A COMPREHENSIVE APPROACH TO ASTHMA MANAGEMENT IN AN INNER CITY HOSPITAL SETTING.R. Shriver1; R. Mangold1; G.A. Salzman1. 1University of Missouri-Kansas City, Kansas City, MO. (Tracking ID #117054)
STATEMENT OF PROBLEM/QUESTION
National agencies such as the NIH and Society of Asthma have educational campaigns for patients with asthma to assist in their medical care. In our inner city hospital we have a large population of asthmatic patients who do not have access to appropriate medical care and medications. Many of these patients primarily utilize only the emergency department for care leading to increased hospitalizations and mortality.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To develop accessible and affordable health care and education for patients with asthma.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We have developed a comprehensive asthma care program that centers around a weekly clinic dedicated to asthma care. Patients presenting to the emergency department, the inpatient service or general medicine clinics with asthma are routinely referred to this clinic and are seen within a two week time frame. The day prior to their visit, they are called to remind them of their appointment. At their visit, all patients fill out a symptom questionnaire, undergo pre and post bronchodilator spirometry and have a chest x-ray. After evaluation by a pulmonologist specializing in asthma, the patients undergo individual education with a trained asthma clinician educator who along with the medical staff develops an asthma action plan for each individual. This guides them though treatment of an exacerbation at home, indicates when they need to seek medical care and provides the phone number for assistance. We have action plans in English, Spanish, and graphic versions. A copy of this is given to the patient and placed in their chart. In addition, it is placed in a computerized data base accessable by the emergency department and nurse advice phone lines. They then are provided assistance with obtaining their medications via samples or a pharmacy discount if needed. All patients are then given a follow up appointment.
FINDINGS TO DATE/ EVALUATION OF WEB SITE
Since instituting this program, the number of patients who have undergone asthma education has increased from 8% to greater than 50% while our patient show rate in clinic has increased by approximately 25%. In addition, our admission rates from the emergency department have decreased from 23% to 16.9%.
KEY LESSONS LEARNED
Having a comprehensive clinic in which patients see a physician, have individualized education and assistance with obtaining medications has improved access to care and patient compliance.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Sample teaching tools and demonstration of computerized asthma action plan database.
A COMPUTERIZED REFILL PROFILE AS A TOOL TO DECREASE MEDICATION ERROR, IMPROVE PATIENT SAFETY AND CLINICIAN EFFICIENCY.O. Melamed1; D. Nguyen-Khoa1. 1Olive View—UCLA Medical Center, Sylmar, CA. (Tracking ID #116538)
STATEMENT OF PROBLEM/QUESTION
In a setting where mostly unsophisticated patients are served, rewriting prescriptions may result in medication errors and may significantly lengthen clinic visit time. This county hospital includes a pharmacy and is associated with three off-site outpatient health centers, two of which have on-site pharmacies. All centers are connected by a computer network. A limited ability exists to share patient charts between centers further complicating medication histories.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1). decrease medication errors by providing clinicians at every visit and any health center with a computer generated list of medications the patient filled at any of our pharmacy sites, 2). shorten the time and increase ease of refilling medications
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
A computer program was developed to compile a list of medications for a patient presenting to a given clinic. This integrated data list printed at the request of a clerk contained: patient ID information, clinics visited with dates, medications filled with directions for administration, the prescribing clinician and the number of refills. The list was then attached to the front of the chart and forwarded to the clinician who was able to make changes on it by checking a box under each medication stating: “refill,”“delete,” or “no action.” The number of refills could also be entered. This revised profile was then used by the pharmacist to dispense medication.
FINDINGS TO DATE/ EVALUATION OF WEB SITE
This computer integrated pharmacy profile provided an updated list of medications at each visit. Provided with this information, clinicians were able to avoid duplications and prescriptions that would cause potential drug interactions. It also made easier tracking prescriptions for controlled substances. This procedure allowed the clinician to check a box instead of rewriting a prescription. It ensured legibility by using printed text. The major obstacles to the implementation of the profile during the pilot were: (1) computer network access, and (2) lack of cooperation of other services, e.g., clerical and nursing likely due to a perception of the lack of benefit from this procedure that increased their responsibility.
KEY LESSONS LEARNED
A computer integrated medication profile may serve as an important tool to communicate information between different clinics and facilities. An updated comprehensive legible medication profile may decrease medication errors when writing for refills and provides important data as described above. It allows providers to be more efficient while improving patient safety.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
A MODIFIED OUTPATIENT PAPER PRESCRIPTION BLANK TO REDUCE PRESCRIPTION ERRORS.A.G. Kennedy1; B. Littenberg1. 1University of Vermont, Burlington, VT. (Tracking ID #115903)
STATEMENT OF PROBLEM/QUESTION
Omissions represent the most frequent category of prescription errors. Information technologies, such as computerized physician order entry, will likely represent the best long-term method to decrease prescription errors. However, these technologies have not yet been implemented in all outpatient settings. Low cost, low technology alternatives that are feasible now and are shown to reduce errors are warranted.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1. Pilot an outpatient, modified, paper prescription blank. 2. Obtain national feedback.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We developed and implemented a modified paper prescription blank in one outpatient adult Internal Medicine clinic. Using a 2-month before-after design, the pilot compared the modified blank to a standard blank. Prescriptions dispensed by the outpatient pharmacy located in the same building as the clinic were reviewed. The primary outcome measure was change in omissions between standard and modified prescriptions per provider. Omissions were based on the 13 legal requirements of a prescription. Scores ranged from 0–13, with a score of 13 meaning 100% complete or 0% omissions. Secondary outcomes included change in clinically relevant problems between standard and modified prescriptions and provider satisfaction. To obtain national feedback, we presented the modified blank as a poster at the 26th Society of General Internal Medicine (SGIM) Annual Meeting. Attendees were asked to complete mock prescriptions and a survey.
FINDINGS TO DATE/EVALUATION OF WEB SITE
A total of 443 prescriptions written by 11 providers were dispensed by the pharmacy during the study. 150 prescriptions (34%) were completed using modified blanks. Modified blanks increased prescription score by 0.47 points (95% CI 0.08–0.86, P = 0.02). Pharmacists documented clinically relevant problems with 1 modified and 9 standard prescriptions (P = 0.18). 55 SGIM attendees completed the mock prescriptions and survey. 38 people (69%) believed the modified blank would prevent errors. 34 people (62%) stated they would be willing to try the modified blanks for 30 days. Feedback was used to revise the modified blank.
KEY LESSONS LEARNED
Modified paper prescription blanks significantly decreased outpatient prescription omission errors. Feedback suggests providers are willing to use modified blanks. The low-cost, low technology modified outpatient paper prescription blank represents an immediate option for reducing prescription omission errors while awaiting the implementation of more comprehensive technology.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
A PRIMARY CARE DISEASE MANAGEMENT PROGRAM FOR PATIENTS WITH CHRONIC NON-MALIGNANT PAIN.P. Chelminski1; T. Ives1; M. Pignone1; S. Prakken1; S. Perhac1; D. DeWalt1; R. Malone1; T. Miller1; B. Bryant1; J. Ripton1; C. Felix1. 1University of North Carolina, Chapel Hill, NC. (Tracking ID #101651)
STATEMENT OF PROBLEM/QUESTION
Effective management of chronic non-malignant pain in primary care is difficult.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To test the effectiveness of a primary care, pharmacist-led disease management program for patients with chronic pain in a 3 month before and after trial.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We developed a multidisciplinary program for chronic pain that combines the skills of internists, clinical pharmacists, and experts in pain and addiction medicine in an academic general internal medicine practice. The program included structured clinical assessments, a computer registry, regular follow-up visits, pain contracts, psychiatric consultation, and substance abuse referral. Primary care providers referred patients for baseline and 3 month assessment of pain, mood, and function using the Brief Pain Inventory (BPI), the Center for Epidemiological Studies scale (CES-D) and the Pain Disability Index (PDI), respectively. We monitored substance misuse through history and urine toxicological testing (UTS).
FINDINGS TO DATE/EVALUATION OF WEB SITE
Eighty-five patients with chronic pain were enrolled in the trial. Mean age was 51 years, 60% were male, and 78% were Caucasian; 93% were receiving opioids. At baseline, the average pain score was 6.5 on an 11-point scale. The worst pain was 9.2; the least pain, 4.5; and current pain, 6.9. The average CES-D score was 24.0. Mean PDI score was 47, suggesting significant disability. Sixty-three patients (73%) completed 3 month follow-up. Fifteen did not follow-up after substance misuse led to discontinuation of opioids; eight were lost to follow up. At 3 months, the average pain score improved to 5.5 (P = .003); the worst pain to 8.1 (P < .001); the least pain to 3.9 (P = .038); and current pain to 5.8 (P = .014). The mean PDI score improved to 39.3 (P < .001). Mean CES-D score was 18.0 (P < .001), and the proportion of depressed patients fell from 79% to 54% (P = .003). Substance misuse was found in 27 (31%) patients: fifteen had UTS positive for cocaine (12) or amphetamines (3); three were receiving opioids from more than one provider; seven had UTS persistently negative for prescribed opioids; one diverted opioids; one altered an opioid prescription.
KEY LESSONS LEARNED
A primary care-based disease management program can improve pain, depression, and disability scores for patients with chronic pain. Substance misuse and depression were common, and effective care of patients with chronic pain should include rigorous assessment and care for patients with these important co-morbid disorders.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Poster/Presentation.
