians and we think that improves quality as well and it improves patient safety. Medication list, problem list, I’ve gone through that, reporting different data points, smoking and so on, patient risk of specific conditions, patient reminders for preventive care, medication preferences. I don’t have a patient portal right now. We’re working on that over the next couple of years. So these green areas I should say are sort of where I think we passed. There will be a couple of areas that are still kind of black there. And that’s where a patient, where we need to have patient portals and communication so we can teach people electronic connectivity to their own medical records. We don’t have any philosophical problem with it. We think it will be a useful thing. But it’s we haven’t had the resources to develop quite yet. And given electronic access to the health information and within five business days, four business days as well. Patient education resources, we have some of those things right now on patients, we give them some of the routine and rest routine clinical conditions. Improving care coordination, this is the whole connectivity that we’re talking about. So a little story, before we had the CIE, I remember a patient, I do primary care at one of the health centers, a patient saw me writing everything in. They said, “If I end up in the emergency department of Boston Medical Center, are they going to see all that information that you’re putting in right now?” And I said – it actually was a parent – just said, “Actually, no.” And now I’ve been able to adopt the patient’s rights to have those questions and so that yeah, we can do that. Surveillance information, a couple of the health centers sort of share it with our- the Boston Public Health Commission, our city health department, and we can share it with the Department of Public Health. Ultimately, everybody will be able to do that. And immunization registries, we’re developing it state-wide. We’re going into go in to check for child immunizations in January. And I know a lot of people listening are in states where that’s already established. Ensuring privacy and security protection, that’s a given. With respect to medical home criteria access and communication. You know, I think that what I showed before on those e-referral projects, so that in and of itself didn’t necessarily- just having referrals. It made the system much smoother, but I use the term “shining the light” on the access to specialty appointments. But it can be used as a management tool. Some of the vice presidents of the hospital are talking to people, how can we improve access because now we have data. We can sort of show where people are in the queue and how long it takes at every step of the way. Patient tracking registry information, this is the demographic information, clinical registries as I’ve mentioned. I think we’re doing okay on that now. It’s going to be much better with those grants. And age appropriate risk assessment, continuity of care which is specialists notes, performance reports as well. I mentioned before, I think we’re going to be a little bit harder on patient self-management support really because we don’t have the patient portal yet. And that’s not to say that we don’t have diabetes forms within the EMR that really can help us make sure that we’re making sure that patients are exercising and reporting on how they’re fasting, you know, things that they’re doing and so on with diabetes. But this is a bit of a checklist that we have in there. It’s not electronically available, so I didn’t give us a good score on that. Electronic prescribing I motioned before, this is just terrific andI forgot to go into detail about that. Physician order entry and with that being implemented and we’re going to be able to order imaging tests as well as labs through computerized physician order entry. Referral tracking, I’ve been talking about that. Performance improvement, so this is the reflective care using these dashboards, comparing with one another and performance reports across practices and intra practices, so between providers as well. And then advanced electronic information and the piece with those dashboards and those activities that we were doing before that care managers were able to really use them as tools to have an idea of how people were doing. So, that’s my final slide. And I’ll be glad to take questions a little later and send it onto the next speaker. Good afternoon and good morning to those of you on the west coast, and welcome. I’m William Malloy, Executive Director of Blackstone Valley Community Healthcare in Pawtucket, located in Pawtucket and Central Falls, Rhode Island. I’m joined on this conference call by my very talented and hard-working staff, as Darren has already introduced. But let me just repeat them. Jerry Fingerut, our Medical Director, and headed by our Quality . Allow me to provide a brief introduction to our presentation today by providing a glimpse of the origin of our efforts to improve the quality of care at Blackstone Valley. Blackstone Valley was introduced to the bureau’s chronic care collaborate program in 2001, at which point we were a member of what may have been the very first asthma collaborative. As I’m sure everyone in the audience an attest, gathering data, reporting on data, providing the necessary feedback to our physicians on the information contained in that data in a paper-based medical record system is not a simple chore. More often than not, the lag time between collecting and reporting the data contributed to its formalness that usually stole any enthusiasm that had been generated. Gusto was very difficult, if not impossible, to maintain. We brought all of this in mind