Project Culmination Summary

Transcription

1 Information Workflow Optimization to Improve Colorectal Cancer Screening An eclinicalworks (ecw) Best Practice Guide on Electronic Health Record (EHR) Use to Improve Colorectal Cancer (CRC) Screening and Treatment in Community Health Centers Project Period: April 1, 2015 September 30, 2015 Project Culmination Summary The Health Center Network of New York (HCNNY) is pleased to deliver the attached EHR Best Practice Workflow and Documentation Guide to Support Colorectal Cancer Screening Improvement with eclinicalworks as a result of this project and is thankful for the support and collaboration from the National Association of Community Health Centers (NACHC), the American Cancer Society (ACS) and the National Association of Chronic Disease Directors (NACDD). The overall goal of the project was to identify and document specific best practice workflows that support appropriate CRC screening and follow up and proper utilization of family history data within the eclinicalworks EHR system (ecw), and further enable FQHCs to employ existing CRC screening improvement tools to ultimately yield improved patient health outcomes. We understand the tool will be made available nationally to FQHCs utilizing ecw through the partnering organizations and a plan will be developed to leverage primary care associations and other health center controlled networks in spreading this resource. HCNNY will promote and make this resource available across its twenty-one health center membership immediately, and will continue to enhance the guide as further information and/or product capabilities related to CRC screening become known. HCNNY and its participating FQHCs learned a great deal throughout this project and while the challenges of ensuring timely colorectal cancer screening for all patients are far from resolved, the detailed recommendations we ve developed provide a roadmap for documentation that will assist health centers in building the necessary foundation for more reliable, actionable information to support their efforts to improve CRC screening rates. To develop the recommended best practices, HCNNY partnered with four health centers - two high performing centers as mentors and two pilots for testing and validation. Both quantitative and qualitative formative evaluations helped inform the product development. We d like to acknowledge and thank our partnering health centers and their representatives for dedicating their time and expertise, and that of their staff, to this import effort. Our partner health centers are: David Skory, MD, Medical Director, Hometown Health Center, Schenectady, NY - Mentor Carla Henke, MD, Medical Director, Community of Hope, Washington - Mentor Rina Ramirez, MD, Medical Director, Zufall Health Center, Dover, NJ - Pilot Michael McNett, MD, Horizon Health Center, Jersey City, NJ - Pilot Through face-to-face and telephone interviews, participating health centers provided detailed workflow, highlighting those aspects which have the greatest impact on the center s CRC screening rates, and the extent and manner in which patient risk is documented and assessed. They also provided review and feedback on HCNNY ecw-based CRC screening configuration and training guides. Additionally, the Pilots participated in evidence-based and ecw-specific CRC screening training 103 Woerner Ave., Liverpool, NY 13088

2 conducted by project staff. The pilot centers initiated implementation of the recommended workflow in at least one service location on September 25, In addition to developing the Best Practices Guide, HCNNY also worked with NACHC and ACS to explore quality of current colorectal cancer screening measures and potentially develop new measures. Data on currently available measures was reviewed monthly and trended during the project period. A data measurement plan and final trends are included as an appendix to this project summary. Measures Currently in Use Colorectal Cancer Screening Past 12 Months and Past Month (UDS; NQF 0034) o % of completed CRC screenings satisfied by FIT/FOBT o % of completed CRC screenings satisfied by colonoscopy While it will take some time to notice improvements in measure outcomes due to recent workflow adoption, one pilot center experienced increases in their colorectal cancer screening rates during the project period by improving their configuration and documentation for FIT/FOBT. HCNNY will continue to produce and monitor these measurements on a regular basis. Exploratory Measurements Screening colonoscopy referrals Screening colonoscopy referral to completion time Adenomas detected during colonoscopy Positive FIT/FOBT Follow up colonoscopies after positive FIT/FOBT Measurement specifications were drafted for each of the exploratory measures, and all except Screening Colonoscopy Referral to Completion Time have been tested. Due to inconsistency across and within practices relative to documentation of screening colonoscopy referrals and results, no data is available to support this measure. Tests of the remaining measures revealed that outcomes would be unreliable at this stage due to the inconsistent workflows in use. Adoption of the recommended workflows will support all of these measurements in the future. With additional time and research, these measures can be further refined and used to assist the effort in improving colorectal cancer screening rates. HCNNY would like to develop a set of process measures to monitor workflow adoption at these pilot sites and potentially other FQHC sites, which in turn would indicate readiness to produce meaningful outcome measurements. As a result of this project HCNNY developed the short list below of vendor enhancements to existing functionality that we will be requesting. These basic enhancements would improve the efficiency and effectiveness of the CRC screening process within ecw. Expansion of Family Hx structured data capture driven by ICD code Ability to lock-down Results fields based on test by test configuration Order screens to provide access to Dx field regardless of where launched Option for CPT code association upon result entry (FOBT/FIT results) We recognize that rarely does one workflow suit everyone s need or style of practice and it is our hope that health centers will be able to use the detail provided within the guide to build suitable workflows for their practice while honoring the most crucial data collection elements. To that end we believe the guide would benefit from a higher-level summary of the flow that calls attention to those most crucial steps identified within the detail but could be easily overlooked by those not motivated to review in- 103 Woerner Ave., Liverpool, NY 13088

