Nursing Care Plans For Hypertension

operator: ladies and gentlemen,thank you for standing by and welcome to the "using anehr and quality data to improve hypertension" webinar,presented by hrsa ohitq. during the presentation, allparticipants will be in a "listen only" mode. however, you may submitquestions to the speakers at any time during the webinar inwriting using the chat feature located on the leftside of your screen. questions will beaddressed as time allows

following the secondpresentation. as a reminder, today'swebinar is being recorded. it is now 2 pm eastern standardtime on february 22, 2013. there will be two presentationsduring today's webinar. in a moment, we will be sendingall attendees a link through the chat feature that they can clickon to download copies of the two slide presentationsfor today's webinar. additionally, all registrantswill receive an email following today's webinar that willinclude an email address where

you can send requests forcopies of the presentations. i would now like toturn the call over to lieutenant michael banyas from the office ofhealth it and quality at hrsa. please go ahead,mr. banyas. lt. banyas: hi i just wantto welcome everyone to this afternoon's webinar productionusing an ehr and quality data to improve hypertension. um, just a few quickannouncements from hrsa

before we turn the webinarover to the presenters. first, all of hrsa's previouswebinars as well as hrsa's health it adoption tool boxesfor quality improvement resources, and other webpages focusing on mhealth, meaningful use,workforce and icd-10, specifically for safety netproviders can be accessed at hrsa.gov/healthit andhrsa.gov/quality. additional questions can besent to healthit@hrsa.gov. next, just a few other health itand quality announcements

for today's audience. the first is, expiring april1st is the competency exam for health it professional. hrsa has free vouchers availablefor free exams and you can email healthit@hrsa.gov torequest a voucher. these exams are a great way toget your staff credentialed in one of the five oncsanctioned workforce areas. and they're a great way to trainstaff in the areas of health it that the office of thenational coordinator

has found to be of value inimplementing and adopting health information technology. once again, to requesta free voucher, please email healthit@hrsa.govand the free voucher program expires on april 1st. the next hrsa healthit and quality webinar, "using clinical decision supportin the safety net provider settings" will befriday, march 22nd, at 2 pm eastern standard time.

registration is now open on thehrsa health it webinar page, and we'll be, and the link willbe posted on the hrsa health it page shortly this afternoon. this webinar um, isa fantastic way to, for safety net providers to findout best practices as well as the importance ofclinical decision making, and how to use your ehr forthis meaningful use objective. next, coming soon in march,hrsa will be launching new hrsa health it workforcemodules for help centers.

the purpose of these modules isto educate and train safety net providers workingin health centers on the areas of health it. once again, an announcement forwhen those modules will be live in mid march willbe sent through the hrsa health it listserve as well as posted on thehrsa health it website. the associations forclinicians for the underserved is hosting their conference onhealth it and the underserved

on march 7th and 8th inpoughkeepsie, new york. registration is availableby visiting acu's website. um, hrsa's txt4tots library isnow live on the hrsa mhealth webpage and thehrsa health it website. this resource just went liveyesterday and is a fantastic way to determine how to send textmessages and other mhealth related resources throughan mhealth system. um, and lastly, two new granteespotlights went live yesterday that align withamerican heart month.

the first is on thehrsa health it website, we profile themarshfield clinic. a recent winner or theonc innovation award for, for healthcare applications, andthis article focuses on how they used mhealth tosupport heart health. the second is, on the hrsaquality improvement website, we focus on project renewalwhich is a help center that services the new yorkcity's homeless population and how they increase access tohigh quality healthcare

within the homelesspopulation and we use, we spotlight their use ofcontrolling hypertension as an example for howthey provide care. i would now like to, i would nowlike to introduce my colleague, anthony oliver, tointroduce today's speakers. oliver: thank youlieutenant banyas. i'd like to welcome all hrsagrantees and members of the safety net community, healthresources and services administration, healthinformation technology

and quality technicalassistance webinar. today's presentation is entitledusing an ehr and quality data future safety net providers whohave successfully used health information technology toimprove health outcomes in patients with hypertension. it will provide an overview ofuseful strategies to address this prevalent condition whichis a core clinical quality measure in the meaningful useincentive program and a priority within the nationalquality strategy.

before i continue withtoday's presentation, this afternoon's presentation,i'd like to add a disclaimer. hrsa would like to add that thiswebinar is intended to serve as a technical assistance resourcebased on the experience and expertise of independentconsulting and hrsa grantees and its contents are solely theresponsibility of the authors and do not necessarily representthe official use of hrsa. in addition, hrsa does notendorse any health it vendors or software systems

including the health itassistance featured in this webinar. now, i pleased to introducethis afternoon's presenters. christopher tashjian is boardcertified by the american academy of family practice,and currently serves as the chief of medicine for theriver falls area hospital, a regional facility ofallina hospitals. his areas of special interestinclude electronic medical records, public health, and quality care in measurement.

dr. tashjian also currentlyserves on the office of national coordinators informationexchange workgroup which focuses on meaningful use ofstages two and three. dr. tashjian realizes theimportance of practicing quality care at an affordableprice, and has implemented a state of the artelectronic medical record which allows directaccess to patient data. this has allowed the clinic tochange the management of chronic diseases from reactive toproactive and contributed to

the clinic's recent rankingas first in western wisconsin for quality andvalue in diabetes and heart care byconsumer reports. we also have sarah woolsey whois board certified in family medicine and is also a medicaldirector with health insight, a community based organizationfocused on redesigning healthcare systems. she has worked with power careproviders to improve diabetes quality care and isthe clinical lead

with the utah beaconcommunities project which uses health itto improve diabetes care in 60 primary care offices. dr. woolsey has worked onquality improvement in outpatient primary care settingfor over ten years and has 13 years of experience withunderserved populations in salt lake city as a fullspectrum family doctor. she currently maintains anactive practice with the community health centers of saltlake city and was chosen as a

centers for medicare andmedicaid innovation advisory in january of 2012. i'd like to thankthe hrsa grantees and safety net community forparticipating in this event or individuals using the pdf. we'll be starting on page 26. i'd now like to turn theevent over to dr. woolsey. dr. woolsey? dr. woolsey: alright.

