235 CIS Role in Performance Measures

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235 CIS Role in Performance Measures

• Randy Snider, Miami VAChristy Zelo, VISN 3Bryan
  Volpp, VISN 21

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CIS Role in Performance Measures

• Learning Objectives
• At the end of this class you should be able to
• 1.  Investigate issues with visits and data
  collection as it pertains to performance measures
• 2.  Play an active role improving performance
  measure compliance
• 3.  Utilize different approaches and tools in
  evaluating performance.

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Quality of Care Performance Measures

• Screening
• Education
• Interventions
• Outcomes
• Access
• Outreach
• Disparities in Care

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Implementation Potential CAC Roles

• Analysis understanding the expectation
• Data Collection what data is needed and
  appropriate
• Process what processes need to be evaluated or
  changed
• Tools how can we help the users to meet the
  expectations
• Troubleshoot where can/do things go wrong
• Measure what reports might help
• Intervene what can be done to improve

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Examples

• OEF/OIF and TBI Screening
• Hypertension
• Consults
• Womens Health Care

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TBI Screening Northern Cal

• TBI Screening Implemented in March 2007
• Email notices sent out to staff with a link to a
  short training PowerPoint
• Dental was notified of the need to screen
• Paper questionnaire posted and its use was
  recommended
• Expectation Nurse and Clinic Managers would pick
  up the ball and run with it.

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TBI Screening Chart Reviews

• Reports on patients seen in NEXUS and Dental
  clinics who had not been screened with chart
  review
• Dental was not doing any screening.
• Some CP patients were on the list of patients
  who had been missed.
• Patients with only telephone notes were showing
  as missed opportunities for screening.

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1. TBI Screening Dental

• Dental Service does not use CPRS except to review
  data and to open DRM
• No process in place in Dental Service to do
  screening or clinical reminders
• Process
• Provide lists of patients with upcoming appts who
  need screening
• Use the paper questionnaire and send the
  completed questionnaires to someone for data
  entry.

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2. TBI Screening CP

• Some patients only seen in CP were on the missed
  opportunity lists
• 1. Visits in regular primary care and mental
  health clinics
• 2. Some CP clinics had a stop code that was not
  the standard national stop code for Compensation
  and Pension
• CP visits to be in CP clinics only
• Fix the clinic stop codes to use the standard

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3. TBI Screening - Telephone

• Telephone notes and visits being created in
  regular (face to face) clinics
• Re-educate those specific providers about the
  need to use telephone clinics

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TBI Screening Locations Missing Opportunities
to Screen

• Identify clinics where opportunities to screen
  were missed
• Run a reminder report on patients seen in the
  past month who were missed
• Create a patient list from that reminder report
• Run a health summary that displays past
  appointments for one month
• Drop the text name of the clinics into a
  spreadsheet and do counts on the clinic
  appointments (not cancelled or no shows)

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Missed Opportunities
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TBI Screening Pre-visit Reports

• Weekly lists of patients with upcoming
  appointments who need screening
• Print to the clinic locations for the clerical
  staff
• Sort by date and include clinic and appt date and
  time
• Running multiple reports
• Create a text document to respond to all prompts

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TBI Screening Prior Diagnosis

• Health factor review showed multiple entries of
  TBI-Previous TBI Diagnosis
• Chart reviews showed no evidence that these
  patient had been previously diagnosed
• Modified the reminder to ask Are you sure?

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TBI Screening - Consults

• Positive TBI Screens need a consult
• Multiple TBI consult opportunities were missed
• Nursing staff expecting the Provider to order but
  completion of the reminder by the Nurses resolved
  the reminder
• Missing the non-required question.

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TBI Screening - Consults

• Modified the TBI Screening reminder
• Does not resolve until the consult order has been
  placed for any Screen
• Introduced branching logic so that if the only
  item remaining to be done is the consult order,
  then only that option shows in the dialog
• Require consults for patients with prior
  diagnosis if not already done

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TBI Screening Refusal

• Health factor review showed multiple entries of
  TBI-Pt Refusal
• Almost all the entries were from one clinic
• Review of the notes showed that this was one
  provider
• Patients were called and screened by phone

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TBI Screening Consult Discussion

• National TBI reminder does not document the
  discussion of the consult being ordered
• EPRP reviews showed that this was not being
  documented
• Altered the reminder to document the discussion
  of the order
• Prioritization of tasks for staff who decides

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TBI OEF/OIF Screening - Reports

