Increasing the Effective Use of Electronic Standing Orders (SO-TRIP) (Text Version)

On September 29, 2010, Lynne S. Nemeth made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (4.2 MB).  

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Slide 1

Increasing the Effective Use of Electronic Standing Orders (SO-TRIP)

Lynne S. Nemeth, PhD, RN
Associate Professor
Medical University of South Carolina
September 29, 2010

Images: The MUSC logo and a map of the USA are shown.

Slide 2

Co-Presenter: SO-TRIP Practice

Steven P. Johnson, MD
New London Family Practice
New London, CT

Image: A town is shown.

Slide 3

PPRNet SO-TRIP Co-Investigators

• Steven M. Ornstein, MD
• Ruth G. Jenkins, PhD
• Paul J. Nietert, PhD
• Andrea M. Wessell, PharmD
• Loraine F. Roylance, MA

Funded by AHRQ Contract No. HHSA290 2007 10015

Images: The MUSC logo and a map of the USA are shown.

Slide 4

Background

Slide 5

Rationale for Study

• Time constraints and competing obligations in primary care practice contribute to inadequate delivery of clinical preventive and disease monitoring services.
• Standing orders for practice staff using reminder systems embedded in EHR systems may help overcome some of these deficiencies.

Slide 6

SO-TRIP Project Aims

1. Facilitate the adoption of an EHR based standing order protocol for selected preventive services, adult immunizations, and diabetes monitoring measures in 8 primary care practices using a validated quality improvement intervention.
2. Identify effective strategies and barriers to the adoption of this protocol.
3. Document changes in the use of the protocol and delivery of the study measures.

Slide 7

Health Maintenance Table

Image: A screen shot of a sample Health Maintenance Table is shown.

Notes: The HM table shown here is a record of all services due for an individual pt based upon age, gender, conditions, or medications prescribed. What appears in red is what is overdue for the patient, the second column provides the rationale/"rule" behind the service and the due dates are shown. Rules are available and customizable by each practice.

Slide 8

Health Maintenance Pop-Up Reminder

Image: A screen shot of a sample Health Maintenance Pop-Up Reminder is shown.

Notes: This is a HM pop up reminder, which can be set up by the practice to appear when opening the patient's record...it provides another immediate reminder that services are overdue.

Slide 9

Chart Summary Screen

Image: A screen shot of a sample Chart Summary Screen is shown.

Notes: Some practices may start their review of a patient record using the chart summary screen, in which HM needed is also listed.

Slide 10

Methods

Slide 11

• Design: Pilot demonstration project from July 1, 2008, to April 1, 2010, using the framework PPRNet-TRIP QI Model.
• Setting: 8 primary care practices in 8 States.

Slide 12

Intervention

• Quarterly audit and feedback on use of Practice Partner™ Health Maintenance (HM) features and adherence with study measures.
• 2-3 practice site visits by study investigators (LN, SO) to help adopt HM features and SO protocol.
• Two annual network meetings with all practice liaisons and study investigators to share "best practice approaches."

Slide 13

Quantitative Methods

Data Collection:

• • Quarterly EHR extract

Analyses:

• • Presence of study measure on HM template.
  • Entry on HM template for study measure.
  • Percent of patients up to date with each study measure.
  • Pre and post-intervention comparison of summary measure.

Slide 14

Qualitative Methods

Data Collection:

• • Interviews:
  • Observation
  • Correspondence

Analyses:

• • Identify approaches, facilitators, and barriers to adoption of SO protocol.

Slide 15

PPRNet-TRIP Improvement Model

• Prioritize Performance.
• Involve All Staff.
• Redesign Delivery System.
• Activate the Patient.
• Use EMR Tools.

Jt Comm J Qual & Safety, August 2004, 30(8):432-441.

Image: A repair man is shown.

Slide 16

Practice Development Model

Image: The practice development model titled "How to Lead Improvement for PPRNET TRIP" is shown.

Notes: The practice development model, also was developed in previous research and has been used in previous research. This model focuses on "how" to develop the staff within a practice. 7 concepts provide a focus on development and improvement.... In SO-TRIP this meant:

Leaders set a vision in the practice for Implementing SO-TRIP.
Seek and use staff input.
Ensure staff know how to use HM; why important.
Standardize the "script" or conversation the practice staff will have with patients.
Consider a trial of one or two HM items, then adopt the rest.
Use reminders in HM consistently.
Encourage staff verbally; use reports for planning future actions.