thank you for theinvitation to speak. i am delighted to be here todayand share some information that i hope will make a differencefor the folks that are doing excellent outpatient care. i am a community health centerphysician at heart and i also get to work with an amazingcommunity in beacon communities which i'll share about and ijust appreciate everyone's time and interest in making carebetter for patients today. as introduced i am a familyphysician practicing

in a community health center. we are in the heartof salt lake city. we have four practices. i'm having troubleadvancing slides, guys. can you see my slides? okay. we have four urbancommunity health centers. you can see ourdemographic breakdown. we implemented e-clinical work,electronic health records

in 2010 and also joinedthe beacon communities project at that time. active participationbegan in early 2011. the beacon communities projectis a project that is assisting providers to demonstrate thathealth it can improve care as well as demonstrate theimprovement of care and of course that entails puttingthe hit into the workflow. in my clinical setting, i workwith an amazing team of folks and i just want to give ashout-out to the beacon team

members from communityhealth centers of salt lake. jennifer, chris, sue,linda, and monica and keith. and they are the folksthat make things happen in our clinical setting. so when we joined thebeacon communities project, we had been working on diabetesimprovement for quite a long time and the first aimthat we set as a group was on blood pressure control. and i have to admit that when westarted i had a funny feeling in

my stomach, i wasn't surewe'd actually do this. i was a little bit concernedthat this wasn't something we'd be able totackle or take on. we'd done a lot of other areas: a1c control and lipid screening, but we had nottaken on blood pressure. but we set the goal, we beganto look at the information, and as you can seehere on the slide, i want to tell youthree things about it.

number one, is that we didimprove care up to ten percent goal of our patients. so of our 2,000diabetes patients, we were able toimprove ten percent, and we were surprisedwith that result. it started with a five percentgoal, went to ten percent. number two, is we were proud tobegin to approach the beacon community benchmark. so on this slide, the greengraph is our data of our

patients, the red lineis our ten percent goal, and the communitybenchmark, the blue line, is the compilationof 22,000 patients across the (inaudible) front, their diabetes control measures. and so not only were weimproving our care but we were beginning to meet the standardof care in our community. you can see that we've improvedand sustained over time. we still have work to do tohit the community target,

but we're providing care that'sequivalent to all the providers in our community, whetherinsured, clinics, or hospital based clinics, we'remeeting the standard of care in our community. we felt that wasreally important. this is just a map showingthe beacon clinics. so again, 60 clinicsacross the (inaudible) front. and the content of my talk is acombination of my experience as a clinician and my experienceof working with these amazing

providers across my valley andwatching them do all the amazing things they do to improvecare using their hit and their clinicalsystem improvements. and i just want to also thankmy beacon team for all the work they've done with thisbroad group of folks. so you might ask, 'why isall this important anyways? why are we talking abouthypertension in heart month?' we know hypertension isepidemic and it's treatable. okay, you guys cansee the numbers there.

30 percent of us have bloodpressure that's over a goal that's healthy for us. and you've invested lots oftime and money in your ehr. you want to make a differencefor patients and you want to get some value out ofthat implementation. ehrs can enable efficient teamcare and all of us know that working in a team can makea huge difference for our patients. it's a lot of fun, andehrs can improve that.

and finally, as we're talkingabout meaningful use, stage 2's gonna ask us todemonstrate our ability to manage our population health. so it's time to get going ondemonstrating all the things that we can do. so, what is an ehr from achronic care point of view? okay, so an ehr isn't gonnamake your patient care better. it's actually a tool. and in the ideal state, it's atool that stores data and allows

you to run patientlists accurately. it's a place to streamlineprocesses of care for your staff and your providers. it allows you todemonstrate your quality, both to yourself aswell as outside folks. it reminds you ofthings you might forget, and there's a lotmore things every day that we need to remember. it allows you to provideevidence-based care to your

patient at the point of care,and it can be a point of communication with your patient. so how do we use that thing? i'm gonna suggest there's sevencore ways to use your ehr for population management. and i'm gonna saythat many of you are probably doing these things. many of you might be doing someof them, but not all of them. use this talk as an opportunityto do a checklist of what you've

implemented in your setting. if there's something you're notdoing, consider making, uh, making gains in that area. and i want everybody to walkaway with one action from my talk or dr. tashjian's talk thatthey're gonna implement when they leave this webinar. so the most importantthing about ehr youth, is you've got to picksomething that's important to you to work on.

take a compellingclinical problem. today we're talking abouthypertension, it's important, you may have another conditionthat's important to you, but the importance of patientcare is gonna drive all the things that you needto do to get your system to the next level. so when patients and providersare working together for better care, we all thinkwe're doing the right thing that we signed up for whenwe went to medical school

or medical assistantschool or nursing school or pa school, ornurse practitioner school. so, pick somethingthat's important. and then, here'sseven steps to try, and i'm gonna gothrough each one. registries and patient lists. these are core topopulation management. all ehrs have somefunctionality in this area. now, the first thingyou've got to do though,

is make sure your registry hasreliable patient lists in it. how many of you have run aregistry of your hypertensive patients and you find outthere's maybe six people in it? there's something disconnecting. the identification of thosepatients and their care to the actual registry. so if you find that's the case,set a billing or clinical team on pulling hypertensionpatients another way, based on their pharmacyprescriptions,

based on labs that you do, basedon old reports you have or third partypayer information. and then, make sure thatelectronic health records automatically updates the datathat you put in every time a patient arrives for visitand clinical work is done. if for some reason thisisn't working for you, have your vendor teach youhow to do this properly. this is base line work forbuilding your chronic care model with your ehr.