A STRATEGY TO IMPROVE UTILIZATION OF GROUP EDUCATION CLASSES FOR PATIENTS WITH DIABETES.R. Stroebel1; T. Poterucha1; R. Chaudhry1; S. Scheitel1; S. Bjornsen1; L. Muller1. 1Mayo Clinic, Rochester, MN. (Tracking ID #116688)
STATEMENT OF PROBLEM/QUESTION
Group diabetes education has been shown to improve clinical outcomes in patients with diabetes. Medicare and many private insurers will cover the cost of group education for qualifying patients. Previous efforts to enroll patients in available group classes, relying on physician referral or patient self-referral, were unsuccessful.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To consistently offer group diabetes classes to all eligible patients and maximize utilization of this resource.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Our diabetes registry was used to identify patients with diabetes who met Medicare eligibility requirements for reimbursement. Lists were generated of patients in a physician's panel with two consecutive HgbA1c values over 7% or with a new diagnosis of diabetes. Letters were sent to the identified patients inviting them to attend a weekly series of four 2 1/2-hour group classes. The letters included a list of covered topics, a description of the group class structure, a statement emphasizing the importance of good diabetes control, and a statement regarding reimbursement. The patients' primary care physician signed the letters. The physician had the option of not sending the letter if the classes were felt to be inappropriate for the patient. Each month for five months (2/03–6/03) two different physicians' patients were sent letters. Class attendance was monitored through 9/03.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Letters were sent to 154 qualifying patients of the ten participating physicians. A total of 23 patients who were sent letters attended at least one class from 2/03 to 9/03. The patients attended an average of 2.9 out of the series of 4 classes. This program improved enrollment in the monthly group classes from an average of 3.6 enrollees per month to an average of 6.5 enrollees per month.
KEY LESSONS LEARNED
The use of our diabetes registry allowed us to identify patients eligible for group diabetes classes on the basis of poor glycemic control or new diagnosis of diabetes. The response rate to letters inviting patients to participate in group diabetes classes was 15%. The strategy of sending letters directly to patients improved the utilization of our group classes compared to our existing options of physician referral or patient self-referral. Further work is needed to reach the 85% of eligible patients who choose to not participate.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
A WEB BASED TOOL TO ASSIST TRIAGE OF UPPER RESPIRATORY INFECTION/SINUSITIS IN ADULTS.R. Stroebel1; R. Chaudhry1; S. Scheitel1. 1Mayo Clinic, Rochester, MN. (Tracking ID #116012)
STATEMENT OF PROBLEM/QUESTION
A registered nurse (RN) managed, phone-based triage and treatment protocol for uncomplicated upper respiratory infection (URI)/sinusitis has been used successfully at our medical center over the past year. The average phone time by RNs using this protocol is approximately 10 minutes.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To facilitate patient access and reduce RN phone time a web-based form was developed to intake significant portions of the history required by the protocol.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
The first three sections of the URI/sinusitis phone protocol were converted to a web-based form. These sections covered current symptoms, associated symptoms, and medical history. A patient care site was established on our institution's intranet. As an initial pilot group an e-mail message was sent to patients who were employed at our institution directing them to the site. Upon completion of the questionnaire and submission of the form an e-mail message was generated and transferred to a web-based messaging center used by the RN staff. Nurses reviewed the message and phoned the patient to complete the treatment protocol. The phone call established proper treatment, confirmed allergies, and identified the pharmacy of choice. If red flag symptoms were identified patients were given an appointment with their physician.
FINDINGS TO DATE/EVALUATION OF WEB SITE
E-mail messages were sent to 1895 medical center employees in November 2003. During the initial 8 weeks of the program 12 employee/patients accessed the URI/sinusitis treatment protocol via the intranet. The previous year we averaged 37 total URI/sinusitis encounters per 1900 patients during the same time period. The average phone time required by the RN to complete a web submission for the protocol was 5 minutes. The nursing staff was uniformly satisfied with the new process. Initial patient feedback has been very favorable.
KEY LESSONS LEARNED
Web access to a RN telephone treatment protocol for uncomplicated URI/sinusitis is a viable option for patients and providers. One-third of employee/patients utilizing the URI/sinusitis protocol chose the intranet option. We anticipate increased usage as familiarity with this option grows. Total phone time spent on each encounter by our nursing staff has gone from 10 to 5 minutes. Future work will involve extending the opportunity beyond the health center employees to all empanelled patients.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
A WEB-BASED TOOL TO IMPROVE DECISION-MAKING AND ADHERENCE TO CORONARY HEART DISEASE PREVENTION.S.L. Sheridan1; M.P. Pignone1; J. Shadle1. 1University of North Carolina at Chapel Hill, Chapel Hill, NC. (Tracking ID #117356)
STATEMENT OF PROBLEM/ QUESTION
Previous studies have documented that patient awareness of global CHD risk is poor and utilization of effective primary prevention therapies to reduce coronary heart disease (CHD) risk is below 50%.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To evaluate a web-based tool to improve patients' awareness of their global CHD risk, physician-patient decision-making about CHD risk-reducing therapies, and adherence to treatment.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We have developed a web-based decision aid, called Heart-to-Heart, that calculates patients' overall risk of CHD event in the next 10 years using a continuous Framingham equation; educates them about their global risk, their contributing risk factors, and the benefits and harms of various risk reducing therapies; and encourages them to choose risk-reducing therapies that would be acceptable and feasible to them for long-term CHD risk reduction. To test this decision aid, we are conducting a pilot randomized trial in our university internal medicine practice that compares the decision aid against usual care among adults ages 35–75 with no previous history of CHD or stroke.
FINDINGS TO DATE/EVALUATION OF WEB SITE
To date, we have enrolled a convenience sample of 33 adults. Mean age was 53. 58% were female, 76% were white and 21% African-American. 64% had at least some college education. 30% had a CHD risk of 0–5%, 27% of 6–10%, 27% of 10–20%, and 12% of >20%. 27% reported they were already planning to do something to lower their CHD risk. 22 patients received the decision aid and 11 received usual care. We have observed no difference in the proportion of patients with a specific plan to adopt a new CHD risk reducing strategy (32% vs. 36%). In pre-post testing, however, patients who received the decision aid (n = 22) had heightened concern about CHD risk (46% versus 36% pre-decision aid) and were more likely to recognize that the same way of reducing CHD risk is not right for everyone (32% vs. 19% pre-decision aid). 67% of patients who received the decision aid additionally reported that they had enough knowledge to make a decision about CHD prevention. 90% of decision aid users reported that they could use the decision aid without help.
KEY LESSONS LEARNED
A web-based decision aid about global CHD risk and CHD risk reduction is feasible for use in clinical practice and offers promise to improve knowledge and attitudes about CHD risk reduction. It is too early to tell whether it will impact patients' plans to adopt risk-reducing behaviors.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
A WOMENS PREVENTATIVE HEALTH CLINIC: A NEW APPROACH TO AN OLD PROBLEM.M. Singh1; J. Rohl2. 1Metro Health System, Cleveland, OH; 2Case Western Reserve University, cleveland, OH. (Tracking ID #115783)
STATEMENT OF PROBLEM/QUESTION
Although routine health promotion has been shown to be beneficial, chronic disease and being female have been shown to be barriers to effective health promotion. In addition, residency training programs with high turnover rates of providers create an environment for “missed opportunities”.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
Using a multidisciplinary approach to improve preventative services for women with chronic medical conditions while providing essential health promotion education to internal medicine residents.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
This multidisciplinary clinic, staffed by Internal Medicine and Obstetrics and Gynecology faculty, meets 1/2 day every other week. The alternating week the residents attend a didactic session on health promotion topics. The first and second year residents rotate through this clinic as part of their ambulatory block rotation. At this clinic visit, the provider focuses on routine screening for osteoporosis, breast, cervical and colon cancers, lipid profiling, CAD risk assessment, depression and domestic violence screening. An electronic intake form, specifically created for this clinic, serves as a prompt for age appropriate screening. The patients, referred from continuity clinic, are aware that their health care maintenance will be the focus of this visit and that only emergent medical issues will be addressed. The residents are required to take a pre and posttest while rotating through the clinic and complete an evaluation of their experience.
FINDINGS TO DATE/EVALUATION OF WEB SITE
To date 15 residents have rotated through the clinic, This focused care clinic has been well received by the residents. Specifically, they like the direct education of patients regarding osteoporosis and hormone replacement. When asked how confident they felt dealing with PAP smears and osteoporosis screening after rotating through the clinic, the response was a 2.5 on a scale of 1–3 (1- less confident, 3- extremely confident). They also stated in their evaluation that they enjoy the focus on health care maintenance given the patients multiple medical problems. In addition, the supervision by the attending during the breast and pelvic exam is cited as an added benefit. The pre and posttest analysis is pending at the time of this abstract but some results should be available at the time of presentation.
KEY LESSONS LEARNED
Key lessons learned: A focused women's preventative clinic allows education of residents on essential health care promotions while providing patients with their much needed preventative care.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
ABIM PRACTICE IMPROVEMENT MODULES: LESSONS FROM THE FIELD.L.A. Lynn1; R.S. Lipner1; J. Folske1; D. Duffy1. 1American Board of Internal Medicine, Philadelphia, PA. (Tracking ID #116443)
STATEMENT OF PROBLEM/QUESTION
The evaluation of performance in practice is necessary in ensuring high quality medical care. The American Board of Internal Medicine (ABIM) developed interative, computer-based modules for this purpose as part of maintenance of certification. Results of a field test of the Preventive Cardiology Practice Improvement Module (PIM) are presented.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
We sought to determine if completing the Preventive Cardiology PIM is feasible and valuable for practicing physicians, and if it identified gaps between actual and ideal care.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
The Preventive Cardiology PIM uses data from physicians' practices, including anonymous patient surveys, chart reviews, and self-analysis of the practice system. The chart review is based on NIH guidelines for cholesterol and blood pressure management. Data are synthesized as an interactive report that summarizes key clinical outcomes, processes of care, and patient satisfaction measures. Field testers developed an improvement plan and evaluated the module.
