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  1. #11
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    Quote Originally Posted by DoctorW View Post
    Having these items visually appealing is very important. Looking down a list , to find items missing is difficult when it is too cluttered.

    Having a list such as below is much easier to keep track of.

    Preventive Health: Adult: Influenza Vaccine: 2015
    Female: Mammogram: 2015

    Having the ACO, billing codes built in , but not displayed would be very helpful.

    James

    Your suggestions are great. We eventually would like to develop a more intuitive dashboard to consolidate the management of many task associated with Population Health Management (PHM) such as this. User demand, and the resources available to us will determine the if/when. For at least the next 6-12 months, we are going to need to take what is available now and make it work it even if not very elegant. Starting with what we have now for the documentation items we can now create the logic within new SMARflows and SMARTreports that can largely drive the dashboard. This is the incremental process in order to get to what will hopefully be more ideal.

  2. #12
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    Timely blog about the challenges ACOs are having collecting and reporting their data - http://thehealthcareblog.com/blog/20...-data-problem/

  3. #13
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    Quote Originally Posted by roates View Post
    Timely blog about the challenges ACOs are having collecting and reporting their data - http://thehealthcareblog.com/blog/20...-data-problem/
    Here is the problem with "Value Based Care". Lisa isn't a doctor. She is just collecting data. She has no idea why. The CMS bean counters who review the data aren't doctors. They think < 141 beans are the perfect number of beans. My BP went up to 142 beans just reading that article.

    http://www.uspreventiveservicestaskf...ome-monitoring

    http://www.kevinmd.com/blog/2014/01/...uidelines.html

    And good luck preventing falls. Maybe give everybody Vitamin D? Oh yeah. That will work. The CMS bean counters will likely next collect data on how many patients have Vitamin D levels <30. Good luck with that one Lisa.


    http://www.uspreventiveservicestaskf...ive-medication
    Last edited by jmcalpine; 05-21-2015 at 20:10.

  4. #14
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    Jim, yet again, we are on the same page. The policy makers refuse to be intimidated by reality. At the point of care, we are evolving from a focus on our medical record documentation having to have enough bullets in the documentation into having to add enough faux-quality measures in order to get paid. Some of my relevant Tweets from just this last week alone...

    ACO risk = Patients not at center of care, more bureaucracy & force docs focus on metrics http://thehealthcareblog.com/blog/20...-data-problem/ … via @The Health Care Blog

    So-called CQMs: They're "Process Indicators," not "Clinical Quality Measures" http://regionalextensioncenter.blogs...e-process.html

    The unintended consequences of bureaucracies of audit of quality of care is often symbolic violence http://www.biomedcentral.com/1472-6939/16/23 #bmcmedicalethics

    Is health care quality more about compassion, comprehensiveness, dignity, and empathy, or is it really about performance on current metrics?

    Family Doctors Who Do More, Save More http://n.pr/1IAeflG ht @EPCoalition pic.twitter.com/n9zdccE7WB And doing more means actual patient care not box-clicking for billing and "quality" data reporting.

    ICD-10: Doctors and Patients Will Bear the Burden http://herit.ag/1Lbg33Q

    "Meaningful Use" is a misnomer -- what we really need is 'Effective Use," from the POV of the patient.

    No sig data P4P improves actual patient outcomes, Some data that it can improve metrics. Sadly, data exists that it worsens actual patient outcomes.

    Sadly our frustration and revealing of the truth is not going to change the bean counters or keep us in business. Its all just the next game so that those that want to shift the financial risk burden to providers of care can justify doing so while they either collect more revenue or cut their expenditures. They want some basis in order to claim that the quality isn't compromised. It matters not to them that they have no valid measures of quality from a patient's perspective.

    I'm seeing more and more of our customers reporting that if it weren't for their ACO bonus this year, they would be out of business. These were often local-regional medical practice environment shifts occurring within a single year. Also, the trends show the direction of things that we simply can't ignore

    MedicalPracticeAdoptionTrends.JPG...
    http://www.medscape.com/features/slideshow/compensation/2015/public/overview?src=txt_stm_compen_4_a#page=19

    Commercial, non-Medicare ACOs are becoming a big trend in a growing number of regions having a few, large employers.

    Direct Primary Care (DPC) is still small (around 4,000 practices) but growing at a 20% annual clip. I'm advocating for them as there is growing evidence they can save 20-30% in total health care costs, and have higher patient and clinician satisfaction. Ironically, what they are missing to really become a major trend is the data to make head-to-head value comparisons to the alternatives. Unfortunately, this is necessary for the major decision-makers purchasing health care.