when we began searching for an electronic medical record in 2005. We searched for a system that would provide for as much automation of quality reporting as possible. We decided to install a NextGen electronic medical record and practice management system as mostly all of the information recorded during a visit was captured as discrete elements and as such could be readily searched, sorted and reported on. The reporting tool native to NextGen is generally very robust and intuitive for the reporting tasks required in all practices on a day-to-day basis, for example simple queries for drug recall lists, missed appointments, etc. The more complex reporting such as HEDIS results, several reports that are typically required, report for the numerator, another report for the denominator. Reports that require information from both the medication record and the practice management system add even more complexity to the reporting task. Therefore, soon after our EMR go-live, we turned to Business Objects Crystal Reports as an optimal solution for our quality reporting needs. Additionally, shortly after our EMR go-live, we were the recipients, as the lead agency, of a HRSA HCCN grant to implement an EMR in a network of reliable health centers. Our solution to accomplish these parallel efforts was to hire a consulting firm to implement the quality reporting suite while we turned our attention to the network EMR rollout. That’s the introduction. Let me now turn the presentation over to Heather Budd. Thank you. Thank you, Ray, for that introduction. Good afternoon, everyone. So, I’m just going to start by talking about the strategy with which we approached the problem of, or the issue of, quality reporting. And the thing that I think Blackstone did very, very well is to set a strategy and align business goals from the beginning. Really, this started at the selection process, and Ray already alluded to that. But certainly through implementation and then evolving with the changing environment. We’re all aware of this, as Ms. Bainbridge indicated, of this constantly changing environment. So, let me talk to you a few minutes about some of the goals that we started out pursuing and that we’re continuing to pursue. Certainly, we’re very committed to improving care delivery quality, and we use reports to monitor that on a constant basis. One of the main things that we’ve been interested in doing is managing our data as an asset. And what does that mean? It means that, from the beginning and that’s why we talked about how important this is to do from implementation if possible, really building a foundation of quality data that’s really complete. And if you don’t monitor how your users are imputting that data into the system from the beginning, you can end up with some pretty significant holes in that data which calls into question the validity of the data you’re reporting on. So, of course, payment reforms a huge issue at the moment. And we need to be able to use our reporting to actually manage to performances that are both from payers as well as the federal government as all of these initiatives advance forward. Certainly monitoring patients that have medical home initiatives as we work toward transforming our practice delivery environment. We need to make that those initiatives are helping the way we expect them to, and we use reports to do that. And then finally, achieving and improving meaningful use. And Dr. Kalish obviously walked us through all the 2011 initiatives. And certainly there’s a great deal of complexity to that as well. But we feel like the systems that we’ve chosen, really prepared us well for doing that. And so, you know, I think we’re in line with being successful. So I’m going to switch slides now and talk to you about how to make the data work for you. And certainly we’ve used the structured data that NextGen EHR and practice management system has provided us. We’re very convinced that an integrated practice management and EHR system has been one of the keys to our success. But certainly what we’ve done is train our users to document using those structured data elements. So, for example, radio buttons, pick lists and others forms of structured data to really make sure that you’re focusing on those required reporting elements. You obviously want them to do this across the board, but in order to really be successful providing a focus of the areas that you really need to be most successful in has been something that’s helped us. And then in identifying a sufficient workload that really helps that be successful. So, what does that mean? It means we need to make sure that providers can get through a visit and actually document things using the approved documentation areas for those reporting elements that you identified at the top that you focused on so that it’s workable for your physician and also your other users as well. The full care team is contributing to this data. Then finally, we think it’s really important to implement a change process for adding any new ways to record information. So again, thinking about the foci that we talked about above, the required reporting elements. If someone comes with a new and brilliant way of reporting information, we’d really encourage that and support it. But what we’ve done is we’ve really put together a process where that new way of entering information gets approved by the team and then rolled out to other users before everybody just kind of goes off and develops their own way of entering information. The reason that that’s really important is that it helps you avoid loss of data again when you go to report on it. If u don’t now where to look for it when you’re building those reports, you can find it being