FINDINGS TO DATE/EVALUATION OF WEB SITE
75 of 192 volunteer physicians (39%) completed the field test; they received credit toward recertification. Half were general internists, and most spent the majority of their professional time in patient care. On average, 18 patient surveys and 20 chart reviews were submitted for each participant, in addition to self-analysis of their practice system, an improvement plan, and evaluation of the module. Time for completion averaged 12 hours. Chart review data showed gaps between actual and ideal care. For example, the average percent of patients at or below the recommended goal for LDL cholesterol was 49%. Patient survey data and practice system reviews also suggested areas for improvement. 93% of the participants rated the overall value of the module as good, very good, or excellent. Participants rated components of the module on a 1 to 5 scale (strongly disagree to strongly agree). They generally agreed that the patient survey questions reflected important processes and outcomes (mean = 4.0, s.d. = 0.9), the chart review raised awareness of the quality of the care provided (mean = 4.2, s.d. = 0.8), and the practice system review raised awareness of how their practice system might be improved (mean = 4.1, s.d. = 0.9).
KEY LESSONS LEARNED
Completing the module was feasible but but complex. The PIM can be a valuable tool that highlights clinical guidelines and raises awareness about the quality of patient care.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
CD-ROM and toll-free telephone.
AN ELECTRONIC DIABETES REGISTRY AND POPULATION-BASED INTERVENTIONS IMPROVE DIABETES CARE.D.S. Smith1; G.M. Murphy1; D.V. Ravi1. 1Yale University, New Haven, CT. (Tracking ID #117135)
STATEMENT OF PROBLEM/QUESTION
Diabetes is a major contributing factor to CHD and stroke, leading causes of death in the US. Traditional paper medical records and encounter-based care often fail to make relevant information accessible for monitoring diabetes control at each visit, and population-level data is difficult to obtain to permit proactive interventions. A disease registry organizes this information and links it to evidence-based guidelines, facilitating tracking and intervention in multiple risk factors over time.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1) Use of a diabetes registry to organize and track key data elements and make them available at each encounter. 2) Apply evidence-based best practices (ADA guidelines) to clinical care. 3) Identify population-level targets for intervention. 4) Identify outlier patients for case management. 5) Improve processes of care and measures of control for our diabetic patients.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We used MS Access to develop an electronic diabetes registry. Each diabetic patient has a registry page containing updated indices, for use at each encounter regardless of the reason for that visit. Each clinician receives a quarterly summary report on the control status of diabetics in their panel. Population-based strategies we have utilized include: 1) Designation of a departmental nurse practitioner to tend the registry and develop programs. 2) Diabetes group visits. 3) Disease management outreach for outliers. 4) Targeted proactive interventions (such as mailed invitations to special flu shot clinics).
FINDINGS TO DATE/EVALUATION OF WEB SITE
In the three years since inception, we have increased our case identification by 19%, to 603 diabetics. There have been significant improvements in processes of care, such as an increase in pneumococcal immunization rate from 23% to 83%, dilated retinal exams from 45% to 71%, and use of urine microalbumin from 18% to 55%. Measures of control have also improved, such as glycosylated hemoglobin <7.0 from 26% to 35%, LDL cholesterol <100 from 42 to 49%, and blood pressure <130/80 from 59 to 78%.
KEY LESSONS LEARNED
A disease registry heightens attention to diabetes care at each encounter. Population-based priorities can be identified, and targeted programs developed. Focused attention uncovers patients “lost to follow-up” for whom control is often suboptimal, and helps identify the highest risk patients for intensive intervention. Significant improvement in control of risk factors can be achieved through intensification of monitoring and treatment, which we know from randomized trials will ultimately lead to improved patient outcomes.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
BUPRENORPHINE INITIATION AND MAINTENANCE IN PRIMARY CARE: A SUCCESSFUL INTERDISCIPLINARY APPROACH.D. Alford1; R. Saitz1; C. LaBelle1; J.H. Samet1. 1Boston Medical Center, Boston, MA. (Tracking ID #116758)
STATEMENT OF PROBLEM/QUESTION
New federal legislation made buprenorphine prescription for opioid dependence possible in primary care in 2003. But improved access to care requires feasible approaches to care for these complex patients.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To improve access to treatment for opioid dependence using an interdisciplinary clinical model.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We implemented collaborative care between primary care physicians and a nurse care manager (NCM). The NCM initially assessed substance use, medical and psychiatric history, and social support by telephone. For enrolled patients the NCM obtained laboratory tests and provided education and reviewed patient responsibilities (including signed consent). The NCM prepared a buprenorphine induction schedule based on physician-developed guidelines. Physicians reviewed and added to assessments, performed physical examinations, and prescribed buprenorphine. The NCM was in contact frequently with the patients until stable maintenance doses were achieved. The NCM encouraged mutual help meeting attendance, referred all patients for addiction counseling, and when needed for psychiatric evaluation, and provided appointment reminders. Patients had access to the NCM by cellular phone. At follow up visits, random urine samples for toxicology, observed dosing and pill counts occurred. With input from a patient's counselor and psychiatrist, individualized treatment plans were developed.
FINDINGS TO DATE/EVALUATION OF WEB SITE
In 6 months, 37 patients with opioid dependence were enrolled; 63% male, 96% white, median age 26 (range 18–52), 84% dependent on heroin and 16% dependent on sustained release oxycodone. Although 28% had medical co-morbidity, most (76%) had no primary medical care; 54% reported psychiatric co-morbidity but only 13% had previous psychiatric care. After 4 months, 30 (88%) remained in treatment; 1 tapered off, 3 switched to methadone maintenance, and 3 dropped out. Opioid urine tests were positive in: 100% at enrollment, 4% at 2 weeks, and 18% at 4 months. Other drug use (present in one quarter) changed little. At 4 months, 82% were regularly attending counseling (46%) and/or mutual-help meetings (50%), and 75% had social supports involved in their substance abuse treatment. The NCM averaged 17 patient contacts during the initial 2 weeks of treatment followed by 1–4 contacts per week. Physicians saw patients twice in 4 months on average.
KEY LESSONS LEARNED
Collaborative management of patients with opioid dependence with a nurse care manager resulted in feasible initiation and maintenance of buprenorphine in the primary care setting.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
CAN DISEASE MANAGEMENT INTERVENTIONS ENGAGE HARD-TO-REACH PATIENTS IN PRIMARY CARE?D. Schillinger1; H. Hammer1; M. Handley1; J. Palacios1; I. McLean1; A. Tang1; M. Schneiderman1; A.B. Bindman1. 1University of California, San Francisco, San Francisco, CA. (Tracking ID #116509)
STATEMENT OF PROBLEM/QUESTION
Little is known about the extent to which population-based approaches can engage high-risk patients with diabetes, such as those with limited health literacy and/or limited English proficiency.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
The goal of the IDEALL Project of the San Francisco Dept of Health is to implement and evaluate self-management support strategies for a diverse population. We are assessing the reach and effectiveness of a technologically-oriented and an interpersonally-oriented intervention, each tailored to the language and literacy needs of high-risk diabetes patients.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Through a primary care registry, we are identifying diabetes patients who have HbA1c >8.0% and speak English, Spanish, or Cantonese, and are randomly assigning them to one of two interventions over 9 months. The first, automated telephone diabetes management (ATDM), employs interactive voice response technology in patients' native language for weekly surveillance of self-care and symptoms. Out-of-range answers trigger a response of ATDM health education or live-person phone follow-up through a bilingual nurse who encourages goal-setting through behavioral “action plans”. The 2nd intervention, group medical visits (GMVs), involves 6–10 patients in monthly meetings. Facilitated by a bilingual health educator and primary care physician, GMVs monitor disease status and encourage patients to become active participants in self-care through participatory learning and action plans.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Our initial findings focus on patient engagement with the two interventions over the first 3 months. Of 53 patients randomized so far, 45 (85%) are non-white, 28 (53%) have limited health literacy, 22 (42%) limited English proficiency, and mean HbA1c is 9.8%. Among ATDM patients (n = 27), 24 (89%) have completed at least one ATDM call; 21 of 24 (88%) have triggered at least one nurse call-back; and 19 of 21 (90%) have generated action plans. Among GMV patients (n = 26),18 ( 69%) have attended at least one GMV session; 7 of 18 (39%) have attended all GMVs; and 14 of 18 (78%) have generated action plans. Facilitators report “moderate” to “full” participation during GMVs for 16 of 18 attendees (89%).
KEY LESSONS LEARNED
Diabetes disease management strategies tailored to the language and literacy needs of high-risk patients appear to be associated with significant levels of patient engagement and have potential as adjuncts to primary care.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
We will demonstrate use of the ATDM system in 2 languages.
CARVING BACK DEPRESSION TREATMENT INTO PRIMARY CARE: A DEMONSTRATION PROJECT.M.D. Feldman1; M. Ong2; J. Bachman3; L. Sept1; P.A. Arean1; M. Wyman1; E.J. Perez-Stable1. 1University of California, San Francisco, San Francisco, CA; 2Stanford University, Palo Alto, CA; 3United Behavioral Health, San Francisco, CA. (Tracking ID #115200)
STATEMENT OF PROBLEM/QUESTION
Depression often goes unrecognized in primary care settings, and even when detected may not be treated according to evidence-based guidelines. Barriers to proper depression care include lack of provider training, lack of adequate systems of care and “carved-out” health insurance coverage for mental illness. When mental/behavioral health care is carved out to and paid by a managed behavioral care organization (MBCO), the primary care practice may have little incentive to improve the quality of depression care.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1) Create and test new financial mechanisms by which primary care providers are paid by the MBCO for provision of depression care. 2) Train primary care providers in the chronic illness model of depression care.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
The UCSF DGIM is leading one of eight national demonstration projects supported by the RWJ Foundation initiative “Depression in Primary Care”. In partnership with United Behavioral Health (UBH-the MBCO) and Blue Shield of CA (BSC-the health insurer) we have modified the economic and clinical relationships among the 3 organizations such that UCSF PCPs are credentialed and paid to treat depressed BSC patients whose behavioral health insurance is managed by UBH. Credentialed PCPs can bill UBH directly for a 15-minute “medication management” visit with their depressed patients. A UBH care manager coordinates the patients' care and maintains a registry to track pertinent clinical data.
