2017 Davies Award. Kressly Pediatrics Case Studies SUSAN J. KRESSLY, MD, FAAP

Transcription

1 2017 Davies Award Kressly Pediatrics Case Studies SUSAN J. KRESSLY, MD, FAAP

2 Who We Are Founded in 2004 by Dr. Kressly with a clear vision:

3 3 Board Certified Pediatricians Susan J. Kressly, MD Karen W. David, MD Sharon Sowinski-Mueller, DO

4 5 Staff: 4 RNs & 1 MA/Biller

5 Driven by the Quadruple Aim Improving the Patient Experience of Care Improving the Health of Populations Reducing the Per Capita Cost of Health Care Improving the Work Life of Health Care Providers

6 NCQA Patient Centered Medical Home Level 3 Recognition 3 Times: December 2010 December 2013 February 2017

7 Driven by Data Wisdom: evaluated understanding; provides the why Knowledge: application of data and information; provides the how Information: data processed to be useful; provides the who, what, when & where Data: symbols, facts & measurements

8 Dedicated to the Relationship

9 Always Working to Improve

10 Case Study 2 IMPROVING HPV VACCINATION RATES

11 Background Human papillomavirus (HPV) is a very common virus that can lead to cancer. Nearly 80 million people about one in four are currently infected with HPV in the United States. About 14 million people, including teens, become infected with HPV each year. HPV vaccination coverage lags behind coverage for the other vaccines recommended for preteens. CDC recommends HPV vaccination for girls and boys at ages 11 or 12 years to protect against cancers caused by HPV infections

12 Local Problem HPV vaccination rates at Kressly Pediatrics were below our goals Needed to change from reactive to proactive population health management Healthy People 2020 and HEDIS measures now incorporating adolescent vaccines (Tdap, MCV4) as well as HPV HEDIS measure: combined in 2017 Kressly Pediatrics practice was < area benchmark 2 Opportunities for incentives to improve: Merck Health in Focus rebates for working to improve ACO Payer QI metric for P4P related to HPV vaccination rates

13 Local Problem From CDC TeenVaxView 2015

14 Local Problem From CDC TeenVaxView 2015

15 Ultimate Goal Meet the 2020 Healthy People Goal of 80% of the teens in our practice have a completed series of HPV vaccine. Stratify by age in compliance with P4P program Completed by age 13 Completed by age 18

16 Design & Implementation Required a CQI format with iterative PDSA cycles, entire practice buy-in with frequent reporting back to entire practice team to collaborate and improve at monthly meetings Physician education, buy-in and strategizing key Governance Structure: PCMH QI team and all physicians

17 Office Meeting Understand Baseline Performance Achievable Goal Practice buy-in Set Goal Identify People, Processes, Technology Identify Owner Agree on the How Identify Technology Efficiencies Measure Report at Medical Home Meeting Adjust Process or Goal Measure, Report, Adjust Implement Plan Execute Plan Identify Barriers/Gaps Monitor Buy In

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19 Phase 1 UNDERSTANDING BASELINE PERFORMANCE LEVERAGING EXISTING FUNCTIONALITY

20 P h a s e 1 P h a s e 1 Baseline year-olds: 13% Initiation, 6% completion Baseline year-olds: 33% Initiation, 22% completion

21 Understanding Baseline Performance Data denial: that can t be right, I know my performance is better than that Physician variability in age of recommendations Physician variability in strength of recommendations

22 People & Processes Physicians needed to come to consensus about following best practice care guidelines: strong recommendations for starting HPV immunization at age 11 years Really two separate problems identified: Initiating HPV immunization at age 11 (provider led) Completing series of HPV immunizations (staff led) Entire practice team then involved on formulating workflows Initial focus was on initiation

23 Leveraging Existing Functionality EHR vaccine logic has embedded ACIP guidance for clinical decision support

24 Leveraging Existing Functionality Vaccine forecasting visible in multiple places: On face of patient chart: While entering a message: While scheduling an appointment:

