Event ID: 2312715 Event Started: 2/12/2014 1:00:39 PM ET

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Event ID: 2312715
Event Started: 2/12/2014 1:00:39 PM ET

Thank you. Hello my name is Nancy Beaumont and I am with the South coded with medical care. I would like to welcome you to our webinar on the topic of patient engagement and team-based care. This is the fourth in a series of webinars but to you by the quality improvement organization in North Dakota and Minnesota, Wisconsin, Iowa and here in South Dakota. Following our presentation today we will open the line for questions. And our guest present her today as Dr. Christopher Cashion. He has a passion for cash they named his clinic number one in Western Wisconsin and value for diabetes and heart care. This is an implementation for state-of-the-art health record allowing direct access and patient data changing from reactive to proactive. Is currently the chief of medicine for River Falls area hospital. A facility of line of hospitals. Special medical interest include EMR public health emergency medicine quality care and measurement and physician leadership. He is also serving on the information exchange for workers were OMC pertaining to stage II and three for meaningful use. He serves the Wisconsin regional extension Center. He is a Dr. of medicine for the dash he most recently graduated from physician leadership college in St. Thomas University. He resides in Wisconsin and he enjoys Boy Scouts computers kayaking and bicycling. Dr. Tashjian welcome I will turn the call over to work

thank you very much. I am very delighted to be here today and to share our stories and among the things that I do what matters the most design the primary care physician working in a to position one TA office in a town in rural Wisconsin. So I speak from the trenches and this is where the passion comes from. The patient's I treat are the people that I work with and see every day. I want to also give a plug for the initiative for the CDC and ONC. For preventing heart attack and stroke. We will talk about that later. Today I would like to talk about care. It starts as a fundamental position and that is the care and healthcare is a physician problem and changing it to a team challenge work it sounds basic but it really is an incredible mind shift for us. We are a small town clinic there are only two doctors and a PA. But it's difficult for us to get our arms around we decided we want to practice enter care and the three of us worked our tails off and still did not get the results that we wanted. When our patients deserve. It was not until we made the decision that we can't do this by ourselves we need to involve the entire team. And the team is everybody. It is a more in then just the physician or nursing team. It's evolving people you don't normally think of. Again it meant the physicians had to give up total honor of patient care. Even as motivated as we were it with them real mine chase to say I am willing to let my medical assistant and lab technicians or care coordinators pick up the ball when I drop it. Because unfortunately half the time when I drop that I am not even aware that it has been dropped. So if we are going to involve the team we had to train them. We set up protocols and standards to say this is what we think blood pressure control is work everyone that works at our clinic knows that our desire is to get people's blood rush or lower than 140\90. Not everyone but the vast the joy of patient. Even the people at the front desk are acutely aware of this work our nursing staff and those who treat the blood pressure on where. We trained lab staff and came up with care coordinators as something that we trained ourselves as a new person as a medical assistant that we taught them a disease management from our standpoint of a small clinic and what we expected of them. You will see in the future care laminators are people who changed our care for being reactive to proactive. They are the people who reach out into the community and as I said last but not least, the front office. Nobody's caribous if they do not get in the front door. We cannot help anybody if our front office staff did not understand and work together with us to bring our patients through the door in a timely fashion. We have a basic philosophy. If you want to call it, we want to see them. If that means we stay late work over lunch so be it. We use advanced access and our goal is to get everybody in when the patient was to be seen. We like to meet them at their level. The second thing it means is that my patients are my partners patients. That means, how many times have physicians said I saw you for your urgent care need in your blood pressure is high so why don't you go back and see this other doctor and have her take another look to see if she wants to change something. We do not do that anymore. If we notice the last four or five blood pressures have been elevated we deal with it. We make every visit a hyper tension visit and we have agreed that it is okay if she start my patient on a hypertension medication. It likewise expected that I help to manage the patient as well. When the timing is right and the patient is in front of us. There is no more of this what I would call, collegiality between doctors trying not to step on each other's toes at our patients expense. The bottom line is everything that we do now is focused around the patient not the physician. We are more concerned with how do we make sure we do