EHR Innovations for Improving Hypertension Challenge

EHR Innovations for Improving Hypertension Challenge

EHR Innovations for Improving Hypertension Challenge

The goal of the EHR Innovations for Improving Hypertension Challenge is to gather specific descriptions of health IT tools and approaches used by individual practices to implement an evidence-based blood pressure (BP) treatment protocol that has led to improvement in practice-wide blood pressure control (Phase 1), and identify models for quickly and widely spreading these to other practices (Phase 2). A comprehensive clinical decision support (CDS) approach supports these five protocol elements:

1. Blood pressure measurement/recording
2. Blood pressure follow-up
3. Initiation and titration of medications
4. Patient engagement
5. Workup/referral for poor control
In Phase 1 (three months), practices will document the electronic health record (EHR) tools they used to implement an evidence-based BP control protocol, as well as describe the details and results of the implementation. Practices must demonstrate high BP control levels and/or improvement to ensure that tools and strategies merit replication across practice settings.


Content

1.68 -> We're recording.
11.61 -> Great.
16.58 -> Thank you everyone for joining today's webinar on EHR Innovations for Improving Hypertension
22.72 -> Challenge in which we are hosting the winners.
25.71 -> And talking a little bit about phase II and what's to come.
31.09 -> Next slide please.
32.949 -> I don't want to take up too much time so that we can get into our content.But my name is
38.94 -> Adam Wong and I am the prize challenge manager at ONC.
43.48 -> The Office of the National Coordinator for Health IT.
46.059 -> And joining me today are Hilary Wall from CDC Million Hearts about their blood pressure
54.68 -> protocols.
55.68 -> Then we will get to Holly Dahlman with Green Spring Internal Medicine and
66.18 -> the team at Vibrant Family Health Clinics.
69.16 -> Christopher Tashjian, Mary Boles and Roseanne Matzek.
72.59 -> What we are going to do is have them each present on their winning submissions and processes
78.9 -> that they developed internally.
79.909 -> After they have spoke, each one, we will host a Q&A.
84.38 -> So please enter your questions in the Q&A box at the bottom right of your screen.
91.4 -> They will take questions and then we will move to a quick discussion about phase II
100.44 -> and what is entailed there.
102.11 -> This webinar is being recorded and will be posted on the challenge website where you
109.35 -> can find all the details about the challenge both phase I and phase II.
115.22 -> We will be hosting the webinar there and that is also where you will be able to download
121.35 -> each winner's participant materials that can be used for phase II.
126.77 -> So without further ado, I'm going to pass this over to Hilary.
131.73 -> Thanks so much Adam.
134.2 -> Hi everyone, I'm Hilary Wall, the Million Hearts science lead as Adam said with the
138.579 -> Centers for Disease Control and Prevention.
140.68 -> And I just want to talk for a minute about cardiovascular disease.
143.659 -> We've seen a gradual decline in mortality in cardiovascular disease over the last forty
149.359 -> years.
150.359 -> But it still remains the nation's leading cause of death for men and women of all races
153.599 -> and ethnicities.
155.14 -> And every year in the US more than 1.5 million people will have a heart attack or stroke
159.469 -> and 800,000 of them will die.
161.7 -> It's the leading preventable cause of death for people under the age of 65.So back in
166.81 -> 2012, to address the burden of cardiovascular disease in our country, the US Department
171.33 -> of Health and Human Services launched a Million Hearts.
174.279 -> And a Million Hearts is being co-led by my agency, the CDC, and the Centers for Medicare
179.209 -> and Medicaid (CMS) but many Federal agencies like ONC are invaluable partners as well.
185.95 -> So he overall goal of our initiative is to prevent 1 million heart attacks and strokes
190.43 -> by 2017 and as you can see from the slide we have a two-pronged for achieving our audacious
198.469 -> goal.
199.469 -> We need to keep healthy people healthy by changing the environments in which we work
202.769 -> and live.
204.359 -> That includes reducing smoking prevalence in communities through smoke free laws as
208.4 -> well as reducing the sodium and eliminating the artificial transfats in our food supply.
213.209 -> But we also need to improve health care for those who need it.
216.599 -> And we can do this most impactly through three strategies.
219.669 -> First by focusing on the ABCs.
222.819 -> Aspirin for those who need it.
223.93 -> Blood pressure control, cholesterol management and smoking assessment and treatment.
228.139 -> Second, through harnessing the power of health information technology, like thoughtful clinical
232.229 -> decision support tools to improve health outcomes.And third by encouraging health innovations like
237.589 -> teen-based care and self measured blood pressure monitoring with clinical support.
242.269 -> And we've determined that blood pressure control is the most impactful strategy for reaching
246.419 -> our goal of preventing 1 million heart attacks and strokes.
248.939 -> So we've been busy mobilizing the nation on this issue.
252.489 -> And so the ONC EHR Innovations for Improving Hypertension Challenge that we're here to
258.539 -> talk about today is a terrific opportunity to address all three aspects of improving
264.439 -> cardiovascular care for disease prevention.
266.59 -> Next slide.
267.689 -> But let's be clear.
269.879 -> I don't mean to glaze over this.
272.169 -> Hypertension control is complicated.
274.069 -> It relies on commitment from both the clinician and the patient.
277.72 -> And there are many choices to be made about type, number and dose of medications.
282.55 -> When to up-titrate or add additional medications and what the optimum follow up time is.
287.849 -> There is also the issue of white-coat and resistant hypertension.
291.98 -> But despite these complications, we know one thing for certain.
295.02 -> That improved blood pressure control equals fewer heart attacks and strokes.
299.24 -> Next slide.
302.11 -> We believe that one of the answer to relieving some of the complexity of hypertension control
307.37 -> is adopting a standardized hypertension treatment protocol.Protocols are called all different
313.009 -> things.
314.009 -> Care Algorithms.
315.009 -> Care pathways, care plans.
316.61 -> Whatever you call it, it is a standardized approach to blood pressure treatment.
320.729 -> We've seen a number of healthcare treatments adopt standardized protocols And see great
326.77 -> improvements in blood pressure control likely because protocols support evidence-based Medicine
331.949 -> and enable all members of care teams play an integral role in caring for patients with
336.669 -> hypertension.
337.669 -> For me the challenging part is figuring out how best to integrate treatment protocols
343.25 -> into electronic health records so that care is optimized and streamlined throughout the
348.069 -> workflow while trying to minimize the burden on clinicians.
351.469 -> And we are absolutely thrilled to have the two phase I challenge winners tell us today
357.759 -> how they've been able to do this kind of work and I'll be honest.
361.409 -> I've seen a sneak peak and they have some fantastic tools to showcase.
365.65 -> I'm really excited.
367.419 -> Next slide.
369.08 -> I will just quickly mention for anyone interested, here is the Million Hearts website.
373.46 -> And we've listed some evidence-based protocols that have been successfully integrated into
377.759 -> health systems like Kais Permanente and the VA.
380.59 -> Now they don't have the electronic components of them but you might find them to be helpful
386.639 -> resources for phase II of the EHR Innovations for hypertension control challenge.
392.05 -> And with that I'll turn it back over to Adam to introduce our phase I winners.
395.81 -> Okay, thank you very much Hilary.
398.639 -> Now we are going to move onto Holly Dahlman with Green Spring Internal Medicine located
404.219 -> in Lutherville, Maryland.
406.49 -> We were really impressed with what Holly was able to do in her small practice.
412.74 -> So I will turn it over to her.
415.849 -> Holly.
416.849 -> Thanks and thanks Hilary for a great presentation.
422.33 -> Good afternoon everyone.
423.779 -> I want to thank all of you for the honor of presenting our EHR innovation
428.11 -> for improving hypertension.
429.389 -> I also want to give a special thanks to the Maryland Multi-payer Patient-Centered Medical
434.21 -> Home Program which is a pilot of 50 practices throughout our state.
439.81 -> All working towards advanced primary care practice.
442.639 -> Especially, I want to thank our leader, Dr. Niharika Khanna who spurred me on to apply
447.58 -> for this award.
448.979 -> And to the Maryland Department of Health and Mental Hygiene who nominated us.
453.84 -> Congratulations as well to Vibrant Health Family Clinics for their award.
459.84 -> Today I titled my talk "IT Toolkit for Hypertension Control."
