Health and Chronic Disease
Management (HCDM)
BEACON
9.8.2010
Overview
• 4 year project
• Purpose:
• Leverage the MHS EMR to deliver point-of-care tools to
providers and care teams
• Develop detailed provider level reporting to advance
ambulatory quality care in areas of prevention and
disease management
• Collaboration between Cerner and Mayo
• 3 components – separate rollouts
HCDM Resources
• Project Team
• Dr. Rick Fleming – Physician Lead – ISJ Primary Care Provider
• Jason Buckmeier – Project Manager
• Divya Pathak – Senior Analyst/Programmer
• Lakshmi Kharidehal - Senior Analyst/Programmer
• Cerner
• Engagement Team
• Discern ABU
• ASYST
• Leadership
• Analysts
• Mayo Health System
• Quality Dept Leadership
• MHS Expert Teams
• Diabetic Registry programmers & AQM programmers
• Ambulatory Care Committee
• Site Quality Coordinators
• HICS/Design Council as the oversight body
HCDM Project Metrics
• AMB, ED, IP Summaries - ~ 6200 users (providers/nurses)
• Condition Management Rules: 435 MHS Providers (Primary Care)
• Populations Evaluated - Current
•
•
•
•
•
Hypertension
Asthma
Depression
Diabetes
Vascular Care
51,777 patients
7,696 patients
19,130 patients
21,903 patients
9,412 patients
• Records reviewed nightly - 30-35,000 patient records per topic
• The total for all topics ~ 180,000-210,000
• Largest population monitoring of any Cerner client
HCDM Interaction
MHS CDR
Site Quality
Directors
MHS Expert Teams
ASYST Site
Liaisons
MHS Determines
Quality
“what” we
build & deploy
ASYST Leadership
MHS Ambulatory
Care Committee
ASYST Clinicals
MHS EMR User
Groups – FirstNet,
Ambulatory, IP
HCDM
Determines
Cerner Engagement
“how” we build
& deploy
& Reporting
ASYST
integrate into
Team
MHS EMR
Oversight
HICS
“Does”
Cerner
Development
majority
of –
Discern ABU
HCDM
Build
ASYST Learning
Team
Mayo-JAX Technical
Team
ASYST
Technical
Team
PWG
HCDM Components
• 10 Algorithms
• 1 Patient Summary Page
October 2009
July 19, 2010
• 4 Condition Summaries w/ Performance Measures
• MPage 2.0 Summaries – AMB, ED, IP
• Reminder Letter functionality
Q4 2011
• Team tools (provider schedule icons and scheduling solution
integration)
Algorithms
Algorithms included:
• Asthma (Adult & Ped)
• Depression
• Diabetes
• (Diabetic Hypertension)
• CAD
• Hypertension
• Hyperlipidemia
• Heart Failure
• (Diastolic Heart Failure)
Link
Launchable from:
• desktop
• intranet
• condition summary
• EMR link
Functionality Goals
• Improve data capture (Tool: Ambulatory Summary)
• More efficient documentation of quality metrics at point of care (foot
exam, eye exam, PHQ-9, recheck BP, Asthma Control Test)
• Advances ability to have responsive reporting
• Educational (data to help support adoption – i.e. PHQ-9 utilization)
• Aids in data collection for 3rd party submission (MNCM - DDS)
• Point of care patient metrics (Tool: Condition Summary)
• Displays to provider/nurse how the patient is performing on quality
targets
• Population Reporting (Tool: Discern Analytics)
• Care-Coordinator/Quality Analyst focus
• All measures, all conditions, all patients – updated nightly
• “Show all patients with HgbA1c not done in past 6 months for Dr.
Fleming”
Improve data capture (Tool: Ambulatory Summary)
Condition Summary
LINK
Population Reporting (Tool: Discern Analytics)
Invitations & other .20 functions
Reminder letters
Scheduler ability to see HM due items
HM: Lipids, Mammo
Health Maintenance
displays
Top half shows health
maintenance overdue and
coming due in defined time
frame
Invitations for
Asthma
Depression
Diabetes(10)
Vascular
Hypertension
Cervical CA
Breast CA
Colon CA
Lead Screen
Health
Maintenance
HM brought into Depart Summary
HCDM Project Timeline
2008
Q2
2009
Q3
Q4
Q1
Q2
Q3
Project year 1
2010
Q4
Q1
Q2
Q3
Project year 2
Phase 1
2011
Q4
Q1
Q2
Project year 3
Next 4 sites go-live
Q3
2012
Q4
Q1
Q2
Project year 4
Last 4 sites go-live
ASYST code upgrade
Feasibility
Phase 2
Design
= Functionality Rollout
Phase 3
Algorithms
Phase 4 Patient & Condition Summaries, Performance Reports
Phase 6
Invitations/.20 functions
Phase 7
Refinement/update
Physician Lead and Project Manager (0.4 FTE & 1.0 FTE x 4 yrs)
Cerner Programmers (contract)
HCDM Programmer/Analysts (2.0 FTE)
This timeline is reflected in the current ASYST Roadmap
Provider adoption and efficiency
locate 10 elements on a diabetic patient
Up to 60 Clicks … … 2 Clicks
< 1 minute
5 minutes
Customizable – by Mayo
New Summary Pages
Open Source Sharing http://mpagescommons.org/
New Analytics Reports
MPage 2.0 Development – via Bedrock
IP Discharge
Process
Nursing
Communication
Utilizes more of the Care Team to
deliver Health Maint and Disease Mgmt
Reminder Letters
Care Coordinator Patient List
Scheduler Notification of due
items
Thank you!