# Presentation: 942580

##  Colorado Associated Community Health Information Exchange

**Lisa Schilling, MD, MSPH**
**AHRQ Annual Conference**
**Sept. 8, 2008**

***Creating a Shared Quality Improvement Reporting System***

## CACHIE Participants

- 14 Colorado federally qualified community  health centers
- Colorado Community Managed Care Network
- Colorado Community Health Network
- Others

## Presentation Objectives

-  Illustrate the use of business process analysis to inform user requirements

## CACHIE Goals

- To promote the use of information technology to support quality reporting and improvement across the CHC networks
- To design, build, & implement a shared system for quality reporting among 6 CHCs with 4 disparate EMR/PMS
- To assist CHC with EMR template implementation to improve care provision, documentation & measurement.

## Data <---> Information

- Provide Care

- Document Care

- Measure Care

- Template

**Notes:**
Its important to understand the genesis of data. First, providers must provide care and a template may prompt care by prompting questions or tasks.
Next, they must document the care provided and optimally it should be documented in a manner that allows it to be easily measured.
Once measured the results inform both the provision and the documentation. (Providers tend to do much more than they document, and EMR systems do not always make documentation easy)
EMR templates or forms assist with provision by providing static reminders, they assist with codified documentation which improves the accuracy of the measurement as it reflect care.  of these improve

## What is a business process?

*Business process:*
*A “business process” describes a ****set of activities**** and tasks that logically group together to accomplish a goal or ****produce something of value**** for the benefit of the organization, stakeholder, or customer.*

_**Dictionary **_

## Why Use Business Process Analysis?

- Everything is not as it appears to be:
- Unintended internal and external consequences
- It’s not just a “flip of the switch”
- Technology must complement workflow
- Expectancy:
- Exceeding capacities
- Fashion:
- Unnecessary complexity
- Remaining current
- Stakeholder interest:
- Varying levels over time
- Developing consensus

## Method

**Business **
**Process **
**Analysis**

**Business **
**Process **
**Redesign**

**Requirements**
**Definition**

**THINK**
***How do we do our work now?***
- Define goals and objectives
- Model context of work
- Identify business rules
- Describe tasks and workflows
- Identify common task sets

**RETHINK**
***How should we do our work?***
- Examine tasks and workflows
- Identify inefficiencies
- Identify efficiencies with repeatable processes
- Refine business processes and rules
- Remodel the context of work
- Restructure the tasks and workflow

**DESCRIBE**
***How an information system can support our work?***
- Define tasks to be performed for optimized business processes
- Describe the implementation of  business rules
- Describe in words and graphics how an information system is to be structured
- Determine scope of next phase of activities

***Method***

**Notes:**
 Understanding the business processes and defining system requirements are the most important steps in developing or acquiring any information system. Developing consensus among stakeholders about the work performed by a system requires a disciplined, analytical approach. 

Output-oriented design starts with the output and works backward. This means focusing on identifying and defining important business processes and their component tasks, changing business process flow or task flow as needed for efficiency, and then defining what the health information system needs to do in order to support these processes. Only at that point can the database design begin. To put it another way:
Database structure exists to serve  
Data outputs, which exist to serve  
Business processes, which exist to serve 
Organizational objectives, which exist to serve  
Organizational goals and vision 

Guiding Principles:
1).Information systems support the work of the organization  2.) Put the logical before the physical  3)Engage all stakeholders 4)Plan for interoperability 5)Look for ways to improve BP to add value 6)Design the system so that data are entered only once 7)Manage for accountability (Project Mgt)  8)Stop analyzing when the incremental progress outweighs incremental gain

## BPA Example #1

- Outcome:Provide a “fast food” customer with their order efficiently and receive payment.

**Notes:**
A method of defining the processes that occur to accomplish a desired outcome.

## Restaurant Order Fulfillment Process

*Amount Due*

*Payment*

*Order Detail*

- Legend

**Order taker**

*Greeting*

*Change*

*Order*

**Burger Station**

**Fry Station**

**Drink Station**

*Food inventory*

*Supplies (wrappers)*

*Food inventory*

*Supplies (oil)*

*Beverage inventory*

*Supplies (straws, cups)*

*Burger Order*

*Fry Order*

*Drink Order*

*Burger*

*Drink*

*Fries*

*Transaction*

*Output*

*Outcome*

*Input*

*Reports, receipts*

***Restaurant Order Fulfillment Process***
***Context Diagram***

**Notes:**
Legend,
Circles- are entities
Customer - triggers the events
Business rules- order taker cannot touch unwrapped food

## CACHIE BPA Purpose

- Align the Information system (IS) with the organization’s mission,
- need a clear model of the desired outcomes and the business processes that result in those outcomes.
- IS should support and enhance business processes.
- Creating a shared system required that we  understand CHC business process similarities and differences.