this is a list of icd-9codes for hypertension. you need to get your patientsattached in their problem list to proper codes. take a course set thatyou're comfortable with. again, like i said, have someonehelp you update those patients and get everybody in yourpractice on that registry list. then, you're gonna want to setregistry care and recall into an office job description. you're gonna have this be partof the metronome of your care.

the cycle of caring your officeincludes regular attention to your registry. you're gonna want to allow yourproviders to give you feedback and update the registryand ensure it's correct. if you don't give them thechance to give you feedback, you're not gonna get buy in and you're not gonnaget an accurate list. in our work in the beaconcommunity we had a geriatric office that had a number ofpatients who'd both passed away

or they had moved to a chroniccare, long term care facility. those patients gettingcleaned out of the list, they spent less timeworking their lists, and the providers respondedbetter to the lists when they got them because theyknew they were accurate. so clean up your lists. like i said, provide regularlists to your teams, to update and recall theirpatients not at goal. that may be something youdo in a centralized fashion,

or in a team fashion. and set standards for useof the lists in the office. in our e-clinical work system,this is an example of chronic care reports that we can runby facility, by condition, by provider, by care. begin to learn to use these. get experts in using these. in my system, i'm happy to havea qi team that's expert at running these lists, helping usupdate them and clean them up,

and we do that ona regular basis. next, we're gonnatalk about templates. so templates. everybody's got them, but noteveryone knows how to use them. they maybe come with your ehr, but they're not customizedto your workflow. if your templates are notcapturing data correctly that you want to track, fix them. get your vendor to assist you.

get the guy down the road usingthe same electronic health record to help you ifhe's doing successfully. ensure that all your staff andproviders are trained on the process for using the templates,and satisfying alerts or captures for datainside of those. they key to standardizingprocesses can be templates. if all teams are onthe same template, systems of consistent caredevelop in the office, and this can be betterfor quality care.

here's an example in our systemof a hypertension template. we're very interested in homeblood pressure monitoring and medication adherence. we want all patientsasked about this. our medical assistants,when trained, can ask these questionsas a patient enters, and we get actionable datafrom the patient's history. clinical decision support tools. again, there aremany types of those.

every system has adifferent flavor. they may be reminders,alerts or flow sheets for evidence-based care. you're gonna want to turn on afew meaningful alerts, okay? too many is gonna havepeople ignore them. you're gonna want to use thealerts to remind your teams of missing care,standards that you set, or that are set bynational organizations, you're gonna teachyour team to respond

and satisfy those alerts. nobody likes it whenyou do the care, and the alert doesn't disappear. they begin to ignore them. so pay significant attentionto fulfilling those alerts. and remember, overloadcauses a team to ignore them. here's an alert thati have in my system. a big, fat, red bloodpressure that's abnormal. hopefully myself, myassistant, won't miss that,

and we can kick in ourprotocol of what do we do when we see a high pressure? we may have the patient sit forfive minutes and recheck it. we may inquire more carefullyabout medication adherence. but we're gonna take actionas we see that big, fat, red number. another importanttool are order sets. these can be very customizable. for hypertension patients,we can put in order sets

for common medicationsthat our practice uses. generics and 90 day prescriptions encourage medication adherencefor chronic disease. program them in. what about labs thatmust be done regularly? make it easy foryour team to order. home monitors, we've picked ahome monitor that we prefer for our patients because it'slow cost, accessible. we've put it into an order set.

it's easy to order and printor send to the pharmacy. the patient can then get it. sodium reduction educationmaterials or referrals to dietary educators. if it's at theirfingertips, it's easy. like i say, if it's easy to dothe right thing they'll do it more often. here are examples of someregistry alerts for diabetes patientsin my system.

medication adherence. this is a place where yourelectronic records can help you as well. consider putting a medicationadherence assessment into your template. ask every patient every timeabout their ability to adhere to their medications, and i'llshow you an example in the next slide. ensure formularies are addedto your e-prescribing list.

if meds are affordableto patients, they're gonna be more likelyto fill them and take them. enable a fillreview in your ehr. some electronic recordshave communication through surescripts back andforth from the pharmacy and you can actually check andsee if your patient has filled their medications regularlyand make follow-up calls to those who have not. this is not available inevery electronic record,

but it's worth inquiring if thatservice is available for you. and then finally,like i said before, e-prescribing 90 day supplies,for most patients that will be appropriate andit will enable adherence. here is an example of the medicationadherence assessments. so asking patientswhat gets in the way of taking your medications. this comes from the new yorkhealth department clinic.

they had a great paper tool. we've now put it intoour electronic record. we're assessing patients fortheir ability to take their medications or forany barriers to them. visit summaries. one of our favoritethings in my office. one of the most difficult thingsfor us to complete in our meaningful use measures. okay?