465.219 -> The objective of the talk is to demonstrate how our small practice (Patient-Centered Medical
472.33 -> Home Pilot) uses a team-based approach, combining health IT tools with evidence-based medicine
481.24 -> to improve hypertension control.
482.919 -> So here are some of our statistics.
487.15 -> Back in 2011, using NQF measures 0018, we realized we had a weakness.
493.94 -> Only 47.71% of our patients with hypertension had blood pressure under control.
499.729 -> This is approximately only 1% above the national average at the time.
504.439 -> So we realized we needed to something.
506.29 -> To pour a little bit of effort into our processes.
510.57 -> Our protocols.
512.039 -> And by 2012, that blood pressure control had improved to 66.
515.529 -> 04%.
516.529 -> And by 2013, a little over 80% which was sustained last year in numbers that are still being
521.579 -> finalized.
522.579 -> Our team is made up of one physician.
528.87 -> That's me.
529.87 -> We also have a nurse practitioner who serves one-third of her position as a care manager.
538.36 -> We have three certified medical assistants and one medical office assistant.
544.01 -> We have seen approximately 2,700 patients in the last three years.
547.82 -> Most of our patients have more than a high-school education but do come from culturally diverse
554.54 -> and economic backgrounds.
556.32 -> Our practice model as I mentioned is around the patient-centered medical home.
563.19 -> And we have been a level 3 NCQA-recognized medical home since 2011.
565.38 -> And that was the same year that we joined the MMPP pilot.
569.16 -> We have a team-based approach and our vision is to equip,
574.24 -> empower and engage patients in their own healthcare.
577.389 -> Our steps to hypertension control can be summed up by what I call the "three R's."
585 -> First of all, we use our registries.
589.6 -> The registry tool is a clinical tool to identify any patients with hypertension who have not
598.93 -> been seen in the past 12 months or patients who had hypertension that was uncontrolled
603.029 -> in the last visit.
604.58 -> We bring our patient resources and many of them are online.
609.61 -> We have the DASH diet linked on our website.
612.73 -> We also have other resources powered by our information technology.
619.17 -> And the third thing is that we go over our patient's home blood pressure readings.
623.12 -> We really believe that reporting and reviewing blood pressure readings
628.37 -> helps patients control their blood pressure.
631.24 -> So the use of our registries is a quarterly process where basically we go into a clinical
640.96 -> record's registry feature and we do two registries.
645.71 -> One of them is to identify patients who have not been in for the past year who have a hypertension
651.12 -> diagnosis.
652.86 -> And the other registry is to find the patients whose blood pressure was greater than 140
656.18 -> over 90 at their last visit.
658.93 -> And then we call those patients into the practice.
662.769 -> We might use a telephone or send them a web message through our patient portal.
668.06 -> We also have an automated system called v-messenger.
672.42 -> Here's some features of our registry.
675.04 -> And you can see that there are various categories that we can use for our 11:17
678.63 -> search.
679.63 -> We have encounters which allows us to look for a certain date range which allows the
684.22 -> registry to look for the date of last visit.
687.86 -> We can also run registries according to ICD and CPT codes.
693.39 -> And there's even a section on medications.
696.1 -> Once we have the patient in the office, we check their vital signs, and you can see here
703.339 -> under this slide that there are red letters under both blood pressure checks.
709.98 -> In fact, the body mass index on this patient is also listed in red.
715.17 -> And what the red letters in the vital section mean is the patient has readings that are
720.06 -> out of range.
723.85 -> We use protocols in our practice in order to improve hypertension control as well.
729.57 -> First, we perform medication reconciliation at each and every visit.
734.769 -> Second, we use the browse section in our electronic health record to quickly pull down detailed
742.66 -> information on the DASH diet actin plan.
745.69 -> And also self monitoring instructions.
748.079 -> Since we opened in 2006, all of our patients receive a note at the end of their visit,
756.04 -> so that they will receive all these instructions in writing and they can review them at their
762.29 -> leisure.
763.29 -> In addition, we use evidence-based prescription favorites which is a feature within our electronic
770.209 -> health record.
771.209 -> So here's a slide that shows the unique features of our medication reconciliation.
777.589 -> And here you can see that there's a little checkbox where we can check off that we verified
786.14 -> the prescription and there are additional features here.
791.149 -> The little balloon boxes are to designate whether the patients are taking, not taking
798.759 -> or discontinued taking their medications.
800.41 -> And there is also an unknown box to check off if we are not sure.
805.569 -> There is also a little note section we can use to describe the reason
810.35 -> why the patient might not be taking their medication.
813.18 -> For example, if the patient stopped taking quinapril due to a dry cough.
818.949 -> Here is a picture of Shannon who often times does medication reconciliation using an I-Pad
825.3 -> feature with the electronic medical record.
828.569 -> We use a browse section in our electronic record to populate standard instructions that
838.339 -> we are frequently giving.
839.709 -> Here is an example of instructions that we have given the patient on the DASH diet action
844.73 -> plan.
845.73 -> And also on the use of their home blood pressure monitor.
849.699 -> We have the DASH diet action plan website linked on our practice website.
860.37 -> I've created what's called the e-library which has indexed references for a variety of illnesses
866.639 -> the patient might have.
867.95 -> And under hypertension, the top link is the DASH diet action plan.
873.01 -> And this is a one-page reference for people who just need to get the basic idea about
877.86 -> the diet.
878.86 -> We do ask our patients to try to obtain the DASH diet book and read the whole thing.
884.259 -> And try to incorporate what they are able to.
886.62 -> But at least this provides a quick reference.
891.72 -> In addition,e-Clinicalworks provides a wonderful patient education feature.
896.68 -> In this case, it is integration with frames, which has low health literacy resources in
903.279 -> English as well as in a variety of different languages.
907.04 -> And these resources can be published to our patient portal or printed out at the time
915.279 -> of the visit.
918.9 -> Our Rx favorites feature is on an evidence-based protocol for hypertension control and in our
924.25 -> office, we base our hypertension control protocol on the National Committee recommendations.
933.79 -> And here is the slide with the My Favorites feature.
936.62 -> Once we check off the first few letters, in this instance "HY" a pop down will come out
945.71 -> showing the top three prescribed medications for blood pressure control.
952.639 -> Finally in the space of our visit, we like to encourage our patients to do home self
960.702 -> monitoring of blood pressure and we coach them how to use it.
966.459 -> And once they are back at their follow up visit, we reinforce the proper way to do self
972.389 -> monitoring of their blood pressure.
975.779 -> Patients report their blood pressure readings to us even in between their visits.
980.579 -> And they can do that by mailing them to us, or sending us a portal messager even faxing
987.029 -> us their readings.
989.029 -> In the space of the office visit, we have the time to review the home blood pressure
994.11 -> log or journal and provide feedback to the patient.
997.839 -> A lot of the times, in this process our patient has a self discovery or self sensitivity.
1004.06 -> Other patients realize the role of stress in causing blood pressure spikes.
1008.519 -> We can also see if we over treated as their readings are actually low at home.
1015.23 -> And based on these readings we're able to coach the patient on targeting their lifestyle
1022.22 -> change to what has 17:04 the most impact.
1025.76 -> We take the time to do motivational interviewing on lifestyle changes.
1031 -> Sometimes that is counseling on weight management or incorporation of exercise.
1038.16 -> Or cutting back on alcohol.
1040.7 -> Other times, we are exchanging recipes within the DASH diet family of foods.
1046.31 -> After we have done that counseling, if need be, we will add medication according to our
1054.53 -> protocol.
1055.53 -> Before the patient leaves the office, we reinforce ongoing blood pressure monitoring and make
1060.97 -> sure they have a scheduled follow up appointment before they go home.
1065.66 -> We use other electronic tips and tricks.
1069.93 -> One of them is called eClinisense which is a feature in our HER
1075.07 -> that learns our regular practice and provides little boxes that we can check to populate
1084.31 -> our note with recommendations that we have commonly used.
1089.58 -> We also have a smart phone app called Healow which is free and available on droids and
1099.31 -> iphones and ipads.
1100.74 -> This allows patients to do all the things that a patient can do on a normal computer
1106.29 -> portal but also integrates with tracking devices and allows for reporting of readings to our
1114.3 -> office through the patient portal.
1115.82 -> We recently came up with a care plan template that I'll talk about in a minute.