3 depth. It is our goal to further enhance the guide with such as summary though no commitment to timeline can be made at this time. I welcome your feedback, including suggestions for improvement, on the final product and on behalf of the staff and partnering health centers at HCNNY, I thank you for your support. Respectfully submitted, Sandy Cafarchio Executive Director 103 Woerner Ave., Liverpool, NY 13088

4 CRC Screening EHR Workflow & Documentation Guide to Support Colorectal Cancer Screening Improvement with eclinicalworks Project Measures Measurement Period: through 10/01/ /30/ day outcomes where indicated represent 09/1/ /30/2015 Measurements Included Pages Data Measurement Plan Required Measures Project Data Required Measures Colorectal Cancer Screening (HCNNY) 12 month outcomes... 4 Colorectal Cancer Screening (HCNNY) 30 day outcomes... 5 Colorectal Cancer Screening (HCNNY) Trends Data Measurement Plan Exploratory Measures Preliminary Data Exploratory Measures Screening Colonoscopy Referrals Adenomas detected during colonoscopy Variations of adenomas/polyps found on Colonoscopy Positive FIT/FOBT Number of referrals for follow up colonoscopies after positive FIT/FOBT

5 EHR Best Practice Workflow Documentation Guide to Support Colorectal Cancer Screening Improvement with eclinicalworks Data Collection Plan REQUIRED MEASURES Measure Name (Source) Colorectal Cancer Screening Past 12 Months (UDS; NQF 0034) Colorectal Cancer Screening Past Month (UDS; NQF 0034) Screening Colonoscopies Completed Past 12 Months Measure Definition Denominator Numerator % of patients ages 50 to 74 who received appropriate colorectal cancer screening who had at least one medical visit in the past year. % of patients ages 50 to 74 with current colorectal cancer screening who received both a complete guaiac fecal occult blood test (FOBT)/fecal immunochemical test (FIT) and a colonoscopy. % of patients ages 50 to 74 with current colorectal cancer screening who received a colonoscopy as their screening test. Males and females ages 51 to 74 with at least one medical visit during the past 12 months. Excludes total colectomy or diagnosis of colorectal cancer. NoShow visits are excluded from this count. Males and females ages 51 to 74 who had at least one medical visit during the past month. Excludes total colectomy or diagnosis of colorectal cancer. NoShow visits are excluded from this count. Males and females ages 51 to 74 with at least one medical visit during the past 12 months who received one or more FOBT or FIT tests during the past year OR who received a colonoscopy during the past ten years. Excludes total colectomy or diagnosis of colorectal cancer. Data Collection Method/ Frequency Patients in the denominator who received appropriate colorectal cancer screening Monthly from June to (one or more FOBT or FIT tests during the September past year OR a colonoscopy during the past ten years) Patients in the denominator who received appropriate colorectal cancer screening Monthly from June to (one or more FOBT or FIT tests during the September past year OR a colonoscopy during the past ten years) Patients in the denominator who received a colonoscopy during the past ten years. Monthly from June to September NoShow visits are excluded from this count. 2

6 EHR Best Practice Workflow Documentation Guide to Support Colorectal Cancer Screening Improvement with eclinicalworks Data Collection Plan REQUIRED MEASURES Measure Name (Source) Screening Colonoscopies Completed Past Month Measure Definition Denominator Numerator % of patients ages 50 to 74 with current colorectal cancer screening who received a colonoscopy as their screening test. Males and females ages 51 to 74 with at least one medical visit during the past month who received one or more FOBT or FIT tests during the past year OR who received a colonoscopy during the past ten years. Excludes total colectomy or diagnosis of colorectal cancer. Patients in the denominator who received a colonoscopy during the past ten years. Data Collection Method/ Frequency Monthly from June to September NoShow visits are excluded from this count. FOBT/FIT Tests Completed Past 12 Months % of patients ages 50 to 74 with current colorectal cancer screening who received a complete guaiac fecal occult blood test (FOBT) or fecal immunochemical test (FIT) as their screening test. Males and females ages 51 to 74 who had at least one medical visit during the past 12 months who received one or more FOBT or FIT tests during the past year OR who received a colonoscopy during the past ten years. Patients in the denominator who received a FOBT or FIT test during the past year. Monthly from June to September FOBT/FIT Tests Completed Past Month % of patients ages 50 to 74 with current colorectal cancer screening who received a complete guaiac fecal occult blood test (FOBT) or fecal immunochemical test (FIT) as their screening test. Patients ages 51 to 74 who had at least one medical visit during the past month who received one or more FOBT or FIT tests during the past year OR who received a colonoscopy during the past ten years. Patients in the denominator who received a FOBT or FIT test during the past year. Monthly from June to September 3