'cause people couldn'tfind the value. here's three ideas for you. use the visit summary to providea teach back about medications, appointments, andlifestyle goals. teach back is a method where youhave the patient express back to you their understanding ofeverything they're gonna do when they walk out of your office. if you'd like moreinformation about teach back, please send me an email and i'llsend you lots of links

to that great method. second thing is present thevisit summary ahead of your visit. there was a pharmacistwho taught me about this. have the patient do their ownmedication reconciliation before they see you. it provides them time tolook at their visit summary, they can correct thingsthat are incorrect, um, and it may actuallygive you feedback

into a better visit summary. finally, make the visit summaryspeak to the patient in their language at theirhealth literacy level. we're all waiting for theday when our emrs are gonna translate our visit summariesinto the language of preference for our patients,but until that time, let's make them asuseful as we can. so, one community health centerthat i have worked with did a focus group with some oftheir patients and asked,

"what do you want the visitsummary to look like? what would be the most usefulthing for you to go home with?" the patients gave them feedback. they were actually surprised atthe number of alterations needed to be made weren't asmany as they thought. patients really appreciatedthe information, they asked for a fewdifferent areas of content, but they were able to makethis patient-friendly. self-management.

this is the key to patientstaking care of themselves and having hypertension control. so how do we dothat with our ehr? things that might help. number one. if you find a patientthat's not at goal, not adhering to medication,there's a barrier, consider using electronichealth records, depression screening function.

most ehrs have phq-9 in themand make a protocol and assess patients with either barriersor all patients with chronic disease for depression,treat them appropriately, and it may decrease thebarrier to them taking care of themselves. number two, use recall functionsto support patients of self-care goals. i do this often withsmoking patients. the patient makes a quit date intwo weeks and i put a prompt in

my electronic records to remindme to have my staff or myself call them in a couple weeks. that reminder makes a hugedifference in their ability to continue with theirpath to quit smoking. upload motivating patienteducation tools that you like for easy print into your ehr. there may be your favorites. make them easy to get to anduse and share them with your patient.

and then portals. having patients connect youthrough the electronic records is a way to have them reporthome blood pressures to you. imagine walking in on a mondayand having a whole list of blood pressures from a patientwho'd been taking them for the last couple of weeks. if the patient wasat goal you can send them acongratulatory message. if they weren't yet at goal, youcan have a conversation about

titrating their medication andknow that the patient needs an intervention before they comeback to see you in a month. it's a great way to help yourpatients adhere to goals they've set. this is just an example ofself-management goal setting that we've put into a template. these are some of myfavorite handouts. patients taking bloodpressures at home thanks to the utah department of health.

salt and sodium in spanish, andthen this is a template we have patients use forhome monitoring. this is not in any electronicformat at this point, except to be printed, butpatients even with low literacy levels can make xs on theirblood pressure marks and bring you in a really useful graph tohelp you manage and assist them with management oftheir blood pressures. last couple slides. report quality, okay?

when we talk about quality, wewant to talk about it inside our organizations, andoutside our organizations. we want team orprovider-specific report cards on measures. this is gonna help you knowwhere you need to target improvement. this is gonna getpeople in action. get those type a, straight astudent doctors in line by showing them report cards andcomparing them

in a safe way to their peers. let the providers correcterrors on reports. let them give you feedbackwhere something's not working. they'll have much more buy in toyour quality program if they get a say in what the data lookslike and how it's recorded. trend your improvement. many electronic health recordsare not trending the improvement month to month at this time. you could do that in a verybasic excel spreadsheet.

if anyone's interested,please email me. i'll send it to you. watching your numbers improve ornot improve over time can really spur action andimprovement activities. use your ehr clinicalquality measures functions. begin to learn howto put the data in. how to get the data out. how to make that data representyour population accurately. use third-party reports ifneeded to validate the data from

payers, from outside labs. consider working back and forthuntil you get a good product in your cqm. so this is our result. you see our trend in data. you see i'm able to demonstratethat we're heading toward a community benchmark in care. we've hit our ten percent goal. should we be hitting more?

yeah, probably, and weknow where we need to go. this is something we can look ateach month and see what's next. never forget workflow. imagine a patientarrives at the clinic, how will you ensure they getall the care elements done and documented properly. this is the question to ask asyou're working on implementing ehr functions thatmake a difference. and second, imaginethey don't come in

but they're apatient of concern. what do you do? that's the workflow you develop. so here's seven ways thatyou can use your ehr. use your powers for good. i hope that makes a difference. i hope you're doing all of themand the quality of care for your hypertension patients isdemonstrably improved, and then brag about it.

i'll take questions at the end,after dr. tashjian and here's my emailcontact information. thank you so much. moderator: thank youdr. woolsey. i would now like to introduceour second presenter, dr. christopher tashjian. please proceed dr. tashjian. dr. tashjian: my clinic is asmall rural clinic in western wisconsin.

in a town of about 2,000, there are two physiciansand a pa in our clinic and i'm gonna showyou what our story is, kind of tell you are story andactually i think it will go nicely with whatdr. woolsey said. first of all, we asphysicians had to change our overall way of thinking. we have pretty, two motivatedphysicians and motivated pa and the best thing we could get towas about 70 percent control

and that's because we heldonto the problem. we felt that it was, we asphysicians had to take on it, and we had to be in control. it's pretty interesting, it waspretty hard to do but we had to say, and change it to say thatit's not a physician problem but it's a team challenge, and wehad to include everybody because one of the realizationswe had was is that we don't see every patientthat walks through our doors. sometimes they comein for an inr check,

sometimes they just come infor a blood pressure check, sometimes they come in to seesomebody else, the dietitian, and so unless weincluded the whole team, we weren't gonna movebeyond this 70 percent. so, again, we had togive up total ownership. as a physician, you canprobably bet that's hard to do. actually in retrospect it wasthe best thing we did and it actually makes our life easier, and it actuallymakes it more fun.

the second thing we had to dois we had to train our staff to understand the problems andwe're just gonna talk about hypertension now. we needed to let our nursesknow that 130/90 was what we considered the upper limit ofacceptable and that anything more than that required uh,bringing it to our attention or reassessing it in tento fifteen minutes depending on which was sooner. we had to let the lab tech know.