lost in what you actually report. So let’s flip to the next slide. And this slide talks, it really just illustrates the difference between structured and unstructured data. And I’m sure most of you are familiar with this, but I just wanted to make sure everyone understood it. The top green box pointing to the radio button really shows you that that’s kind of a structured data element and it specifically can be reported upon just like Ray talked about earlier. And then the bottom green arrow box points to a comments section in this HPI template from NexGen. And basically it’s a memo field, so you’re typing in prose then and it becomes very, very difficult to report on any prose element because it requires very complicated coding and programming. And we obviously don’t want to get into that level of complexity. I’m going to go ahead and switch to the next slide. And this slide really addresses using the right tool for the job in front of you, though first I’m going to talk about the NH EHR report writer. Most EHRs come with this on board. And our experience has been that the prebuilt reports or using this tool for one-off reports like medication recalls is very simple. They’re very strong. And also, running reports from EHR report writers such as basic areas that are looking for only a few data points per patient. So, I gave the example of mammograms for female patients who are age greater than 50 and encounters from- within a particular date range. What we did find though is it – and this is where the consulting team that helped build reports for us came in handy. They were able to write SQL reports and of course, that basically is accessing the data directly out of our EHR database. And then what we did, we used Business Objects simple reports to display that information in a report. And what this is, we essentially build a reporting framework with that SQL code. And essentially what that means is it’s just a collection of tables that bring together elements of data about patients. And that enabled us to look at a patient’s information over a period of time. And that’s what I mean by longitudinal. And then it also enabled us to gather that information by registry, so a cohort of patients, for example your diabetic patients, and bringing together that data into summary tables. Using those tools, we can automate cumulative reporting and comparative process. So, that means I can look at data over time but also across different entities. So, for example, if I want to compare one provider’s performance against another’s or different practices performance. And one of the ways that we’ve been able to do that, we set up jobs and that began sort of programming language. But it’s a job that takes a snapshot of the data for a specific time period. And then, the Crystal reports tool enabled us to look at those snapshots of frozen data. And it stores them over time so again we can compare them to one another. And then finally, we used this tool to design reports for unique needs. Because, as Ray said, we were the recipient of a HRSA grant, we had to put together particular reporting requirements that we would report to them on a regular basis. We’ve also used this tool for implementation management. And that gets back to the point I made earlier about managing your data as an asset from the beginning, making sure that providers are actually using the EHR as you expect them to and putting data into the spot that you’ve taught them to use. Practice for information, so that refers to the medical home type projects that we’ve already talked about. Payment incentives, so of course that relates to payment reform and payer contract incentives. And then certainly you’ll all be familiar with the collaborative, both state-wide and then nationally. And then I just referenced again the grants and the federal requirements. So certainly, UDS reporting would fall into this realm. And I’ll talk about that a little bit later. So, I’m going to go ahead and switch the slide to choosing your approach and tools. So I want to talk for a moment about this question that I think many of you have probably explored or you may be thinking about – build versus buy. And as Ray said, we did hire a team of experts to help us build these reports. Certainly if you were a very large organization, sometimes it does make sense to develop an in-house technical reporting staff, especially with constant changing requirements. But we did make the decision to hire this other team so that we could focus on obviously care delivery but also implementation rollout for the rest of our network. And we did find it to be successful for us. So then in choosing software tools that work for you. So certainly it’s important to choose a reporting tool that’s going to integrate very well with practice management and the EHR system that you actually have. And that’s not necessarily as easy as it seems, but that’s what we did with Business Objects Crystal reporting. The nice thing for us was that NexGen actually came with that tool. We then added to that by purchasing the Crystal report server edition so that we could automate report distribution. And this is something that’s been very helpful to us. Our Medical Director, Jerry Fingerut, set up a whole series of reports that would be sent on a monthly basis to our providers that essentially are performance reports so that they are constantly being flooded with the idea – not flooded I guess but they’re being presented information that helps them in terms of giving feedback on their performance. They can actually look at patient-level data, not just their own but also their colleagues’ so they can benchmark themselves against each other. And this is incredibly valuable