7 Colorectal Cancer Screening BridgeIT Source Report: CQI Colorectal Cancer Screening Count of Screened Report Timeframe: Rolling 12 Months ending 09/30/2015 Denominator: Males and females ages 51 to 74 with at least one medical visit during the past 12 months. Numerator: Patients in the denominator who received appropriate colorectal cancer screening (one or more FOBT or FIT tests during the past year OR a colonoscopy during the past ten years). Excludes total colectomy or diagnosis of colorectal cancer. Colon Cancer Screened Patients by Test Status NOTE: If FIT and colonoscopy are current, they show up in FIT. Further investigation/refinement is necessary to ensure that diagnostic colonoscopies are excluded. 4

8 Colorectal Cancer Screening 30 Day Outcomes Colon Cancer Screened Patients by Test Status NOTE: If FIT and colonoscopy are current, they show up in FIT. Further investigation/refinement is necessary to ensure that diagnostic colonoscopies are excluded. 5

9 Rolling 12 month outcomes Colon Cancer Screening Rates % Screened FIT/FOBT % of CRC Screenings that were FIT/FOBT Colonoscopy % of CRC Screenings that were Colonoscopy 6

10 30 day Trends 7

11 Information Workflow Optimization (IWO) to EHR Best Practice Workflow Documentation Guide to Support Colorectal Cancer Screening Improvement with eclinicalworks Data Collection Plan EXPLORATORY MEASURES Measure Name (Source) Screening Colonoscopy Referrals Measure Definition Denominator Numerator % of patients ages 50 to 74 who received a referral for a screening colonoscopy in the past year, who had at least one medical visit in the past year. Males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Excludes total colectomy or diagnosed with colorectal cancer. Patients in the denominator who received one or more referrals for a screening colonoscopy during the measurement year. Screening Colonoscopy Referral to Completion Time % of patients who had screening colonoscopy completed within 3, 6 and 9 months of referral Males and females ages 51 to 74 who had at least one medical visit during the past 12 months, with current colorectal cancer screening who received a colonoscopy as their screening test Numerator #1 Number of patients in the denominator who completed colonoscopy within 3 months of referral Numerator #2 Number of patients in the denominator who completed colonoscopy within 6 months of referral Numerator #3 Number of patients in the denominator who completed colonoscopy within 9 months of referral Adenomas detected during colonoscopy FIT/FOBT Completion Positive FIT/FOBT % of patients ages who had adenomas detected during Colonoscopy % of FIT/FOBT tests returned % ofpositive FIT/FOBT returned tests Males and females ages 51 to 74 who had at least one medical visit during the past 12 months who received a colonoscopy as their screening test Number of FIT/FOBT kits distributed to males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Number of FIT/FOBT kits received from males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Patients in the denominator who had adenomas detected during colonoscopy. Patients in the denominator who returned a FIT/FOBT test Patients in the denominator who had a positive FIT/FOBT tests 8

12 Information Workflow Optimization (IWO) to EHR Best Practice Workflow Documentation Guide to Support Colorectal Cancer Screening Improvement with eclinicalworks Data Collection Plan EXPLORATORY MEASURES Measure Name (Source) Measure Definition Denominator Numerator Colonoscopy referrals following positive FIT/FOBT % of positive FIT/FOBT referred for colonoscopy Number of positive FIT/FOBT tests for males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Patients in the denominator who were referred for colonoscopy after receiving a positive FIT/FOBT. Time from referral to colonoscopy following positive FOBT % of patients who had follow up colonoscopy after positive FOBT completed within 3, 6 and 9 months of referral Males and females ages 51 to 74 who had at least one medical visit during the past 12 months, with positive FIT/FOBT who received a follow up colonoscopy Numerator #1 Number of patients in the denominator who completed follow up colonoscopy within 3 months of referral Numerator #2 Number of patients in the denominator who completed follow up colonoscopy within 6 months of referral Numerator #3 Number of patients in the denominator who completed follow up colonoscopy within 9 months of referral Colorectal Cancer Detection % of patients who had a colorectal cancer screening and were diagnosed with colon or rectal cancer Males and females ages 50 to 74 who received appropriate colorectal cancer screening who had at least one medical visit in the past year Patients in the denominator who received a diagnosis of cancer 9