and you said, "wellwhy the lab tech?" well sometimes the lab techdraws up inr or they draw lab work and they get a bloodpressure and we're not aware of it and so if sheknows that, you know, that elevated blood pressurerequires treatment, she'll intervene at the pointwhere she sees that patient and actually bring it to ourattention or make sure that the patient gets seen or setup for an appointment. next is care coordinators.

that's somethingwe had to develop. we talked earlier, as we saidearlier is we really changed our practice being reactive/proactive. that's where thecare coordinators come in. in our group, they're nursingassistants so they're, or medical assistants,they're not nurses, they're not the pas or anythinglike that but we've trained them to say, this is what's importantto us, this is how you, you know, query the charts andfind out and create lists so

that we know who needs tobe seen and who doesn't. these are patients at risk, wewant the care coordinators to call them, makesure they get in. and we found that to beincredibly successful. and patients really, really likeit when their providers office calls them and says, 'hey wehaven't seen you for a while, the last time in the office yourblood pressure was elevated. you know, we don't want yougetting a stroke or a heart attack, you know,that's important to us,

we know it's important to you'. the patients really,really relate to it. and last but not least, peoplewonder, well, why do you have front office on here? front office is an integralpart of our practice. if people can't getthrough the front door, they can't get treated. and so we made it clear to ourfront office personnel that it's important to get these people inand get them seen in a timely

manner and they wantto get in, you know, we need to do everythingwe can to get them seen. we've gone to advanced accessscheduling so we do as many things, same day,as we possibly can. okay, the secondthing is what does our overall pattern mean, iswe've gone away from my patients versus my partner's patientsversus the pa's patient and the answer is they'reall of our patients. so if i see my partner's patientand their blood pressure's too

high, it's my responsibilityto address it. it's not myresponsibility to say, 'gee your pressure's a littlehigh why don't you go back and see dr. lijewski and see what, you know, if shewants to do something about it.' same thing as i expect her to dothe same thing for my patients. and last but not least,as part of (inaudible) to get a bloodpressure on everyone. and we, you know, even beforethat we got a blood pressure

on everyone and bottomline is, in our office, every visit is ahypertension visit. if their bloodpressure's elevated, we feel a need to address itand to pay attention to it. and even if they're infor some other reason. now if the other reason explainswhy their blood pressure's up, that's fine, we'lldeal with that. but if they're in for a rashand their blood pressure's up, we know the rashisn't causing that,

we're still gonna address theblood pressure at that visit and for us, that's a change. so first i'm gonna go over thelow tech solution and i'll be honest, we stole this fromor cousins in new richmond, another clinic, a small clinicwho developed this and this is kind of one of my basic rulesof quality, is you know, beg, borrow or steal anything and we just took a pieceof construction paper, we printed out'recheck blood pressure'

and we taped amagnet to the back. and it does a coupledifferent things. every time my nurse takes ablood pressure and it's above 130/90, she takes this magnetand she takes it from the inside of the door and puts it onthe outside of the door. what that means is that it cuesher to keep paying attention to it and she knows that if theirblood pressure's elevated and i see that and that not on theoutside that we'll at least have a brief discussion onhow important it is.

the second thing is, is itcues me as a provider to say, 'hey this person's bloodpressure's elevated'. i don't have to turnon the computer, i don't have tolook at anything. i see this red little magnet,probably cost 25 cents, and it automaticallycues me into saying, 'time to do something orpay attention to this'. at the very minimum recheck itand see and if it is elevated, to deal with it.

so then we move to high tech,and as dr. woolsey said, she, you know, they implementedeclinicalworks, we use cerner ambulatory and you know,i think all the emrs, you know, you could make this availabilityif you work with them. we work with ourvendor quite closely. but the first thing wehad to do, as i said, we get a blood pressure onevery single patient that walks through the door. so the first thing we had to do

is export it to anexcel spreadsheet. since our data manipulationpeople know how to use best. from there, we take it from thatexcel spreadsheet and we put it in an access database, and thereason we do that is it allows us to manipulate the data, wecan use and access database viewer that we canput on every desktop and we don't haveto pay for that. you know, microsoft gives theviewer away so we really only have to buy one or two copiesfor the data people to work

the data and then the rest of us access database right on ourdesktops in our exam rooms. and so we have that there. and then what do wedo with our data? the first thing we so, iswe generate patient lists. so, again, here would be a caseobviously for a couple reasons. these are all testpatients and hypothetical. but what you see here is itgives me a list and if you look up there's a little box you cancheck diabetes, hypertension,

ischemic vascular disease. you can chooseage, and you can parse it anyway that youwant to set it up, that your docsthink are important. and then what this does is ituses a computer just as what it is. it's a tool and it uses thecomputer to help you identify who needs help and who doesn't. so everything in these meansthey're out of parameters.

and sometimes they're outof parameters because of date, so their blood pressure was goodbut it's been over a year since we've checked it. sometimes, like if youlook at some of these ldls, they weren't done, and soobviously missing data also would be (inaudible). and then our carecoordinators, as we said, will use these lists and they'llsit down with the provider at least once a month and we'll goover what it is that we want

to do with these patients. most of the time i'll tellthem, please call her or him, and have them come in and havethem do this before i see them. but again, it creates a muchmore proactive way of looking at the chart. next thing, as i said,we can use filters. so we can filter byprimary care provider, we can filter it by disease,we can filter it by age, and we can filter it by anywaythat we want to do so that,

you know, some providers aremore interested in one thing or the other and you can dothat, and again, what it is, is taking that data andputting it to work for you. most of the times i tell people,boy you really like your ehr and i remind them, i don't workfor it, it works for me, and it is nothingmore than a tool. a lot of people, i think itcaught up as trying to make it fit in the emr's parameters, andin my world i make the emr fit my parameters.