25 Informed Workflow: Awareness Touch Chart: Provider or Staff Documenting Message: Provider or Staff Aware Due for HPV Vaccine Strong recommendation and opportunity to provide or schedule HPV Immunization Appointment Making Appointment: Provider or Staff

26 Additional Clinical Decision Support Added HPV vaccine as a routine immunization for all well visits starting at age 11 years

27 Additional Clinical Decision Support Having routine on the template, makes ordering HPV during well visits easy with 1 click for providers

28 Challenges/Adjustments Initial focus showed success, but focus and performance waned after a few months Identified barriers including: Community/family hesitancy at younger age Resistance on all stakeholders (physicians, nurses, patients and parents) to give 3 shots at the 11 year old visit Variation among providers in willingness to engage with hesitant families

29 Phase 1 Successes Initial increase of initiation from 13% to 31% in year-olds and 33% to 49% in year-olds (237% increase and 149% increase respectively) Gradual increase in completion of series as well Entire staff more aware and processes aligned Nursing staff initiated own efforts to complete series

30 Process/Workflow for Series Completion 1 st HPV administered At time of administration staff schedules appointment for dose 2 Appointment reminder/confirmation sent 1 week prior to appointment If appointment missed, staff proactively reaches out to reschedule When dose 2 administered, repeat process for dose #3

31 HIT Leveraged in Phase 1 Embedded EHR clinical decision support for vaccine forecasting Customization of well visit templates to include HPV vaccination beginning at 11 yearold well visit Use of integrated patient messaging system for appointment reminders Use of Quality Improvement Calculator: created custom report for HPV initiation/completion

32 Phase 2 PATIENT EDUCATION IMPLEMENTING NEW APPROACHES

33 P h a s e 2 P h a s e 2 Phase 2 Baseline year-olds: 21% Initiation, 17% completion Phase 2 Baseline year-olds: 46% Initiation, 36% completion

34 Addressing Barriers to Success Concerted effort to strengthen the recommendation language according to AAP, CDC best practices. You are due for HPV and meningitis vaccine today instead of You are due for the meningitis vaccine today and what would you like to do about HPV? Moved Tdap to routinely give at age 10 so that only 2 vaccines given at age 11 (HPV and MCV4). Educated physicians about focus on cancer prevention, not sexual activity. Educational outreach to family via social media and poster in waiting room about HPV.

35 New Opportunity Merck created Health in Focus Program where select practices could get rebates for reporting on projects related to improving HPV immunization rates and reporting metrics on patients eligible/patients who received vaccines. HIT Leveraged: custom SQL written to be used in database viewer of EHR to calculate and report required data for program (shared with entire pediatric EHR user community). Slight variation in reported metrics but goals aligned

36 Additional HIT Leveraged Changed templates in EHR to recommend Tdap at age 10 Added HPV Vaccine Information Statement as standing patient education handout (available on portal once the appointment is confirmed).

37 Adjusted Workflow Staff identified 3 rd dose was often not scheduled/missed. Families would say we can t schedule that far out, we will call back and that never happened. Changed the workflow to schedule both dose #2 and #3 when 1 st dose given Initial barrier was that our schedule is not in the computer 6 months in advance, but then realized nursing schedule never changed so could put in before the calendar was finalized Parents who said I don t know my schedule, staff pointed out: You schedule your dental cleanings 6 months in advance. Let s take a best guess and you will get an automated reminder for the visit. If you can t make the appointment, use that opportunity to call and reschedule but at least it will be on your radar.