1121.58 -> And then we use other social media for a like facebook, twitter and pintrest to engage our
1128.77 -> patients in their health.
1130.52 -> Here's an example of our facebook page.
1134.53 -> A couple of weeks ago, I posted an article on the benefits of the DASH diet which happens
1139.85 -> to be particularly effective in African Americans.
1143.34 -> So we wanted to make this avaialble to our patients so that they can read the same article
1149.49 -> that we are reading in plain language.
1155.41 -> The newest addition to our electronic protocols is the care plan template.
1160.59 -> And here is the author of the care plan template who is the nurse practitioner and care manager.
1168.15 -> And she works together with our consultant to design a care plan template that satisfies
1175.88 -> all the criteria of the new Medicare chronic care management code.
1181.32 -> And this involves phone calls to patients who are high risk to do various assessments
1185.42 -> and help people with their self management.
1188.65 -> So we are really excited about this new automated feature In summary, we have used the three
1196.1 -> "R's," registries, resources and reporting to improve hypertension control in our practice.
1203.51 -> In so doing, we are using population tools.
1207.51 -> We are using resources and we are using self management and efficacy tools to empower our
1214.47 -> patients for better hypertension control.Thanks so much for the opportunity to bring you all
1220.95 -> this exciting development from our practice.
1223.22 -> I would like to acknowledge a large number of people
1227.43 -> who have contributed to our success.
1232.84 -> Adam thanks to you for questions.
1237.79 -> Great.
1238.79 -> Thanks a lot Holly.
1239.79 -> That's terrific.
1240.79 -> So can we go to the last slide.
1244.31 -> Jennifer do we have any questions queued up.
1248.83 -> No, no questions have come in.
1252.51 -> We'll give people a minute.
1257.54 -> If things are not coming at the moment, we can tackle them later in the webinar.
1265.42 -> I have a question for you Holly.
1269.68 -> How are you using Pinterest?
1271.72 -> And how are your patients responding to that?
1276.44 -> Yes, I'm trying to get more of our patients to be engaged in social media.
1283 -> How I'm using it is to actually Post photographs of really healthy food and to post how to
1291.11 -> grow food.
1292.11 -> We live in the Baltimore area andwe have a very lush Spring, Summer and Fall.
1298.98 -> So our area is really great for growing fresh fruits,
1302.45 -> vegetables and herbs.
1303.54 -> So I'll post photos of growing ideas or cooking ideas.
1308.41 -> I was very inspired by the healthy kitchens, healthy lives conference last year out in
1315.4 -> Napa valley that Harvard School of Health puts on with the Culinary Institute of America.
1322.24 -> A lot of great ideas came out of that conference.
1325.38 -> But one of the funny points that was made was there is so much food marketing out there
1333.05 -> that is marketing unhealthy food, so why not market really healthy food.
1338.07 -> So I'm using pinterest to really market healthy food and health ideas.Okay, we got a question
1346.04 -> in.
1347.04 -> This person is interested in the care plan format and who initiates the care plan.
1351.5 -> And at what point in the process is it initiated?
1354.091 -> And also are the MDs actively involved?That is such an excellent question.
1361.08 -> So, the use of care plans has really evolved over the years.
1368.68 -> In our pilot program, our care program wasn't even a participant in our MMPP pilot.
1376.98 -> Just this month, Medicare has incorporated a chronic management code which will actually
1384.03 -> pay practices up to $42/month to call patients and assist patients with coordination of their
1392.2 -> healthcare or to try to intervene with patients who have declining health due to
1397.28 -> multiple chronic conditions.
1399.06 -> And patients need to meet two chronic conditions to qualify for that code.
1402.87 -> We are just starting a protocol and reaching out to our high risk patients.
1412.78 -> The trick of the Medicare chronic management code is that you actually have to obtain written
1420.58 -> consent for the service.
1422.92 -> So we are going to try to use the office visit to identify some of our patients who are at
1428.93 -> high risk and sign them up at the time of the visit.
1433.41 -> The other trick of the Medicare chronic management code is you have to actually collect an $8.52
1441.4 -> co-pay which is the patient's responsibility for the visit.
1446.43 -> So those are some of the obstacles.
1449.61 -> We just created an information page that provides an advanced beneficiary notice and that has
1457.35 -> all the information about what the chronic care management call is all about.
1462.1 -> And apprising patients of their responsibility payment-wise and what our responsibility in
1470.74 -> that service will be.
1472.62 -> The Care plan is often carried out by people with a nursing license although some practices
1481.32 -> use medical assistants as their care managers and others have had physician assistants.
1488.12 -> I even know of some practices where the physician himself or herself is actually doing the
1494.95 -> care plan.
1495.96 -> I think in terms of what makes business sense, it probably a non-physician task.
1505.27 -> So at this point we are planning to have our care manager conduct the care plan calls.
1511.04 -> It's a really good thing with some of our patients to realize that they may not be taking
1519.1 -> their medication not because they don't like us or they don't like the recommendation or
1524.28 -> the medicine.
1525.28 -> Sometimes they don't take the medication because they can't afford it.
1530.13 -> Or sometimes they don't take the medication because of the belief about their medication
1536.65 -> that they got from talking to their neighbor.
1539.54 -> So the care plan conversation allows our nurse practitioner to really identify the barriers
1551.9 -> to care and work with the patient.
1555.01 -> It's a really great thing to do.
1558.69 -> And now that Medicare pays for it, there should be a lot more uptake.Okay, I have another
1566 -> question.
1567 -> Does your registry include patients with HTN diagnosis who have only been in for an acute
1573.41 -> visit in the past year?
1577.17 -> I would say that our registry is more blunt force.
1580.07 -> It is not going to tell us who is on for an acute visit versus who is in for a physical.
1592.32 -> We can use the E&M code so we can look to see who is in for a V70.0 versus a 99213.
1604.5 -> We haven't chosen to differentiate between acute visits and regular check ups because
1614.94 -> we think hypertension is something that we can address at every single visit.
1619.54 -> But I will say a number of people with high blood pressure readings will come in when
1625.45 -> they have fallen and their hips hurt or they're in a family crisis.
1633.28 -> But one of the things about hypertension control is that we should not be
1640.45 -> aiming for 100% hypertension control.
1642.8 -> There are always going to be some patients who should not have a blood pressure of under
1650.01 -> 140 over 90.
1651.62 -> I don't know if that answers your question.
1653.27 -> Okay I have another one.
1655.85 -> Great presentation.
1657 -> Can you discuss your metrics and outcomes including cost savings?
1661.96 -> Yes, so I'm not fully prepared to discuss all of those matters.
1670.28 -> One of the challenges that we face is that we don't get a lot data back from payers as
1676.44 -> of yet.
1677.44 -> So, for example, the PCMH pilot just provided data from 2013.
1684.11 -> We don't have data back to our practice in real time so that we can actually use it to
1691.91 -> modify a process.
1694.87 -> I wish it were otherwise.
1697.99 -> Do I believe that controlling hypertension will generate cost savings to those of us
1704.76 -> who are in models of shared savings?
1708.06 -> I do believe so.
1709.06 -> I believe it might take a number of years because this is a long view of prevention.
1714.34 -> But if you only costs $300-400 to control hypertension on a yearly basis and then a
1723.03 -> bypass grafting is over $100,000.
1725.77 -> Dialysis is $80,000/year.
1726.88 -> Renal transplant is $100,000+, it kinda does make sense.
1731.25 -> Because someone who has a heart attack has an expensive hospital stay.
1736.81 -> I wish that we had the cost data in real time.
1744.91 -> We just joined the Medicare shared savings program ACO so my hope is that we will at
1751.581 -> least have Medicare cost data back.
1754.04 -> But not super frequently.
1756.75 -> Maybe quarterly.
1758.11 -> It would be great to have cost data.
1762.68 -> I think if the payers can recognize that primary care can really save money, they would share
1771.77 -> cost data with us more expediently.
1774.38 -> Okay, another question.
1777.19 -> When did you change the blood pressure control protocol?
1781.64 -> And what was the percentage of patients with uncontrolled blood pressure before and after
1786.76 -> the new protocol?Yes, if you can go back to my slides.
1795.13 -> About the fourth slide please.
1802.16 -> The year that we joined the PCMH pilot was also the year that we tested Meaningful Use.
1809.86 -> So we were really getting our act together as far as capturing quality measures.