FINDINGS TO DATE/EVALUATION OF WEB SITE
At baseline, PCP's felt that the current “carved-out” mental health system was unresponsive to their patients needs. To date, 79% (31) of eligible primary care PCP's at 4 UCSF primary care practices have been credentialed. They have identified 20 eligible patients. PCP's report participating in the project because they are financially compensated for spending more time with depressed patients and because they have access to a care manager and psychiatric consultation. PCP's are eligible to be paid directly by UBH for depression care in a unique financial arrangement not previously reported. Treatment outcomes, utilization, costs and patient and PCP satisfaction are being measured.
KEY LESSONS LEARNED
Primary care practices and patients are frustrated by the “carved-out” mental health system and are open to new clinical and economic models that incorporate the chronic care framework for depression treatment. Reimbursement of depression treatment by primary care providers can be achieved in an open health care system.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
poster/oral presentation, PCP training/credentialing materials.
CATCHING DEPRESSION EARLY: OUTREACH SERVICES TO MEDICALLY ILL PATIENTS.M.K. Ong1; M.D. Feldman2; J. Bachman3; F. Azocar3. 1Stanford University, Stanford, CA; 2University of California, San Francisco, San Francisco, CA; 3United Behavioral Health, San Francisco, CA. (Tracking ID #117191)
STATEMENT OF PROBLEM/QUESTION
Medically ill patients often have co-morbid mental illness, particularly depression, but are less likely to use mental health services compared to other patients. Early detection and treatment of depression may minimize the health and economic costs of depression.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
Determine whether telephone-based outreach services can improve utilization of mental health services by medically ill outpatients. Future analyses will examine the cost-effectiveness of these outreach services.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Medically ill individuals were identified from a large national employer by administrative health care utilization data. Primary-care patients in the intervention group were contacted by telephone-based outreach counselors, who performed behavioral health screening and offered referrals to mental health clinicians, support groups, support services, financial counseling, and legal aid. These patients will be matched to controls by demographics, medical diagnosis, and prior year medical costs. Cost and utilization data are being collected for the intervention and control groups.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Preliminary data on the 164 intervention individuals shows 135 (82%) were contacted by outreach counselors. Of the contacted individuals, 19% declined services and 9% did not need services. Among the contacted individuals, specialty mental health utilization increased from 2% six months prior to referral to 29% within six month of referral. During the six month period after referral, 9% of intervention individuals and 6% of controls had medical claims including a mental illness diagnosis. In the subsequent 11 months, 4% of intervention individuals and 8% of controls had medical claims including a mental illness diagnosis. Depression and adjustment disorder together made up 63% of all mental illness diagnoses.
KEY LESSONS LEARNED
Telephone-based outreach services are an effective method of engaging medically ill patients at risk for co-morbid depression with the mental health care system. These services could be incorporated into general medicine practices to improve the care of medically ill patients with co-morbid depression and other mental illnesses.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
DETERMINING REASONS FOR NONCOMPLIANCE WITH HEDIS DIABETIC MELLITUS GUIDELINES USING AN ELECTRONIC MEDICAL RECORD.P.E. Roemer1; D. Dunham1; D. Baker1. 1Northwestern University, Chicago, IL. (Tracking ID #117467)
STATEMENT OF PROBLEM/QUESTION
While it is understood that many patients who have diabetes do not get regular HgbA1C testing, little is known as to why this is the case.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
Our goal was to identify and quantify the reasons in which patients with diabetes did not get HgbA1C testing, and to determine the role of the electronic medical record (EMR) in measuring HgbA1C compliance in diabetic patients.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We used our institutional EMR to employ a quality improvement query to identify our patients who had a diagnosis of diabetes but who did not have a HgbA1C tested over the ensuing year. After identifying the patients who did not have a HgbA1C checked, we developed a protocol for chart review to determine why patients did not have this routine screening test done.
FINDINGS TO DATE/EVALUATION OF WEB SITE
We found that of our approximately 20,000 patients we had 1403 that were diabetic. 200 of the 1403, or 14% did not have a HgbA1C checked in the year queried. Of those 200: 16, or 8% were misdiagnosed with diabetes and did not have a HgbA1C checked; 15, or 7.5% were first diagnosed with diabetes in 2003 (after the 2002 audit period); 12, or 6% had blood work for HgbA1C done at another site; 35, or 17.5% had blood work ordered but not completed by the patient; 14, or 7% did not adhere to recommended follow-up visits made by the physician; 63, or 31.5% were seen for urgent care appointments only and did not have follow-up for diabetic care; 26, or 13% of the patients were thought to have terminal illness and did not warrant tight glucose control; 19, or 9.5% had no reason not to have HgbA1C checked.
KEY LESSONS LEARNED
1) An EMR can effectively identify diabetic patients who have not had HgbA1C testing 2) Non-adherence to physician recommendations was the main reason for not having a HgbA1C performed in this study.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
EMBARKING ON A HOSPITAL-WIDE TOBACCO USE CESSATION INITIATIVE.C. Milch1; S. Campbell1; A. Simon1; A. Huse1; P. Noga1. 1TUFTS-New England Medical Center, Boston, MA. (Tracking ID #116146)
STATEMENT OF PROBLEM/QUESTION
Approximately 6.5 million smokers are hospitalized annually, motivating many to consider quitting, however, most are not advised to quit. Although the AHRQ Clinical Practice Guidelines recommend that hospitals institute systematic identification and treatment of every tobacco user, most hospitals have not due to organizational issues and financial concerns.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To design and implement a hospital-wide Tobacco Cessation Initiative to systematize the identification of patients who use tobacco and provide them with cessation assistance.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
The overarching goal of the initiative was ease of use to promote acceptance and adoption of its components. Key components were: a) Development of a brief form with checkboxes to assess and document patient tobacco use and desire to quit, and to prompt cessation assistance by clinicians; b) Partnering with a free tobacco cessation resource service offered by the Massachusetts Department of Public Health; and c) Implementation within existing hospital budget. Implementation occurred by: a) Securing top-level physician and nursing leadership support; b) Building a multidisciplinary team of dedicated physicians, nurses, and administrative personnel; c) Identifying unit-based nurse (RN) “champions” to promote the initiative and oversee operational aspects; d) Educating clinicians to become cessation “experts” through monthly education sessions; and e) Training a certified Tobacco Treatment Specialist (TTS) for post-discharge referral. To ensure equal care for non-English-speaking patients, the assessment form was translated into 7 languages and hospital interpreters were instructed on its use.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Based on pilot data, an estimated 25% (4,000 per year) of patients hospitalized at our institution use tobacco. 50% of patients agreed to the cessation referral service. The program implementation non-salary costs were $1300 for TTS training and development of educational sessions. We estimated annual additional RN time spent identifying tobacco users and offering cessation support is 667 hours (0.17 hrs./smoker). If the initiative doubles quit rates from 5% national baseline to 10%, the estimated additional annual RN time per additional quitter is 3.3 hrs. (667 hrs./200 quitter) and per additional life saved is 10 hrs. (667 hrs./prevention of 30% premature deaths: 67).
KEY LESSONS LEARNED
A hospital-wide initiative to systematically identify tobacco users and offer cessation support is achievable without substantial practice changes or additional costs, and can be widely replicated in hospitals throughout the US.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING: SLIDES AND HANDOUTS.
GROUP VISITS AND ACADEMIC GENERAL INTERNAL MEDICINE.D.E. Clancy1; K.S. Davis1; E. Brownfield1; M. Poston1; T. Wolfman1. 1Medical University of South Carolina, Charleston, SC. (Tracking ID #115666)
STATEMENT OF PROBLEM/QUESTION
Are group visits for inadequately insured patients with type 2 diabetes feasible and acceptable in an academic general internal medicine setting?
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1) Evaluate the acceptability of health care delivery in group visits by patients, physician faculty, and trainees. 2) Evaluate the feasibility of healthcare delivery in monthly group visits for inadequately insured patients with type 2 diabetes in an academic setting. 3) Evaluate health outcomes as measured by HgbA1c, BP, and cholesterol response in patients with type 2 diabetes seen in group visits. 4) Evaluate effectiveness of group visits as a method for healthcare delivery in an academic setting through adherence to American Diabetes Association guidelines, as compared to usual care, and RVUs, as compared to national benchmarks.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
188 patient with type 2 diabetes were randomized to receive care in group visits or usual care for 12 months. Six General Internal Medicine Faculty Physicians conducted the monthly group visits in a clinic that predominantly serves inadequately insured patients. Internal Medicine residents, medical students, and physician assistant students observed group visits during their month long ambulatory care rotations, completing Pre- and Post-observation Patient Physician Orientation Scale questionnaires to evaluate attitudes and expectations before and after the observation periods. Hgba1c, cholesterol, and blood pressure measurements, as well as patient satisfaction questionnaires were obtained from the patients at baseline, 6, and 12 months. Faculty physician opinions and expectations were elicited through focus groups before and after the 12-month intervention.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Patients, trainees, and General Internal Medicine Faculty physicians have found group visits an acceptable and feasible method of healthcare delivery. We are analyzing the data and will present results/trends in health outcomes, guideline adherence, patient, faculty physician, and trainee satisfaction.
KEY LESSONS LEARNED
Group visits are acceptable and feasible as a model for healthcare delivery in an academic General Internal Medicine setting.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Videotape of group visit; poster of findings; onsite discussion with participating Faculty Physicians from the group visits.