sort of very real-time in the sense that they’re used to getting data on their performance several month later. And even years later sometimes when you’re thinking about plain data. But this is really something that they can make interventions and changes on a much more nimble basis. And so that’s been very valuable to us. We also use these reports on a weekly basis for visit planning. We have a diabetic educator. And just as an example of one of the ways we use it, and we print out reports for the patients coming in for the next week. And we have a whole staff of medical assistants that help prepare those visits based on the care that’s been identified at a patient level that’s needed. So, and we use standing orders to help facilitate that. I’m going to go ahead and switch to the next slide. And this really just talks about the different types of quality reports that we use as an organization right now. The first is prospective, or visit signing reports, and I already talked a little bit about this. It basically references all the patients that have appointments, so this comes out of our practice management system and integrates with our EHR, so those patients that are coming in the next week. And like I said, the pre-order of the lab and other services needing those standing orders because we want to make sure that our team is practicing to the top of the licenses or the capabilities that they all have to support the physicians and clinicians on our staff. And then we also used this opportunity to update our chart with any sort of external information that has come in as well so that when the provider sees the patient, they really have all of the most recent information in front of them. We also use the same set of reports and we set them up to look backwards, so retrospective. This gives the exceptions for patients who came in and had appointments during this time that we identify, we’ll look and make sure that we didn’t miss something. And, of course, there’s always things that we do miss. And what we can do it we can actually use this as an outreach list to make sure that we can contact those patients. And we used various staff members to do that and get them back in to schedule the care. And then finally, we have a bucket of performance and regulatory reporting. And so first the UDS clinical core measures fall into this as well as the collaborative reports that I talked about earlier. So, for example, are members of text collaborative. And I wanted to just clarify too the difference between some of you are probably familiar with the text registries where you actually have to have a staff member who’s entering information into a separate database. What we’ve actually done is we’ve used our own EHR data and we’re pulling that out in these reports. And we running it against our diabetes registry, or cohort of diabetic patients using the ICD-9 coding as opposed to using that separate registry database that you might be thinking of. So I’m going to go ahead and switch to the next slide. And this is really just- I wanted to kind of show you what does it actually look like. So this is the Business Objects Crystal reporting tool that we talked about. And at this point, I’ve already selected the diabetes labs report because I want to run a report on my diabetic patients. And what I’m showing you here in this slide is first that I select the date range, so the start date up at the top, then the end date. And this, I think, report actually is showing me three months worth of data from August to October. And then I’m going to go ahead and select the registry. And you can see that there’s a whole list of registries that we’ve actually built. So, you know, I’ll just read a couple of them off. Adult females – those are our patients, our adult female patients that are greater than 18 years. You know, we have the depression registry, which is the one that’s highlighted. We have diabetes registry based on the diagnosis code of 250.XX, so any of the diagnoses that fit within that realm. And, of course, you can do all patients if you want to. We have pediatric patients, we have laryngitis, or a particular measure that we’ve been pursuing. So that’s obviously something that you can build according to your needs. And then down here where you can’t see, I actually can select certain physicians that I want to include in our report. And I’m going to go ahead and include all of them if you’re going to want to see their performance. Okay, I’m now going to switch to the next slide, so we’re pretending that we’ve actually run the report in this case. And I’ve covered up the patient’s information on the left hand side there, but I just want to orient you to what this report is all about. So, as I said, this is a diabetes report in particular. And this is pulling data directly out of our EHR. This is being run for our practice, BVHC in this case. It’s running against the registry that I talked about: diabetes for patients with the ICD-9 code 250.XX. This particular report that I ran is actually for March because the screen shot that I showed you before was a separate one. So this is for a week in March. So this was used as a visit planning, but now it’s back in time. So we’re looking to see which things have missed on a particular patient. We’ve organized all these reports by our concept of usual provider. And what does that mean? It means that this is the provider who’s designated to be responsible for this patient’s care. Often times, that’s the PCP, but we want to distinguish between a PCP from an insurance perspective and the PCP from a care delivery perspective. We know, and we want to recognize here, that all the members of the care team are inputting data to the record. And