REGISTRIES AND DISEASE MANAGEMENT
CASE 1: REGISTRIES AND DISEASE MANAGEMENT
UHC’s Care Team Model
Union Health Center (UHC) embraced the patient-centered care team model very early on, which helped ease the transition to new workfl ows, processes, and features that are critical to change management and quality improvement. UHC clinicians and staff members are assigned to clinical care teams, composed of physicians, nurse practitioners, physician assistants, nurses, medical assistants, and administrative staff members. The practice uses a full capitation model with standard fee-for-service and a fee-for-service plus care management payment model. Ten years ago, UHC instituted the California Health Care Foundation’s Ambulatory Intensive Caring Unit (AICU) model, which emphasizes intensive education and self-management strategies for chronic disease patients. The model relies heavily on the role of medical assistants (called patient care assistants or PCAs) and health coaches. Working closely with other members of the care team, PCAs and health coaches review and update patient information in the record, conducting personal outreach and self-management support, and providing certain clinical tasks. For instance, all PCAs have been trained to review measures (e.g., HgbA1C, blood pressure, and LDL cholesterol), provide disease education, and set and review patient health goals. A subset of higher- trained health coaches works more intensely with recently diagnosed diabetic patients or those patients whose condition is not well managed.
UHC’s eHealth Strategies
Patient registries. UHC uses patient registries to identify patients with specific conditions to ensure that those patients receive the right care, in the right place, at the right time. In some instances, they use registries to target cases for chart reviews and assess disease management strategies. For example, patients with uncontrolled hypertension are reviewed to help identify treatment patterns, reveal any need for more provider engagement, and may indicate the need for care team workflow changes. In the future, UHC would like to construct queries that combine diagnosis groups with control groups and stratify patients by risk group. For example, care teams could pull a report of all patients over the age of sixty-five with multiple chronic conditions or recent emergency room admissions.
Maximizing time and expertise. UHC uses technology such as custom EHR templates to support PCAs and free up clinicians for more specialized tasks and complex patients. For example, a PCA or health coach taking the blood pressure of a high-risk diabetic patient has been trained to determine whether or not BP is controlled. If it is not controlled, the health coach checks the electronic chart for standard instructions on how to proceed and may carry out instructions noted in the record. Or, if no information is available he or she will consult with another provider to adjust and complete the note. Following all visits with PCAs or health coaches, the patient’s record is electronically flagged for review and signed by the primary care physician.
Working with medical neighbors. The teams also collaborate with on-site specialists, pharmacists, social workers, physical therapists, psychologists, and nutritionists to enhance care coordination and whole-patient care. UHC has also adopted curbside consultations and e-consults to reduce specialty office visits. For example, if a hypertensive patient has uncontrolled blood pressure, the record is flagged by the PCA for further follow-up with a physician or nurse practitioner, who may opt for an e-consult with the nephrologist to discuss recommendations. UHC also has a specialty coordination team—composed of two primary care physicians, one registered nurse, one PCA, and one health coach—which functions as a liaison between primary and specialty providers.
Customized reporting. With their most recent upgrade to a Meaningful Use–certified version of their EHR, UHC will have the capacity to generate standardized Meaningful Use reports. UHC intends to construct queries that generate reports that group diagnosis groups with control groups and identify and manage subgroups of high-risk patients (or risk stratifi cation). For example, care teams can run a report of all patients with diabetes that have an elevated LDL and have not been prescribed a statin.
Challenges and Lessons
Learned Recruiting staff members with IT and clinical informatics expertise. Over the years, UHC has faced challenges in identifying and recruiting staff members with the right mix of IT and clinical informatics skills. Although effective in troubleshooting routine issues and hardware maintenance, UHC felt there was a clinical data analysis gap. To resolve this, UHC works closely with an IT consultant and also recruited a clinical informatics professional to work with providers and performance improvement staff members.
Consistent data entry. UHC’s lack of consistent data entry rules and structured data fields led to several challenges in producing reports and tracking patient subgroups. The problem stems from UHC’s lack of internal data entry policies as well as the record’s design. For instance, UHC cannot run reports on patients taking aspirin because this information may have been entered inconsistently across patient records. Moving forward, UHC will be implementing data entry rules and working closely with their vendor to maximize data capture.
Real-time data capture. UHC realized that by the time data reach the team, they may no longer be current. As a workaround they considered disseminating raw reports to clinical teams in real time, followed by tabulated, reformatted data. They are exploring the possibility of purchasing report writing software to streamline the process.