not drop the ball for each and every patient. How do we make sure they get the care that they expect from us and what we will you want to give. That means my patients are my partners patients and vise versa. That includes our physician assistant as well. Rule this is a nice pictogram that talks about a small office kind of like hours. It talks that everybody matters. We talked about the nursing staff and receptions. It's important for them to make sure the patient get in. The office manager has a theme that we are staffed adequately. I want to talk a little bit more about the physician assistant. Because we use our PA is little bit different team member than the average clinic does. For at least half a day our PA sees his own patients and has a steady patient load of his own. But equally he also is spending time working on quality measures and assisting the other positions. He goes through our inbox and takes all the normal labs and clears them. He deals with any miscellaneous questions he answers all at the faxes from the nursing homes. He goes to the nursing homes every day and that out little fires that get in our way of taking care of our patients in the clinic. And he makes our life better. I hate to admit it. When I am gone I am not just too much. When our PA is gone he is very missed. Because we as physicians are now doing all of that work that he has been allocated to do that prevents us from seeing patients and treating them in a manner that we have become accustomed to. It is a different way of looking at a PA as somebody who actually assist the positions and help them practice care as opposed to just the provider. We found that to be extremely helpful. He also answers questions from the office staff and works with the care what Nader to manage that as well. This talks about the provider visit, that is such a small portion of our patients help and a small portion of how we have to work on quality. This quality process has to occur from the beginning to the post visit. Our nursing staff was screen patients and how we get them ready for which patients are high risk or which patient is control. Who needs lab work or who needs to take medication. We do homework on our patients before they come. We do a lot of same day registrations so we need to take advantage of the tools in our EMR to be able to do that real-time as opposed to having to do it the day before their this talks about registration and getting the patient settled. How to take appropriate blood pressure. Went to take it. What to use. All of the things that was a good refresher course for us to go over. What is really involved in a blood pressure that we will use to change people medication management. Then the check out to make sure that the appropriate things are done. We use our computer to make sure that every patient has a return to clinic so they know when it is expected. If there is any lab work or anything we would like done we put that into our return to clinic order so when I see somebody to follow up with hypertension even if at the year down the road, I will want to see how the kidney function and sodium or potassium. I want to put those orders on the chart every time I check them out. When the patient comes all of that testing can be done a day ahead of time so when he sees me we can make the absolute most of that visit. It wastes less time for the patient and makes the visits more actionable. And we don't have to waste time eating for lab work. So many people use EHR as a hurdle as something that slows you down.. We look at it as a hammer. It is nothing more than a tool. If you use a hammer to On glass you will at the results you like. If use it to build things you will get excellent results. We have taken the position since day one that the computer is here to help us. It is not our intention to make the computer work better it is the other way around. We have customized everything to our computer to make it work for us. I want to talk a little bit about the stages of the meaningful use. These are well-designed in my opinion. They help us design better processes to improve care. Stage I. The whole purpose of this is to capture data and get that data in a format where you can then react on it and do something with it. Stage II. People are now starting to collect data for out of station. It's about information exchange and care coordination. Population management and stats. And stage III is all about improved outcomes. Because in the end that is what we are here for. I will show you real-time data that shows how you can actually document how many hearts you can say. How many eyes you can save and to me that is what it is all about. We are working with the ONC to not have quite as many hoops or hurdles that you have to jump. If you can improve outcomes that will do away with a lot of reporting. If you can control you have better control of diabetics, hypertension, that would be enough and a significant part four stage III. It's about improving outcome for your patience. So the main -- Milion Hearts initiative is to prevent heart attacks the dash we will have 1 million heart attacks in five years and that is a lot of what talent he if you think about it. The question is can we do that and do we have the capabilities. Will it work. I will show you that yes we can and yes it makes a difference. Difference will be in our patients as providers to me that is very important. Our -- heart disease is the leading killer of the United States because we have done