so that’s all going to be reflected here. We’re just organizing it under the provider because we view this person as responsible for the care under the patient’s diabetical home model. And so over here, if you could see under here, you would see each patient’s name. These are all patient lines, and so these are the patients that were scheduled to come in during this particular week for this provider. And then you can see the metrics across the top. And I’m not going to go through all these. I’m sure they’re somewhat familiar to you, and you see that in patients. But eye exams and lab tests such as A1c’s and LDLs, etc. But it’s nice because you can kind of visually see where there are particular holes. That’s where you’d want your staff to focus. And you can also use this to figure out where do you need to retrain staff if they’re missing something repeatedly. So I’m going to switch to the next slide now. And what this is essentially is a continuation of the report that I was just showing you. This occurs at the bottom of that report. So, after you’ve seen all the patient level data, this is our summary data. We like to call this the provider report card, but of course it’s a report card on the whole care team taking care of these patients. And what it does is it summarizes all of those metrics that you saw across the top of the screen in the last slide. And what I want to point out here, so it gives you basically performance metrics. We show it in percentages, but you can certainly display it in numerator versus denominator or numerator if you wanted to. At the bottom here you can see the number of patients that we’re talking about because that, of course, would be your denominator of patients. I do want to point out one thing, this average A1c result will tell you a little bit of a story in terms of how helpful this can be in managing data. We saw that number starting to climb into the 11s and 12s on a particular provider. And it was a real anomaly, and when we investigated further, we realized that the medical assistant that was working for that provider was incorrectly entering into the A1c result field because it’s a point of care test for us. They were entering that result, they were entering the glucose result into the A1c field. So, of course, those results tend to be in the hundreds, and that was throwing off our average. So it was a very quick way for us to realize that we needed to retrain that medical assistant staff member. And really, without the electronic reporting, we would never have found that problem. Certainly, that’s an example of something that could occur in a paper record, but without this kind of summary data we wouldn’t have noticed it. So, that’s been a huge help to us. And I’m now going to switch to the next slide, but I’m going to actually go ahead and share my desktop with all of you because I want to show you a live demonstration of what it’s like to run these reports because I want to show you how fast we can actually get to some of this data. So, the first one I’m going to show you is actually a UDS clinical core measures report. I know it’s something that you all struggle with creating because of the number of different metrics and you’re obviously crossing the ethnicity with the various different UDS races. So I’m just going to click the Refresh button. Uh-oh, looks like I have to log back in. Sorry, this will take me two seconds. So you’ll see the whole process. So all the reports down the left, and I’m going to select my UDS. And I’m going to select this particular version of it. You can see we kind of improved the versions over time, especially as the government has changed the regulations and the requirements for the report. So what I did there was I basically selected one of the drop-down frozen time periods that I talked about earlier, and I just selected the most recent one. Certainly, UDS, we report that in March but we’d be looking at one year’s worth of data. So this is a 12-month trailing report, so those snapshots all look back 12 months in terms of the data. And I’ll just show you essentially this is what it looks like. I’m going to close this little folder structure so you can see it a little bit better. So basically, like I said, it shows you the races down the side and the ethnicity at the top. And if I scroll through this, you can see that now you can see the non-Latino patients and all their metrics. And if I go one further, those that refuse to report, the races, probably ethnicity for unreported. And then this is the center summary of all ethnicity and the races together so you can kind of see where your data lies. And the rest of these tables are the rest of the 6D and 7 tables. So I’m not going to spend a ton of time on the content. Really, the idea is how quickly can we actually get this data. And then the final report that I want to show you is the PECS diabetes report. And again, the whole idea here is just to show you quickly we can get I think it’s about 140 different data points that we have to report for this. So you can see again these are the snapshots. And again, this is one year report, so it will be looking back 12 months. And I’m going to select the registry that I want to see, and this is obviously a diabetic report so I’m going to select my diabetic registry. And I click “Okay” and very quickly I want to just close this folder structure again. You can see all these data points that we just pulled straight out of our database. Then I can just scroll down for you. So this is, again this just saved us a ton of time because for those of you who are familiar with that text registry where you’re entering into a second database, an immense amount of staff time goes into doing that