GUIDELINES VS. REALITY: PHYSICIAN EXPLANATIONS FOR NOT ADJUSTING CHOLESTEROL THERAPY.W.T. Lester1; R.W. Grant1; H.C. Chueh1. 1Massachusetts General Hospital, Boston, MA. (Tracking ID #117030)
STATEMENT OF PROBLEM/QUESTION
Despite awareness of evidence-based guidelines, cholesterol management remains persistently sub-optimal in clinical practice.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
Efforts to improve quality of cholesterol management require a clear understanding of physician reasons for not optimizing therapy. We conducted a randomized trial of an informatics-based intervention to identify patients with coronary artery disease (CAD) or risk equivalents with LDL cholesterol (LDL-C) levels >100 mg/dL. The intervention facilitated cholesterol management via a “one-click” order-writing (described below). When primary care physicians (PCPs) deferred action, a “pop-up” questionnaire enabled PCPs to explain why evidence-based guidelines were not applied for that particular patient. We report here the results of this questionnaire (trial results will be reported elsewhere).
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
For each intervention patient, the PCP was alerted by a content rich e-mail message that provided: recent LDL-C trends, current medications, decision support with predicted LDL-C decline by statin dose, and other pertinent clinical data (co-morbidities, most recent visit note, allergies, liver function results). By clicking on one of three icons, PCPs could: 1) print a new statin prescription and corresponding patient letter, 2) print a completed lab requisition for a repeat fasting lipid panel and corresponding letter, or 3) defer any action. PCPs did not receive any information regarding their control patients. Block-randomization ensured equal numbers of intervention and control patients for each PCP.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Fourteen PCPs and 276 patients participated. Intervention patients (n = 124) were 51% women, 17% non-white race/ethnicity, with mean age = 64.8 (14.7) years and mean LDL-C = 125 (22) mg/dL. PCPs ordered a new prescription or repeat testing in 34 patients (27%) and deferred action in the remaining 90 (73%). The most common explanation for deferring action was “close enough” LDL-C (32 patients, 36%; mean LDL-C = 111.4 mg/dL). Explanations among the remaining 58 patients included: upcoming appointment (9 patients), other medical problems, e.g. metastatic cancer, severe stroke, alcoholism (9), cared for by another physician (8), and patient refusal to increase regimen (4). Two patients had adverse effects to statins, 2 were deemed too elderly (98 and 80 years old), and one had myocardial infarction by non-CAD mechanism (chest trauma).
KEY LESSONS LEARNED
An intervention to identify patients above cholesterol goal and facilitate evidence-based care resulted in therapy changes for less than a third of patients. Quality improvement efforts must account for the many reasons PCPs may have for individualizing their management of this seemingly straightforward clinical issue.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Powerpoint screen shots of e-mail intervention, new prescriptions, laboratory requisitions, patient letters, and “pop-up” PCP questionanire.
HELPING PRIMARY CARE PHYSICIANS COUNSEL MENOPAUSAL WOMEN: THE MENOPAUSE INTERACTIVE DECISION AID SYSTEM.N.F. Col1; G. Weber2; M.G. Cyr3; J.M. Fortin1; C. Landau4; D. Snyder1; R. Goldberg5. 1Brigham and Women's Hospital, Boston, MA; 2Harvard University, Boston, MA; 3Brown University, Providence, RI; 4Rhode Island Hospital, Providence, RI; 5University of Massachusetts Medical School (Worcester), Worcester, MA. (Tracking ID #117470)
STATEMENT OF PROBLEM/QUESTION
The complex health needs of menopausal women are poorly met.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To develop and test a Menopause Interactive Decision Aid System (MIDAS) to help clinicians counsel women about menopausal symptom management and prevention.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We developed the web-based MIDAS, which embeds a patient-specific Markov model and an evidence-based database of menopausal treatments. Treatment options are presented in an interactive matrix that can be sorted according to efficacy, treatment type, and symptom concerns, and includes explanations about treatment risks and benefits. Other features include personalized risk reports (cardiovascular disease, breast cancer, hip fracture); the impact of common treatments on these risks and menopausal symptoms; contraindications to specific treatments; tools that track symptoms; and a clinician summary of the patient's information. MIDAS was designed to enable immediate updating of the content database and risk models. Healthy peri- and postmenopausal women between the ages of 45 and 65 were recruited through fliers and clinician referral for usability testing lasting 1–2 hours. Participants independently interacted with MIDAS, performed structured tasks, and evaluated each section.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Usability testing (N = 9) results were favorable overall (89%). The treatment matrix and risk report sections were well-received and easily navigated. Specific responses included “attractive, clean, clear, easy to manipulate, helps you get answers you need”. These usability findings are limited by small sample size, but guided the design and content of MIDAS. A randomized, controlled trial evaluating the impact of MIDAS in various primary care settings is in progress (N = 220), measuring its impact on patients' decisional conflict, decision satisfaction, knowledge, and risk perception; on patient-provider communication; on the efficiency of the counseling session and provider evaluation; on medical errors; and on utilization of health care resources.
KEY LESSONS LEARNED
Usability data suggest that MIDAS is well-received by women who are making decisions about menopausal therapies and has the potential to improve menopausal counseling.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
MIDAS will be shown using an online demo.
IMPLEMENTING A GROUP VISIT MODEL FOR ADULT PATIENTS WITH DIABETES: A PILOT.V. Weber1; J. Bulger1; J. Sim1. 1Geisinger Medical Center, Danville, PA. (Tracking ID #115691)
STATEMENT OF PROBLEM/QUESTION
Optimal control of type 2 diabetes mellitus is an important and common clinical challenge in general internal medicine practice. One-on-one physician-patient encounters often do not provide adequate resources or time to address the educational and preventive needs of this population.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
In a data inquiry of our electronic medical record, we determined that ony 39% of our patients had hemoglobin A1c levels of less than or equal to 7.0%. Similarly, performance in screening interventions fell short of benchmarks. The goal of this pilot was to test new, team-based approaches to providing diabetes care and prvention.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Group visits provide an alternative to one-on-one physician visits which can enhance patient satisfaction and improve patient outcomes. Our practice has previously reported the successful use of a group model in osteoporosis education, however we wanted to extend the model to combine education, the performance of screening and prevention measures, and clinical care. A physician and RN Certified Diabetic Educator (CDE) devised a joint group visit model. Diabetic patients from this physician's panel were invited to participate in a series of evening sessions which combined group education with individual one-on-one time with their physician. Four visits were held once weekly over a four week period. Education topics included basic monitoring, nutrition, exercise, foot care, and self-management. The physician met with each patient individually to make decisions regarding medication adjustment and answer questions. The patients received a follow-up appointment at three months and at one year to monitor progress, and maintained contact with the CDE in the interim.
FINDINGS TO DATE/EVALUATION OF WEB SITE
In the pilot group, the average hemoglobin A1c decreased from 8.5% to 7.5% in the first four months of the program. At baseline, only 14% of the group had a hemoglobin A1c below 7.0%. This increased to 43% over the period of study. Patients were highly satisfied with the program, and demonstrated improved knowledge of diabetes standards of care and glucose monitoring as a result of the pilot.
KEY LESSONS LEARNED
Group visits can improve short term diabetes control as measured by hemoglobin A1c, as demonstrated in this pilot study. Although a larger study involving longer term endopoints and clinical outcomes is needed, this pilot gave the impetus to expand the program within our practice, and provides evidence that this model can succeed in a traditional general internal medicine practice.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Poster, one-on-one interaction.
IMPROVEMENT OF BILLING IN A UNIVERSITY MEDICAL CENTER.D. Mcadams1; D. Simak1; W.N. Kapoor1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #117250)
STATEMENT OF PROBLEM/QUESTION
Our practice experienced wide billing variability and inappropriate levels of charges for inpatients.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1. Improvement in admission, subsequent, and discharge day billing for the appropriate level of complexity. 2. Decreased variability of billing among physicians in our practice.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
By internal department review we found that many of our physicians were far under their potential inpatient billing level, despite seeing highly complex patients in a tertiary care center and completing the necessary chart documentation. Also, there was wide variability of billing practices for physicians in our group, even though the inpatient population seen by these practitioners was the same. There are several reasons for these problems. First, physicians do not understand billing rules or remember charting guidelines. Second, physicians often do not understand the implications of incorrect billing for their practice. Finally, time constraints occasionally restricted a physician from seeing a patient, and therefore a bill could not be submitted. Through a Quality Improvement initiative at our facility, we proposed several interventions to address and correct these problems. We hired a full-time Patient Billing Specialist to train, audit, and support faculty physicians. The billing specialist would meet with physicians prior to inpatient medicine rotations to review guidelines and cases; would attend a weekly meeting with physicians on the inpatient service to review their ongoing billing and documentation questions; and would review charts with physicians in real-time on the medical wards. Billing cards were revised for more simplicity and clarity. Finally, the attending-resident teaching conferences were reorganized to allow for increased clinical and charting time.
FINDINGS TO DATE/EVALUATION OF WEB SITE
1. Billing appropriateness improved as compared to the National E/M bell curve and as confirmed by billing specialist chart review (Admission High Complexity billing increased from 17 to 51%; Subsequent Care Moderate Complexity billing increased from 42 to 85%; Discharge Day billing increased from 77 to 96%). 2. Physician billing variability was substantially reduced. 3. Billing revenue increased an estimated $78,000 for one quarter.
KEY LESSONS LEARNED
1. Inpatient billing is within the control of the Division of Internal Medicine, and it improved with corrective actions set about by a Quality Improvement team. 2. Appropriateness of physician billing will increase if practitioners are educated, if they have time to document encounters, and if they are given technical support. 3. Physicians were given reassurance by having an accessible billing specialist.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
IMPROVING ACCESS.S.M. Scheitel1; R.J. Stroebel1; R. Chaudhry1. 1Mayo Clinic, Rochester, MN. (Tracking ID #115465)
STATEMENT OF PROBLEM/QUESTION
Patients in the primary care internal medicine practice at Mayo Clinic, Rochester could not get timely access to see their physicians. The average number of calendar day until the third available appointment was 37 days.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To provide timely access to patients who called for an appointment with their physician or physician team.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Piloted the intervention with three physicians and disseminated to the entire practice of 35 physicians. Two simple ground rules were established: 1. If you are working you see your own patients 2. When you are absent your team sees your patients. During the early stages of the intervention physicians worked down appointment backlog. The estimated demand for same day appointment slots was determined for each day of the week. The number of appointment types was simplified. Appointment type prioritization was eliminated. Optimal patient panel sizes were established to provide timely access. Appointment capacity was created by increasing non-visit care options for patients such as treating acute ills by nurse telephone protocols, communicating test results by telephone or correspondence, re-designing the delivery of preventive services and examining return visit intervals.