13 PRELIMINARY DATA EXPLORATORY MEASURES Screening Colonoscopy Referrals Goal: Identify the number of patients referred for colonoscopy, and of those how many were completed. Additionally, we intended to explore the feasibility of measuring the timeline from referral to completion for those colonoscopies completed. Findings: Referrals are currently documented in many ways across the practices, often inconsistently within practices. Referral and Order features are the most commonly structured elements used, but often the referral is recorded elsewhere in the notes and entered as a structured element upon results delivery. The data below was culled from data on use of the Referral feature with no consideration for completion status. Future Feasibility: Further refinement is necessary to include those referrals placed using the Order feature and then to encompass the multitude of options indicating completion status. The identification of referrals placed is feasible; accurately capturing completion status will be challenging today. As the recommended workflow is adopted that will become more reliable. Measuring time from referral to completion will only be feasible once workflow changes occur, adherence will impact reliability. Timeframe: Rolling 12 Months ending 07/31/2015 BridgeIT Source Report: Colonoscopy Referrals with Attachments_Custom (filtered for Primary Diagnosis V76.51) Denominator: Males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Excludes total colectomy or diagnosed with colorectal cancer. Numerator: Patients in the denominator who received one or more referrals for a screening colonoscopy during the measurement year. (Primary Diagnosis on referral = ICD 9 = 76.51) 10

14 PRELIMINARY DATA EXPLORATORY MEASURES Adenomas Detected During Colonoscopy Goal: Identify the percentage of completed colonoscopies in which adenomas were detected. Findings: Analysis was based solely on completed colonoscopies documented using Orders (best practice). Results capture in ecw is not structured and permits free text entry, making reliable result analysis challenging. Shown below are results from a query designed to select key text from the Results field. The pages that follow illustrate the variances found in result entry. Future Feasibility: Without vendor enhancement to require structured result entry, reliability of this measure will remain suspect. Though the best practice recommends a specific manner in which to document the free text results, the odds of strict adherence are very slim. Timeframe: Rolling 12 Months ending 07/31/2015 BridgeIT Source Report: CQI Cancer Screening: Colorectal Cancer Screening: Colonoscopy Results Denominator: Males and females ages 51 to 74 who had at least one medical visit during the past 12 months who received a colonoscopy as their screening test. Numerator: Patients in the denominator who had adenomas detected during colonoscopy. 11

15 PRELIMINARY DATA EXPLORATORY MEASURES Variations of adenomas/polyps found on Colonoscopy BridgeIT Source Report: CQI Colorectal Cancer Screening: Colonoscopy Results 12

16 PRELIMINARY DATA EXPLORATORY MEASURES 13

17 PRELIMINARY DATA EXPLORATORY MEASURES Positive FIT/FOBT Goal: Identify the number and percent of completed FIT/FOBT with positive results. Findings: Though the variances in result entry for FIT/FOBT are not as extensive as those for colonoscopy, variances do exist. The snapshot of data below illustrates such. Future Feasibility: Further research is needed to evaluate result variability across more practices. Assuming what is shown below is representative of most, it is feasible to produce this measure with some degree of reliability. Timeframe: Rolling 12 Months ending 07/31/2015 BridgeIT Source Report: CQI Colorectal Cancer Screening: FOBT or FIT Results Denominator: Number of FIT/FOBT results from males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Numerator: Patients in the denominator who had a positive FIT/FOBT tests 14

18 PRELIMINARY DATA EXPLORATORY MEASURES Colonoscopy Referrals Following Positive FIT/FOBT Goal: Identify the number and percentage of patients with positive FIT/FOBT results that were referred for colonoscopy. Additionally, we intended to explore the completion percentage of those referred for follow up. Findings: Due to the inconsistent manner in which colonoscopy referrals are documented it is challenging to identify such. The snapshot of data below represents a count of referrals documented through the Referral feature using the appropriate ICD code for the reason. Further research is needed to evaluate the prevalence of accurate ICD code usage which is a foundational element for this measure. Future Feasibility: Refinement of the measure specification to include referrals documented using the Order feature would produce a more valid result, assuming analysis of ICD code usage indicates some level of reliability. BridgeIT Source Report: ColonoscopyReferralswithAttachments_Custom_MT (filtered for Primary Diagnosis 792.1) Denominator: Number of positive FIT/FOBT tests for males and females ages 51 to 74 who had at least one medical visit during the past 12 months. Numerator: Patients in the denominator who were referred for colonoscopy after receiving a positive FIT/FOBT (Primary Diagnosis on referral = ICD 9 = 792.1). 15