work. And so we don’t have to do that anymore. And we actually are able to see more patients. Our diabetic educator was the person doing that. So now we can actually see more patients and educate them about self-care instead of spending time doing data entry. So that’s been a huge benefit to us. I’m going to go ahead and stop sharing my database now and just go back to slide presentation. I included screen shots of all of these reports for you so that you can reference them as you want to. You know, I’ll just let you know that that’s sample data, so if you find little anomalies that’s because it’s not fully vetted data. But we certainly welcome any questions from you if you have them. We’re happy to help if you need it. So I’ve included our contact information. It’s the last slid. And I’ll turn it back over to our host. And let me just click to the last slide. Great, thank you so much, Heather. We really appreciate all of the speakers for joining us today and all of the participants. We’re so grateful for your time. We posted, again, the information on the Website and again the email if you would like a copy of the presentation to be sent to you. We now have the polling questions available. Please, if you would, take a few moments to complete that. And now we will have our question and answer session. The first question I would like to direct to Dr. Kalish. The question was about your data warehouse and associated reporting and analytics and if they were provided by GE Centricity or if they are currently being developed outside of the EMR and- but custom and technology vendors are being utilized. Okay, I’m going to take this question sort of back to our IT department at Boston Medical Center. But much of it had to be done outside of GE. We kind of pushed them along a little bit. You know, they’ve been helpful but I think we’ve done some pushing. You know, that care effects with the e-referrals was really a key was to sort of bridge everything together for our CIE, who is a very critical vendor. But the beginning that’s a question I don’t think I could answer as well, I would bring it back to IT. But I’ll get that from our IT department and get back to the questioner. That’s great, thank you. Actually another question for Ms. Bainbridge: do you have some specifics of how you can encourage provider engagement buy-in and change management for these meaningful use objectives. I think probably the most important thing is the provider involvement in figuring out how we’ll design the system and how we’ll pull that, the data and the information together and how we’ll use it. I think, as I watch hospitals and different providers begin to transition their quality programs, our traditional quality structures were a very top-down approach. And what we’re finding is that it’s much easier on the providers when they’re part of that process of figuring out how to do this because they can generally figure out a more efficient approach than we can at the top of our organizations. It’s not that we’re not well intentioned, but the fact of the matter is, they can figure out where the fine tuning is or the more simplistic processes are. And what I have found, in working with a lot of facilities to do this is when those people, the providers themselves are directly involved in the process, there’s much greater buy-in. And the reality is that we’re finding they frequently will come up with much more user friendly approaches to them for themselves than what we can come up with. And I think that’s really important. So, as I work with hospitals and other providers around the country implementing their EHRs and integrating their quality programs, I think many of the people on this call today are finding the same thing. As we introduce the EHR, it is actually making work more difficult for our staff initially than it is making it easier. And we keep promising them that this will get better. And I think making sure that they’re involved in their process is the best way we’re going to make sure it truly does get better for them because making these EHRs work in our buildings is not going to happen if they perceive it’s going to add to their long term burden. Most of these caregivers are overwhelmed most days as it is. And having now been a patient inside our healthcare system for the past three years, I watched them. And, you know, they’re working hard. They’re giving us everything they’ve got. And anything else we add to the plate that they perceive, long-term, is going to increase their burden that they have to carry, it’s going to have a very poor potential for turning out to be what we need it to be. Thank you very much. Next question I would like to address to Heather Budd and Dr. Lavoie. Specifically, they want to understand if you have to hire new staff to monitor these quality measures or if you have to restructure your current staff. And also, if your IT administrator has access to all of this electronic information, even the confidential information. Well, we did hire additional staff, and she’s the one made the presentation. Very glad to have Heather. But we’re convinced that all the reporting tools, the technological wizardry, we realize that quality has to be designed from the get-go. And so that’s pretty much what Heather spends her time with in working with the clinical staff to design quality into the visit, the beginning. And so, as she alluded to, we make sure everyone is uniform as far as recording data during a visit because the reports have been set up to look in those certain tables and fields for that data. I’ll just add to that as well that we do have our diabetic educator, for example, and other educators running these reports, you know, in the field