Month: April 2017

#MEQAPI – Tweetchat April 27th 2017 2:30ET: EHR Success Story

Topic:  Quality Improvement vs EHR Success Story with James Legan MD

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This chat is about using an EHR to improve practice and patient experience.

The HITECH, ARRA, and Meaningful Use programs greatly accelerated adoption of electronic health record (EHR) systems by providers. Adoption by office-based providers rose from 21%  in 2004, to 87% by 2015. Many will, however, say that the cost was too high, the results too poor, and that it has potentially soured an entire generation of providers to the idea of Health IT solutions in general and EHR in specific.

While this may be true, there is considerable variation in outcomes and realized value, and wherever there is variation, there is opportunity for quality improvement. For some, the EHR is a frustrating waste of time that is added to an already cramped schedule, and represents an additional burden of several hours of duplicitous administrative work at the end of each workday. For many, the EHR is just another administrative chore. For a few, the EHR has reduced administrative work, improved efficiency, and supportedthe ability to serve patients.

This week the #MEQAPI topics relate to a specific healthcare provider’s experience that may be seen as a positive outlier. Dr. Legan has put together a solution that pairs an EHR and a CRM, and has seen improvements that many would envy. Dr. Legan is an Internal Medicine Physician, in his 23rd year in Private Practice in Great Falls, Montana.Great Falls is in the North Central Montana region, and has approximately 50,000 population, served by two large multi-specialty hospitals. The practice is outpatient-only, and consists of eight physicians: three Internists, four Family Practice, and one Pediatrician, each with approximately 1,200-2,000 patients. Ancillary staff includes five shared in-house billing staff, and each physician has one to three additional support staff.

Dr. Legan has a patient-facing display so that the patient sees everything in the EHR as it is being reviewed or entered.

legan

Dr. Legan describes his outlook on EHR as follows:

I am convinced the electronic health record (EHR) needs to be shared as a visual interactive medium at the point of care.  The primary role of the EHR should be educational, all other uses secondary.  I discuss this approach #ProjectedEHR on twitter.

Videos of #ProjectedEHR I Periscoped to You Tube

  1. https://www.youtube.com/watch?v=moTXADdpHtU (me being interviewed)
  2. https://www.youtube.com/watch?v=HOlKbl1dAWE(interviewing a patient)
  3. https://www.youtube.com/watch?v=EA5X_LP5_PQ (Wall mounted TV/chromebook)
  4. https://www.youtube.com/watch?v=kz9rVtRpuI0 (Dual monitored desktop/chromebook in office carried to exam room)

#ProjectedEHR–User friendly EHR that projects well, 14 inch Chromebook, 24 inch TV, 10 foot HDMI cord, 8 inch HDMI extender, wall mount, remote access application made for chrome & encrypted (VNC viewer made for Chrome, Enterprise Version).  The chromebook simulates my dual monitored desktop, so I take my “virtual desktop” into the exam room and plug in the HDMI cord to extender and the learning begins.  Always check with your IT support to make sure everything is HIPAA compliant and secure.

Some supporting reading for the chat comes from Physician’s Weekly:

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI EHR

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Insurance Models, payer systems
      • Home visits
      • Charting – automatic vs manual
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
    • Measurement
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc.
      • Monitoring of home-care
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: ergonomic requirements of system- maybe leading to cramped, uncomfortable work space etc.
      • Time: Too little time per patient, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient

Dr. Legan will be responding to the following topics with regard to his own system, and will field questions from other participants. Participants are also invited to respond with regard to their experiences of EHRs, and offer their insights and observations.

Topics

  1. What risks, issues, opportunities, or observations did you have related to Methods and your EHR/CRM solution
  2. What risks, issues, opportunities, or observations did you have related to Machines and your EHR/CRM solution
  3. What risks, issues, opportunities, or observations did you have related to People issues and your EHR/CRM solution
  4. What risks, issues, opportunities, or observations did you have related to Materials and your EHR/CRM solution
  5. What risks, issues, opportunities, or observations did you have related to Measurements  and your EHR/CRM solution
  6. What risks, issues, opportunities, or observations did you have related to Environment issues and your EHR/CRM solution

 

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

#MEQAPI – Tweetchat April 20th 2017 3ET: Quality Improvement vs Patient Readmission

Topic:  Quality Improvement vs Patient Readmission

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This chat is about patient readmission.