um, next thing is you canget patient scorecards. so what you could do is, is wetry to run these squares at least one a month, but oftentimes more than that so the data is never older than that. but again, we're doingthis on you know, that we fully expect our vendorto be able to have the time within this year, but we've beendoing this for three years and, as you pull up, soif this patient, this laurence testpatient calls in,

my nurse can pullthis up and glance and say, 'huh, laurence hasn't had hisldl done' and she can go ahead and order it, and get itset up by standing orders, and she doesn't evenneed to contact me. that goes again, backto this team concept, is that it's you know, ifyou let the team help you, the team could, can see patientsthat you don't see or take care so that you as a physiciandon't have to deal with it. again, i think that's where thestrength in our numbers are.

the other thing as dr. woolseycommented on is as physicians, we like to do well, welike to look at each other, we like to compete. we share provider statisticsand i've blanked them out here but again, it's just whichprovider has which kind of control and again, ifyou can see what we did, this is for optimal vascularcare there's four controls, and you see the overall controlfor each individual item, blood pressure, ldl,aspirin, and tobacco,

but then to the right of ityou can also see that which, you know, how many of thepatients are in all four, how many have three of four,how many have two of four, and so forth. why this is valuable is wefound out that some patients, or some providers are reallygood at stressing ldl or tobacco sensation, but maybe not as goodat aspirin or paying attention to blood pressure. so you can see as a providerwhere your strengths are,

where you tend to do well andwhere you tend to fall short so you can concentrate on it. the second thing you can do isyou can start working on those people that arethree out of four, or in diabetes four out of five,in kind of what we would call the low hanging group, and tryand get those people back to ideal control. so it just allows you to be moreefficient and better able to manage your population.

so again, and they told youwe've been doing this for four years now. we've been measuring fora long time and as i said, we were stuck at that70 percent number. so again, this is again a smallrural clinic that's literally the cheese curdcapital of the world, we're in western wisconsin wherewe have more cows probably than people, but we were able to bumpthose numbers up from 73 percent to 97 percentcontrols for people

with ischemic vascular disease. but the one we're most proud ofbecause it's the one we spent the most time on, is this as ofdecember of last year, all our patients with hypertension,regardless of anything else, we were finally able to getthat number over 90 percent. you know, and you got toremember the national average is about 50 percent. so again, it shows youthat hard work pays off. now why is that important?

well just doing those numbers, we figure we stop twoor three strokes a year. that means two or threemore of our patients can play with their grandchildren. you know, we stop fourof five heart attacks. same thing. those people can live the livesthat they wanted to live and they have, they have lessmorbidity and less mortality. i mean, 'cause to be honest,we're not treating numbers,

we're treating people. so, we were pretty excitedwhen janet wright came out and recognized our little bittyclinic along with a clinic from, another small clinic,kaiser permanente, with having excellentblood pressure control. um, and for the businessguys and the you know, i run my own business,it's a private clinic, it makes a difference. consumers reports comes outand says, you know,

'you're the mosteffective clinic in your neck of the woods'. that's really helpfuland it helps that way. so in the end, the bottomline, it takes team work. this is our team and in summary,i'd like to say, you know, the biggest thing that wefound is we needed a different mind set. we address bloodpressure at every visit, we use low techand high tech tools

and we use everything we have. there's no point inleaving anything on the table. anything you can use,take advantage of it. we call it a teamsport and as i said, most importantly itmakes a difference in your patients' lives. it does allow patientsto live better. last but not least, and i'llbe really quick on this, 'cause i know we'restarting to run out of time,

is i wanted to sell a differentway to look at quality. as most of you know,about a year ago, the pharmacy peoplecame out and said, simvastatin andamlodipine which is right... and i don't know if that'sgonna work or not but i'm going to red towards the bottom, youshouldn't use those together. well we use a tremendousamount of generics. you know, that's oneof things we measure. i have over 80 percent ingenerics and so we use a lot of

amlodipine and alot of simvastatin so in all of our clinics,including the two clinics north of town that we have that'sa bigger clinic than ours, we have 241 people that wereon amlodipine and simvastatin. because we e-prescribed it,because we used our electronic record, we were actually ableto reach out to them and find a better solution for them,each individualized, without, actually without much workat all, just doing a query. in the old days, i'd besurprised if we got ten percent

of them covered and we just hadto wait to wait for them to come in andhope we remembered. so that's a differentway to look at quality, but one we think is important. so last but not least, you knowif you're gonna make a big step, don't be afraid to takeone on what is needed. you can't crossthe quality chasm, two little babysteps won't make it. thanks very much.

moderator: thank you,dr. tashjian. um, i'd like to thank both thepresenters and now move into the question and answer session. um, i'll, going forwardi'll be asking questions. in some cases they'll bedirected to a specific presenter but i'd like to open it up toyour thoughts from both the presenters on anything thatyou'd like to speak to with respect to the questionwhether it's targeted or not. i'd like to start, dr. woolsey,there was a question with

respect to how you, if youcould discuss a little more, how you reached the hispaniccommunity and in that regard, whether you got the hispanicpatients to use the ecw patientportal, and if so, how? dr. woolsey: so, againthis is sarah woolsey. we have just begunoutreach on that. we first had startedwith just text messaging, text message tools, and ourportal is still slow and coming. i'll be honest, i do not haveany spanish speaking patients

on the portal at thismoment, but we're in an active recruitment phase,so we're just starting that. now, in, i know that our, mypartners who are in our homeless works, have done quite a bit ofoutreach with cellphones and texting, butnot portals yet, and we're gonna bebuilding that capacity. we're collecting emails,though, to start, and we've been surprisedat the number of emails we're getting back.