FINDINGS TO DATE/EVALUATION OF WEB SITE
The number of calendar days until the third available appointment fell from 37 days to 7 days after the first 7 months of implementation. The number of calendar days for the third same day appointment fell to zero days in the pilot group and remained at 8 days in the non-pilot group. Most days the number of patients seen by the pilot physicians roughly matched the number of allotted appointment slots. Appointment capacity was available for new patients. There was increased patient, appointment secretary and nursing satisfaction.
KEY LESSONS LEARNED
Providing timely access to patients is achievable in an academic, primary care, internal medicine practice. Patient's needs must be accommodated by both by visit and non-visit care. Ongoing measurement is essential to maintain optimal access.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Will present in any format.
IMPROVING ACCESS TO CARE FOR PATIENTS WITH CHRONIC HEPATITIS C IN AN INNER CITY HOSPITAL: PAIRING GENERAL INTERNISTS AND SPECIALISTS IN A MULTIDISCIPLINARY CLINIC.J.I. Tsui1; N. Traub1; N. Levy2; C. Iverson1. 1Emory University, Atlanta, GA; 2New York University, New York, NY. (Tracking ID #116928)
STATEMENT OF PROBLEM/QUESTION
Increasing numbers of patients are becoming aware of that they are chronically infected with hepatitis C (HCV). Recent improvements in HCV therapy offer better outcomes, however, inadequate access to care may limit the number of patients receiving treatment. We recognized that many patients with chronic HCV infection at Grady Memorial Hospital (a large public, urban hospital in Atlanta) were not receiving treatment for their disease. We perceived that this was because most general internists did not feel comfortable treating HCV-infected patients in medical clinic, and specialty resources were limited.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To create a multi-disciplinary clinic where general internists take primary responsibility for managing patients with chronic HCV infection in conjunction with a hepatologist.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
The Grady Health System Liver Clinic is an innovative clinic designed to facilitate referral and treatment of patients with HCV. It operates one half day per week out of the General Medicine Clinic. The clinic is staffed by three general internists, a physician assistant, pharmacist, social worker, and a hepatologist. The hepatologist serves primarily as a consultant for the internists who do the majority of direct patient care. Patients are able to self-refer to the clinic.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Since its inception in May 2002, the clinic has a rapidly growing patient base. During the first 18 months, 468 patients have been enrolled in the clinic. The clinic demographics are as follows: median age 48 years; 45% female, 55% male; 76% African American, 20% White, 3% Hispanic/Asian/Other. The frequency of substance abuse problems is high: 56% report a history of IVDU, 63% report a history of cocaine use, and 31% report current alcohol use. Educational and employment levels are low: 43% have not graduated from high school, and 80% are unemployed. The majority of patients were diagnosed after 2001, demonstrating that newly diagnosed patients are expeditiously being referred to the clinic for care. The internists report that their knowledge and skills have rapidly improved, and they feel comfortable managing their patients within a multidisciplinary setting.
KEY LESSONS LEARNED
A multi-disciplinary clinic based in the general medicine setting for treating patients infected with HCV is feasible. The benefits for such a clinic are: 1) improved access to treatment in a setting where specialist resources are limited 2) multi-disciplinary support for the complicated patient needs associated with HCV treatment 3) expanded physician expertise in the management of chronic HCV infection.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
IMPROVING SURGICAL RISK ASSESSMENT, RISK FACTOR DOCUMENTATION, AND PERIOPERATIVE BETA BLOCKER UTILIZATION WITH A EVIDENCE BASED PHYSICIAN RISK EVALUATION FORM. R. Robinson1; R.C. Bussing1; C.Y. Todd1; L. Rogers1. 1Southern Illinois University, Springfield, IL. (Tracking ID #117224)
STATEMENT OF PROBLEM/QUESTION
Beta blocker therapy in intermediate and high risk patients is known to reduce peri-operative cardiac events in non-cardiac surgery. Clinicians do not consistently recognize surgical risk factors and underutilize beta blockers.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
The purpose of this study was to determine the impact of an evidence based risk assessment form on: 1. physician recognition and documentation of risk 2. utilization of beta blockers.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We designed a pre-operative risk assessment form incorporating the Revised Cardiac Risk Index (Circulation 1999; 100:1043–49) and minor predictors of cardiac risk from Mangano (NEJM 1996; 335:1713–20). This form was provided to the 15 members of the SIU division of general internal medicine. Form use was voluntary.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Charts from 161 patients (100 pre-intervention, 61 post-intervention) undergoing risk assessment for non-cataract surgery were reviewed. The Chi square test was used to compare data before and after intervention. The study population was 38% female and 83% Caucasian with a mean age of 64 +/− 14 years. No significant demographic differences were found between the pre- and post-intervention groups. At the time of risk assessment, 24% were on beta blocker therapy for another indication. The preoperative risk assessment form was used for 82% of the post intervention preoperative risk assessments, and documentation of surgical risk factors improved from 59% to 79% (P = .01). Greater documentation of operative risk was found for the post-intervention group when compared with pre-intervention (82% vs. 36%, P < .001). Similarly, the post-intervention group demonstrated more frequent initiation of new beta blocker therapy at the time of the preoperative risk assessment visit (18% vs. 1%, P < .001), and greater overall rate of beta blocker therapy (43% vs. 25%, P = .015).
KEY LESSONS LEARNED
1. Use of a standardized physician preoperative risk assessment form improves documentation of operative risk and surgical risk factors. 2. The use of this form also increases utilization of beta blocker therapy to reduce perioperative cardiac risk.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
1. small group presentation with power point and handouts 2. poster presentation.
INCREASING UTILIZATION OF PREVENTATIVE SERVICES IN AN INTERNAL MEDICINE CLINIC.G.S. Fischer1; B. Ling1; D. Simak1; W.N. Kapoor1. 1University of Pittsburgh, Pittsburgh, PA. (Tracking ID #115912)
STATEMENT OF PROBLEM/QUESTION
A chart review in an internal medicine clinic revealed underutilization of widely-accepted preventative services (PS).
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To increase utilization of PS (cholesterol screening, colorectal cancer screening, mammography, Pap tests, and vaccinations against Pneumococcus, influenza, and tetanus).
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
A multi-disciplinary Quality Improvement Team was assembled, consisting of physicians (MDs), nurses, medical assistants (MAs), phone receptionists, and medical records clerks. The team developed a multi-leveled intervention that included: (1) mailing patients (PTs) birthday cards reminding them to schedule annual prevention visits (PVs), (2) offering PVs to PTs when they call, (3) streamlining the electronic health maintenance flow sheet (HMFS) and reeducating MDs in its use, (4) having medical records clerks enter outside reports of PS into the HMFS ahead of PT visits, (5) developing patient education material to assist MDs in explaining PS, (6) creating electronic alerts to prompt MAs to order immunizations, and (7) providing quarterly feedback to MDs.
FINDINGS TO DATE/EVALUATION OF WEB SITE
There were increases in cholesterol screening (from 85% to 94%), colorectcal cancer screening (65% to 73%) mammography (69% to 76%), Pap testing (57% to 72%), and immunizations against pneumococcus (13% to 86%), influenza (55% to 76%), and tetanus (34% to 58%). There was striking interphysician variability. Physicians who were poorly compliant admitted to not using the HMFS regularly. Resident PTs had lower utilization rates than faculty PTs.
KEY LESSONS LEARNED
1. An approach involving interventions at various points in the health care delivery system increased utilization of PS. 2. PTs of physicians who used the HMFS regularly utilized more PSs. 3. Interventions to increase the usage of the HMFS will be critical to ongoing improvement, and 4. Residents will need to be more fully included in ongoing improvement efforts.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Demonstration of computer based HMFS and immunization alerts. Presentation of work products of the multi-disciplinary project team, including flow charts and cause and effect diagrams.
INNOVATION IN PRACTICE: ATHENA DSS HYPERTENSION MANAGEMENT SYSTEM.M.K. Goldstein1; A.S. Chan2; S.B. Martins3; R. Coleman3; M. Shlipak4; H.B. Bosworth5; E.Z. Oddone5; M.A. Musen6; B.B. Hoffman7. 1Stanford University, Palo Alto, CA; 2Stanford Medical Informatics, Stanford, CA; 3VA Palo Alto Health Care System, Palo Alto, CA; 4University of California, San Francisco, San Francisco, CA; 5Duke University, Durham, NC; 6Stanford University, Stanford, CA; 7Harvard University, West Roxbury, MA. (Tracking ID #116784)
STATEMENT OF PROBLEM/QUESTION
Information technology can support improved physician adherence to practice guidelines; however, it is hard to integrate decision support into clinical workflow
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
(1) Implement a guideline-based clinical decision support system for hypertension (HTN) into the clinical workflow of primary care clinics. (2) Evaluate the implementation by observing the extent of the clinician's use of the system.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
We provided automated decision support, ATHENA DSS, through pop-up windows in the Computerized Patient Record System (CPRS) in primary care clinics at three geographically diverse VA medical centers. ATHENA DSS combines patient data from CPRS with a HTN knowledge base to generate advisories about blood pressure (BP) control and drug management for hypertensive patients at each clinic visit. Clinicians may interact with ATHENA DSS by updating BP measurements from those recorded in CPRS, clicking a button indicating that recommendations have been considered, or simply allowing ATHENA's window to timeout (close). ATHENA also has a window to collect clinician feedback by checklist or free text.