Implementation Science 2008, 3:3

Slide 17

Measures

Screening*	Adult Immunizations**	Diabetes***
Cholesterol (≥20 yrs in past 5 yrs)	Tetanus (Td or Tdap) ≥12 yrs in past 10 yrs>	Urine microalbumin (annual)
HDL-Cholesterol (≥20 yrs in past 5 yrs)	Pneumococcal ≥65 yrs ever	HgbA1C (biannual)
Mammogram ≥40 yrs (women ≥40 years old in past 2 years)	Pneumococcal (18-64 yrs high risk patients) ever	HDL-Cholesterol (annual fasting)
Bone Mineral Density (women≥ 65 yrs) ever	Influenza ≥50 yrs in past year	LDL-Cholesterol (annual fasting)
	Influenza (18-49 yrs high risk patients) in past year	Triglycerides (annual fasting)
	Zoster vaccine ≥60 yrs ever

* U.S. Preventive Service Task Force recommendation.
**Center for Disease Control Advisory Committee on Immunization Practices guideline.
***Expert consensus or clinical experience, AHRQ National Healthcare Quality Report and American Diabetes Association current guidelines.

Slide 18

Results

Slide 19

Practice Characteristics

State	Location	Specialty	Adult patients (n)	Providers (n)
ID	Urban	Family Practice	1224	2
MO	Rural	Family Practice	3313	4
MD	Urban	Family Practice	3578	3
CT	Urban	Family Practice	3767	4
WA	Rural	Multi-Specialty	3872	11
NY	Urban	Internal Medicine	10400	11
NC	Urban	Family Practice	11057	14
TX	Urban	Multi-Specialty	28893	25
		Total	66104	74

Slide 20

Approaches to Adoption of SO Protocol

• Regular meetings to support implementation, reach consensus, and provide feedback.
• Establish formal policies/protocols approving staff to act upon the electronic SO's.
• Adapt EHR tool to include patient and staff in adoption of SO protocol: with significant behind the scenes "tweaking" of templates, rules, and utilities.

Slide 21

Health Maintenance Table

Image: A screen shot of a sample Health Maintenance Table is shown.

Notes: The HM table shown here is a record of all services due for an individual pt based upon age, gender, conditions, or medications prescribed. What appears in red is what is overdue for the patient, the second column provides the rationale/"rule" behind the service and the due dates are shown. Rules are available and customizable by each practice.

Slide 22

New London Family Practice: Office Flow

Four images are shown: A health professional working on a computer; a doctor working on a computer; a print button; a form that is filled out.

Slide 23

Patient Flow

Medical assistant (MA) discusses with patient:
Need CPE?
Mammogram?
Flu or Pneumovax?
Tetanus?
Zostavax?
Cholesterol?
Urine Microalbumin?

Images: An MA taking a patient's weight, and an MA showing a patient a form is shown.

Slide 24

Patient Info Update

Image: Screen shot of a sample Patient Info page is shown.

Slide 25

Progress Note From Note Template (example)

Image: Screen shot of a sample progress note is shown.

Slide 26

Personalized Patient Handout

Image: Screen shot of a sample Personalized Patient Handout page is shown.

Slide 27

Quantitative Analyses

Slide 28

Process: Median Percent of Eligible Patients with Measure on HM Template

Image: A bar graph.

Notes: The process measures for the study included the median percent of eligible patients having the measure on their HM template. The blue components on the stacked bars refer to baseline presence of the measure on patients HM template. Yellow shows the change at the end of the study period. (21 months later) It is clear that for a good number of the measures, these were already applied to the HM templates to a fair extent. Other measures such as HDL cholesterol, influenza for adults >50 and zoster for adults >60 were added for a larger number of patients.

Slide 29

Process: Median Percent of Patients with HM Template Entry

Image: A bar graph.

Notes: This graph shows the entry on the template reflecting some action was addressed. We saw significant improvement in use of the HM templates.

Slide 30

Outcome: Screening—Monthly Medians

Image: A line graph.