Managing multiple data sources. Similar to many practices, UHC pulls data from its billing system and clinical records, causing issues with data extraction. For example, pulling by billing codes does not provide the most accurate data when it comes to clinical conditions, health status, or population demographics. UHC recognized that to reduce errors in identifying patients and subgroups this will require custom reports.
• Forty-six percent reduction in overall annual health costs
• Eighteen percent reduction in total cost of care
• Signifi cant decline in emergency room visits, hospitalizations, and diagnostic services
• Signifi cant improvements in clinical indicators for diabetic patients
CASE 2: IMPLEMENTING A CAPACITY MANAGEMENT INFORMATION SYSTEM Doctors’ Hospital is a 162-bed, acute care facility located in a small city in the southeastern United States. The organization had a major fi nancial upheaval six years ago that resulted in the establishment of a new governing structure. The new governing body consists of an eleven-member authority board. The senior management of Doctors’ Hospital includes the CEO, three senior vice presidents, and one vice president. During the restructuring, the CIO was changed from a full-time staff position to a part-time contract position. The CIO spends two days every two weeks at Doctors’ Hospital. Doctors’ Hospital is currently in Phase 1 of a three-phase construction project. In Phase 2 the hospital will build a new emergency department (ED) and surgical pavilion, which are scheduled to be completed in eleven months.
Information Systems Challenge
The current ED and outpatient surgery department have experienced tremendous growth in the past several years. ED visits have increased by 50 percent, and similar increases have been seen in outpatient surgery. Management has identified that inefficient patient flow processes, particularly patient transfers and discharges, have resulted in backlogs in the ED and outpatient areas. The new construction will only exacerbate the current problem. Nearly a year ago Doctors’ Hospital made a commitment to purchase a capacity management software suite to reduce the inefficiencies that have been identified in patient flow processes. The original timeline was to have the new system pilot-tested prior to the opening of the new ED and surgical pavilion. However, with the competing priorities its members face as they deal with major construction, the original project steering committee has stalled. At its last meeting nearly six months ago, the steering committee identified the vendor and product suite. Budgets and timelines for implementation were proposed but not finalized. No other steps have been taken.
CASE 3: IMPLEMENTING TELE-PSYCHIATRY IN A COMMUNITY HOSPITAL EMERGENCY DEPARTMENT
Westend Hospital is a midsize, not-for-profit, community hospital in the Southeast. Each year, the hospital provides care to more than twelve thousand inpatients and sixty thousand emergency department (ED) patients. Over the past decade, the hospital has seen increasing numbers of patients with mental illness in the ED, largely because of the implementation of the state’s mental health reform act, which shifted care for patients with mental illness from state psychiatric hospitals to community hospitals and outpatient facilities. Westend ED has in essence become a safety net for many individuals living in the community who need mental health services. Largely considered a farming community, Westend County has a population of 120,000. Westend Hospital is the third largest employer in the county. However, Westend is not the only hospital in the county. The state still operates one of three psychiatric facilities in the county. Within a fi vemile radius of Westend Hospital is a 270-bed inpatient psychiatric hospital, Morton Hospital. Morton Hospital serves the citizens of thirty-eight counties in the eastern part of the state. Westend Hospital is fiscally strong with a stable management team. Anika Lewis has served as president-CEO for the past fifteen years. The remainder of the senior management team has been employed with Westend for eight to thirteen years. There are more than 150 active or affi liate members of the organized hospital medical staff and approximately 1,600 employees. The hospital has partnered with six outside management companies for services when the expertise is not easily found locally, including HighTech for assistance with IT services. In terms of its information systems, Westend Hospital has used Meditech since the 1990s, including for nursing documentation, order entry, and diagnostic results. The nursing staff members use bar-coding technology for medication administration and have done so for years. CPOE was implemented in the ED four years ago and hospital-wide two years ago along with a certified EHR system.
