For children with asthma, and their families, a trip to the emergency room due to a severe asthmatic flare-up can be a traumatic and frightening experience and can often lead to a hospital stay. For a pediatric healthcare system, effective management of the pediatric asthma population improves the wellbeing of the patients and their families, reduces emergency department visits and improves overall health outcomes.
With this goal in mind, physician and IT leaders and care management teams at Children’s Hospital of Orange County (CHOC Children’s), based in Orange, California, leveraged health IT tools to improve the health of pediatric asthma patients through a population health approach in the health system’s primary care clinics. CHOC Children’s is a regional pediatric healthcare network that includes a 279-bed main hospital facility in the City of Orange and a hospital-within-a-hospital in Mission Viejo. CHOC also operates many primary and specialty care clinics, more than 100 additional programs and services and four centers of excellence – The CHOC Children’s Heart, Neuroscience, Orthopaedic and Hyundai Cancer Institutes. CHOC Health Alliance, an IPA comprised of Children’s Hospital of Orange County and CHOC Physician Network, manages approximately 160,000 fully capitated Medicaid pediatric patients through a contract with the Orange County-affiliated health plan, CalOptima.
Alexandra Roche, M.D., pediatrician at CHOC Children's
The pediatric asthma population health initiative, which entailed the implementation of health IT-supported care model redesign, has produced impressive results so far, with emergency department visits reduced 18 percent year-over-year, with asthma-related issues driving many of those ED visits. Further, this reduction in ED visits has resulted in $1 million in avoided emergency room costs. For their use of health IT to improve health outcomes and patient care, the editors of Healthcare Informatics have named CHOC Children’s as a semi-finalist winner in the 2017 Healthcare Informatics Innovator Awards Program.
Health IT-Supported Care Model Re-Design
Four years ago, CHOC Children’s developed a strategic plan, the “CHOC 2020,” and a major pillar of the strategic plan was the development of the CHOC Pediatric System of Care to better manage pediatric lives in the communities that the healthcare system serves.
“As part of that, we built in physician alignment, we built in care model redesign, we built in the information technology pieces that need to support that, and with all those being successful, we built in the ability to take on innovative payment models,” Mike Weiss, D.O., vice president of CHOC Health Alliance, CHOC’s Children’s health insurance plan. “As part of that foundation, we quickly realized that we could look at small segments of our population where we had an opportunity to use data to effect change. So we incorporated some tools, specifically disease registries, to approach a very common clinical condition that leads to a lot of morbidity and mortality and high cost, which is pediatric asthma.”
Three years ago, clinician, care management and IT leaders at CHOC Children’s working collaboratively on the Pediatric System of Care began looking at analytics tools to support population health programs. For this particular initiative, the collaborative team includes Bill Feaster, M.D., CHOC Children’s chief medical information officer; Weiss, who also works with the population health division; Bonnie Wolf, IT program manager at CHOC Children’s and Christina Grapentine, informatics specialist. Also instrumental in this effort were Cathy Nesselroad, R.N., care manager at the CHOC Primary Care Clinic and Carmen Namenek, manager of clinical operations for the CHOC primary care clinic, who implemented the technology tools within the primary care practices.
The team decided to focus on pediatric asthma patients in four CHOC primary care clinics in order to develop care models that could then be rolled out to other primary care practices, and they implemented Cerner’s HealtheIntent population health management platform in those four primary care clinics. Approximately 27,000 pediatrics in the CHOC Health Alliance are seen in the health system’s primary care clinics, and of this, 6,000 are registered in the asthma registry, Wolf says.
“Two of the diseases we decided to focus on were asthma and seizures, based on the fact that those are two of the highest utilizers within the hospital for ED and hospitalization services,” Feaster says. “So asthma was our first registry that we really developed. It was a multi-disciplinary group of primary care and specialty physicians, Dr. Weiss, myself, and Bonnie, we had a very broad-based approach to defining the measures of the asthma registry. We have been a development partner with Cerner, so that asthma registry, and the other registries we developed, are now the pediatric registries for Cerner.”
As part of this registry, the CHOC Children’s team worked together to research and define measures that were appropriate for the care of pediatric asthma patients. Ten measures were defined and built into the HealtheIntent asthma registry. Of these, two were selected for a focus on improvement—patients with an asthma control test completed in the past year and patients with an asthma action plan completed in the past year.
Once the database was built and the measures mapped to the database, a key factor for effectively using the measures and the patient registry was making the status of those measures available in real time in the clinical workflow and in the electronic medical record (EMR). For example, if a child who has asthma has a visit with a physician at a primary care clinic and that patient has not had an asthma control test in the past year, the project leaders wanted to ensure that information would be front-facing to the providers and the care teams. In addition, to track improvement, a dashboard was built and baseline data was documented and the dashboards are now used to provide information on the completion of measures.
“The key there is taking that technology that we had and operationalizing it and really putting in front of the caregivers, in real time, up front when the patient is walking in the door. And that’s where Cathy and Carmen’s team really took the technology and took it to the team,” Wolf says.
