Posts Tagged ‘EMR’

8 Effective PCMH Tools to Protect the Medical Home Investment

March 19th, 2015 by Cheryl Miller

The patient-centered medical home (PCMH) model is one of the top five investments in 2015, according to Accenture’s recent analysis of government-sponsored State Health Innovation Plans. Researchers from Accenture found that states are investing in PCMHs in order to strengthen primary care integration with specialists and community health workers. Most will also integrate physical and behavioral care.

Embedding care coordinators in physician offices so they can work with case managers is one way to achieve this integration, according to respondents to the seventh comprehensive Patient-Centered Medical Home (PCMH) survey by the Healthcare Intelligence Network (HIN). We asked survey respondents what other tools they felt were most effective in implementing the medical home. Following are their responses:

  • Electronic communications that include actionable data and access to patients to initiate the change, and a focus on minimal hassle to physician office.
  • The NCQA PCMH tool.
  • Pre-visit planning and ‘huddles.’
  • Patient registries.
  • Monitoring. We fundamentally changed how we operate daily and monitor change. We incorporated our goal measures into the very fabric of what we do.
  • Using templates in electronic medical records (EMRs) for pre-visit planning and coordination of relevant visits.
  • Home care nurse management system.
  • Patient-centered scheduling.

Source: 2014 Healthcare Benchmarks: The Patient-Centered Medical Home

http://hin.3dcartstores.com/Remote-Monitoring-of-High-Risk-Patients-Telehealth-Protocols-for-Chronic-Care-Management_p_5008.html

2014 Healthcare Benchmarks: The Patient-Centered Medical Home is the Healthcare Intelligence Network’s in-depth analysis of medical home adoption, tools, technologies, challenges, benefits and outcomes. Based on HIN’s PCMH survey administered in February 2014, this resource takes the industry’s pulse on patient-centered activity. Now in its seventh year, it is designed to meet business and planning needs of physician practices, clinics, health plans, managed care organizations, hospitals and others by providing critical benchmarks in medical home implementation and results.

Rectifying System Disparities within ACO Improves Data Capture, Quality Reporting

October 30th, 2014 by Cheryl Miller

Addressing the disparity between data systems was one of the operational and information technology (IT) issues the John C. Lincoln (JCL) Accountable Care Organization (ACO) addressed at the end of its first year as a Medicare Shared Savings Program (MSSP) ACO, says Karen Furbush, business consultant with JCL ACO. Here she explains the steps taken to rectify the situation.

I was brought on board in July 2012 and was given the ‘playbook,’ or answers that John C. Lincoln provided to the Centers for Medicare and Medicaid Services (CMS) on how they would structure their ACO over the next three and a half years. It was my job to figure out from the IT perspective how to address all the new advancements with the Transition Coach program.

My job was to figure out this new EMR EPIC® system that was being installed, and how we were going to get data back out. It took us a while once we got our membership list from CMS to find addresses and do the mailing, which we decided to do. This is not required, but we wanted to get the information out to patients about what an ACO was; that we were now providing their basic primary care physician (PCP) services. And we wanted to communicate that as early as we possibly could.

Along with doing those initial mailings, we determined any additional data we needed from our system in order to respond to CMS reporting requirements for 33 quality measures. We took a two-day workshop in November 2012 and realized that not everyone was on the same EMR at the very beginning.

We have a lot of disparity between systems; not all data comes from one system to the next, due to business decisions. We had to go back and determine what we needed from each different system and how long this was going to take. Then we had to figure out how we would normalize or make sure that this data was specific for reporting back to CMS.

In this two-day workshop, we broke it down measure by measure. There are 15 different categories in which CMS places all of their reporting. We went through each — for example, for the emergency area, the hospital and in the physician practices — and asked ourselves what we were doing for each. Just because you’re on one EMR doesn’t mean the data capture model is the same. But I still needed to account for every time those things occurred; they are discretely reportable. That’s not always easy; even though you’re on one single platform, there are a lot of factors that play into why that’s very difficult to get to.