FINDINGS TO DATE/EVALUATION OF WEB SITE
The ATHENA DSS displayed HTN advisory pop-up windows to 91 clinicians over a 15-month period. Recommendations were displayed for 10,165 unique patients (mean 112/clinician) and 17,219 patient visits (mean 189/clinician). Of the 86 of 91 clinicians who interacted with ATHENA DSS, eighty-six percent (74/86) updated the advisory by entering a new BP. Forty three percent of clinicians entered free text feedback. Overall, clinicians interacted with the ATHENA DSS for 55% of the patient visits, an interaction rate stable throughout the study period. Clinicians have interacted with the system extensively- updating BPs, sending text comments, and considering recommendations.
KEY LESSONS LEARNED
Integration of automated decision support for hypertension into primary care clinics is feasible and the usability and usefulness of the system is demonstrated by the extensive clinician interaction with the system.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
—Microsoft Powerpoint—Live demonstration of ATHENA DSS.
INTRODUCTION OF AN ADVANCED ACCESS MODEL INTO AN ACADEMIC SETTING.D.N. Goldson-Prophete1. 1University of Medicine and Dentistry of New Jersey, Newark, NJ. (Tracking ID #115388)
STATEMENT OF PROBLEM/QUESTION
How to reduce the wait time for a new appointment in an outpatient ambulatory care practice?
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
1. Decrease wait time for new appointments to 14–21 days 2. Increase patient visit volume
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
A typical “open-access” model reduces the time to the next available appointment to zero. This model is predicated on full–time physicians that maintain a percentage of open appointments on each day. However, in our academic practice faculty members are only available for clinical duties on a part-time basis each day. The Modified Open-Access Model (MO-AM) was an attempt to adjust a typical open access model to the challenges of an academic setting. All new patients were given the choice between the next available regularly scheduled appointment (4–6 weeks), or an MO-AM appointment in 24–48 hrs (72 hrs on a Friday afternoon). A limited number of appointments are available on each day for these patients. These appointments are kept in a separate book wherein slots are only made available on a weekly basis to avoid “booking” into the future.
FINDINGS TO DATE/EVALUATION OF WEB SITE
MO-AM was implemented in January of 2003. There were 7522 patient visits in the period from January to May of 2003. There were 5493 visits during the same period in the prior year (January to May of 2002). This represents a 36.9% increase in the visit volume for the practice. In addition, the actual number of patients seen in this period was 3391 as compared to 2736 in 2002—an increase of 23.9%. The average number of days to a new appointment between August and December of 2002 ranged from 17–56 days, with a median of 43 days. The average number of days to a new appointment between January and May of 2003 ranged from 8 to 43 days, with a median of 17 days. Implementation of the Modified Open Access Model reduced the average wait time for a new appointment from 4 weeks to 1-2 weeks overall, and <72 hrs for those that needed to be seen urgently. The no-show rate for new patient visits decreased from 50% to 20%.
KEY LESSONS LEARNED
1. Decreased wait time resulted in increased compliance with appointments 2. MO-AM resulted in true growth of the practice with an increase in actual patient base 3. Open access appointment availability should be limited to one week in advance to avoid pre-booking
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
Poster Laptop.
INTRODUCTION OF COMPLEMENTARY AND INTEGRATIVE MEDICINE BY GENERAL INTERNISTS INTO THE PRACTICE OF AN ACADEMIC MEDICAL CENTER.D.L. Wahner-Roedler1; P.L. Elkin1; A. Vincent1; T. Schilling1; M.C. Lee1; L.L. Loehrer1; B.A. Bauer1. 1Mayo Clinic, Rochester, MN. (Tracking ID #116076)
STATEMENT OF PROBLEM/QUESTION
Problem: With patients' (pts) increasing use of Complementary and Alternative Medicine (CAM), academic medical centers need to provide evidence-based CAM information and services within the cultural context of tertiary care.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
Objective: To introduce evidence-based CAM into the practice of our medical center.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Intervention: To achieve our aim we initiated a 3-pronged approach described below.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Findings to Date: 1. Creation of an interdisciplinary CAM interest group: Regular meetings focusing on education, research, practice, open to all physicians and allied health staff of our medical center were initiated by a group of internists. 2. Survey of CAM use in 1,514 pts: a 85 question survey of CAM use addressing 3 domains: a) treatment/techniques, b) vitamins (vits)/minerals (excluding multiple vits with and without minerals, vit. D, folic acid, calcium, iron, potassium), c) herbs/dietary supplements, was administered to 1,514 consecutive pts presenting for an appointment. Response rate: 99.5%; median age: 61 years, gender: male 45%, CAM use: 76% (80% women, 72% men). The 5 most frequently used CAM treatments were: vit.E, exercise for a specific problem, vit. C, chiropractic, spiritual healing. 3.Pilot Study – CAM consults for 102 pts: after documenting a high CAM use we initiated a pilot study offering CAM consults at no cost to 102 pts presenting to a General Internal Medicine Division. Consults were performed by a licensed pharmacist (TDS) with back-up by an MD (AV) trained in CAM. Results: gender: 78% females, median age: 56 years, median length of consult: 30 min. CAM modalities used by pts were reviewed, drug interactions discussed, and questions in regard to use of CAM for a specific medical problem answered. Pts were encouraged to review the information with their primary MD. After the consult pts were asked to fill out an evaluation form. All pts found the session helpful and indicated that a CAM consulting service should be implemented at our center. Ninety-eight percent of pts were willing to pay for the service, if not covered by their insurance, with 44% willing to pay $41.00 or more.
KEY LESSONS LEARNED
Key lessons learned: Involvement of individuals from multiple disciplines across the Institution under the leadership of general internists helped to build support for CAM. Documentation of our pts' use of CAM emphasized the importance of this issue. Our consult pilot showed that pts are very interested in receiving evidence-based information about CAM. As a result the CAM-Program has been endorsed by the Department of Medicine. A routine, fee-for-service CAM consulting service will be implemented at our institution in 2004; contract discussions with local CAM providers are underway to explore opportunities to provide specific services to pts and staff.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
PHYSICIAN-NURSE COMMUNICATION IN INPATIENT GENERAL MEDICINE.J.J. Mohr1; C.T. Whelan1; J. Arneson1; J. Gradman1; M. Ang1. 1University of Chicago, Chicago, IL. (Tracking ID #117141)
STATEMENT OF PROBLEM/QUESTION
The literature suggests that poor MD-RN communication patterns are associated with poorer clinical outcomes and patient satisfaction, lower job satisfaction for nurses and increased nurse turnover. Poor communication and conflict is a common problem on the inpatient medicine units at UCHospitals and is cited as affecting provider, staff, and patient satisfaction.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
The purpose of this study was to gain insight into communication patterns between inpatient MDs and RNs. Results were used to design interventions to improve MD-RN communication using quality improvement methodologies.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
During May 2003, we conducted 4 focus groups, 2 with nurses (n = 8) and 2 with housestaff (n = 8). Questions elicited opinions and stories about MD-RN interactions within the institution, perceptions of actual vs. ideal MD-RN relationships, experiences of MD-RN conflict, and suggestions for improvement. Discussions lasted 1 hour and were audiotaped and transcribed for analysis. Members of the research team independently coded transcripts using the constant comparative method. Discrepancies in coding were reconciled by research team consensus.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Five factors emerged from the analysis: 1) Education and Training, 2) Organizational Support, 3) Culture, 4) Relationship, 5) Team Approach. Subcategories further defined each factor, e.g., subcatories for the factor Relationship were racial differences, respect, trust, socio-economic differences, and gender differences.
KEY LESSONS LEARNED
Knowledge gained from this study was used to design initiatives that are currently underway to improve MD-RN communication and working relationships. Three specific interventions based on suggestions from the focus groups and our perceived ability to affect change are currently being pilot tested to improve MD–RNcommunication on the inpatient medical wards: 1) Include nurses on attending rounds. 2) Send alphanumeric pages to housestaff. 3) Create educational materials for monthly housestaff orientation.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
We will present a brief description of how to design and facilitate focus groups and provide multiple examples from the rich narrative that resulted from our study. The coding structure will be presented in a cause and effect diagram that clearly outlines the factors that emerged in our study of MD-RN communication.
PHYSICIAN-TO-PHYSICIAN COMMUNICATION: METHODS, PRACTICE AND MISGIVINGS WITH PATIENT HANDOFFS.D.J. Solet1; J.M. Norvell2; G.H. Rutan1; R.M. Frankel1. 1Indiana University Purdue University Indianapolis, Indianapolis, IN; 2Respiratory Consultants, Methodist Hospital, Indianapolis, IN. (Tracking ID #116981)
STATEMENT OF PROBLEM/QUESTION
A daily ritual in teaching hospitals is the changeover or hand-off, whereby physicians or medical teams relay patient information to a covering physician, and in this presentation we will highlight problems in communication when the care of hospitalized patients is transferred from one physician to another.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
Our objectives were to identify current problems with the changeover process, obtain data to elucidate how medical students and residents are taught this process and to propose a feasible solution to the problems encountered.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Gaining a better understanding and standardization of the changeover process could lead to a reduction in the number of “near misses” and harmful medical errors; therefore, the process by which changeovers occur was evaluated and three major barriers to effective communication in patient handoffs were identified.
FINDINGS TO DATE/ EVALUATION OF WEB SITE
First, we identified problems with the physical setting like lighting and background noise and with the social environment where social hierarchies can interfere with the changeover process. Second, while physicians speak a common “medical language”, a great deal can be lost in the transfer of information between physicians of different ethnic backgrounds or when colloquialisms are used. Finally, the medium of communication can be a barrier to providing an effective changeover. The method by which medical students and residents are taught the changeover process is variable, and medical educators across the United States are being surveyed to inquire about how and when their medical students are taught the changeover process. Preliminary data suggests that most medical students are taught informally by housestaff and these housestaff were in turn taught by the same method, but empiric data is pending.