1824.03 -> So that year, 2011, we figured out how to capture hypertension control
1830.4 -> and I think hypertension control out of all our Meaningful Use measures was the most reliable
1835.27 -> because it's a super central data capture.
1838.63 -> So when I saw this number, I was pretty surprised.
1842.9 -> I thought I was a pretty good doctor actually and this is only slightly above average.
1851.36 -> That made me realize we needed to do something about blood pressure control.
1855.52 -> We were also asked to present our efforts with hypertension control to a Million Hearts
1863.06 -> symposium.
1864.62 -> I started to say yes but we really hadn't done that much so it spurred me on to do something
1874.15 -> more.
1875.15 -> So that's a true confession.
1877.31 -> We chose the three conditions at the beginning of our PCMH pilot program.
1887.94 -> We chose obesity, hypertension and diabetes as our disease conditions of focus.
1894.37 -> So we poured extra energy into those conditions.
1897.27 -> We not only run hypertension registries, we run registries on obesity and diabetes that
1905.4 -> is not well-controlled.
1906.87 -> Or the diabetes patient who we haven't seen in a year.
1910.46 -> And believe me there is a lot of crossover between the three conditions.
1917.21 -> So a lot of those patients are on our registry calls but we try to call just once a quarter.
1924.05 -> I think the use of registries really began solidly that first year.
1933.57 -> I have been recommending the DASH diet action plan for over five years since data was presented
1941.78 -> at Border U courses, mainly Dr. AJ ?? who is a pathologist at Brigham has presented
1951.74 -> powerful evidence that the DASH diet can result in a 10-point in blood pressure.
1960.85 -> And a lot of our patients want to know what they can do with their lifestyle to control
1966.24 -> their blood pressure.
1967.24 -> They don't just want to be treated with medicine.
1969.71 -> Some of our patients are resistant to being treated with medicine.
1972.63 -> But if we bring in a lifestyle that empowers them to control their blood pressure, a lot
1977.46 -> of them have expressed real satisfaction.
1978.86 -> One of our patients actually lost 30 pounds on the DASH diet.
1985.48 -> So it sometimes can help achieve multiple goals in one.
1990.16 -> So we have really been recommending the DASH diet for some time.
1994.42 -> The self monitoring, I'm not totally positive when that became our strong recommendation.
2005.06 -> But I'm pretty sure it was pretty early on because..right along with the DASH diet data
2010.81 -> that was presented.
2015.83 -> Research that has basically shown that home blood pressure readings correlate more tightly
2022.41 -> with long term hypertension outcomes than in office blood pressure readings.
2028.18 -> So I would say we are privileged to be in practice in a community where most of our
2035.34 -> patients can afford a home blood pressure monitor.
2038.83 -> A lot of others can't afford a blood pressure monitor which is a limitation in our protocol.
2048.179 -> But really we tried to push all three "R's" all at once pretty early on in our pilot program.
2057.19 -> And that actually leads to another question.
2060.7 -> How are you coordinating care for patients who may not be able to afford a home blood
2064.81 -> pressure monitor?
2067.01 -> So that's an excellent question.
2072.51 -> So in some cases pharmacies have blood pressure cuffs.
2078.799 -> I'm never sure how reliable those really are.
2083.01 -> Some of our pharmacies have a clinical pharmacist who has some clinical skills in counseling.
2089.55 -> They tend to have a higher quality blood pressure monitor in those pharmacies.
2094.609 -> I would love to see more access for home blood pressure monitoring.
2099.819 -> For example, in the city of Baltimore, hypertension is highly prevalent but is perhaps unrecognized.
2107.38 -> It's out of the state of my expertise but I think that it is low hanging
2114.349 -> fruit that people might want to invest in so that patients can get a sense of control
2122.849 -> over their conditions.
2127.66 -> We are able to have our patients come through the office here and have the staff check the
2131.97 -> blood pressure as well.
2133.2 -> But usually I try to make sure that anyone coming through a blood pressure check is on
2138.71 -> my schedule because I want to be able to be involved in real time decision-making once
2143.789 -> we know what the blood pressure really is.
2148.769 -> And the last question I have is have you considered using the American Heart Association e-health
2155.619 -> tool Heart 360?
2156.83 -> Would this be a good idea to supplement what is being done in the clinic or is it something
2163.21 -> extra that may not be needed in the care of hypertension?
2167.67 -> I'm unaware of that so I'm unable to comment on
2182.65 -> that.
2183.65 -> Holly, could you talk a bit about the logistics such as setting up your EHR patient wise?
2190.22 -> How it has been for your office?
2197.079 -> I think that we've been using e-clinicalworks since 2006 so the implementation was quite
2202.96 -> some time ago.
2204.2 -> But we had a second build-live in 2011 which simply involved mapping all of our quality
2213.67 -> measures so that we would actually capture data reliably at every visit.
2217.68 -> So as far as mapping, it would be ideal if her companies would actually do mapping for
2227.869 -> practices so they wouldn't have to try and figure out workloads for their data capture.
2234.11 -> We wound up doing quite a bit of it ourselves.
2238.02 -> What we realized when we decided to focus on blood pressure and obesity and diabetes
2245.759 -> was that it was critical to have these vitals checked at every visit.
2254.089 -> So basically what we calculate is when our patients check in we do their blood pressure,
2261.329 -> height and weight to get the body mass index.
2264.589 -> The body mass index as a number allows us very quickly to know if a patient is overweight
2275.509 -> or obese.
2276.589 -> And that has greatly helped us to improve recommended weight loss to our patients.
2286.059 -> So that is a workflow where we insist on vitals getting into the chart at every visit.
2293.07 -> As far as setting up the browse feature, it really evolved into thinking about how it
2300.119 -> works in plain language for the patient.
2307.95 -> I recommend reading the DASH diet action plan book.
2315.27 -> The info about the diet is linked on our practice website and my specific instructions about
2323.49 -> home blood pressure readings.
2324.52 -> So once I draft what to say for 95% of our patients about hypertension, I've been able
2334.79 -> to create macros that allows the information to be populated without me having to think
2339.569 -> about it.
2340.589 -> And that allows me to spend more time with the patient.
2343.44 -> So getting the EHR set up with some of the customizations are helpful.
2350.71 -> I would say customize the EHR enough but not too much is what is critical for data capture.
2360.23 -> I know some practices are having a really hard time because one doctor captures measure
2368.329 -> this way and another that way, but people need to adopt the same work flow in order
2374.96 -> to capture accurate quality metrics.
2379.049 -> And accurate quality metrics are of the essence that doctors actually buy into them and believe
2384.69 -> in them.
2386.19 -> Especially doctors.
2388.97 -> Because doctors are cynical about whether their data is accurate and become disengaged
2397.02 -> in.
2398.02 -> Doctors need to stay engaged in quality measure efforts in order to succeed.
2403.96 -> In some ways I think we were blessed because we are a small practice and we can implement
2410.99 -> changes and make them across the board without having to have a committee meeting.
2417.859 -> But because we are small a lot of the ability to address all these tasks fell upon me.
2427.95 -> And it was hard work.
2431.98 -> But it was good thinking about how to set it up in the beginning saved hours and hours
2438.859 -> of training time.
2440.13 -> We are hoping to use our IPad for home visits and use the blood pressure data and other
2448.88 -> data at home visits.
2451.72 -> Basically including in our office quality measures so that we can more hone down elderly
2456.46 -> patients and their care is captured.
2463.059 -> So the IT is definitely an evolving process.
2471.52 -> I have an affection for technology so I was drawn to it.
2476.22 -> If someone throws out an idea, I wanna try it.
2479.34 -> A lot of this was trial and error.
2484.14 -> One challenge we had was there were many paths to the same data capture in our electronic
2494.799 -> medical record and there are several different ways of reporting data.
2498.05 -> So it was also deciding what reporting software feature you were going to use.
2507.48 -> What shortcuts you were going to decide to use or not use.
2511.339 -> What clinical decision support is actually supportive of the decision.
2515.99 -> Hypertension is something that we do multiple times every day in practicing medicine so
2523.44 -> having algorithms or having guidance for what we do clinically but we really haven't memorized
2534.9 -> because we do it all the time is probably not as necessary.
2539.81 -> The cardiovascular tool which is an app that I do use is the atherosclerotic cardiovascular
2546.83 -> disease or ASCVD calculator.