Re-admissions within 30 days of  discharge often result from patient harm, and may result in payment clawback from insurance providers, Medicare, Medicaid, etc. Readmission may reflect a quality issue,  and as such, readmission often acts as a signal that something went wrong – something was missed, something caused harm, etc.

There are many different risks, issues, and opportunities related to patient readmission, including patient knowledge deficits, home care, weekday vs weekend discharges, self-care, and dealing with complex patient comorbidities and home/work environment.

This week the #MEQAPI topics relate to Physician’s Weekly articles related to readmission::

The period immediately following discharge is associated with several heightened risks, and has a very high need for patient or carer participation – if the patient doesn’t fully understand their post-discharge duties, needs, and risks, there can be significant harm, resulting in readmission or even post-discharge mortality. Readmission may also be due to indirect issues, such as self-harm. The period immediately following discharge carries a high risk for suicidality.

Standardizing the patient discharge process and making it a “no interruption” activity can reduce readmission risk, but readmission may be due to a wide range of causes, including the patient or carer not having the knowledge or means to carry out ongoing care. 

Quality Improvement approaches can greatly reduce readmission risk by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the discharge process and remove risks.

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Readmission

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

  • Methods
    • Policies: either unit, office, organization, or national policies
    • Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps self-care, etc.
    • Insurance Models
    • Home visits
    • Transportation option
  • Machines (equipment, EHR)
    • Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
    • Home equipment specific to the patient condition
    • Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
  • People
    • Staffing: insufficient or unqualified staff
    • Training: insufficient base training, incorrect training, insufficient CME, etc. or insufficient patient or carer training
    • Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
  • Materials
    • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
    • Supplies: medical or office, inferior fax paper, lack of coffee(!)
    • Data? – sent to wrong recipient, not shared with pt or specialist, etc.
    • Patient self-care materials including checklists and how-to instructions, contact information for questions, and slef-care consumables
  • Measurement
    • KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
    • Poor quality and safety metrics
    • Targets: improper or unachievable performance targets
    • Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
    • Monitoring of home-care
  • Environment
    • Noise: distracting noises, sound levels too high, etc.
    • Space: cramped, uncomfortable, slippery surfaces, etc.
    • Time: Too little time per patient, too little time in a day, too many demands
    • Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.
    • Readiness of receiving point of care to cater to patient needs

The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.

  1. What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a readmission
  2. What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a readmission
  3. What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a readmission
  4. What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a readmission
  5. What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a readmission
  6. What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a readmission

 

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

#MEQAPI – Tweetchat April 13th 2017 3ET: Quality Improvement vs Patient Discharge

Topic:  Quality Improvement vs Patient Discharge

This chat is over, but you can see the #MEQAPI storify thread

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This week the #MEQAPI topics relate to British Medical Journal and Physician’s Weekly articles related to safe and effective patient discharge.

Patient handoff and discharge are two of the most risky events in the patient journey through the care process, and account for the lion’s share of mistakes and missed opportunities. Incomplete or incorrect information transfer, (or failure to transfer at all) can result in sub-optimal patient outcomes, injury, or death.

There are many different risks, issues, and opportunities related to patient discharge, including patient knowledge deficits, home care, weekday vs weekend discharges, self-care, and dealing with complex patients.

Standardizing the patient discharge process and making it a “no interruption” activity can reduce risks due to distraction, multitasking, and missed steps, while also reducing missed opportunities. Patient discharge also has a very high need for patient or carer participation – if the patient doesn’t fully understand their post-discharge duties, needs, and risks, there can be significant harm.

Quality Improvement approaches can greatly increase adoption and effectiveness of standardized discharge processes by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the discharge process and remove obstacles to adoption and compliance.

We will take a QI approach, and discuss the next topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Discharge

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

  • Methods
    • Policies: either unit, office, organization, or national policies
    • Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps in discharge, etc.
    • Insurance Models
  • Machines (equipment, EHR)
    • Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
    • Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
  • People
    • Staffing: insufficient or unqualified staff
    • Training: insufficient base training, incorrect training, insufficient CME, etc.
    • Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
  • Materials
    • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
    • Supplies: medical or office, inferior fax paper, lack of coffee(!)
    • Data? – sent to wrong recipient, not shared with pt or specialist, etc.
  • Measurement
    • KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
    • Poor quality and safety metrics
    • Targets: improper or unachievable performance targets
    • Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
  • Environment
    • Noise: distracting noises, sound levels too high, etc.
    • Space: cramped, uncomfortable, slippery surfaces, etc.
    • Time: Too little time per patient, too little time in a day, too many demands
    • Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.