Source: Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care

http://hin.3dcartstores.com/Beyond-the-EMR-Mining-Population-Health-Analytics-to-Elevate-Accountable-Care_p_4900.html

Karen Furbush is a business consultant with John C Lincoln (JCL) Accountable Care Organization in Phoenix. She is responsible for coordinating and managing all things related to IT integration, data analysis and reporting for JCL’s CMS MSSP ACO and Employee ACO programs. She has over 20 years of technical program and IT management experience, and has held a wide variety of information technology roles in the healthcare industry.

Deeper Data Dive Improves ACO Performance, Quality

August 1st, 2013 by Jessica Fornarotto

Performance Quality Measurement and Reporting for Accountable Care webinar replay

What started as a closer look at John C. Lincoln Network’s 30-day Medicare readmissions for heart attack, heart failure and pneumonia kicked off a plethora of quality improvements for the Medicare Shared Savings Program, including the hiring of care transition coaches, extension of primary care hours and tightening of key gaps in care.

During HIN’s webinar, Performance Quality Measurement and Reporting for Accountable Care, two experts from JCL shared how their organization modified reporting processes — from workflow changes to customizations within its EMR — to improve performance results during its 2013 reporting year.

For its transition coach program, developed to reduce Medicare 30-day readmissions, JCL hired trained military medics to help recently discharged patients transition more easily from one setting to another, explained Heather Jelonek, chief operating officer for ACOs at JCL.

“These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients, they develop a rapport, and they also start to prepare the patients for discharge.”

After discharge, these coaches follow the patient for a minimum of 30 days to follow up on medical care, monitor blood pressure, explain medications and teach the patient about nutrition with the help of a registered dietician.

A deeper data dive also identified a trend among its Meals on Wheels beneficiaries: 85 percent of these patients were readmitted within 30 days almost always on Friday evenings. The patients did not have enough food to get them through the weekend since Meals on Wheels only delivers during the week.

This program has helped to reduce readmission readmission rates from almost 20 percent to just under 2 percent for those patients receiving Meals on Wheels and became an assessment area for the transitions coaches.

Encouraged, JCL sought to learn what additional data they needed from their system to respond to the reporting requirements for CMS’s 33 quality measures. They determined their course of action for 2012 and the building requirements for 2013. According to Karen Furbush, business consultant for JCL, “we have to continually re-educate each of the practices at the hospital and the ED so that they can continue to remember what’s important. And it’s not just for the ACO measures, but in general for better coordinated care.”

One change implemented immediately was the addition of a new message within EPIC, an ADT inbasket message that alerts the primary care physician (PCP) to schedule a follow-up visit within seven days. The PCP then reviews the message and forwards it to the medical assistant (MA) to schedule the visit. This change helped to meet one of the ACO quality measure as well as the transitional care management incentive.

Realizing that enhancements were needed for quality reporting, JCL added additional logic to its patient health questionnaire for future fall risk, aspirin usage and a depression scale. JCL also has ACO patient navigators who analyze reports to determine which patients were missing required measurement values and then schedule those patients by the end of the year as needed, noted Ms. Furbush. “We learned how to get the information out and quickly assess who hasn’t had the influenza or pneumococcal shots, or […] a mammography or a colorectal screening. We wanted to go out and capture that information as quickly as possible because we still had three months left to be able to find that information, whether it was in a previous system or if it was in our current EMR,” explains Furbush.

“We immediately tried to get on the phone to start scheduling these appointments, working through all the things that we need to do for the ACO, as well as just bringing the patient into the EMR completely,” Furbush continued.

Furbush also started a weekly ACO quality reporting call to discuss a group of measures to see what kind of challenges were being faced and what was being implemented. JCL also hosted two EPIC-specific subset calls to learn how everyone was using EPIC.

Once JCL received its patient sample from CMS, it sent samples to each practice. According to Furbush, “We said [to the practices] this is what CMS said this person happens to be associated with. There are 15 categories and CMS will provide a rank of one to 616, one being the highest. You have to report on 411. We had to let them know where the patients ranked for each of the disease states and that we needed information back from them if we couldn’t get it from the EMR.”

JCL continues to struggle with integration opportunities. According to Jelonek, “This includes talking to other communities and looking at HIEs as we’re making an acquisition of a new practice or signing a new community physician onto the ACO. In other words, bringing everybody to the table so that we’re all speaking the same language.”