2549.28 -> That gives me the patient's ten year risk for a cardiovascular event.
2554.2 -> And then I can get more aggressive with their therapy.
2559.93 -> Focus more on blood pressure control or what not.
2564.9 -> Thank you Holly.
2566.43 -> I'm afraid I'm going to have to cut you off so we can get to our next group.
2573.64 -> But that was terrific.
2574.88 -> Thank you very much.
2582.42 -> We look forward to seeing Holly as a panelist at the upcoming ONC annual meeting which is
2589.23 -> coming up on February 2nd and 3rd.
2592.19 -> While online registration is closed, you can still attend and register onsite.
2599.079 -> Next up, we have our second co-winner from Vibrant Health Family Clinics with Chris Tashjian,
2609.48 -> Mary Boles and Rosanne Matzek.This is Dr. Tashjian and all three of us are here and
2627.749 -> happy to participate in any forward.
2633.71 -> So we are Million Heart winners.
2635.099 -> We actually have won Million Heart Challenges two years in a row and this is something that
2641.839 -> we have taken seriously and like Holly did, we made it an imperative in our group to provide
2649.269 -> better care.
2650.269 -> And we have found that the way to do that is teamwork.
2653.099 -> So if you look here, we have the entire team on the left.
2657.6 -> And even though our Packers lost last week, we are still avid Packer fans.
2663.309 -> We are still vibrant members of the community which you see in the upper right hand corner.
2668.249 -> That's also important.
2670.309 -> Community involvement and making them part of the solution.
2676.38 -> So who we are.
2679.97 -> We are a family practice clinic with a couple internists, a pediatrician.
2685.72 -> We have a general surgeon and one obstetrician.
2688.369 -> We have cardiologists and ENTs in our clinics but not part of our group.
2692.39 -> But we do have direct access on site.
2694.79 -> Our primary care team members and our care coordination members include the providers.
2701.92 -> We have both physicians, PAs, nurse practitioners.
2706.18 -> We use medical assistants extensively.
2708.64 -> We have care coordinators whose sole role is to handle the care of our chronic disease
2716.319 -> patients.
2717.319 -> We use midlevel as we talked about before.
2719.359 -> We use front office staff.
2721.079 -> I think this is one of the most overlooked team members that we pay close attention to.
2728.309 -> And people ask why do the front staff need to know about hypertension?
2732.39 -> Well the bottom line is that nobody gets into see me and nobody can get through the phone
2737.099 -> bank to talk to our coordinators if they can't get through the front office staff.
2741.749 -> So we have included them in all of our planning and coordination.
2745.95 -> And again, we think of them as an active member of our team.
2750.13 -> We have been NCQA certified, Level III (Patient centered medical homes) since 2013.
2758.609 -> In three clinics that we server, we see 65,000 patients annually.
2763.829 -> This is our improvement philosophy.We come at it from different ways.
2770.98 -> We obviously use a registry.
2772.15 -> We implemented our EMR in 2010 but we have been driving for a registry since day one
2779.99 -> because we think that's the best way to do population management.
2782.97 -> And it is the best way to manage the data.
2785.97 -> We are continuously looking at ways to develop and utilize direct patient care staff, health
2792.57 -> coaches and care coordinators to make the offices last more than the 10-15 minutes of
2804.059 -> the provider.
2805.059 -> There has to be a discharge process in which patients know what our expectations of them
2809.88 -> are and what we want them to do.
2811.849 -> And with the medical home closing the loop to ensure that they do the follow up and we
2817.66 -> keep engaging with them.
2818.66 -> Then in the bottom right hand corner is engaging community members and resources.
2823.18 -> We use the pharmacists in the community.
2825.049 -> We will use who ever we can.
2827.99 -> Public Health and anyway we can get more involvement and engagement we do that.
2835.16 -> And this development, creativity and engagement is how we really bring everything together.
2840.17 -> So this slide is complicated but a couple basic points that we wanted to go over.
2847.849 -> Basically in the center where it is supposed to be, we talk about medicine being a team
2853.89 -> sport.
2854.89 -> This is a philosophy that we will be talking about over and over again.
2859.44 -> My role is actually at the top.
2862.66 -> And you can see the interaction between me and the patient is very small.
2866.249 -> I tend to spend 10-15 minutes with them in the exam room.
2869.49 -> I may be the leader to the team but clearly the patient does not spend the most time with
2875.94 -> me.
2877 -> He or she can interact with the clinical staff, the hospital, the care coordinator, and then
2882.47 -> all the things that go around outside of the clinic as a satellite.
2888.2 -> We view our role is to coordinate those activities and use those activities to help get better
2893.839 -> control because I think like everybody on this teleconference, we really think that
2901.72 -> if we can control blood pressure, we can improve our patients' lives.It is not about getting
2905.94 -> a number down.
2906.94 -> It is about getting a blood pressure low enough so the patient doesn't have a stroke, can
2912.4 -> play with their grandchildren.
2914.329 -> Doesn't suffer a heart attack, incur costs that they can no longer afford.
2918.299 -> So we are really talking about people here.
2922.17 -> So the way to do it and the way to solve something is through the use of the team.
2929.51 -> Again as the physician, I spend the least time win direct patient care.
2937.039 -> So we also develop protocols.
2941.51 -> We have a philosophy that if you care enough to call, we care enough to see you.
2946.4 -> And we want to be your primary care.
2948.559 -> So we have ways and I talked about our front staff.
2951.95 -> We talked about getting people in and making sure that they have their appointments and
2958.099 -> are able to get in when they need to.
2959.609 -> That they keep their appointments and we close the loop.
2964.28 -> Our appointments are twenty minutes and for a lot of primary care that is a long appointment.
2969.28 -> But we want to have enough time to go over everything with our patients and make sure
2975.4 -> they understand how to interact with the rest of the staff and what they should expect.
2981.66 -> The other thing we look at with appointments is that anyone with a chronic disease has
2986.739 -> a return to clinic order with a specific date.
2989.77 -> One month, two months, three months, six months, once a year.
2993.329 -> Whatever is appropriate.
2994.509 -> So when this patient leaves, everyone know what the physician or provider wants in terms
3001.96 -> of seeing them back.
3003.69 -> So it gives them a timeline and sets the timeline up so that they can be clear and very objective
3009.059 -> so people can plan accordingly.
3015.92 -> So we track it and use our AHB version which means that the actual EHR is in Kansas
3024.54 -> City.
3025.54 -> That has been quite beneficial to us.
3028.079 -> Because like our colleagues in Maryland, we are a small clinic and we can't afford a large
3032.73 -> IT staff.
3033.73 -> So having it there has been real helpful.
3035.859 -> You can see that it will flag blood pressures that are elevated.
3040.019 -> It will compare the last three blood pressures every time we open the chart so we can look
3045.89 -> at it.
3048.569 -> You can see the BMIs on there.
3050.799 -> Height, weight, temperature, heart rates.
3053.009 -> Those are all things that were already made.
3055.569 -> We did nothing to create this.
3056.67 -> This is all out-of-the-box in 51:00 the EMR.
3061.309 -> Very helpful.
3062.309 -> Very useful.
3063.309 -> In the lower right hand corner you can see what our team did.
3067.119 -> I'd like to say that I had any input in this but our team did this themselves.
3073.009 -> And this is probably the third or fourth iteration of this.
3075.43 -> They do a pre-visit screening and planning.
3078.019 -> My medical assistants will go over the chart.
3080.859 -> They will find out about immunizations, about when they had their preventive services done.
3086.539 -> When the labs were done.
3089.119 -> And all of that will come through the protocol.
3091.869 -> So when I see the patient, it is already prioritized as one of the things that I need to do to
3096.91 -> make sure this patient is up to date.
3099.309 -> For example, if they haven't had their mammogram in over a year, our expectation is for them
3104.579 -> to have one annually.
3105.579 -> We are a little bit more aggressive than the medical services task force.
3110.2 -> If they haven't had their electrolytes checked in over a year and they are on diuretics,
3114.829 -> we are going to want to know that.
3116.869 -> So those are things that are brought to the forefront on those pre-visit screenings.
3121.74 -> Again, this is done even before our patient is seen in the clinic.
3126.259 -> And this is done by our medical assistant and as I said, they were the ones that created
3130.22 -> this form.