essentially. So it’s not just coming from the top down. We do have our actual clinicians able to run reports, and they have access to these in order to make sure that they’re monitoring their own performance. So that’s been a key. And then, just to address the question about privacy regarding IT having access to this information, the answer is, yes they do have access to it but they are bound to confidentiality, just like all of our staff members are. It’s a great question, it’s a good consideration. And I’ll tell you too, as the consultant to worked on this project, that’s how I ended up becoming part of this team. So I was part of the consulting team that built the reports. We sign business associate agreements essentially to bind us to those same confidentiality laws. So it’s certainly something that you’d want to do if you outsource any of this. But then also, if you’re building it internally, it’s very important to make it clear to your IT staff that they are bound to these laws. It’s essential. Great, thank you. Another question for your team is, they want to know does your EHR data governance plan include a data integrating validation process or data cleaning plan? And, for example, is there a data manager assigned to govern this data for specific departments, how do you conduct these continuous quality improvements to maintain data integrity? Okay, so essentiality what we did, I’ll try to answer the question the best that I can. In terms of data validation, what we did at every step of the quality reporting project is we actually did go through a process of testing and validation with the clinical staff here at Blackstone. And so, as each report was built, we tested it to make sure that it was returning the data that we expected to see. And so, that’s been a very important thing in terms of building buy-in to the credibility of the data from the clinician and staff perspective because obviously, if they’re not bought to it being correct, then you start to really lose momentum. And so, that’s the way we handled that. In terms of actually cleaning data out of our system, we really haven’t done any of that. We’ve left it the way that it is, from a records perspective. We haven’t had any major issues around that particular issue, so it might just be that we don’t really have experience with that sort of challenge. I don’t know if that fully answers the question. That’s excellent, thank you. Another question basically there are a lot of auditing and legal stuff to help match medical record rules, different patient electronic signatures needed, a lot of these medical implications for obtaining those signatures on the data. How do you go about dealing with some of those issues, and I’ve addressed this, Dr. Kalish, from a provider standpoint in his organization. I want to make sure I understand the question. The getting electronic signatures on documents to a provider’s desktop, is that what you’re saying- asking? Yes, exactly. And just those auditing and following those legal steps to do that. So you know, people have always- there’s been questions, and there should be questions about privacy. But in my mind, you essentially use your password, your fingerprints are all over a document. So we know who goes into certain patient’s charts. We have rules about a thing called breaking the block, you know, if it’s say a lot of health centers, for instance, might have employees that are seen as patients. And you have to have a good reason to go into this. That’s because you’re involved in the patient care, so you have to attest to that. But I think most electronic records kind of work the same way. I have a desktop, documents that I need to sign when I see a patient, labs I need to sign off on. Anything that’s scanned into the electronic record because that works better with connectivity than we used to be. I’ll just take the records from a patient that’s seen at a hospital outside of our system that I need to sign off on. And that’s this is all vendor’s compliance. Nurses will send us a system of flags and so on, what goes to me, that’s going to be an electronic world equivalent of what used to be a sticky on a paper chart. And that’s a nice tool to have if you don’t necessarily want something to be in the chart body. Great, thank you. And another question for you, Dr. Kalish, what are some of the areas where you’ve had the most difficulty with workflow redesign such as lab results, prescription refills, charting referrals, that sort of thing? Well, e-prescribing, anybody that’s not doing that, that was just a tremendous thing and but maybe our biggest win ever. So that was a good thing. Things that have become, I guess, more difficult is some of the connectivity to the non-Centricity sites. I did talk a little bit about the clinical, the community information exchange. Right now the filtering is not great, so if I want to go into, say, if I knew that a patient was seen by a cardiologist at Boston Medical Center, I could sort of flag that. I can sort of — I know that will be in the CIE. But if somebody wants to push something to me, it’s not so easy. So, we’re looking soon, and with a sort of an important workflow piece is that I’ve got some banner across my record. I should say that I can go into Boston Medical Center because I’m credentialed there — get into their database. But I don’t really go into the 14 other health center databases. But, rather than going into Boston Medical Center’s database to look for something, I want to be able to use the CIE, and I want to have a signal telling me that there’s something waiting for me. So, you know, that old term, you know, you have mail. Well, now you have CIE. And ideally I have CIE on a specific patient, so that