    ACOs, on average, are saving less than 2% in total costs of care. If their set-up costs are factored in, then their actual, total costs would actually be greater than it would have been for fee-for-service. This is yet another unfortunate truth that is largely being ignored. - http://thehealthcareblog.com/blog/20...are-decisions/ - I'm going to predict the only ACOs surviving will be those integrating more efficient, smaller practices into larger networks. The current, larger systems ACOs will mostly implode, and likely they will create more monopolistic Clinically Integrated Networks (CINs) that can preserve high costs and revenues to the corporate entities. These will lower the incomes of physicians (now at 8-10% of health care costs) and have sophisticated systems in place to get the docs to deny "unnecessary" care. Additionally, the physicians will be not only taking on the malpractice risks for denying care, but will also be financially penalized when they actually deliver care. Increasingly, physicians will bear the burdens of high cost (often non-adherent) patients and 5% of them consume 50% of healthcare costs. Holding physicians responsible for what are social-societal issues beyond their control is simply doomed to failure.

    Over 30% of Medicare patients are in Advantage plans that have just as much if not more focus on faux quality measures, and the repeal of the SGR bill only accelerates the inclusion of faux-quality metric performance greatly within payment formulas.

    Our professional organizations have largely become either pawns or have become complicit. Another of my Tweets - Does the faux-quality "transformation"in health care involve any sort of CorpGovAcademia revolving doors? http://www.medtees.com/blog/RevolvingDoor.png … This illustrates how the ABIM leaders are in and out of CMS and the NQF creating the main "quality" measures. It is scandalous the degree to which they are profiteering from the faux qualty measures and MOC.
    Medical Mystery: Making Sense of ABIM’s Financial Report http://www.newsweek.com/medical-myst...-report-334772 - Is it time for doctors to grow a backbone?

    Sad, sad, sad, but so what, now what in the trenches?

    At SOAPware, we must figure out how to minimize faux-quality measure adherence interfering with the delivery of quality care. - "To have striven, to have made the effort, to have been true to certain ideals - this alone is worth the struggle." - Sir William Osler, MD



    Last edited by roates; 05-26-2015 at 05:02.

  5. #15
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    Quote Originally Posted by roates View Post
    Progress is being made toward more automation. In fact, auto-insertions are one of the available Actions within SMARTflows. So, we have the foundation to eventually automate many tasks that are now requiring manual action. The if/when is directly proportional to the amount of revenue/resources we have to develop them out. Additionally, the rapidity of changes within gov mandates, rules and specifications we are forced to address going forward could slow automation down as well. Hopefully, and in spite of these two main obstacles, we can be one of the first systems to actually automate a lot of what is now manual work. Ironically, if the gov would shift to assisting the development of useful standards (i.e. encourage consistent means of identifying report types such as "This is a mammogram") instead of being focused on developing algorithms for reporting "performance," this could greatly accelerate progress.

    Progress will be incremental, and we are starting out with what we have available and are attempting to optimize that. Your valuable feedback helps greatly.
    Just playing around I decided to try to auto-insert 3 of the ACO items. I chose ACE/ARB, BP>140, Mammograms.

    I added a Site custom code that identifies Lisinopril as an ACE (kooacearb) and created a Plan Item with Header "On ACE/ARB". I then created a When-Check-Do Smartflow that inserts "On ACE/ARB" when custom code kooacearb is present.
    I similarly created a When-Check-Do Smartflow that inserts "BP Systolic >140" when Systolic >140 in Vital Signs.
    I created a When-Check-Do that looks for "Mammograms reviewed" in Interventions and moves to Plan.

    They all work BUT the Triggers are an issue. The Triggers seem to ignore Constraints. Once the triggers work properly this is really going to automate things.

  6. #16
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    Quote Originally Posted by jmcalpine View Post
    Just playing around I decided to try to auto-insert 3 of the ACO items. I chose ACE/ARB, BP>140, Mammograms.

    I added a Site custom code that identifies Lisinopril as an ACE (kooacearb) and created a Plan Item with Header "On ACE/ARB". I then created a When-Check-Do Smartflow that inserts "On ACE/ARB" when custom code kooacearb is present.
    I similarly created a When-Check-Do Smartflow that inserts "BP Systolic >140" when Systolic >140 in Vital Signs.
    I created a When-Check-Do that looks for "Mammograms reviewed" in Interventions and moves to Plan.