we did a survey '05 and didn'tfind a lot of email addresses with patients as we werebeginning to look at that as a new avenue, but now in 2012, we're startingto collect a lot more and especially with ouryounger patients. so, the news is to come on that. sorry. moderator: great, thank you. question two to both presenters,the question is how do you,

how do you answer a providerthat tells you that signing the encounter and providing avisit summary is challenging? it specifically just concernsabout making sure all the information's beenentered, any potential legal implications,those types of concerns. dr. tashjian: i'll take thefirst stab at that 'cause we providea summary after, and i'm sure dr. woolseydoes too, after every visit. but the answer is, that's whereyou work with your vendor,

because our vendor makes it easythat the visit summary pulls in all the necessary dataand one of the big, probably the most key importantdata is that we have our docs do, routinely, and say whenis that next appointment, and we actually make that in theemr right there at the visits that it goes both to ourscheduling people in case that patient doesn't show up so ithelps you with your, you know, patient centered medical whole,but it also automatically shows up on that visit summary,

for which i circle it and justremind the patient, this is when we want to see himand this is what we plan to do at the next visit. so the answer is, you takethe time necessary to do it. does that mean thatyou see fewer patients? i haven't found that tobe the case, but again, i think that goesto the workflow. if you set it in and makeit part of your workflow, it just becomes habit.

dr. woolsey: i'lljust add two cents. so number one i agree. the vendor can work with you tohave flexible choices so in my visit summary i can actuallycheck how much or little information gets in there. of course you have to have a fewbasic parts to have anything there, but of course follow upappointments and medication lists are standard for us. the second piece i would say, soone is allow them to customize

it as you're gettingused to them using it. ideally it'll become a toolthat's more and more valuable and we'll all justwant to use it. number two is, there is a newshift happening, where you know, in the old school, and i've hadphysicians say this to me in presentations, especially abouthealth information exchange, that's not the patient'schart, that's my chart. and really, there's a whole newopening of access to patients, for patients to theirown medical records.

there's a culture change that ishappening in medicine where the patient's information isthe patient's information. right then, right there. so whatever you put in it,you're gonna want to make sure that it's appropriate to thecontext of you and the patient are using that information. so i think there's a little bitof a culture shift we have to be aware of, but this is thepatient's record and they're going to have increasingaccess to every part of it,

and that's somethingthat physicians will need to move forward with. so that's just another comment. moderator: excellent, thank you. the next question was directeddr. tashjian, to you, but i'd actually like toopen it up to both of you. can you speak more to how youcreate the patient scorecard? dr. tashjian: yeah, well again, when we create thepatient scorecard,

we look at what theirchronic diseases are, their chronic illnesses, andbecause there's a fair amount of overlap, we kind of check forthe five basic things that we see with diabetes and if theydon't have diabetes we just ignorethe a1c and so for ischemic vascular diseaseor hypertension, then those come up. and again, the way we do it, iswe have it so that that nurse or my medical assistant pullthat up when she sees

that this patientis on the list. it's kind of a form ofelectronic pre-visit planning and you know, we try topre-visit plan all of our patients prior to them coming inand this has made it a way to do it more easily when theyhave same day appointments. so, we generally look at thefive things that we look at for ideally controlled diabetes andif they're not diabetes we just kind of ignorethe a1c component. dr. woolsey: and this is sarah,and we do not have

an electronic scorecard, but we have hand done,i guess you'd say, scorecards in english andspanish and really we use it as a teaching tool, either havingpatients enter their own information in it as wetalk, or we do it with them, in an educationalsettings with ourselves, our health educator staffif that's available, or in some settings i'm seeingcare coordinator or medical assistants who are functioningin a higher capacity in

education to go throughthose scorecards. so we're at low tech. moderator: okay, thank you both. dr. woolsey, actually letme follow up with you. can you, there's a couplequestions on explaining the business summaryahead of time concept. actually this is kindof getting at more um, what it means from a practicalaspect of how it works. dr. woolsey: yes, so,this is something

at our practice weexperimented with. i currently don'tdo that anymore, but one thing is so you canprint, you have schedule, you print the visitsummaries ahead of time. now, those aren't going tobe updated with the current information, yet it can beused as a couple of things. number one, a tool as describedby my pharmacist friend where you give it to the patient,let's say the front desk gives it to the patient and theyreview their medication that are

on that list and couldmake corrections, so that's one option formedication reconciliation. number two, i have a very, iwould call meticulous internist that has been a mentorand educator for me. he prints themout ahead of time, and any changes that hemakes in the patient's care, he actually thinks the exerciseof discussing the visit summary, crossing out medication changes,doing that by hand is an opportunity to be aneducation with the patient.

so that's another opportunity. you actually demonstrateto the patient, you're making a change byslashing out that dose and increasing the dose. again, if your handwriting islegible and you have time, that can be a very engagingway to deal with the patient. so those are two options. i would advise that if you didthe med reconciliation model where the patient'swriting the meds, you know,

that they're takingahead of time, you're gonna want to givethem another one at the end. but this is just a way tocommunicate that information and actually have the patient getfamiliar with the visit summary and used to how it looksand what's on there such that they use it as a valuable toolsometimes when they go home. so just two ideas. the next question was directedto you, dr. tashjian, but again i'd like to openit to both presenters.