3131.22 -> They were the ones that knew what we were asking for something that worked better for
3136.16 -> them.
3137.16 -> You can see right there, bolded at the top, recheck blood pressure.
3140.759 -> We know that sometimes we need to check blood pressure twice because the original blood
3148.329 -> pressure when they first sit down and haven't had a chance to rest and collect their thoughts,
3155.78 -> the patient may have elevated numbers so we want to recheck it to see if it is truly an
3163.31 -> elevated blood pressure.
3165.259 -> Again this is another screen shot from our EMR which is making recommendations by our
3174.759 -> medical assistants on what services are needed, what are essential.
3178.39 -> And it also helps in our reminder process.
3185.529 -> So we think communication is a big key.
3188.14 -> Anytime you are working with a team, you need to communicate in a clear concise manner.
3196.269 -> Our EMR allows us to do that.
3198.059 -> We can send messages back and forth.
3200.049 -> Those messages can either remain part of the chart.
3202.619 -> Or they can be just like a post it note.
3205.47 -> They can be removed when we're done with it.
3207.289 -> It is up to the person reading the message to decide what they want to do with it.
3211.7 -> But it makes it clear.
3213.81 -> You can see this is a message from a care coordinator to a provider asking things 53:38
3222.63 -> about like would you like to restart the hydrochlorothiazide.
3225.73 -> The patient doesn't have to come in for this to happen.
3228.549 -> The provider can answer the question and the care coordinator can take over and see that
3234.769 -> it is done and make sure that it is taken care of.
3238.94 -> If you look at the bottom, it is more of a reminder process with a little bit of how
3244.94 -> we set up or turn the clinic.
3247.48 -> We use part of our EMR as a tickler file so if I ask as a provider that the patient comes
3256.819 -> back in six months and they don't, someone will look through that and
3260.829 -> say "Gee they are not on the schedule so let's call them up and see what's the problem."
3268.95 -> We found that we catch a lot more people that used to fall through the cracks.
3274.7 -> This is interesting.
3279.089 -> We went to low tech before we started high tech.
3282.509 -> So what you see here on the left hand side is a simple little red sticker that says recheck
3290.96 -> blood pressure.
3291.96 -> And that is because my medical assistant checked the blood pressure when the patient entered
3297.489 -> the room.
3298.489 -> If it is elevated, above 140 over 90, she puts the red magnet on the door or inbox.
3307.15 -> And it reminds me when I go in that no matter what I see that patient for that I need to
3311.93 -> recheck the blood pressure or address it.
3315.01 -> Or do something with it.
3316.369 -> But ignoring it, isn't an option.
3319.14 -> And it brings it to the forefront.
3320.799 -> This piece of paper probably costs a quarter to make and is one of the cheapest things
3325.45 -> you can do and have a big impact.
3326.83 -> But if you notice on the right hand side a green piece of paper that says blood pressure
3332.39 -> check.
3333.39 -> And again this is another recurrent theme.
3335.8 -> The staff changed it.
3337.569 -> They said while this red magnet works, we think we have a better idea.
3342.15 -> So they came up with a pad of paper with this blood pressure that has a little bit more
3347.549 -> information.
3348.549 -> And they stick it on my keyboard and my EMR.
3352.519 -> So when it is on my keyboard, I physically can't ignore it.
3359.66 -> I can't say sorry I missed it.Or I rushed by it.
3362.819 -> So it is a one step improvement but again it was an improvement that I had nothing to
3370.569 -> do with.
3371.569 -> Our staff took the ball and ran with it.
3373.859 -> They made it better and it gives us better control.
3377.999 -> So now there is the expectation that if there is a green slip in our keyboard, you have
3384.95 -> to do something with it.
3386.14 -> That second blood pressure will be written on the green form and will be taken by the
3391.229 -> provider.
3393.22 -> Very clearly spelled out and not ambiguous.
3396.4 -> We know it is expected of us.
3397.97 -> It shows the value of a team.That my MA is helping me to not let things drop through
3405.42 -> the cracks.
3406.529 -> So these are other things that you can get patients involved in.
3412.47 -> I will show these patients these graphs that our EHR can print out.
3417.079 -> It can be weight.
3418.24 -> It can be blood pressure.
3419.66 -> It can be cholesterol.
3421.4 -> But these graphs are very easy to come by.
3423.98 -> We can it put on the IPad app or the desktop and they can see what their pressure has done
3429.73 -> and they cansee where we started this medicine or that medicine.
3431.579 -> For those of us that are more pictorially oriented rather than looking at just raw numbers.
3438.749 -> I think this is a very effective way to communicate with the patient something important.
3443.46 -> Something that we engaged our staff in is that every patient with a blood pressure is
3450.019 -> a hypertension patient.
3452.43 -> We made notepads with "Why does my blood pressure matter?"
3457.94 -> And we can pull it off just like a stickee note with the website of the CDC.
3463.72 -> It gives them the opportunity to further engage and to understand the reasons why.
3469.979 -> So again patient education, we actually useEducare like what was talked about earlier.
3481.2 -> It is built into our EMR.
3482.69 -> We use it.
3483.69 -> It is part of our Meaningful Use.
3484.69 -> We've also been able to customize it.
3487.14 -> If you look at the bottom, they are very specific customized education forms that we basically
3494.229 -> configured our EMRs to do and that gives us two values.
3497.69 -> One is its readily available.
3499.64 -> I don't have to worry if it is stocked in the room and two I can give it to our patient
3504.74 -> with printers in every room.
3507.069 -> And three it documents it so I know exactly what I have given to the patient.
3512.539 -> It handles everything in one fell swoop without having to do the same process more than once.So
3519.23 -> that is one of the things that we really try to make our EMR do.
3522.9 -> We think of it as a tool not a hurdle.Let's have it make our work life easier not harder.
3534.029 -> And let's make it more efficient for us.This is an example of how that works.
3541.42 -> Fun ways to have Blood Pressure recheck competitions with our office staff.
3551.029 -> We don't think this has to be all nuts and bolts.
3557.64 -> That making it fun helps all the way around.
3561.779 -> So the care coordinators keep track of the medical assistants as they document.
3570.15 -> And when you redocument they end up in the file and someone wins something.
3577.75 -> Again something simple but also motivating.
3582.059 -> And it emphasizes that we are a team.
3585.119 -> It doesn't happen by itself or because of one person.
3590.109 -> But because of all of us.
3592.94 -> And that goes a long way.
3596.829 -> So again, we use titration methods.
3602.18 -> We have algorithms that we've established.
3604.41 -> We got together as a medical group and the physicians agreed that this is a reasonable
3609.24 -> algorithm that our share coordinators to work off of.
3612.849 -> As you saw earlier, they have the ability if they don't feel comfortable when using
3617.42 -> the algorithm to shoot a message to the provider.
3620.989 -> But we don't wait for the provider to say "now you move from plan A to plan B."
3626.5 -> But we give the ability of our care coordinators to say "So we are not where we want you to
3634.38 -> be.
3635.41 -> The plan is for you to do this and have you follow up with the provider."
3640.18 -> The provider is engaged but they are not the stumbling block or the reason things don't
3648.98 -> get done.
3650.849 -> The providers have all agreed to this protocol so it is helpful and gives our care coordinators
3659.97 -> some leeway to improve the care of our patients.
3665.549 -> So again, reporting and registries.
3672.069 -> We didn't have registries when we got our EMR.
3674.38 -> They didn't understand why we needed them.
3677.46 -> We made it really clear that we need them.
3681.119 -> We use the report writer in our EMR and export all our data to excel.
3685.91 -> Then we wrote an excel spreadsheet that had all the parameters that we wanted.
3691.72 -> So if you notice anything in yellow is out of parameter.
3697.16 -> We have excel do that rather than having to do that manually.So it gives us a list of
3703.239 -> our patients and targets the people we need to work on and the people we need to help.
3710.779 -> You notice across the top, we are looking at systolic, diastolic, PM level ACs, LDLs,
3717.65 -> alcohol use, tobacco use.
3720.609 -> So the computer can't keep track of all of that but we can spit that out on one sheet
3725.29 -> of paper.
3726.29 -> And with that one sheet of paper, I will sit down with my care coordinator and my medical
3730.68 -> assistant and we will go over the patients that we've seen in the last 40 days that are
3738.559 -> out of parameters.We used to do it every month and switch between diabetes, hypertension
3747.099 -> and then heart disease.
