Southeast Texas Medical Associates, LLP James L. Holly, M.D. Southeast Texas Medical Associates, LLP

Transforming Your Practice - Clinical Decision Support
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The following are examples of Clinical Decision Support materials which have been developed by SETMA and which are used every day in our clinical, EMR workflow.  There are many others we use, also.  In February, 2011, ETMA was named one of Thirty Exemplary Practices for Clinical Decision Support by the U. S. Office of the ONC for HIT -- "Advancing Clinical Decision Support" is an intensive, multi-part project funded by the U.S. Office of the National Coordinator for Health Information Technology (ONC) to address the major barriers to achieving widespread use of clinical decision support. The project is being led by the RAND Corporation and Partners Health Care / Harvard Medical School. Rand Case Summary.

    May, 2011 -- How can healthcare providers design a solution to a complex healthcare problem, particularly when the problem is not generated by a patient's request but by a public-health need. In the former case, the provider simply determines if the request is appropriate or not. In the latter case, no one is in the provider's office requesting a service; a requirement has been established and it is up to the provider, in the midst of many other demands, to remember and to fulfill the requirement. In the case of infectious diseases, requirements have been published for providers to report the occurrence of dozens of conditions.  The problem is that the medical literature is filled with studies showing very low compliance of physicians with reporting infectious diseases to State Health Departments.  In Texas, there are 78 infectious diseases which require reporting. The window for reporting compliantly varies from immediately, to one working day, to one week, to ten days, to one month. It is improbable that many healthcare providers know the entire list or the requirement for reporting. The Department of Health wants the report to be triggered by a suspicion and not by a confirmed diagnosis. If the provider waits until the confirmation is made, the opportunity for a public health intervention is lost. A systems solution would be best. The ideal solution would be an electronic medication record (EMR) system in which the reporting action is triggered by the documentation of the diagnoses in the assessment in the EMR.

    One of the most difficult management issues in outpatient care is the making certain that patients follow through on recommended, or scheduled studies, or evaluations. Also, it is the following up with a patient to whom you have given a target for smoking cessation, or other behavior modification to see if they are have succeeded.  Many efforts have been made to create a tool for managing these complex problems over a large population.  In 1998, SETMA adopted an EMR, particularly one that has Microsoft Outlook embedded, it occurred to us that we could use the EMR and Outlook to create an Electronic Tickler File.  Because Microsoft Outlook allows delay of the delivery of an e-mail and actually to specify the time and date for that delay, it because obvious that we could use this function as an Electronic Tickler File.  SETMA uses the Electronic Tickler File in many applications...

    The two most difficult, chronic problems in medical recording keeping are valid, complete medication records and valid, complete problem list.  Unfortunately, they just happen to be the two most important parts of the record.   Both issues are foundational to the fulfillment of the Triple Aim and to patient safety.  Because the chronic problem list is also critical for reimbursement, the sustainability of excellence in care, which is fundamentally an economic issue, the list is critical to quality outcomes.  This is particularly related to HCC and RxHCC values which are not important not only in Medicare Advantage, but also in ACO work with Fee-for-Service Medicare and for Patient-Centered Medical Home.  (for the full tutorial see:  Problem List Reconciliation: The Tools Required to Facilitate the Maintenance of a Current, Valid and Complete Chronic Problem List in an EMR).

    In January, 2013, CMS published two new Evaluation and Management Codes (E&M Codes) which were adopted in order to recognize the value of the processes of transitioning patients from multiple inpatient sites to multiple outpatient venues of care.  The value of this work is now being recognized by enhanced reimbursement.   CMS has also published three codes for Complex Chronic Care Coordination, which is considered bundled payments in 2013 but in 2014 are scheduled for additional payment to primary care providers.  Those will be discussed later.  SETMA has been tracking and auditing the Physician Performance for Performance Improvement Transitions of Care Quality Metrics since they were published in 2009.  By provider name, those metrics are published at under Public Reporting for 2009, 2010, 2011, 2012.  In the past 36 months, SETMA has discharged over 14, 000 patients from the hospital.  98.7% of the time patients have received their Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan (previously called “Discharge Summary “when they left the hospital.  Since 2010, SETMA’s Care Coordination Department has also been involved in the transitions process. It is only logical that SETMA would be prepared to utilize the new Transitions of Care Codes.  At this time, there is only one unresolved issue related to using these codes.  Neither CMS nor the Medicare State Contractors are willing to clarify that issue.  In order to determine which of the Transitions of Care Management Codes to use, the healthcare provider must distinguish between a Moderately Complexity visit and a High Complexity visit.  This tutorial assumes that the complexity discriminator refers to the E&M codes for 99214 and 99215, in which case it would generally be possible for a provider only to use the lower of the TCM codes, i.e., 99495.

    One of the most neglected areas of acute and critical care is nutrition. Also, one of the most litigated areas in long-term residential and/or nursing home care is malnutrition.  SETMA’s Nutrition Assessment Template makes it possible to objectively document a patient’s nutritional status in regard to:   Risk Factors for Malnutrition; Physical Signs and Symptoms of Malnutrition; Chemical and Metabolic Indications of Malnutrition.