• For one-time interventions, as the denominator
  and numerator grow larger, the rise (or fall) in
  the overall requires a large change.
• For TBI, once a site is at 90, it would take
  many weeks to see a significant fall even if
  screening stopped completely
• Create a report to identify of due screens
  being done

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OEF/OIF Related Problems

• Completing all screening but missing 1 or more of
  the 4 ID/Other symptom questions
• Done at another site
• Actions
• Report every 2-3 days on screens missed
• Users notified and ask to contact the patient
• Encouraged to use the paper form
• Chart reviews for all outside screens
  demographics on a patient list shows when and
  where patients have been seen
• Reentered as historical information

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Control of BP in HTN and DM

• NCHCS does not usually meet these goals
• VISN 21 has missed making these goals partly due
  to NCHCS being below the VISN average

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Control of BP
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Report by Provider

• Reports by Division show marked variability
  across the system (2001)
• Reports by individual provider clinic for all
  levels of BP control (2002) show marked
  differences
• HTN 140/90 and 160/100
• DM 140/90 and 160/100 130/80 added 2008
• Reports for re-privileging and provider
  performance include these also (2005)
• Provider performance reports included in
  performance pay (2007)

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Reports Missed Opportunities

• Identify patients with HTN/DM whose last BP was
  elevated and who do not have an appointment for
  recheck in the next 2 months
• Weekly report by site and by provider
• Nursing to call and reschedule patients
• Staff time
• Additional disparities dependant on staffing

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Control of BP
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Compliance with the Consult Performance Monitor
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Stakeholders

• Miami VA as a Facility
• Chief of Staff
• Quality Management
• Performance Improvement Council
• Business Results Council

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Implementation Team

• Data Management Group
• Service/Section Chiefs and AOs/HSSs
• Consult Managers
• MAS Support Staff
• Clinical Application Coordinators
• Service/Section ADPACs/SuperUsers

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Results

• Negative impact on the consult performance
  monitor.
• Consult/Request Performance Monitor
• FROM Jan 01, 2007 TO Apr
  30, 2007
• SERVICE OUTPATIENT SUBSTANCE ABUSE CLINIC
• Total Requests To Service
  203
• Total Requests Pending Resolution
  0
• Total Requests completed
  203
• Total Requests completed with Results
  30
• Percentage of total requests completed
  100.00
• Percentage of total completed requests with
  results 14.78

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Problem

• CLINICIANS were not linking their notes to a
  consult.
• Program support staff were administratively
  closing consults and annotating in Comments,
  "PLEASE REFER TO NOTE TITLE on DATE OF NOTE.

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What did the CACs do to assist in resolving the
problem?

• Created a tutorial on how providers are to
  complete consults.
• Trained Service ADPACs/SuperUsers and Consult
  Managers on the appropriate way to complete
  consults.
• Provided assistance to the ADPACs/SuperUsers in
  training residents and clinicians.
• Reviewed the Consult Monitor Report with Consult
  Managers to monitor compliance.

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Results

• Very little improvement
• Consult/Request Performance Monitor
• FROM May 01, 2007 TO May
  31, 2007
• SERVICE OUTPATIENT SUBSTANCE ABUSE CLINIC
• Total Requests To Service
  54
• Total Requests Pending Resolution
  0
• Total Requests completed
  54
• Total Requests completed with Results
  11
• Percentage of total requests completed
  100.00
• Percentage of total completed requests with
  results 20.37

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Implemented a different approach Make
Corrections to Consults Not Linked

• Reviewed and explained the Consult Performance
  Monitor Report.
• Reviewed how to run Consult Performance Monitor
  Report.
• Assigned the Integrated Document Management menu
  option.
• Assigned the Consult Managers the Consult
  Linker ASU Class.
• Created Business Rules to be able to change a
  progress note title and link the consult to the
  appropriate consult service.
• Reviewed the process for giving access to
  consults.
• Reviewed the process for changing a document
  title to a consult title and linking to the
  appropriate consult.
• Reviewed the process for running consult tracking
  reports.