Westend Hospital has seen increasing numbers of mental health patients in the ED over the past decade. For the past three years, the ED has averaged one hundred mental health patients per month. Depending on the level of patient acuity and availability of state- or community-operated behavioral health beds, the patient may be held in the ED from two hours to eight days before a safe disposition plan can be implemented. The ED mental health caseload is also rapidly growing in acuity. Between 20 percent and 25 percent of the behavioral health patients are arriving under court order (involuntary commitment). The involuntary commitment patients are the most difficult in terms of developing a safe plan for disposition from the ED. The Westend Hospital’s inpatient behavioral health unit is currently an adult, voluntary admission unit and does not admit involuntary commitment patients. The length of stay for involuntary commitment patients in the ED can be quite long. In some cases, it may take three to four days to stabilize the patient on medication (while in the ED) before the patient meets criteria for discharge to outpatient care. Approximately 40 percent of the mental health patients in the ED, both involuntary commitment and voluntary, are discharged either to home or outpatient treatment. The psychiatrists and the emergency medicine physicians have met multiple times during the past six years to develop plans to improve the care of the mental health patients in the ED. Defining the criteria for an appropriate Westend psychiatrist consultation remains a challenge. The daily care needs of the mental health patients boarding in the ED are complex. The physicians have not been able to reach an agreement on this topic. Senior leaders have suggested that tele-psychiatry may be a partial solution to address this challenge.
Tele-psychiatry as a Strategy
Westend Hospital has chosen to consider contracting with a tele-psychiatry hospital network to provide tele-psychiatry services in the ED. The network has demonstrated good patient outcomes and is considered fi nancially feasible at a rate of $4,500 per month. This fee includes the equipment, management fees, and physician fees. The director of tele-psychiatry in the hospital network has verbally committed to work very closely with the Westend Hospital team to ensure a smooth implementation. Technology to support tele-psychiatry uses two-way, real-time, interactive audio and video through a secure encrypted wireless network. The patient and the psychiatric provider interact in the same manner as if the provider were physically present. The provider performing the patient consultation uses a desktop video conferencing system in the psychiatric offi ce. Tele-psychiatry as a solution to the mental health crisis in the ED was not immediately embraced by the medical staff members. They did agree to the implementation of tele-radiology four years previously. However, the most recent revision of the medical staff bylaws to support telemedicine explicitly states that the medical executive committee must approve, by a two-thirds vote, any additional telemedicine programs that may be introduced at the hospital. The medical staff leaders wanted to preserve their ability to maintain a fi nancially viable medical practice in the community as well as protect the quality of care. The idea of tele-psychiatry was introduced to portions of the medical staff. The psychiatrists realized that tele-psychiatry could relieve them of the burden of daily rounds in the ED for boarding patients. They were also concerned about their workload when tele-psychiatry was not available. The emergency medicine physicians immediately verbalized their disapproval on several levels. First, they were concerned about the reliability of the technology based on their experiences over the past several years with video remote interpreting. Then, the emergency medicine physicians were skeptical about the continued support from the psychiatrists when an in- person consultation might be clinically necessary. Physicians outside of the ED and psychiatry could not understand why the current psychiatrists could not meet the needs of the ED. The barriers to adoption of tele-psychiatry crossed three arenas: financial, behavioral, and technical. Subsequently, many conversations were conducted. Eventually, the medical executive committee approved tele-psychiatry as a new patient care service on June 25 of this year.
The CEO appointed the vice president of patient services as the executive sponsor. The implementation team includes the IT hardware and networking specialist, IT interface specialists, nursing informatics analyst, ED nurse director, behavioral health nurse director, assistant vice president patient services, physician clinical systems analyst, and the medical staff services coordinator. These individuals represent the major activities for implementation: provider credentialing, physician documentation, equipment and technical support, and patient care activities. Because of competing projects and psychiatry subject matter expertise, the executive sponsor will also serve as the project manager. The mental health crisis affecting the ED is the focal driver for change. Patient safety is at risk. Barriers to implement tele-psychiatry have been well documented. The strategies to overcome the barriers include defi ning the new role for the Westend psychiatrists, developing a process for ease of access and reliability of equipment for the ED physicians, and development of a plan when the tele-psychiatry program is not available. An unexpected barrier has been recently identified. On initiation of the tele-psychiatry provider credentialing process, the medical staff services coordinator discovered that the bylaws do not have a provision for credentialing of physician extenders in the telemedicine category. The tele-psychiatry providers include six board-certified psychiatrists and twelve mental health–trained nurse practitioners. The medical executive committee has agreed to ask the medical staff bylaws committee to convene and revise the bylaws accordingly. The original go-live date of September has been changed to December.
The executive sponsor along with the implementation team will be responsible for managing the organizational changes necessary to support the introduction of technology and new patient care flow processes. Managing organizational change will be essential to the success of this project. Some items in the project will be viewed as incremental change and other items will be viewed as step-shift change. Communication strategies will be developed to support the change