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Providence Health System Task Force on Tobacco Cessation and Prevention Physician Leader Access Services Respiratory Care Health Services Integration Long Term Care Human Resources Behavioral Health Employer Health Prov-RN Health Education Research Analyst Home Care Quality Management Women & Children’s Program Diabetes Disease Management Pharmacy C.O.R.E Community Health Worker
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Technological Innovations to Improve Tobacco Cessation
In Health Systems
Charles J. Bentz MDMedical Director: Tobacco Cessation and Prevention
Providence Health System: Oregon
Providence Health System: OregonEmployees: 11,954Active Medical Staff: 1,967Providence Health Plan (HMO): 321,621Providence Preferred (PPO): 362,979Licensed Beds (acute & long-term): 1,474Admissions: 59,188Births: 8,965Outpatient visits: 2,054,612
Providence Health System Task Force on Tobacco Cessation and Prevention
• Physician Leader• Access Services• Respiratory Care• Health Services Integration• Long Term Care• Human Resources• Behavioral Health• Employer Health• Prov-RN
• Health Education• Research Analyst• Home Care • Quality Management• Women & Children’s Program• Diabetes Disease Management• Pharmacy• C.O.R.E• Community Health Worker
SMOKING CESSATION AND PREVENTION: 2002
Providers•5 A’s Training/Education•Reimbursement •Physician Leadership
Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN
Clinics•5 A’s Training•EMR Resources•Resources: Primary Care, Specialties, Pediatrics, OB/GYN
Health System•AAHP Awards •Funded Research•NCQA Accreditation
Target Groups•Women & Children•HRA, High Risk•Disease Management•PHS employees •Web-Based
Community•TOFCO•Oregon Quit Line•Legislation
Hospital-Based•Inpatient Program•Behavioral Health/CD
Evaluation•C.O.R.E.•Programs•CQI
SMOKER(who wants to quit)
Smoking Prevalence in PHP vs. Oregon
15%16%17%18%19%20%21%22%23%24%
'88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000
State of Oregon (BRFS) Providence Health Plan: Oregon
HEDIS Tracking Code Pilot Project• Develop codes to track prevention and disease management• Implement Tracking Codes in Two Offices
– Paper Chart Based office• Paper “CPT-like” billing codes for tobacco cessation
– Smoker: Current, Recent Quit, Remote Quit, Never, Advice to quit
– Electronic Medical Record (EMR) Based office: • Same measurements as in paper-clinic
– Observation Headings in EMR database and encounter forms• CQI process evaluation of implementation• External Validation of TR Codes: Chart Review
Paper-Based
Tracking Codes
Immunizations TR700 DtaP (DTP ACELL) TR711 DTP w/Polio TR701 DTP TR712 OPV TR702 DT TR713 Polio (inj) TR703 Tetanus TR716 Varicella TR704 Mumps TR718 Tetanus & DT (adult) TR705 Measles TR019 Diphtheria TR706 Rubella TR720 DTP/HIB TR707 MMR TR724 Influenza TR708 Measles & Rubella TR732 Pneumococcal TR709 Rubella & Mumps TR737 HIB TR710 MMRV TR724 Influenza TR732 Pneumococcal TR021 Prior Hx Varicella Diabetic Indicators Hemoglobin A1c Level TR800 Dilated retinal exam TR203 > 9.0 TR801 Foot exam TR202 >8<9.0 TR220 Negative both micro & macroalbuminuria TR201 >7<8.0 TR221 Positive either micro & macroalbuminuria TR200 <7.0 Smoking Indicators Counseling TR001 Smoker TR100 Smoking cessation TR002 Non-smoker/remote quitter (>6 months) TR101 Substance abuse TR003 Recent quitter (<6 months) TR102 Sexually transmitted disease Disease management/prevention LDL Cholesterol Level TR600 Cholesterol and lipid drug management TR232 >160 TR601 Beta Blocker after MI TR231 >130<160 TR602 Aspirin use TR230 >100<130 TR603 ACE Inhibitor Use TR229 <100 TR301 Lead Screening Questionnaire Women’s health TR520 Mammography TR521 PAP Smear TR010 Prior total hysterectomy TR011 Bilateral mastectomy TR500 Prenatal visit TR510 Postnatal visit
Preventive care (Medical Office)
Office billing dept
Claims processing
(Health Plan)
(Feedback on preventive care)
Paper Chart Environment: Flow of preventive care data
(Tracking Codes)
Financial Incentive (quality bonus)
Preventive Care (Medical office)
Fee ticket(billing service)
Claims processing
(Health Plan)
HEDIS/Quality Bonus incentive
(Feedback on preventive care)
Electronic Medical Record (EMR) Environment: Flow of preventive care data
EMR (Direct reporting to Health Plan)
Percent of Patients with Documentation about Tobacco Use in the Paper-Based and EMR Clinics
45% 42% 42%
79% 80%88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jun-99 Jul-99 Aug-99
Perc
ent o
f Pat
ient
s w
ith D
ocum
enta
tion
Paper Clinic EMR Clinic
Summary: Paper-Based Record
• Paper Tracking Codes CAN WORK• Data loss was an issue• MCO delay (feedback vs. reporting)• Physician memory: Double documentation • Time intensive, wide practice variation• Single Health Plan Only
Summary: Electronic Medical Record • Much easier data collection• Measurement built right into practice• Entire clinic population vs. one health plan• 50% provider turnover during study period• Issues of data ownership (private practice)• Return on investment (ROI) of EMR
Using Logician™ (EMR)
Using Logician™ (EMR)
Paper Quit Line
Fax Form
Electronic Quit Line Fax Form
Providence Health SystemInpatient Smoking Cessation
Referra lQ u it L in eC lasses
Surviva l K itR esou rces
D is trac t ion A id s
Pharm a cotherapyP h arm ac is t-B ased
G u id e lin e
Notific a tion of PC PP erson a l L e tte r
R esou rces
INTERVENTIONAssessm ent by Trained Therapist
"D o you n eed help w h ile in H ospital? ""A re you in teres ted in rem ain in g Sm oke-F ree?"
RESPIRATO RY CAREDaily Census of Inpatient Sm okers
ACCESS SERVICESSystem atic Identification of Current Sm okers
Systematic vs. Non-Systematic: PHS Inpatient Cessation Program
0
2000
4000
6000
8000
10000
1994 1995 1996 1997 1998 1999 2000 2001 2002
Face to Face Interventions with Hospitalized Smokers
Data: HBOC
Inpatient Program Database
Percent of Inpatient Admissions who have Tobacco Status Ascertainment: PSA Hospitals
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Jun-00
Jul-00 Aug-00
Sep-00
Oct-00
Nov-00
Dec-00
Jan-01
Feb-01
Mar-01
Apr-01
May-01
Jun-01
Jul-01 Aug-01
PMH PPMC PSVMC
“You can’t improve… what you can’t measure”
• Seek usefulness (not perfection) in measurement• Balance process and outcome measures• Keep the measurement simple• Use qualitative and quantitative data• Operational definitions of the measures• Measure small, representative samples• Build the measurement into daily work• Develop a measurement team Nelson EC, Annals Int Med. 1998, 128:460-466