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How to Run the Consult Performance Monitor Report

• Select Consult Tracking Reports Option Consult
  Performance Monitor Report
•                   Consult/Request Performance
  Monitor - 1QFY08
•                 Fiscal Quarter Dates Oct 01,
  2007 - Dec 31, 2007
•               30 Days Before Start/End Sep 01,
  2007 - Dec 01, 2007
•               60 Days Before Start/End Aug 02,
  2007 - Nov 01, 2007
•  
• SERVICE AUDIOLOGY
•                                                   
     WITHIN     IFC     
  IFC
•                                                   
      FACILITY   SENT    
  REC'D
• All Requests in 30 Days Before Start/End of
  Qtr     943         0        0
• All Requests in 60 Days Before Start/End of
  Qtr     999         0        0
• Complete with Results in 30 Days of
  Request         780         0        0
• Complete with Results 31-60 Days of
  Request        162         0        0
• All Requests Created 60 Days Before Qtr
  Start   28110     0        3
• All Requests Pending 60 Days Before Qtr
  Start         0         0         0
• Percent Complete w/Results in 30 Days of
  Request  82.71     N / A    N / A
• Percent Complete w/Results 31-60 Days of
  Request  16.22     N / A    N / A
• Percent Still Pending Created Before Qtr
  Start        0.00     N / A    0.00

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Delegated Integrated Document Management menu
option to Users

• Select Delegate's Menu Management Option EDIT A
  USER'S OPTIONS
• Select NEW PERSON NAME
• SECONDARY MENU OPTION TIU MAIN MENU MIXED
  CLINICIAN has been added!
• SECONDARY MENU OPTION
• Select NEW PERSON NAME

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• Create a New User Class
• Select User Class Management Option USER CLASS
  DEFINITION
• Select User Class Status ACTIVE//
• Start With Class FIRST//
• Go To Class LAST//
• Searching for the User Classes..................
• Find Expand/Collapse
  Class Change View
• Create a Class List Members
  Quit
• Edit User Class
• Select Action Next Screen// CREATE A CLASS
• Select CLASS CONSULT LINKER
• Are you adding 'CONSULT LINKER' as a new USR
  CLASS (the 195TH)? No// YES
• USR CLASS ACTIVE ACTIVE

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• Add users to a User Class
• Select User Class Management Option LIST
  MEMBERSHIP BY CLASS
• Select CLASS CONSULT LINKER Active
• Searching for the User Classes...............
• CONSULT LINKERs
  No CONSULT LINKERs found
  
• Next Screen - Prev Screen ?? More
  Actions
• Add Remove
  Change View
• Edit Schedule Changes
  Quit
• Select Action Quit// ADD
• Select Another MEMBER SNIDER,RANDY L RLS
  11 PROGRAM SPECIALIST
• MEMBER

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Associating Business Rules to a User Class

• Select User Class Management Option MANAGE
  BUSINESS RULES
• Select SEARCH CATEGORY DOCUMENT DEFINITION//
  USER CLASS
• Select USER CLASS CONSULT LINKER Active
• Find Edit Rule
  Change View
• Add Rule Delete Rule
  Quit
• Select Action Quit// ADD RULE
• Please Enter a New Business Rule
• Select DOCUMENT DEFINITION PROGRESS NOTES
  CLASS
• DOCUMENT DEFINITION PROGRESS NOTES
• STATUS COMPLETED
• ACTION CHANGE TITLE
• USER CLASS CONSULT LINKER Active
• AND FLAG
• USER ROLE
• DESCRIPTION

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Gave the Consult Management Option to
Service/Section ADPACs to update users.

• Select Consult Management Option SERVICE USER
  Management
• Select Service/Specialty OUTPATIENT SUBSTANCE
  ABUSE CLINIC
• SERVICE INDIVIDUAL TO NOTIFY
• Select SERVICE TEAM TO NOTIFY
• Select NOTIFICATION BY PT LOCATION
• Select UPDATE USERS W/O NOTIFICATIONS
• Select UPDATE TEAMS W/O NOTIFICATIONS
• Select UPDATE USER CLASS W/O NOTIFS
• Select ADMINISTRATIVE UPDATE USER
• ADMINISTRATIVE UPDATE USER
• NOTIFICATION RECIPIENT
• Select ADMINISTRATIVE UPDATE USER
• Select ADMINISTRATIVE UPDATE TEAM
• SPECIAL UPDATES INDIVIDUAL

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Demonstrate how to change the note title and link
to the appropriate consult service

• Select Action Next Screen// CT CT
• TITLE DERMATOLOGY PROGRESS NOTE// DERMATOLOGY
  CONSULT RESPONSE TITLE
• You must link this Result to a Consult Request...
• The following CONSULT REQUEST(S) are available
• 1 Jan 07, 2008 C1351887 DERMATOLOGY s 0
  notes
• 2 Dec 05, 2006 C1138212 AUDIO c 1
  note

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How to change a title and link a consult

• Run your Service Consults Schedule-Management
  Report.
• Identify consults that are in a scheduled linked
  checked out status.
• Review the notes tab in CPRS to identify the
  progress note that is related to the consult in
  question.
• How to access the progress note in Vista to
  change the title and link the consult.