KEY LESSONS LEARNED
We gained knowledge on the key elements that should be included in the changeover form and effective communication tactics that should be employed in the changeover process. In the upcoming year, we will institute a pilot program at our institution that will provide strict guidelines for the changeover process.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
The guidelines for preparing and executing an effective changeover will be demonstrated along with a demonstration of a computer-based model currently used to generate a changeover list.
SUCCESSFUL STRATEGIES FOR INCORPORATING PREVENTION IN GENERAL INTERNAL MEDICINE PRACTICES: PROJECT 90 BY 2000.R. Chaudhry1; R. Stroebel1; S. Scheitel1. 1Mayo Clinic, Rochester, MN. (Tracking ID #116372)
STATEMENT OF PROBLEM/QUESTION
Assessing and delivering adult preventive services during busy clinical encounters is a challenge which all practices face. Project 90 by 2000 was undertaken to improve delivery of adult preventive services in a multispecialty practice at Austin Medical Center-Mayo Health System which serves a population of 40,000 citizens in southeastern Minnesota.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To improve delivery of adult preventive services.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Thirty charts of adult patients were abstracted every month for the delivery rates of age appropriate colon, breast, and cervical cancer screening; tobacco use and cessation advice; lipid screening; hypertension screening; and tetanus, pneumococcal, and influenza screening. A goal to achieve 90% of all eligible adult preventive services by end of year 2000 was established. A multidisciplinary team was convened to oversee the project. QI teams for individual preventive services were established. USPSTF guidelines were followed. Clinical practice was tooled with past history forms, pocket prevention guides, and standing orders for nursing staff. Physician and nurse education was undertaken to standardize the preventive services delivery. Public education was also undertaken by posters in exam rooms, hallways, waiting areas, grocery stores, nursing homes, and pharmacies. Newspaper articles and advertisements in newspapers were also undertaken.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Colorectal cancer screening improved from 60% in 1997 to 94% in 2000. Breast cancer screening improved from 72% in 1997 to 96% in 2000. Cervical cancer screening improved from 84% in 1997 to 94% in 2000. Influenza vaccination improved from 38% in 1997 to 96% in 2000. Pneumococcal vaccination improved from 50% in 1997 to 100% in 2000. Tetanus vaccination improved from 40% in 1997 to 92% in 2000. Tobacco use screening improved from 88% in 1997 to 98% in 2000. Tobacco cessation advice improved from 60% in 1997 to 82% in 2000. Lipid screening improved from 90% in 1997 to 98% in 2000. Hypertension screening improved from 86% in 1997 to 92% in 2000. All eligible preventive services completed improved from 70% in 1997 to 94% in 2000.
KEY LESSONS LEARNED
Utilizing principles of quality improvement and having all members of the health care delivery team contribute in the process of assessment and delivery of preventive services can help reach the goal of improvements in the delivery of preventive services. Educating the patients about the needed preventive services, clinical information system development, delivery system redesign, and leadership support are all necessary for a model of successful delivery of preventive services.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
THE DISCHARGE NAVIGATOR: A WEB-BASED INNOVATION TO BETER MANAGE INFORMATION FLOW DURING HOSPITALIZATION.J.M. Kramer1; W.F. Bria1; S. Lim1; F. Lee1; J. West1; S.K. Saint2; A.M. Fendrick1. 1University of Michigan, Ann Arbor, MI; 2Ann Arbor VA Medical Center, Ann Arbor, MI. (Tracking ID #117416)
STATEMENT OF PROBLEM/QUESTION
Maintaining the continuity and quality of healthcare, from outpatient care to hospital care and back, challenges almost every health delivery system. The management and transfer of critical information is likely a key to successful practices providing high quality of care. However, managing the chain of communication throughout a patient's hospitalization to the time of discharge is made far more difficult with decreasing length of hospitalizations and increased patient turnover. Even more challenging are the multiple providers, roles, and increasing number of handoffs. These factors are likely increasing the loss of critical information about discharge plans. Any discontinuity may result in medical error, reduced quality, and increased resource utilization.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To address these challenges, we created the Discharge Navigator. This is a web-based, information management tool, integrated with the enterprise electronic medical record. Key objectives for this system include better coordination of tasks, interdisciplinary use of information, elimination of redundant information tasks, and improved timeliness in our communications to referring physicians.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
Focus groups and user-centered design resulted in a unique 12-step task and workflow representation that produced nursing and physician discharge documentation. In addition to managing inpatient summaries, the information collected allowed the generation of cross-shift reports or “sign-outs.”
FINDINGS TO DATE/EVALUATION OF WEB SITE
The system has been well received and has been used to produce 528 discharge summaries during 564 inpatient encounters. We will demonstrate the innovative results of our design process including the task breakdown structure, task state manager, electronic medical record integration methods, and the incorporation of the process knowledge into each task.
KEY LESSONS LEARNED
Discharge information can be managed in a coordinated fashion and can replace traditional discharge work products. Careful application design allowed a successful implementation and improvments in information coordination among multiple inpatient information stakeholders.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
We will present the key features the Discharge Navigator in an oral presentation or in poster format.
THE RACE FOR EFFICIENCY: AN INNOVATIVE METHOD TO IMPROVE PATIENT CARE IN AN ACADEMIC MEDICAL CENTER.R. Blankstein1; J.W. Nathanson1; J.N. Woodruff1. 1University of Chicago, Chicago, IL. (Tracking ID #117296)
STATEMENT OF PROBLEM/QUESTION
Prompted by the new ACGME duty-hours guidelines, we sought to identify inefficiencies in hospital operations at a large academic medical center. Past attempts (i.e. committee meetings, incident reports, and safety hot-lines) failed to gather adequate detail for prioritization of problems.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
(1) To quantitatively identify patient-care related problems which are encountered by residents on the general medicine wards. (2) To determine “root cause” for a maximum number of incidents through collaboration with hospital support services and other departments. (3) To propose and implement high yield solutions to the most common problems, thereby making the most effective use of limited hospital resources.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
A one week period of intense data collection was used to identify problems encountered by the house staff on the general medicine wards. Residents completed “Data Cards” on each problem they encountered. Information collected included the details of each adverse event as well as a quantitative estimate of the impact on patient care and on resident work time. Cards were reviewed daily and assigned to the appropriate “Problem Area”. Each card was faxed in real time to the appropriate care center manager for investigation of “root cause”. After collection of the data was complete, a working group was established to review the data, identify fixable problems with the highest frequency, and propose changes to improve patient care and efficiency of hospital operations.
FINDINGS TO DATE/EVALUATION OF WEB SITE
Over one week, we identified 199 problems in 25 different categories relating to patient care. On average, each problem consumed 26 minutes of resident time. Problems resulted in 31 delayed discharges. Most complaints (72%) were associated with a minor effect on patient care; 26% were associated with a significant effect and 2% with a severe effect on patient care. Twenty-six percent of the problems arose from inefficiencies at the Ward Clerk position.
KEY LESSONS LEARNED
A short but intense resident-driven effort to comprehensively identify problems encountered on the medicine wards was very effective. Collaboration with hospital leadership and commitment of hospital staff to follow up each problem in “real-time” allowed us to determine root causes as well as potential solutions. This detailed information enabled better targeting of limited resources in an effort to create meaningful changes in the efficiency and safety of patient care.
MODALITY(IES) USED TO DEMONSTRATE INNOVATION AT MEETING
TO STUDY PATIENT SATISFACTION WITH THE USE OF A NURSE-BASED TELEPHONE PROTOCOL FOR MANAGEMENT OF URI SYMPTOMATOLOGY.R. Chaudhry1; R. Stroebel1; H. VanHouten1; J. Naessens1; S. Scheitel1. 1Mayo Clinic, Rochester, MN. (Tracking ID #116144)
STATEMENT OF PROBLEM/QUESTION
Acute upper respiratory infection is a common, self-limiting viral infectious illness. Patients can be treated by RN telephone protocol for patients with symptoms of viral URI or acute sinusitis. Patient satisfaction with RN telephone management has not been assessed in past.
OBJECTIVES OF PROGRAM/INTERVENTION/WEB SITE
To determine if a nurse-based telephone protocol for management of URI and acute sinusitis will result in patient satisfaction equivalent to usual care.
DESCRIPTION OF PROGRAM/INTERVENTION/WEB SITE
January 2002 to July 2002 patients calling with symptoms of cough, runny nose, sinus pain or infection were triaged to a guideline-based registered nurse (RN) telephone treatment protocol (intervention) or usual care (control). Patients of 10 physicians were enrolled in the intervention group, whereas patients of the other 21 physicians received usual care (cluster randomization). Based on protocol questions, the RN determined if the patients' symptoms were suggestive of viral infection, bacterial sinusitis, or another diagnosis requiring physician evaluation. Symptomatic measures only were suggested for presumed viral infections. Cases of presumed bacterial sinusitis were treated with first line antibiotics (amoxicillin, erythromycin, or sulfamethoxazole/trimethoprim). Patient satisfaction was assessed by sending all patients in both groups a survey form within 30 days of their initial contact.
FINDINGS TO DATE/ EVALUATION OF WEB SITE
Forty-five out of 77 patients in nurse telephone treatment group (58.4%) and 76 out of 135 patients (56.3%) in the usual care group responded to the survey. 88.9% in telephone group rated the care to be good to excellent whereas 100% in the usual care group rated care to be good to excellent (P = .006). 89% in the telephone group and 96% in usual care group thought that it was somewhat to very easy to have illness evaluated (P = .146). 60% of patients in telephone group and 52.6% of patients in the usual group will prefer telephone care in the future, whereas only 31.1% of patients in the telephone group and 39.2% in usual group would prefer clinic visit for evaluation of their symptoms (P = .455).
KEY LESSONS LEARNED
Both telephonic and office-based evaluation and treatment for URI can result in high levels of satisfaction. Although use of a guideline-based nurse telephone triage protocol for evaluation and management of URI symptomatology had lower satisfaction compared to usual care (P = .023), a majority of patients in both groups desire telephone evaluation of their symptoms as an alternative to a visit with their physician.