would be a big improvement of workflow. That’s been a big challenge. But, having said all that, the CIE has moved us much further ahead. We have data to the point that locating a record of a patient, that still takes much less time than logging into a new database. Great, thank you so much. Is there anyone else that would like to weigh in on that question about work for redesign? This is Darlene. I just want to- and this was alluded to earlier, but I think one of the most important things going into this process is to understand your current workflow design so that you can utilize your electronic health record to retool that to make it more efficient. I watch a lot of facilities, and what they do is they jump into the electronic health record without really even understanding what their current work processes look like. And when I map, when we go through mapping exercises, is always amazes me how many people in their organization have no idea that certain steps go on, or that certain steps are important to the patient process. And so, I think making sure that you do those mapping exercises right up front and figure out where your opportunities are for improvement is extremely important. Absolutely, thank you very much. Another question that came across is to our Blackstone Group. They wanted to know if you are involved in any human subject research and if you’re registry helps you gain IRB approval, if you have to have that for your registries, or were they established with a quality management intent. We do some limited analysis with clinical research projects that we would do programs out of Brown University and the medical school here. And we’ve been able to use the reports that you saw, particularly the registry, to identify particular patient populations. And then to follow — for example, there was one related to colonoscopy and a particular subgroup. We could identify the age groups, identify the patients who were candidates for the program and then go back and review our routine visit data and determine if they had a procedure or what other information was relevant, generate those summaries in the same way that others showed their reports. And it lends itself, as well as the design work up-front is consistent with what’s clinically going on to really produce a lot of the data in a fairly straightforward fashion. And I think that after that, none of our research as far as I know has required IRB approval. Even when we are referring someone that we’re not directly doing the project, even if it’s not required, we will want to pull our internal IRB just so that we know we’ve touched all the bases, particularly if we’re using anything that’s coming out of our EMR. This is Rich Kalish, and we use- there’s a lot of researchers at CPU school of medicine using our database. Another question of — and I would just echo the last comment there that run it through the IRB, let them make a determination whether this is exempt, you know, you’re just passively involved and applying data, it’s better to be safe. Great, thank you so much. One last question to our presenters, basically wanting to know how you go about conducting chart reviews and auditing for this data, both internal and external. And anyone, feel free to weigh in on that. Well, I’m happy. This is Heather from Blackstone, I’m happy to weigh in on that. Essentially, these reports that we’ve developed, as an example I showed you the diabetes labs report. And that essentially has replaced our chart review process that we used to have before to make sure that clinicians were charting in the way that we expected. So it saves us a ton of time. We have adult maintenance reports that look at mammograms and Pap tests and from then TSA tests etc. to make sure that those are happening from a primary care perspective and then also from a documenting in the EHR in a proper way perspective. And this is Jerry, I would add that we’ve also been able to contractually reach arrangements. For example, if our major payer, that instead of somebody having to come in to review 30 charts, we can send them data on 800 diabetic patients for HEDIS measures. I would say that the only time that we go into an individual chart is that we may be reviewing something with the clinician that questions data. And then we can do it in real time and go right into the list that was generated by the report. Yes, I would agree with that. And I’ll point out to you that our EDS clinical core measures are for all of our patients as opposed to a sample set. And so, that very much reflects that idea. Just to add real quick to that, both of those examples are great examples of what I was talking about in the beginning when I talked about now learning to move this stuff, so we’re managing to the left instead of to the right in the 110/100 rule. It saves us money, it saves us time, it allows our patients a better chance at the right outcome the first time. And it just all around works so much better for everybody involved in the health experience. But, as was pointed out during that presentation, they planned for it up-front. They sat down, they figured out exactly what they wanted out of it, and they planned to make it happen. And probably the most important step right now in these electronic health records is the planning phase. Thank you so much. We are so grateful to our presenters, to our participants for coming to this Webinar. Our next Webinar will be on November 19th, and we look forward to all of your participation. Then again, thank you to Ray Lavoie, Heather Budd, Jerry Fingerut, Darlene Bainbridge and Richard Kalish, and to all of you. And we look forward to meeting together again.

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