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Service Consults Schedule Management Report
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Identify consults with a status of SCH, LINK,
Ckd Out
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Identify the consult in question. The consult
information will display on the screen to the
right under Facility Activity.

• In this section, you are provided with all the
  activities or actions that occurred with this
  consult. This consult is in a scheduled status
  and has an appointment linked to it dated
  8/22/07.

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The progress note was linked to the appointment
visit location that was used to schedule the
consult. This is the reason the status of the
consult is Sch, Linked, Ckd Out. Before
changing the progress note title, make certain
the progress note is linked to the correct title.
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To ensure the progress note is linked to the
correct visit location, you can use the Cover
Sheet, PCE, or Appointment Management to access
this information. The fastest way to find out is
by clicking on the visit location from the Cover
Sheet to see what progress note is linked to that
appointment
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How to access the progress note in Vista to be
able to change the progress note title and link
the consult.
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Type in a date range or the exact date the
progress note was written.
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To change the title, you will select the option
CT.
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After successfully changing the note title, you
will be prompted to link this Result to a
Consult Request.
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Progress note is now linked to the consult.
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Results after implementation
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Professional Service Encounters (Inpatient
Encounters)
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Stakeholders

• Miami VA as a Facility
• Chief of Staff
• Quality Management
• Business Results Council

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Implementation Team

• Neurology and Emergency Department Service Chiefs
  and AOs/HSSs
• Data Management Group
• MAS Support Staff
• Clinical Application Coordinators
• Service/Section ADPACs/SuperUsers
• Fiscal and Revenue Service

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VHA Directive 2006-026 May
5, 2006Patient Care Data Capture

• Purpose Establishes the policy requiring the
  capture of all outpatient encounters, inpatient
  appointments in outpatient clinics and inpatient
  billable professional services.
• VHA information system have been modified to
  enable the transmission of all encounters from
  Patient Care Encounter (PCE) to the National
  Patient Care Database in Austin, Texas.
• Each clinic must be set up by Decision Support
  System (DSS) Identifier.
• VHA facilities utilize a variety of software
  packages to capture inpatient and outpatient
  workload. All data must also pass or be
  transferred into PCE (if not directly entered
  into PCE).

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Workload SolutionsHealth Data Informatics

• Modify software and business processes to allow
  inpatient encounters to be transmitted to NPCD.
• Activate interface between Medicine/Surgery
  Package and Primary Care Encounter (PCE).
  Collect all inpatient and outpatient procedures.
• Eliminate the use of paper logs in procedures
  areas and capture non-operating room procedures
  in VistA.
• Objective Measure of physicians productivity
  including physician pay for performance.
• Regular maintenance of Encounter Forms is
  required at least twice each year.

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Implementation at the Miami VA Healthcare System

• Physician workload was mapped by service and
  ward assignment, but the majority of the consults
  and inpatient procedures were not captured. Some
  sections were partially using Event Capture.
• Inpatient Encounters were piloted in Neurology
  Service on Oct 1, 2006. Other specialty
  services followed.

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Inpatient Clinics Set Up
Clinic NEUROLOGY INPATIENT AM Abbr.
NEURO Location INPT
Telephone Days clinic meets
Start
date 09/18/2006 Increments 30 Minutes
Hour display begins 7 AM Appt.
length 30 Minutes
Variable length appts. NO Stop Code 315
Maximum overbooks per day 0 Credit Stop
Code Non-count
clinic NO Prohibit access NO Maximum
days for future booking
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Neurology Inpatient Encounter
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Neurology Inpatient Encounter
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Neurology Workload
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How Information is Transmitted
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Specialties consulted to the Emergency Department

• Clinics are set up with the naming convention
  ED/Specialty Service i.e. ED/Neurosurgery.
• Clinics are set up with the stop code 130
  Emergency Room and the credit stop code based
  upon the specialty service.