## CACHIE BPA Goals

- Develop a common definition of quality improvement reporting system
- Describe and visually document how quality improvement efforts are accomplished
- Describe how the quality improvement efforts will function with the quality IS
- Develop a list of functional requirements to drive information system design and implementation

## On The Road

**Clinica**

**Sunrise**

**Valley**
**Wide**

**Peak **
**Vista**

**High **
**Plains**

**Mountain**
**Family**

**Notes:**
Barriers- geographical, cultural, technical

## Slide 14

## BPA Example #2

- Outcome: Improve the provision and documentation of guideline concordant care in primary care clinic.

**Notes:**
A method of defining the processes that occur to accomplish a desired outcome.

## Provide  & Document DM Eye Care

**Goal: **Provide DM pts guideline concordant care
**Objective: **Ensure DM pts receive eye exams
**Business rules: **Electronic referrals are not possible, referrals to both internal and external providers.
**Trigger: **DM pt presents for care (other?)
**Task Set: **Care for any acute needs, refer for DM care
**Outcome**: Provide & document DM eye care

## Providing and Documenting Guideline

*Document Care*

- Legend

**Provider**

*Enter Eye Referral*

**Internal **
**Ophthalmologist**

**External**
**Ophthalmologist**

**Med Records**

*Referral to*

*Referral to*

*Retinal Exam documented*

*Scan*

*Transaction*

*Output*

*Outcome*

*Input*

***Quality Reports***

***Providing and Documenting Guideline***
***Concordant Care***

**EMR-**
**Codified, **
**text, scan**

**Diabetic**
**Patient**

- Ophth note

**Notes:**
Now since health care is much more complex than fast food, this example focused on one small piece of care provision and documentation- the diabetic eye exam.
In addition to explaining this slide...

## BPA- other topics

- Lab ordering & results handling,
- Documentation of foot exams & self-management goals,
- Incorporation of new or modified guidelines into their patient care processes, into their EMR templates, into their quality reporting,
- Current methods of creating & using quality reports from EMR data, challenges and successes.

## Slide 19

**Notes:**
Context diagram

## What We Learned

- Templates
- Not uniformly available,
- Require costly professional support to develop/modify,
- Require lots of CHC staff time,
- When available, not always used,
- Not automatically linked with “forms” -> double data entry,
- Desire for more & improved

## What We Learned- con’t

- Quality Reporting
- Great variability among CHC capacity
- Requires professional support ($$) to develop reports
- Reporting limited by $$$
- Reporting limited by system
- Desire for data (re-)use

## What We Learned- con’t

- Quality Reporting-2
- Analyze at provider, pod, clinic site, CHC level
- Analyze discrete specified time periods
- Track trends for individual patients
- Provide pre-built reports (UDS, etc)
- Easily create reports for individual CHC needs
- Save & share built reports
- Run “huddle” reports based on scheduled patients

**Notes:**
Want huddle reports
Want to assess Q at a variety of levels

## Slide 23

## It Takes a Village...

_**CACHIE Steering Committee**_
- Ross Brooks, Director
- Molly Brown, Manager
- Art Davidson, Co-Medical Director
- Jason Greer, HIT Director
- Molly O’Fallon, Clinical Quality Director
- Lisa Schilling, Co-Medical Director
- Dan Tuteur, CCMCN Ex. Director

- _HIT Committee_
- David Adamson, Mountain Family HC
- Kitty Bailey, CCHN
- Andrew Bienstock, Salud Family HC
- David Fleurquin, Pueblo Community HC
- Pete Gutierrez, Denver Health, Committee Chair
- Annette Kowal, CCHN
- Pete Leibig, Clinica Family Health Services
- Konnie Martin, Valley-Wide Health Systems, Inc.
- Pam McManus, Peak Vista Community HC
- Mitzi Moran, Sunrise Community Health
- Paul Olson, Peak Vista Community HC
- John Santistevan, Salud Family HC
- Pat Tellez, Metro Community Provider Network

**AHRQ**
- Marybeth Farquhar

**Notes:**
Want huddle reports
Want to assess Q at a variety of levels

## Contacts

- _CACHIE Project Manager_
- Ross Brooks 	ross@cchn.org
- _CACHIE Medical Directors_
- Lisa Schilling 	lisa.schilling@ucdenver.edu
- Arthur Davidson	art.davidson@dhha.org

**Notes:**
Want huddle reports
Want to assess Q at a variety of levels