3750.039 -> Our staff decided it would be better to wait three months to focus on a patient to look
3757.369 -> at every patient in the last 40 days who are not in parameters.
3762.109 -> And let's keep it fresh.
3764.71 -> Again another example of the team taking the ball and saying I have a better way of doing
3769.65 -> it.
3773.65 -> In the bottom, you see the averages.
3781.88 -> Every provider gets this every month which they go over with the care coordinators.
3787.249 -> And they can see how many patients they have, the various kinds of diseases and what their
3793.999 -> control rates are.
3798.289 -> And our care coordinators create a plan.
3802.44 -> And like our colleagues in Maryland, we also plan on submitting our coordination through
3808.799 -> Medicare.
3809.799 -> It means the plan has to be there.
3811.75 -> It has to be written out and available to everybody.
3815.039 -> It is in a place where we can talk about it.
3820.94 -> So if there is a question about what we do with this patient, there is a direction in
3829.219 -> the plan.
3830.219 -> It's organized by patient.
3832.569 -> By provider.
3833.609 -> There are patient goals and self management.
3837.239 -> So measuring success and staying connected with the data.
3844.119 -> As you can see we work our EMR hard.
3848.89 -> Our expectation prior to 2010 was to do this manually so at best we could do this once
3854.99 -> a year.
3855.99 -> But now we can do it on a monthly basis.
3860.66 -> And we have far more data to work with.
3862.979 -> So we look at our data monthly.
3865.549 -> We report it annually on the web through Minnesota community measurement.
3877.299 -> We share it with the health plans.
3879.44 -> Our patients have access to it through these various websites if they are so inclined.
3888.499 -> We are also transparent.
3892.38 -> We've been this way pretty much from the start.
3894.98 -> If you look at the bottom left hand graph, you are seeing all the providers in the clinic
3900.13 -> across the bottom and their "n" number.
3903.609 -> And these are their hypertension control rates.
3907.109 -> And the other thing we attach is their MAs.
3911.349 -> And I go over this with my MA.
3916.049 -> The format above the clinic average if I'm leading it or close to leading it, I find
3924.259 -> the MAs are competitive as the physicians are.
3929.2 -> So we are working that dyad.
3930.999 -> It spurs people to work better and try harder.
3937.519 -> Our focus is on any patient with hypertension including those with co-morbidities.
3944.869 -> We don't just look at their blood pressure but their LDL, their AICs, their tobacco cessation.
3953.119 -> We look at their using aspirin.
3955.63 -> We are big believers that if we want to get the best results.
3959.589 -> And by results I'm not talking numbers.
3961.45 -> If we want the most stroke preventions, the most preventions of heart attacks , we have
3966.57 -> to attack all 5 in our diabetics and all 5 in our hypertension and coronary artery disease
3972.819 -> patients.
3973.869 -> So we believe getting blood pressure control is important, but it is more important if
3980.9 -> we do all of it.
3981.99 -> The blood pressure, the cholesterol.
3983.4 -> The aspirin.
3984.4 -> We stop the smoking.
3986.15 -> We do all the ADS' of Million Hearts.
3991.839 -> So why this all works.
3994.519 -> The leadership is behind this.
3998.469 -> The physicians are engaged.
3999.869 -> Patients are engaged.
4001.229 -> Staff are engaged.
4002.229 -> We believe it is important to help our patients get well and then stay well.
4010.859 -> We have done that through care coordinators.
4014.029 -> And more importantly, this is nobody's problem.
4018.019 -> This is everybody's problem.
4023.069 -> We share our successes as a team and work on our improvements as a team.
4028.65 -> That is the most fulfilling for us as providers.
4033.279 -> And it has shown the best improvements as far as actual numbers such as reductions in
4040.71 -> strokes and heart attacks.
4042.349 -> We can quantitate that number over the last four years.
4046.299 -> We know there are people in our community that are out walking, playing with their grandkids.
4051.539 -> Doing things that they wouldn't have done had we not helped them get things under control
4058.289 -> to prevent a heart attack or a stroke.Thanks a lot Chris.
4067.42 -> That was terrific.
4070.19 -> So we will move to the Q&A section.
4084.64 -> Do we have any questions?
4088.859 -> No, I have not received any yet.
4092.109 -> So let me ask you a question that was asked of Holly initially.
4098.25 -> Chris, have you considered using the American Heart Association's ehealth tool Heart 360?
4107.25 -> And do you think it would be a good supplement?
4117.09 -> We haven't spent a lot of time into it.
4118.98 -> A lot of our partners are looking at the American Heart 20 and whether these people should be
4123.98 -> on a statin or not.
4125.96 -> We are trying to figure out if that is something we want to distribute clinic wide since the
4131.52 -> data is pretty clear that the risk estimators are we can do that.
4138.2 -> We've not actually done the 360.
4143.46 -> Something we will be looking into after this.
4155.94 -> I have a question.
4160.56 -> Tell us what it is like to integrate the care coordinators into your practice.
4165.48 -> Were they already part of your team and took on the responsibility or did you hire somebody
4170.69 -> else?
4171.98 -> What we did and maybe Roseanne can speak to this as a care coordinator.
4175.27 -> Roseanne used to be my medical assistant.
4177.4 -> And she was looking for something more.
4182.23 -> So we developed this position and she essentially along with her cohorts and Mary created this
4191.34 -> position.
4192.34 -> And we modified it as time went on to adapt to what our needs were.
4199.19 -> Care coordination started five years ago and we didn't know what it was or what our job
4211.64 -> entailed.
4212.64 -> And through trying, we found out what the needs of our patients were.
4221.14 -> Right now we are doing hospital discharges.
4223.44 -> Patients were coming to the clinic who had no idea of medical changes that were made
4225.87 -> at the time of discharge.
4227.7 -> That was a very important part of care coordination.
4232.33 -> We also not only started calling patients and saying that you are overdue for a visit,
4241.91 -> but also diving into why they are not taking care of their medications.
4246.38 -> We are helping them find resources for medicine, outside care.
4252.13 -> Just a simple thing like finding volunteer activities.
4261.1 -> We've helped patients find transportation to the clinic.
4265.27 -> So we've discovered that the little time our patients are in the clinic is not what is
4273.39 -> going to keep them healthy.
4274.65 -> We've had some wonderful success stories of keeping patients on the edge, healthy and
4278.02 -> alive far more years than we thought they would be.
4280.85 -> This is Mary.
4281.85 -> We also just historically took medical assistants who had been with the clinic quite some time
4285.17 -> who were knowledgeable with all our processes as they
4290.51 -> needed to know what was happening throughout all our clinic.
4294.6 -> And then we participated with one of our third party payers to do a research project related
4301.93 -> to cardiac disease and that was focused around having an RN in the care coordination team.
4307.74 -> So we did go through a three-year process and hired an RN on a temporary basis through
4312.45 -> this research grant.
4313.45 -> We then went to our clinics and developed our medication titration process and some
4325.05 -> protocols.
4326.41 -> Since that time, we hired an RN to help us to get it implemented.
4339.96 -> She's since left so instead of hiring another RN, we've decided to use our midlevel group
4346.38 -> to continue with the medical titration process.
4350.02 -> So the patients identified by the care coordinator off of our registry list can have the mid-level
4359.69 -> provider be the Intermediary to help the patient with medication management without having
4371.86 -> the physician involved.
4377.17 -> That's all the questions I have at this time.
4386.7 -> Chris for us here at ONC, we are all about pushing forward the e-health record and the
4396.51 -> digital tools.
4397.51 -> You guys have several steps that are more analog or at least not digital that are very
4405.14 -> important and are not huge lifts in terms of getting new things into your work flow.
4414.21 -> Do you anticipate at some point feeling like you won't need the little slips of paper on
4423.44 -> the Keyboard.
4424.62 -> That the behavior will become ingrained enough.
4428.79 -> That new doctors will come in and pick up where that is?
4432.66 -> Or do you see analog steps continuing?
4437.91 -> Are there any other things that might be helpful in your process use?
4444.81 -> No, I look at the analog things as an adjunct.
4448.79 -> And I don't see them going away for two reasons.
4450.86 -> One is because, and I'm a big technology person, as much as we use technology, sometimes over-designing
4460.08 -> it can actually make life more difficult.
