10/25/2018. Welcome TPCA Lead the Way with Advanced Care Management. Introductions

Transcription

1 Welcome TPCA Lead the Way with Advanced Care Management Introductions Let s get to know a little about each other! What emr do you use? NextGen, GE Centricity, ecw, Athena, Allscripts, emds, other: How would you rate your level of Tracks expertise? Beginner, Intermediate, Advanced? Data Element Manager It s here! Centralization of all i2itracks data mappings in one library 1

2 Data Element Mapping Uses Reports and Dashboards Patient Searches Disease Management PopIQ Data Element Benefits Makes setup easy Saves time and resources More accurate and consistent data across reports Built-in mapping automation tools All ICD and CPT codes are mapped based on definition of the National Library of Medicine. Using i2itracks for Tracking Populations of Interest 2

3 Disease Management A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease Management Goals Increase the quality of life for patients Improve the quality of care Study & improve patient outcomes Cost effectiveness Other thoughts? Disease Management in i2itracks Identify populations at risk Use evidence based guidelines in a proactive manner Promote self-management - Get the patient involved 3

4 Take Inventory What are you currently Tracking? Pg 2 Identify Populations How do you determine WHO you want to manage?? Questions to identify populations that need management What are the most commonly used diagnoses? Have you noticed any recent trends in diagnoses lately? Who are the high-utilizers of care and why are they seen? What patients take the longest with the provider? What incentives/grants do you receive for specific populations? What clinical measures are you required to track for reporting purposes? (UDS, MU, HEDIS) 4

5 i2itracks Tools What i2itracks Tools can you use to help answer those questions? External Data Diagnostic Tool Searches Risk Scores Framingham Risk Score NACHC Risk Score Tools to Help you Identify Populations External Data Diagnostics Tool The External Data Diagnostics Tool is a window into the EHR data that i2itracks is interfacing with. This data is presented in a way that makes it easy for users to explore their EHR data: what s being entered into the system, who is entering it, and what type of data issues are they experiencing. Patient Search The Patient Search is an easy way to query i2itracks to identify a population. Other ways to use the EDD Finding problems with data Studying data (i.e. Vicodin vs generic drugs) Data validation for interfaces Finding out who entered incorrect data See if a data item was used and when The value is worth its weight in gold! 5

6 Identifying High Risk Patients What kind of data do you need to quickly and easily identify patients that are high risk those that take longer or require more resources?? Identifying High Risk Patients Use the Patient Search to show you data that will help you. Tools & Methods to Identify High Risk Patients Framingham Risk Factor Estimates the 10-year cardiovascular risk of a patient what are their chances of developing CVD NACHC Risk Score New algorithm available in Latest Version of Tracks Member Equivalent Scores This is an algorithm used to measure the acuity of a patient s health Other Patient Search Fields Weight gained/lost, Change in lab result, Change in BP Pg 29 6

7 Questions? What s Next? Now that we ve identified our population that we want to track. What s next? Tracking Types Tracking Types are used to group like patients together allowing you to: Follow the same guidelines for care based on: Best practices Evidence based guidelines Requirements of grant/funder Reporting requirements 7

8 Other Tracking Types i2itracks allows you to create an unlimited number of Tracking Types for the disease or condition of your choice built to your specifications Diabetes Asthma Controlled Substance Cardiovascular Disease Care Coordination Care Transition High Risk And more! Diabetes Tracking Type Diabetes Profile : Base Profile Items are health indicators: The building blocks of Disease Management 8

9 Profile Items are health indicators Categories of profile items: Allergies, Education, Immunizations, Medications, Problems, Procedures, Goals, Treatment Plans, Events and Other (Lab tests are also health indicators but are configured separately from the profile items) 10 categories of Profile Items Lab Tests Profile Items are updated automatically three main ways: 1. Items can be updated directly through the EHR Interface Allergies, Immunizations, Medications, Problems & Labs Lab Tests Profile Items are updated automatically three main ways: 1. Items can be updated directly through the EHR Interface 2. Items can be automatically updated through CPT or ICD codes 3. Items can be automatically updated through the CDI Lab Tests 9

10 Any Profile Item can have a schedule or protocol for proactive alerts Lab Tests Diabetes Profiles The Diabetes PROFILE is a collection of the individual profile items for our Diabetes care model. Diabetes Profile Diabetes Tracking Type Diabetes Profile 10

11 Questions? Building a Tracking Type Northwest Clinic has decided they want to start tracking High Risk Patients: patients with at least 5 problems and 5 or more medications. Your job is to build the Tracking Type in i2itracks, as well as supporting reports, searches and pro-active tools to help their care teams. Easy Steps Disease Management Setup in Tracks can be easier when you follow this order: LINKING DATA LINKED FROM VISIT OTHER TYPES SYSTEMS For: Educations, Procedures, mapping Immunizations, Tracking Type PATIENT PROFILE ITEMS PATIENT PROFILE Attach the Patient Profile Items to the Patient Profile TRACKING TYPES Attach the Patient Profile and the Linked Visit Type for Auto Assignment to the Tracking Type SCHEDULES FOR PROFILE ITEMS Attach the Tracking Type to the Schedule This order is not mandatory. And if you are used to following a different order of entry, that is OK too! Pg

12 Questions? Section 2: Preparing Searches and Reports to Analyze Data for Better Care Delivery Analytics Tools in i2itracks Easy/Customizable Health Registry Reports Patient Search Population Analytics Reports Population Analytics Dashboards 12

13 Health Registry Easy Disease Management Report Limited to ONE Population of Patients View Statistics Drill down to the patient level Customizable features Let s create our own! Pg 10 Questions? Advanced Patient Search You ve got the basics of Patient Search, so now let s dive into creating more detailed Patient Searches. 13

14 Creating a Search First, ask yourself a few questions: What population do you want to identify? How will this Search be used what is the purpose? Who will be running the Search? What search criteria will be used? (FILTERS) What information do you want to see about this population? (FIELDS) Advanced Filter Criteria The advanced features of Patient Search uses logic operators: AND Include this AND that Diabetes Problem AND HbA1c <9 Female AND Abnormal Pap AND Recall completed Advanced Filter Criteria Use advanced logic operators OR Include this OR that Age 65+ OR Diabetes Problem Patients with Obesity Diagnosis OR BMI >25 OR Obesity Problem Each OR starts the search over again Patients with Obesity Diagnosis Patients with BMI >25 Patients with Problem of Obesity 14

15 Advanced Filter Criteria Use advanced logic operators NOT (but exclude) Include this NOT that Active AND NOT had a Visit in the last 3 years Diabetes Problem AND NOT had a HbA1c test in last 6 months Advanced Filter Criteria Use advanced logic operators Parentheses Include this and (either that or that ) Active and (had a visit in the last 3 years OR have an appointment this week) Advanced Filter Criteria Look at a few examples: Caution: Active Status only applies to the Visit! 15

16 Let s Create More Advanced Searches Patient Search Exercise Pg Questions? Care Coordination/Care Management Identifying patients who would benefit from Care Coordination Creating a Tracking Type for each Care Coordinator to manage their panel of patients. Utilizing a Patient Visit Summary for patients in Care Coordination Tracking. Structured, reportable and secure data entry in Tracks for data that is not documented in EMR. 16

17 Questions? Thank you for attending Lead the Way with Advanced Care Management 17