38 Adjusted Workflow for Series Completion 1 st HPV administered At time of administration staff schedules appointment for dose 2 and dose 3 Appointment reminder/confirmation sent 1 week prior to appointment If appointment missed, staff proactively reaches out to reschedule (if for dose 2, adjust dose 3 if needed)

39 Phase 2 Successes Steady improvement in both HPV immunization initiation and completion of series in both age groups More confidence among all practice team members regarding HPV vaccination

40 Phase 3 REDUCING PROVIDER PERFORMANCE VARIABILITY RAISING THE PERFORMANCE BAR

41 P h a s e 3 P h a s e 3 Phase 3 Baseline year-olds: 45% Initiation, 28% completion Phase 3 Baseline year-olds: 61% Initiation, 49% completion

42 Communicating Strong Recommendation Discussed at a practice meeting need to have actions that supported strong recommendations Agreed on the following: Every parent who refused/declined HPV vaccine sign AAP vaccine refusal form Add to diagnosis for visit Z28.82 (immunization not carried out due to caregiver refusal) Add to problem list for patient chart: parent refused vaccine

43 Leveraging Health IT Ability use coded data to document refusal that also goes to payer for claims data

44 Leveraging Health IT Ability use coded data (SNOMED) to document refusal on patient problem list Also goes on patient portal for parents to see importance and elected to make sort order 1 so families could see seriousness

45 Additional Opportunities to Improve ACO that practice belongs to negotiated new P4P Quality Metrics including HPV immunization rates (aggregated data) AAP epros (Electronic Pediatric Research in the Office Setting) applying for grant to use EHR data, and learning collaborative format to improve HPV Immunization rates PA AAP QI project participation which includes Part 4 MOC credit for lead physician involved

46 epros Crowdsourcing: Leveraging HIT & User Community Created an custom SQL for HPV immunization rates Queries supported the baseline data epros network needed for grant proposal Shared on pediatric EHR user community via with instructions to copy/paste SQL into database viewer (some cloud, some client server based users: supported in both environments) Created google spreadsheet to record/share individual practice performance

47 epros Crowdsourcing: Leveraging HIT & User Community Created an custom SQL for HPV immunization rates

48 epros Crowdsourcing: Leveraging HIT & User Community Shared on Provider Listerv and invited to submit results to spreadsheet:

49 epros Crowdsourcing: Leveraging HIT & User Community Raw data converted to percentages and shared:

50 Leveraging User Community Spontaneous learning collaborative resulted on EHR provider listserv Providers asking who is practice ID 879 and how did you get your initiation rate to 76%? Practices across the country shared challenges/successes/strategies to improve

51 Variability of Physician Recommendation Practice seemed to plateau on performance QI team had a suspicion regarding difference in variability of the strong recommendation in the exam room As a proxy for assessing strength of recommendation leveraged HIT by creating an SQL query to identify missed opportunities to give HPV at well visits stratified by physician (shared SQL with EHR pediatric user community) to test hypothesis

52 Health IT Leveraged Custom SQL in Database viewer

53 Variability of Physician Recommendation Identified physician with lowest performance and encouraged her to sign up for PA AAP project and get MOC Part 4 credit for American Board of Pediatrics Project team included a non-physician staff to work with lead physician Continue to measure, report, remeasure and compare performance with other 29 practice in state project/learning collaborative Continue to identify opportunities to educate, implement and improve Most recently started to ask and document why parent refused

54 Phase 3 Successes Continue to improve in both HPV immunization initiation and completion of series in both age groups More alignment in strong recommendations across all providers Captured better refusal data for future study

55 Value Derived Improved Patient Care: following evidence based guidelines HPV infections prevented (patients with completed series over ): Men: 90 infections, 50 high risk infection Women: 80 infections, 41 high risk infections According to the CDC: During , prevalence of any and high-risk genital HPV for adults aged was 45.2% and 25.1% in men and 39.9% and 20.4% in women, respectively. Less stress on practice/staff from variability of strength of recommendation

56 Value Derived: Hard ROI Additional incremental revenue from vaccine codes (90649 and 90651) and vaccine administration code (90460) compared to 2013 baseline HPV vaccination rates: $56, from P4P bonus 2016 $11,090 Merck rebates (3% of HPV cost): $6, (for 2015 & 2016) Participation in PA AAP QI Project $1,000 Total: $74,714.70

57 Q Q Q year-olds: 64% Initiation, 57% completion Q year-olds: 73% Initiation, 66% completion

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