Notes: This graph shows performance data on the screening measures. Monthly medians calculated (baseline through 21 months). Practice-level repeated measures analyses (using a mixed model approach) were used to examine for significant increases in these measures over time. All of the measures showed a trend towards improvement, and in osteoporosis screening a significant improvement is seen in the monthly medians.

Slide 31

Outcome: Immunizations—Monthly Medians

Image: A line graph.

Notes: All of the immunization measures improved, but we noted a dip in influenza immunization, which corresponded to supply issues experienced by the practices in the last season.

Slide 32

Outcome: Diabetes-Monthly Medians

Image: A line graph.

Notes: In DM significant improvements were noted with urinary microalbumin. The lipid measures tracked together as they were usually ordered as a panel.

Slide 33

Summary Performance

Practice	1-Jul-08	1-Apr-10	Improvement
1	35.9%	62.8%	26.9%
2	37.9%	49.1% >	11.2%
3	52.8%	63.8%	11.0%
4	42.9%	51.3%	8.4%
5	39.0%	45.5%	6.5%
6	49.4%	55.6% >	6.2%
7	29.1%	31.6%	2.5%
8	45.2%	40.1%	-5.1%

Slide 34

Qualitative Analyses

Slide 35

Staff Quotes from New London

Medical Assistants:

• Better patient care.
• Overwhelming at first, but becomes very routine after.
• Patient information sheet a good tool... patients more in tune with their medications.
• We feel more involved in patient care.
• I like how we can have lab slips etc. ready for patient when they come out, so things move more smoothly.

Slide 36

Staff Quotes from New London

MDs:

• Helps maximize program potential and make it more powerful.
• Improves medical care.
• Realize how many patients with diseases we need to capture.
• Patient info sheets great for patients to check on bio, HM, and medication information.
• Some chance for MAs to off load HM items.

Slide 37

Staff Quotes from MD's continued

• We definitely improved immunizations and HM items.
• It would be better if Connecticut MAs could give shots.
• HM items get done often without me even realizing.
• More is done because MAs have prepared patients so no long discussions needed during the visit.
• We have expanded the concept beyond the SO-TRIP parameters to also include pap smears, complete physicals, monofilament testing, and basically all the "red" areas of HM.

Slide 38

Facilitators of SO Protocol Adoption

• Tech savvy leaders helped create tools that made process easy for staff and helped activate patients:
  • Nursing note templates
  • Electronic patient update forms
• Leaders redesigned systems for efficient patient flow:
  • Practice policies/protocols; education, follow-up
  • Clinician follow-up; collaboration/communication
• Staff that were non-supportive of the changes left practices and were replaced by staff "buying-in."

Slide 39

Barriers to SO Protocol Adoption

• Spread:
  • Getting all staff to implement SO's.
  • Staff selectively implementing only some SO's.
  • Some providers uncomfortable with SO's.
• Staff perceptions:
  • Time management: SO's slowing patient flow.
  • Need to double check with provider re: SO.
  • Need for decision-making re: screening lipids (fasting or non-fasting) or for additional labs; mammogram without breast exam.

Slide 40

Barriers to SO Protocol Adoption

• Staff education or follow up on project plans limited.
• Practice reimbursement, patient funding or lack of availability limits implementing some vaccine SO's.
• Patient refusals or disinterest.
• Technical issues with EHR; use of HM tools/utilities.
• Legal regulations in some states prohibiting SO's or immunizations by unlicensed clinical staff.
• Competing priorities: new facility/merged providers.

Slide 41

Discussion

Slide 42

1. In SO-TRIP 6 of 8 practices were able to successfully adopt an electronic standing order protocol and had meaningful improvement in delivery of the study measures.
2. Staff in successful practices were able to incorporate new activities without significant time burdens and found doing so a source of empowerment.

Slide 43

3. Technical competence/leadership are needed to optimally adapt and use the EHR reminder tools.
4. More research is needed to evaluate effectiveness of an EHR based standing order protocol in a broader sample of practices and to identify which clinical measures are best suited for inclusion in such protocols.

Slide 44

Questions and Discussion

• Correspondence: Nemethl@musc.edu

Image: A question mark along with an image that says "Thank You" is shown.