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Inpatient Clinics Set Up
Clinic ED/NEUROSURGERY Abbr. EDNS Location ED

Telephone Days clinic meets
Start date
09/18/2006 Increments 60 Minutes
Hour display begins 7 AM Appt. length 60
Minutes Variable length
appts. NO Stop Code 130 Maximum
overbooks per day 0 Credit Stop Code 406
Non-count clinic NO Prohibit
access NO Maximum days for future
booking
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ED Subspecialty Clinics
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ED Subspecialty Clinics
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Pre-implementation

• Reviewed Progress Note Templates and Titles
• Reviewed current capture methods (Inpatient
  Encounters vs Event Capture)
• Reviewed Inpatient Consult Process and Inpatient
  Documentation
• Run ACRP Reports and Event Capture reports
• Created Training material

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References

• VHA Directive 2006-026, Patient Care Data
  Capture, May 5, 2006
• John Quinn, National Data Systems, VHA OI Health
  Data Informatics, Austin, Texas

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Gender Disparities in Select Performance Measures

• Christy Zelo, MS, RD
• Sarah Garrison, MD, MPH

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Background

• March 2007 Dr Kussman approved change from
  Women Veteran Program to Women Veteran Health
  Strategic Healthcare Group
• Moves focus beyond gender-specific care to the
  comprehensive care of women
• Increase focus on quality of care issues and
  comprehensive longitudinal care for women
  veterans (with particular emphasis on endocrine
  measures, Influenza immunization, and colorectal
  cancer screening)

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Women Veterans

• Currently about 7 of veterans are women and
  rising
• Generally younger than their male counterparts
• Generally more educated then their male
  counterparts
• Top 3 diagnostic categories for Women Veterans in
  2006 Post Traumatic Stress Disorder,
  Hypertension, Depression

http//www1.va.gov/womenvet/docs/WomenVet_History.
pdf
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Recap V03 2007 4Q Review

• Reviewed following measures by facility, using
  Clinical Reminders reports run on NEXUS Cohort
• Influenza immunization
• Colorectal Cancer Screening
• Diabetes control (hgba1c
• Lipid control in diabetic patients (LDL
• HTN control (160/100)

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Recap V03 2007 4Q Findings

• In general women veterans with diabetes and
  hyperlipidemia had worse performance measures
  than their male counterparts in V03
• Some facilities had greater gender differences
  than others
• Clinical reminders reports, when run on the NEXUS
  cohort, provide important information about our
  performance, and should be ongoing

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2008 V03 Gender-Specific Data

• Instructions to CACs
• Run reminder reports on NEXUS Cohort, by gender,
  for 1st and 2nd quarters ? potential for
  redundancy in data w/ over-reporting of patients
  w/ multiple visits
• Not all facilities have Clinical Reminders for
  each measure looked at ? missing data points
• Where available, VISN EPRP data included
  (pre-release report) for comparison

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Influenza Immunization rates FY08 12Q Data
(age 50 64)
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Influenza Immunization rates FY08 12Q Data
(age 64)
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Colorectal Cancer Screening FY08 12Q Data
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Diabetes HgbA1c 88
Diabetes Lipid Control FY08 12Q Data
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HTN - BP 90
Findings 1St 2nd Q 2008

• More consistent gender disparities seen than
  suggested at end of FY07
• Substantial gender differences seen
• influenza immunization rates
• colorectal cancer screening
• HgbA1c
• LDL in diabetics

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Brainstorming

• Why the differences exist?
• Focus on family before individual needs
• Competing life demands
• Inflexible clinic schedules
• open access may be better but inconsistency
  across clinics isnt
• Possible disproportionate of women with Mental
  Health diagnosis
• Women more likely to seek out Alternative instead
  of Traditional medicine
• Some women polled identified following
  barriers
• Eating on the run
• Children/Husbands/Family/Jobs come first
• Some w/MST history felt colonoscopy was too
  invasive and humiliating
• Disease acceptance this runs in my family,
  thats just the way it is

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Brainstorming

• Potential solutions / interventions
• Cooking classes
• MOVE! Program for women
• Support groups
• Share barriers / fears
• Invite women veterans who have overcome to share
  their experiences
• Education should focus on their barriers
• How to eat while on the run, better sources of
  fuel for a busy lifestyle, importance of putting
  yourself first why you cant take care of
  others if you arent taking care of yourself.
• How can we help those who are non-compliant due
  to MH diagnosis?
• How can we help those who fear invasive tests due
  to MST history?

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Implications and future directions

• As a network, we are not achieving goal for our
  women veterans in several quality measures
• Next steps. . .
• Raise awareness
• Proposal to involve graduate students to
  interview women veterans and determine barriers
  to receiving care
• Continue to drill down data and look for more
  opportunities for improvement

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• Special Recognition to
• Dr. Sarah Garrison and the
• VISN 3 Women Veterans
• Healthcare Council!