    The next template which is unique to the Nursing Home Suite of Templates is Skin Lesions.  The full name of the template is “Clinically Unavoidable Skin Lesions.” Skin lesions are common in long-term care facilities, and often are unavoidable.  This template helps identify the patients who are at risk of unavoidable skin lesions.  Risk Factors - 22 conditions are listed which contribute to the patient’s being at risk for “Clinically Unavoidable Skin Lesions.”  These should be reviewed and any risk factors which apply to the patient should be documented by checking the box next to it.  These are in demographic fields, which means that once they are checked, they remain checked in subsequent visits until they are unchecked...

    It is often relatively easy to demonstrate that a patient is currently dehydrated or hydrated. However, it is often difficult to declare with objective evidence that while the patient is dehydrated today, he/she was not dehydrated at their last healthcare encounter. The Hydration Assessment tool is designed to enable you to objectively establish the patient’s state of hydration and to document that in an objective, supportable way. This tool is particularly important to use in the Nursing Home setting as the patient’s state of hydration is an important aspect of long-term residential care and is often the focus of malpractice actions.

    This is one of the greatest health threats to all elderly patients but particularly to those who are in long-term residential care.  Through the review of seven categories, a score is developed which indicates whether the patient is at high risk or low risk of falls.

    Depression is a serious and often life-threatening problem in the elderly and particularly in the elderly in long-term residential care facilities.  In addition, the complexity of mediation treatment of the elderly is greater because they are often on multiple drugs which have serious interactions.  While this template is mostly educational, it is key to the successful treatment of residents of long-term care facilities

    The following is a common event in a patient’s visit to a physician. The doctor says, “I would like for you to return on Friday for lab work.” The patient complies but when he/she arrives at the laboratory, they have no idea what the doctor wanted. The lab calls the doctor, but he is not in. The nurse says, “I’ll page him and find out what he wanted to order.” The nurse reaches the doctor and he says, “I don’t remember, look it up in the chart.” The nurse looks and there is nothing there. Meanwhile the patient has been waiting for 45 minutes in the lab. To avoid this, SETMA has designed a Future Labs function which the healthcare provider can complete at the time of his/her discussion with the patient. When the Future Lab template is completed, the patient arrives at the lab, the orders are already there and the tests are done efficiently and the patient is on his/her way.

    As end-of-life planning becomes increasingly an important part of patient care, it is important to find ways of quantifying patient’s qualification for hospice care and where possible, a means of quantifying a reliable estimate of survival time for patients.  While there will never be an absolute, four scores are being used to aid in this process.  The first, the Karnofsky Scale, was first described in 1949; the second, the Palliative Performance Scale has been used in cancer patients since 1996; the third the Braden Clinically Unavoidable Skin lesions and the fourth Functional Assessment Testing Alzheimer’s and Related Conditions (FAST).  SETMA has deployed all four of these scores, along with a fifth which is the Lansky Scare.  The Lansky is like the Karnosky Scale but is used with patient under 16.  These tools can be found by going to GP Master Template.  In the second column you will find these four scales.  They are also deployed on the Master Template in the Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Suite of templates. 

    In 2007, Medicare Advantage programs (HMO) were funded by CMS (Center for Medicare and Medicaid Services) using both demographics and the Hierarchical Conditional Codes, known as the HCC Diagnoses.  2007 also was the year that RX HCC codes were added to complement the reimbursement for managing patients with illnesses,  which while they did not rise to the level of complexity and cost-for-care, as the HCC diagnoses, they did qualify for a lower additional payment due to increased medication costs. In the interim, the use of HCC and RxHCC designation has been expanded to include not only Medicare Advantage beneficiaries, but also Medicare Fee-for-service beneficiaries through Accountable Care Organizations (ACO) and patients treated in a Medical Home.  In the case of the ACO, the savings for the calculations of shared savings will be determined by actual cost of care measured against the benchmark costs including the HCC and RxHCC factor for the patients in the benchmark.  In the case of Medical Home, the payment of the per member per month (PMPM) payment will be calculated with the level of Medical Home recognition and the HCC/RxHCC coefficient aggregate value, i.e., if a patient is being treated by a Tier III Medical Home and the aggregate HCC/RxHCC score is 2.0 or above, the provider would be eligible for the maximum PMPM as determined by contract.

    This represents SETMA's refill policy. This policy will print on the pain management document that will be given to the patient at the end of the visit. This policy states:  Under no circumstances will the medication be refilled:

    1. Prior to the renewal date at the prescribed dosage and frequency of use.
    2. Without the patient being seen in the office
    3. Without evidence of continuing need for medication
    4. On the weekend, evenings after hours, holidays or other times when your regular doctor is not available.

    The following reasons will not be accepted by any SETMA provider for an early refill of pain medication and/or medication with a significant potential for habituation:

    1. My medications were stolen.
    2. I only got half of the prescription filled.
    3. I dropped my medications into the sink, the sewer, the swimming pool or other watery body.
    4. I left my medication in my hotel on my trip.
    5. I missed my appointment.
    6. The neurosurgeon and/or the surgeon cancelled my appointment.