    They all work BUT the Triggers are an issue. The Triggers seem to ignore Constraints. Once the triggers work properly this is really going to automate things.
    That is way cool.
    I will ask the experts to weigh in on the Triggers ignoring Constraints. I will also ask if an Activity can be created that would allow a SMARText item to be inserted into the Preventive Health item in the CARE PLAN. We need to ensure that data can be uploaded to the C-CDA as that, increasingly, is the way things are going to be shared-transferred.
    Thanks so much for the feedback.



    Addendum: I've been brainstorming on this and can't get past some deficiencies of needing to have a framework that can be more automated-updated over time and have the structure to create patient recall lists and alerts when patient encounters occur. In your example, there is no structured date to indicate timing of when the Mammogram was reviewed. Further, just putting "Mammogram reviewed" into the Plan does not enter the G-code needed for reporting. This is really the minimal information to be able to satisfy all needed functions, rules and mandates -

    Breast Ca - Mammogram: Diagnostic mammography, digital, bilateral. CPT#G0206 Performed Date/Time: 05/23/2015

    The challenge is that in order to have what is visually easier to use with existing tools, it will end up requiring more manual steps. As a result, I'm concerned it will be little better than the current Health Maintenance workflows.

    Brainstorming for future – Possible Preventive Health Grid that could be displayed from using the existing SMARText in existing workflows:

    PreventiveHealthGrid.JPG

    Could we collaborate in order to get the necessary workflows and data flows in place with intent to make it more graphically appealing in time?
    Last edited by roates; 05-24-2015 at 09:38.

  7. #17
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    I'm happy to collaborate. I'd love to get in on the ground floor of this one. Unfortunately I don't see a way to upload and download Smartflows so it would be hard for you to send me examples and vice versa.

    With Smartflow you can move whatever ST you want into whichever Encounter or Summary field you select. In other words, you can move the Plan item containing the Mammogram G code and performed date into the Plan when the Smartflow checks that "Mammogram reviewed, Performed date: whatever" is in the Interventions. What is missing is that you currently have to manually enter the "Mammograms reviewed, Performed date: whatever" in Interventions. I think Andy and DoctorW have mentioned this, but what you need is a way to make the Mammogram ST flow from the actual Mammogram document name/title (with date) to Interventions (or Health grid) to Plan.

    I'm not sold on putting everything in Interventions, but currently Smartflow only allows you to choose a Summary or Encounter Field as the source/destination. Interventions could therefore be used for your grid until a better solution is developed. If you store everything in Interventions for now, all you have to do is change your destination later and point it to the grid.


    The problem with the grid is you have to check it, just like you have to check the old Health Maintenance module. That requires an extra 2 clicks, one to open and one to close. Interventions is there when you first open the chart.

    The problem with the Triggers is that they need to occur after the Chart is checked and/or only need to occur once. Example.
    Document Added to chart: This trigger runs the smartflow when you create a new SOAP note. But it is supposed to check to see if the document is face to face, contains certain Smartext header, etc.

    Smart Text Inserted: This keeps reinserting the Smartflow item every time any Smart text is inserted.

    Document signed: That works for moving Plan items to Interventions, but would not work the other way since the document is already signed.
    Last edited by jmcalpine; 05-26-2015 at 10:32.

  8. #18
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    I have never been comfortable with the Plan being the place to document that something was done.

    Regarding having to check the grid: Smartflows should be able to tell you if something is missing from the grid without your having to look at it.

    I also ran into trouble with triggers when I was playing with Smartflows. As I recall, things tended to not get put in the chart, or get put in repeatedly. I think the way Smartflows are written you should be able to say IF NOT mammogram recorded in interventions < 2 years ago THEN search Radiology for mammogram date < 2years ago and Insert in Interventions if found. But as I recall, it would ignore the "if it isn't there" part and insert it again.

    Andy

  9. #19
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    The current Health Maintenance section has some very good points, with its major downfall being the great difficulty of manually updating it. If SMARTflows could update HM, that might solve some of the display issues. It shows you what has been done in an orderly way, and keeps track of when it needs to be done again. I'm not at all opposed to coming up with something better but IF making SMARTflows update it wouldn't be hard, then using HM might be a major shortcut.

    Andy

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    And so it happens that something once of little concern becomes interesting.
    This tread looked like the education I require and then it just stopped a little over 2 years ago.
    A couple of comments make it seem that people have been thinking about and making improvements in this area for over 2 years and would be sharing info about "future" (at the time) improvements. Hope there will come a time that I can benefit even more from all of that experience.

 

 

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