the question is, do you thinkit'd be beneficial to shift to thinking of the patient as a keymember of the team who needs to adopt this improvementchallenge? as physicians,you've shifted focus, do you think a new viewof the patient is needed to achieve meaningful change? dr. tashjian: yeah, i thinkthat's exactly right. as we put the patient at truly,you know, on a patient centered, but we also, whenwe look at the team,

we really tend tohave looked at the patient as the captain of the team now. and part of that, then, ismaking sure they understand what we expect of them. they understand that we expecttheir blood pressure to be at lower than 140/90and we tell them why. we tell them that you know, thiswill create fewer heart attacks, you'd be less likelyto have a stroke, you'll have more time to playwith your grandchildren or

children and that we're notdoing this just because we're looking at numbers, andthey can relate to that. but you need patient involvementand patient engagement if you really want to seethe numbers change. now, living in asmall community, that's one of the key advantagesthat we may have is, you know, i know virtually everybody that walksthrough that door. i've delivered most of them.

dr. woolsey: so, i would liketo just comment that this, this isn't a keyfocus of this talk but there's another onethat i've done around self-management. we've really opened up ourself-management in hypertension in our practice. and i want to just challengethe group to think about this. would you ever put a patienton insulin or a hyperglycemic agent without at leastconsidering a glucometer?

we consider patientself-management and knowledge of their blood sugarsas standard of care for much of our diabetes care. not everybody but many people. well, what do we thinkabout blood pressure? are we aggressively having ourpatients have access to their blood pressure? and i will tell you, just aquick story of a gentlemen with low literacy could not figureout what the heck was going on

with his blood pressureat his clinical visits. with a cuff at home, and that check boxform that i showed you, and he's an english speaker,but a check box form, he was able to begin to bringme blood pressures on a regular basis. and with feedback in six weeks, we had his bloodpressure at goal. and he continues to be at goal.

his cardiologist loves that factthat he has a home monitor and he checks that. we have gone to providing lowercost monitors that we trust that are fda approved and we have away to train our patients to use them because it's not theeasiest thing in the world to take a good blood pressure. so we have a training module,we provide the patient with a monitor, and we ask thatthey track just like sugars. so really consider that that'sthe ultimate goal is that the

patient knows exactly whenthey need to call you because something'sout of range. moderator: thank you both. next question isto both presenters. could either of you elaborate onreporting out of the controlling high, excuse me, controllinghigh blood pressure cqm? specifically has it taken a lotof resources to develop the reporting out tools, especiallyto report to entities outside of ems and with this focus, did yourely mostly on internal staff

or vendors to assistin this process? dr. tashjian: i'll go first.dr. woolsey: want to go first? dr: woolsey: yep. dr. tashjian: yep. behappy to go first. we use our vendor and ourvendor could do part of it. he could not, they could notdo all of it so we got like an advance reporting system thatwas available with our ehr and through that advancereporting system, were able to pull outall the data we need,

both for our pqrs and for, and for any of our payerplans that want it. so it's like anything else,it took a little bit of extra effort and a little bit ofextra money to get it set up, but once it's set up, it runsmuch more seamlessly and much, much more efficiently than weever had in the paper world. as i said, we measurethese every single month, not for the payers, butjust for our own knowledge, and in the paper world we werelucky to run it twice a year

and even that wasprohibitively expensive. dr. woolsey: and i'll justcomment on working with, we're actually working with 19electronic health records in our beacon community and there's awide range of answers to that question. some platforms have had a betterability for a third party vendor, like dr.tashjian's talking about, to be able to do this stuff. other folks are able to doit within their cqm in their

electronic health record. but it varies. vendors can beextremely helpful, partners that are doing it withthe same emr in your community can be extremely helpful. and unfortunately trial anderror, putting patients in, seeing if they track through. our process is has been, we've been workingon that extensively.

literally, there's a point atwhich we just put the blood pressures, you know, in a wrongplace and they wouldn't track, they wouldn't getpicked up by the cqm, they would get pickedup by the registry. so we have had quite abit of trial and error. we have had to use third partysort of data lists to compare to what our ehr is doing tolearn how to use it better. and so i would say that theanswer's still out and it very much is vendor dependent, butmost likely you're gonna need to

do some extra work to makethese cqms as valuable as they are designed to be. moderator: very good. thank you. given the time, let's finishwith one last question here which i, again, will setout to both presenters. how do you encourageportal use within the safety net population? specifically access to computersand, and public information, public health information onpublic machines

is always a concern. can you address thoseideas, concerns? dr: tashjian: we actually have afair number of (inaudible) in our rural community ofsmartphone users and we're finding that that's probablygoing to be even more than the desktop, going to be thebiggest access issue. we still have people thatuse the public library, and you're right, thoseare public computers, but as long as theyclose out of the browser,

all of that informationis, is removed. we are working with our vendor. we would really, really liketo have either an ipad or an android app, or preferablyboth, that'll allow us to text information to our patients aswell as deliver it to an app that they don'thave to log in with, but that they could just use oneither their smartphone or their ipad. dr. woolsey: yep,and i'll agree.

just in our community atthis point, smartphones, but also just plain old phoneswith texting ability seem to be the common placethat people have, even people with lowincome and transient people, are maintaining phones. it's amazing. and so that will be the way. i agree, you know, secure emailor portal logon are designed to be opened and closedso training patients

on the importanceof that is good. i suppose someone could go printout extensive amounts of labs or something and they'd beon a printer somewhere, but to you know, maybetraining patients of that importance is there. but we're experimenting texting. it is just a thing we're reallyexperimenting with to see how much we can get and ideally twoway texting is a thing that we're looking at in our system.

moderator: thank youboth very much. in conclusion, we would like tothank everyone who submitted questions duringtoday's webinar. any questions that were notanswered during today's webinar will be addressedfollowing this event. the question and answer sessionsummary will be posted on the hrsa ohitq website along withthe recording of this webinar. we would like to thankeveryone who attended today. we very much value your feedbackand use it to plan upcoming

webinars, so please take amoment to provide your feedback on today's event by completingthe questionnaire that will appear on your screen shortly. operator: this webinarhas now concluded. we thank you for attending.