Rheumatoid Arthritis Learning Collaborative Sponsored by AMGF and AbbVie

Transcription

1 1 Rheumatoid Arthritis Learning Collaborative Sponsored by AMGF and AbbVie August 13-15, 2014 Ochsner Best Practices in Managing patients with Rheumatoid Arthritis

2 2 Medical Group Profile When was your group established 1946 # of sites/clinics 2 Rheumatology sites # physicians, rheumatologist (7.4 FTE (3 at site 1 and 4.4 at 2 nd site, 3 Rheumatology NP s) # specialties 80 # patients (average # rheumatology annual outpatient visits) 2012: 10,986 Visits 2013: 10,553 visits 2014: 8,892 visits (annualized) Do you currently have an EMR, if so what are you using? EPIC

3 3 Team Composition 1. Dr. Robert Quinet MD 2. Dr. William Davis MD 3. Arif Shahzad MD 4. Timothy Hilbun

4 4 RA Goals & Objectives Evaluate the use of DMARDS in our RA population compared to previous surveys. Develop an action plan on RA disease activity level. Monitor HAQ score entry by provider. Currently we are documenting MD HAQ, DAS-28 or RAPID 3, and ESR/CRP in all our RA patients Evaluate the use of biologic order set which include pre DMARD labs and vaccination checks. Link our EPIC therapy plans with medication list so non rheumatologist are aware of all medications.

5 5 DMARD Hydroxychloroquine(Plaquenil) Sulfasalazine(Azulfidine) Methotrexate(Rheumatrex, Otrexup) Leflunomide(Arava) Rarely used: Gold injections(im) Cyclosporine Azathioprine(Imuran) Minocycline(Minocin)

6 6 RA BIOLOGICS Self administered: Etanercept(Enbrel) sc Adalimumab(Humira) sc Certolizumab(Cimzia) sc Golimumab(Simponi) sc Abatacept(Orencia) sc Tocilizumab(Actemra) sc Anakinra(Kineret) sc

7 7 Infused IV: Infliximab(Remicade) Golimumab(Aria) Abatacept(Orencia) Tocilizumab(Actemra) Rituximab(Rituxan) SMALL MOLECULE INHIBITOR Tofacitnib(Xeljanz)

8 8 MEASURES DMARD 94% 95% 94%

9 9 RA Intervention & Population Baseline Describe your target RA population(s) and how you identified them. 868 patients. ICD-9 code714 Provide demographics on target population(s). 0.1% 34.8% Race % 63.6% White Native Hawaiian or Other Pacific Islander Asian Unknown Patient Refused 0.2% 0.1% 0.3% 0.9% Black or African American American Indian or Alaska Native

10 10 RA Intervention & Population Baseline Did you set up a RA registry to identify patients, collect additional data elements, etc. NO. We will explore setting up a registry in the future with the EPIC application coordinator. Describe what went behind the scenes to implement this intervention. Created documentation menu in EPIC with automatic calculation of Scores which includes MDHAQ, DAS 28, RAPID3, and CDAI. What changes, if any, required in the workflow. Automatic calculation of Rapid 3 upon entering MD-HAQ scores in EPIC. Instructed Medical Assistants to score HAQ

11 11 RA Intervention & Population Baseline How was healthcare information technology used in this intervention. Created a special section in EPIC for entering HAQ data Describe staff who were involved in this intervention. Epic Super users- Dr. Collins, Dr. Quinet and Dr. Lindsey Marilyn Porter, our EPIC programmer What methods were used to change physician practices. The use of this section was discussed and encouraged at the monthly faculty meetings, and all members were asked for verbal agreement to participate

12 12 Improvement Interventions Epic PQRS-RA dot phrase: to facilitate documentation of CMS quality measures at RA patient visits. Pre-DMARD/Biologic lab order set: Hep B/C, HIV, quantiferon gold TB. Availability of 2 portable ultrasound machines. Utilization of ACR RA and specific drug handouts from ACR website given to patients.

13 13 Measures Used What national clinical standards, if any, did you use as your guideposts and why? MD- HAQ (function) / Rapid 3 /DAS28 Pain, Fatigue, global health, AM stiffness Lipids, ESR, CRP 28 Joint count Serial joint xray s MEASURES PATIEN T COUNT PERCENTA GE (7/1/13-6/30/ RA-RAPID3-DAS28-CDAI % 31.7% 40% RA-HAQ % 58.3% 60% RA-Population 868

14 14 Challenges or Obstacles What were your biggest challenges? We have an EMR (EPIC) but cannot easily extract data from it readily to help identify and characterize our RA population We share a builder who has responsibility for several departments in the institution.

15 15 Challenges or Obstacles Ability to engage clinical providers for whom there is a high demand Constant reinforcement at monthly meetings, engagement of support staff, and non structured one on one interaction/dialog involving RA project members and other rheumatology faculty and fellows Physician Rheumatologist have to meet a certain threshold in documentation of functional end disease activity as part of their compensation plan

16 16 Outcomes and Successes What are the key elements that contributed to the success of your initiative? We have the outcome measures built into our EPIC note writer Automatic calculation of RAPID 3 and RA DAS-28 upon entering data Dedicated assistance in generating report from our EHR.

17 17 Future Steps What are your next steps? Encourage patients to use My Ochsner Continue to collect data on our RA population. Will have an incentive plan in place for MA for entering HAQ/rapid3 score. Physician incentive plan is in place What do you hope to achieve? Searchable data base/registry to be sure we are evaluating and treating our patients appropriately. Track annual Flu vaccines, Pneumovax q5 yrs X 2, and Prevnar 13 Facilitate electronic completion of questionnaires via cell phone or waiting room kiosk that can automatically be uploaded to EPIC Ensure to treat to target with target being remission or low disease activity

18 18 Lessons Learned Describe your lessons learned. Advantage of having an IT with research background in helping us report data Importance in minimizing change in physician workflow Standardized the intake form among several providers

19 19 Questions Do you have any questions you d like to pose to the group? Which EMR system are you using to track RA patients? How cost effective and efficient is your EMR