The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.

  1. What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a bad patient discharge
  2. What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a bad patient discharge
  3. What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a bad patient discharge
  4. What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a bad patient discharge
  5. What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a bad patient discharge
  6. What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a bad patient discharge

 

meqapi number april 13

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

 

 

 

#MEQAPI – Tweetchat April 6th 2017 3ET: Quality Improvement vs Patient Handoff

Next tweetchat: Thursday April 6th, 2017 3:00-4:00 PM ET

Topic:  Quality Improvement vs Patient Handoff

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

This week the #MEQAPI topics relate to British Medical Journal and Physician’s Weekly articles related to safe and effective patient handoff.

Patient handoff and discharge are two of the most risky events in the patient journey through the care process, and account for the lion’s share of mistakes and missed opportunities. Incomplete or incorrect information transfer, (or failure to transfer at all) can result in sub-optimal patient outcomes, injury, or death.

The BMJ Quality & Safety report that over 6000 doctors, nurses, and therapists have been trained on the I-PASS patient handoff method at Massachusetts General Hospital to improve handover quality, and reduce preventable errors and adverse outcomes.

Dr. Amy Starmer wrote in Physician’s Weekly of positive effects of a patient handoff program that she and colleagues developed using I-PASS. Dr. Starmer has offered to attend the chat to provide additional insights and updates.

Standardizing the patient handoff process and making it a “no interruption” activity can reduce risks due to distraction, multitasking, and missed steps, while also reducing missed opportunities.

Quality Improvement approaches can greatly increase adoption and effectiveness of standardized handoff processes by identifying what works and observing what doesn’t work, and intervening in an effective and timely fashion to refine the handoff process and remove obstacles to adoption and compliance.

 

We will take a QI approach, and discuss the next topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Handoff

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

  • Methods
    • Policies: either unit, office, organization, or national policies
    • Workflow: how things are done that might increase risks of errors, or harm the patient, or create gaps in handoff, etc.
    • Insurance Models
  • Machines (equipment, EHR)
    • Medical or office equipment that might increase risk: old, broken, poorly installed, etc.
    • Software systems (especially EHR?), that might lead to duplicate work, frustration, cause medical errors like wrong pt, wrong site, wrong meds, and create hours of extra work per day.
  • People
    • Staffing: insufficient or unqualified staff
    • Training: insufficient base training, incorrect training, insufficient CME, etc.
    • Attitudes: staff attitudes e.g. paternalism, rudeness, and workplace bullying.
  • Materials
    • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
    • Supplies: medical or office, inferior fax paper, lack of coffee(!)
    • Data? – sent to wrong recipient, not shared with pt or specialist, etc.
  • Measurement
    • KPIs: operational metrics that focus on the wrong things, or are poor measures, and that drive wrong behavior
    • Poor quality and safety metrics
    • Targets: improper or unachievable performance targets
    • Incentives: improper, biased, or discriminatory rewards, conflicting or perverse
  • Environment
    • Noise: distracting noises, sound levels too high, etc.
    • Space: cramped, uncomfortable, slippery surfaces, etc.
    • Time: Too little time per patient, too little time in a day, too many demands
    • Location: things not where they should be, too much movement of staff, pt, or equipment needed, etc.

The aim of this chat is look at each of these dimensions of causation, and discuss what we have seen before that has been a risk or developed into burnout, or that we anticipate is likely to become an issue.

  1. What Methods (policies, workflow, etc) have you seen or anticipate may increase risk for a bad handoff
  2. What Machines (med/office equipment, EHR/SW) have you seen or anticipate may increase risk for a bad handoff
  3. What People issues (staffing, training, bullying) have you seen or anticipate may increase risk for a bad handoff
  4. What Materials (forms, supplies, data?) have you seen or anticipate may increase risk for a bad handoff
  5. What Measurements (KPIs, targets, incentives) have you seen or anticipate may increase risk for a bad handoff
  6. What Environment issues (noise, space, time) have you seen or anticipate may increase risk for a bad handoff

Background

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

MEQAPI numbers Apr 6

 

MEQAPI Participants