a better job was -- job. We are still looking at 800,000 deaths a year. 444 $444 in healthcare cost. Significant cost and loss productivity. There is a good return on investment. Last but not least is the greatest contributor to racial disparities in life expectancy. We have to customize our care to our patient load and in my mind one of the reasons people ask me and stage I, why do we have to ask what race they are or and the city. -- Ethnicity. Our goal is to improve it for everybody and to be able to measure it. In our feelings it a good thing to be able to measure. Because we want to do it. The key could run it is first of all optimizing care. Preventing a heart attack is much easier than treating it. We focus on the ABC's. And again we will go over what the simple ABC's are and use technology to manage population and I would look at clinical novations. I will talk about innovations that I can leave with today that will cost your administrations a quarter or maybe a dollar to implement clinic wide. To actually improve the care that you deliver. I don't know any administrator that would balk at those numbers. We are mistaken if we don't talk about immunity prevention as well. Because we figure and studies out of Wisconsin showed that we are probably accountable for 20% of help. But that means 80% of health happens outside of our offices so we need to work on that aspect as well. So smoking prevention. Reduced salt intake. Reduction entrance that. Getting everyone involved. We work with churches and immunity groups and Rotary clubs and whoever is to get public health involved and work at a communitywide level as well. If you want to take the pledge for the Milion Hearts . There is nothing in here as far as I can tell that I have not signed up for when I went to medical school. What I have it wanted to do to provide the best care to my patient. Treat blood pressure. Use aspirin when necessary. Discuss goals of your patient work out your patience to develop heart healthy habits. After patient about smoking. Provide help in stopping. Ask about barriers to medications and adherence. We feel, something that we measured because we can measure it in our electronic record. 85% of the medications that we prescribe are generic. They do not need to be expensive and they do not need to be the reason a patient can't get their blood pressure under control. Last but not least we agreed to use technology and let technology help us. It is interesting, we are learning that a lot of the public health, as far as population management is related who have been ticking care of this and doing a better job over the last four years. The civil clinical prevention is focusing on the ABC's. We all know that and the question becomes how do we measure it. How do we go after this so that we can do any systematic approach. We are relying on memories and good intentions doing the best we can if not nearly as good as having a systematic a Trojan that involves everyone on the team from the front office staff to the clinical people to the lab technicians to the care coordinators. It much better way of doing it. Goals for Milion Hearts , our goals are higher. 75% of people are on aspirin. Only 45% of people that are on it should be on it. We would like to have that 100% sure blood pressure control. The national average is only 46% of the people who need to be told work our goal would be 90%. I don't think anybody ever expects blood pressure control to be 100. Because if you are at 100% you are harming patient and we are not interested in doing that. There are certain patients that the side effects and bottles of bringing their blood pressure under 140/90 just aren't worth the side effects or the clinical problems that needy caused because of that. Cholesterol management. We are the advent of statins and recently we heard the American College of cardiology's thanks most people should be on statins these days. We can get the LDL below 100. The goal there is 70% but I don't see a reason why we cannot get it lower. And smoking. It's the number one thing that we can do as physicians to improve the care of our patients. It's sad but it's not using high-tech equipment, not using aspirin or blood pressure pills. But just getting people to stop smoking is the number one thing we can do to improve their health. Is also one of the number one things we can do to improve their pocketbook. Anything we can do their is worthwhile. I told you about my dollar solution and you are looking at right here. This is a piece of construction paper that we put recheck blood pressure on. We could to a magnet. We have one of these for every exam room that we have. This little queue does a number of things. In every single rooms on the inside of the door. When a medical assistant takes the blood pressure. If it is above 140/90 she was it from the inside of the door to the outside. That accuse her to say I must pay attention to blood pressure when I take it. If I have time I will recheck it and if I don't have time I will queue the doctor to check the blood pressure. So even on a busy day when I going to see this patient before I even know what I'm saying the patient for. I have a queue that says it recheck this patient blood pressure it is above goals and let's see if it is real or if we just rushed the patient or gave them a chance to relax first. Oftentimes it goes down. But sometimes it does not. It brings blood pressure to the forefront of your mind that makes it harder to skip over mask.