4463.3 -> A single paper like that conveys a tremendous amount of Information yet it costs almost
4470.46 -> nothing to do and it keeps everybody engaged because multiple people have to touch that
4476.5 -> piece of paper.
4479.3 -> And the patients are really intrigued by that.
4482.06 -> They want to know what that's all about.
4485.51 -> So it engages them as well.
4488.94 -> So personally, I don't see that as going away.
4491.59 -> Do I see it being modified.
4494.33 -> Probably.
4495.71 -> Because I didn't see it being modified before and they modified it and made it better.
4500.02 -> I have no doubt that our staff can continue to improve on that.
4506.58 -> I actually have another question.
4510.85 -> You mention that you are NCQA certified.
4514.18 -> In your opinion, was the process worth the outcomes?
4517.87 -> Yes.
4519.16 -> It was a lot of work but I do believe that in order to move forward in this team-based
4529.56 -> care, we needed to put all those processes in place.
4532.22 -> Not they are so ingrained in our practice, that is has done nothing but help improve
4539.1 -> the care of our patients and got everyone engaged.
4541.79 -> Because when you went through the process you had to engage everyone in the facility
4546.65 -> as part of the team.
4548.27 -> And I think really helping everybody like the front office makes them feel valued and
4551.83 -> they are part of the team.
4553.83 -> This came to focus when we worked on that project.
4558.05 -> It also helped us to help advance the things in our EMR.
4567.19 -> There were some things in our EMR that weren't there.
4571.76 -> So we had to develop our own process to get certified.It pushed us to work with our EMR
4580.86 -> vendor to make sure that they understood the things we needed and they were really great
4586.44 -> about working with us to get those things put into our EMR.
4591.34 -> So I think it was well worth the process.
4594.31 -> Let me give you another example of where it really helps.
4597.92 -> And that's in closing the loop.
4599.73 -> We knew we needed to close the loop.
4602.52 -> Whether x-rays, lab work.
4603.67 -> Things like that.
4604.67 -> Never occurred to me that we needed to close the loop for our referrals to our specialists
4611.41 -> and making sure that they got done.
4615.23 -> So it allowed us to get much more organized and a more systematic approach.
4621.64 -> So fewer bad outcomes slip through the cracks.
4627.75 -> Okay, I have another question.
4630.5 -> What training on the proper way of taking blood pressure is provided to the medical
4635.37 -> assistants and nurses?
4637.11 -> My sense is that there is variability in the reading unless BP training is institutionalized
4644.79 -> in a practice.
4647.06 -> When we decided to move forward with this, we had classes with everyone on how we wanted
4653.12 -> to take it.
4654.12 -> For example, your feet can't be crossed, you can't sit on the floor.
4658.77 -> This is how you inflate it.
4660 -> And to be honest, we didn't just teach the medical assistants but the doctors as well.
4670.47 -> This is the standardized way of doing it.
4674.52 -> I have another one.
4676.99 -> Who is your EMR vendor?
4679.03 -> We use Cerna.
4680.87 -> We use their ASP.
4683.91 -> Cerna houses it in their facility in Kansas City as an application service provider.
4697.35 -> So we access our EMR over the internet.
4702.01 -> If we have an internet connection anywhere in the world, we can access our EMR and it
4708.01 -> is safe and secure.
4709.52 -> And we found that to be very helpful.
4712.81 -> Because everything is there.
4714.33 -> We don't need a special connection.
4718.56 -> We just need internet.
4720.23 -> We don't have to maintain servers.
4725.85 -> It just works.
4727.72 -> Cerna has been good to us.
4731.53 -> But just using an application service provider has been a huge plus with the EMR stuff.
4739.02 -> And I have another one.
4742.72 -> Is your practice a partner in your state Million Hearts partnership.
4747.88 -> If so what has been the nature of your participation?
4751.15 -> We're not actually a partner in that other than I do a fair amount of advising for them.
4757.44 -> We have been trying to get grants and things going.
4764.88 -> But it hasn't been as successful as we would have liked but we keep plugging away at it.
4772.39 -> Okay that's all I have for right now.
4780.774 -> I want to reiterate to say how important this is to me.
4784.3 -> Million Hearts is really great for what it does.
4791.79 -> Preventing heart attacks and strokes.
4794.96 -> That's where the focus has to be.
4802.77 -> You can look at numbers and the ways to convey it but in the end what we are looking at is
4807.86 -> reducing heart attacks and strokes in real lives.
4811.74 -> People that we live with, see in the grocery store, work with.
4817.31 -> People in our community.
4818.31 -> That is the most compelling reason to be doing this.Great.
4824.8 -> Thanks a lot Chris and Mary and Roseanne.
4828.59 -> We got some great questions in today.
4831.98 -> We are going to take these last few minutes to talk about phase II of the challenge.
4836.74 -> So just to reorient, our original goal of this challenge was to celebrate improvements
4847.44 -> on the Million Hearts blood pressure goals.
4852.19 -> Reward innovation and enable quality improvement.
4856.81 -> To promote evidence based treatment protocols.
4859.66 -> Leverage clinicians expertise and recognize real-world successes.
4865.71 -> And reward scalable resource tools that are being used effectively across many clinical
4873.06 -> practices.
4874.17 -> These last few are what we are focusing on for Phase II.
4881.77 -> So what we are looking to accomplish in Phase II is to spread these two Phase I winning
4893.76 -> Interventions to as many practices as possible and to demonstrate success in that.
4900.62 -> Submissions for phase II must include CDS intervention details.
4909.55 -> So not just which of these two were utilized but also any changes to them that were used.
4918.89 -> The actual results from any practices where they were implemented.
4924.2 -> So this is not just demonstrating the actual improvements of blood pressure control but
4931.69 -> we also want to know how many new practices it was implemented in or have demonstrated
4938.57 -> a commitment to implementing them.
4941.28 -> And finally to learn more, we want to know about your spread strategy.
4949.23 -> So how you decided to reach out to the ones you talked to.
4960 -> What key points you hit upon to convince practices to make these implementations.
4969.27 -> And note that by CDS, we mean that large scale.
4974.74 -> Like registries,reminders and protocols are included.
4981.09 -> The challenges website is there on the screen.
4985.33 -> We will be awarding one final winner with a $30,000 prize.
4988.62 -> So the review criteria stem from those submission aspects I just detailed.
5001.26 -> So the number of practices the interventions were implemented or is underway.Or the number
5010 -> of practices that have expressed interest in doing the implementation.
5015.5 -> Demonstrated blood pressure control improvements.
5018.21 -> And if that is not quite available yet, then any leading indicator that would lead one
5026.15 -> to believe that blood pressure will be improving.
5030.6 -> We want to know about the comprehensiveness and innovation in supporting blood pressure
5041.77 -> protocol with CDS tools.
5044.42 -> And lastly, the capacity for the implementation spreading strategy to be scaled and used outside
5051.79 -> the challenge on a further basis.
5059.17 -> So we have a nine-month long submission period that will end on October 23, 2015.
5066.88 -> We will be announcing winners in November or December.
5071.84 -> Again, the grand prize is $30,000 and we will be having honorable mentions depending on
5078.61 -> the types of submissions and the entities that are targeted.
5085.77 -> And along with the $30,000 prize, you will be receiving recognition, publicity, credibility
5094.21 -> and reach.
5096.19 -> So again the challenge site url is up there at top along with the Million Hearts address.
5105.54 -> If you have any questions, please email them to [email protected].
5113.71 -> We did receive a number of questions about the webinar and we will be emailing
5118.52 -> everyone with the recording of the webinar and the basic slide deck.
5124.17 -> And slides for each of the submissions are available for download at the challenge site
5131.56 -> right now.
5134.21 -> We have about two minutes for questions.
5137.89 -> Otherwise, I just want to thank again Holly and her team and the team at Vibrant Health
5150.27 -> Clinics.
5151.27 -> They've done some excellent work and we are really excited to see how Phase II goes and
5159.08 -> how many new practices can utilize these fantastic blood pressure protocols and implementations.
5178.81 -> In lieu of dead space, we are going to close up shop.
5194.46 -> You will bereceiving the recording, slides, and urls of everything shortly.
5203.92 -> Thank you and have a good day.
5218.78 -> 27

Source: https://www.youtube.com/watch?v=vy8NfnmIbbI