Further, in the primary care clinics, new workflows were rolled out to include a morning huddle with the entire care team where important information about the patients to be seen that day are reviewed including any outstanding measures for the asthma patients. Clinical staff were also provided with additional training on completing and documenting the asthma control test.
At the registration level, medical assistants within the primary care practices chart prep for the visits, with the status of the measures feeding into the physicians’ notes. “This ensures that there’s no missed opportunities at the time of the visit. So if that asthma control test is due, it’s handed out to the family at the start of the visit, prior to the provider seeing them, so we could get the score into the EHRs. That enables the provider to document it and talk to the family at the time of the visit about the outcomes of the control test, and also augmenting that the asthma action plan has been completed,” Nesselroad says.
“That information has always been in the chart, but it wasn’t forward facing, and now it identifies that there is an asthma patient, and it looks at these measures and identifies whether it’s on-time or behind and puts it forward facing on the summary screen so clinicians aren’t looking all over for it,” Namenek adds.
Making that information available in real time in the clinical workflow helps physicians to maximize the effectiveness of his or her patient visits, Nesselroad says, “Which is important when thinking about providers and how busy their schedules are. For our PCPs, their visits are precious, and only have so many in a day. If the care team can identify gaps in the service and be proactive about getting some of those gaps met prior to the visit or in between a visit without taking up another visit, that maximizes our ability to see our other patients who really need to be seen as well.” She adds that this new process also facilitates better monitoring of the patients to ensure that follow-up appointments are scheduled.
The population health management initiative went live in four primary care clinics in September 2015, and year-over-year results have been impressive. “Looking at the process outcomes, which were the completion of the asthma control test and completion of asthma action plan, for the most part, we were fairly abysmal to start with. About 15 percent of the time, overall, we were completing those two tasks, which we know are very important to reducing ED visits and inpatient stays,” Weiss says. Year-over-year, the percentage of pediatric asthma patients with those two measures completed rose to about 45 percent. “More importantly, as an outcome measure, for that population of patients, the 27,000 patients in our CHOC clinics, we reduced ED visits for nine-month period, year over year, by 18 percent, which translates to a savings of over $1 million based upon our cost of care, and all we did was implement this care team model and use the registries and the data.”
Feaster contends that one lesson learned from this initiative is that technology or workflow, alone, can’t improve care as much as when developed and implemented together. “Technology should not drive clinical care, it should support clinical care. I think this is a good example of how we have used that to our best advantage where the technology was developed to support the care model and the care model was developed around the technology, so they were done in tandem,” he says.
Weiss agrees, adding, “What we really did here, and I’m a doctor at heart, is that we didn’t allow the technology to drive what we did. We developed a care model and then presented that care model to our technology colleagues and created a solution to solve our clinical problems, which to me is what was really exciting about this and continues to be exciting.”
Wolf also notes that being a Cerner development partner enabled IT leaders to develop a solution that would work for the organization, rather than buying something off the shelf. “I think that gave us a great opportunity to partner with the technology, and say, ‘wouldn’t it be great if it could this, because this is what we would do with that’ and really have both sides of the clinical operations and technology people all together working toward making a system that not only is great technology but really supported how we practice and operate.”
High-level leadership buy-in also was critical to the success of the initiative, Weiss says. Feaster and Weiss both say that is represents a change in paradigm to focus on managing populations rather than hospital visits and revenue. “That’s a big step for a hospital-based system to take. We’re very privileged that our leadership sees that, and that transitioning is occurring,” Weiss says.
Further, that leadership buy-in goes all the way to the individual clinic level. “It’s the physicians and nurse managers, at a given location, because if they don’t believe in this and are not stakeholders, it won’t be successful,” Weiss says. “And, it’s important to really involve the front line workers as you design the operation. So Cathy and Carmen, to their credit, spent hours with those medical assistants and nurse managers and people at the front lines who do the work, answer the phones, all of that, to get their feedback and input as we developed the process.”
Next Steps and Future Work
In September 2015, CHOC Children’s was one of 29 healthcare collaborative networks selected for the Transforming Clinical Practice Initiative through the Centers for Medicare & Medicaid Innovation (CMMI). The health system received a $17.7 million grant, starting with $4.8 million in 2016, to fund quality improvement strategies in clinician practices, with asthma being one of CHOC Children’s target conditions for that initiative.
“Part of the grant is building guidelines into the EMR to help to build order sets that implement guidelines. And, so, one of the first ones we put into place, that is now available to primary care practitioners, is the ambulatory asthma guidelines implementation, which is very complicated to build but also very useful for practitioners. And that is now available to them, in addition to the data on their patients in the form of registries. So we present them the upfront data at the point of care, and then give them tools to more easily manage those patients, and that is based on national guidelines of care,” Feaster says.
Moving forward, CHOC Children’s plans to continue its population health initiatives with a focus on implementing an already developed well child registry, which, Weiss contends, will be more challenging, and a “game changer.” “We will actually be able to track children proactively for their immunizations and all their preventive care,” he says. “We’re also working with four or five other disease-specific registries, including rolling out this care model into our GI clinic to do this with the inflammatory bowel disease population. We’re focusing on areas where we know we have solid data to drive the care model re-design.”