Healthinsight Beacon Project Report

solutions success sustainability

the IC3 Beacon Project

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Solutions. Success. Sustainability.

The IC3 Beacon Community project—funded by Cooperative Agreement #90BC00006 from the Office of the National Coordinator, Department of Health and Human Services, allowed unprecedented innovation and flexibility in improving health care and reducing costs.

In forming our Beacon Community, we sought out problems and devised solutions. Centered on improving diabetes care, our Beacon Project also devised solutions to improve the free exchange of clinical information, streamline public health reporting, and advance end-of-life planning. We charted a

course, and changed course when necessary.

We worked together, achieving extraordinary levels of cooperation never before experienced.

And we succeeded. In every area, the Beacon Community achieved measurable successes. From small gains with large ramifications, to major changes

for the better, our Beacon Community proved that improvement is achievable.

Our successes are worth celebrating.

But we’re not finished. The knowledge gained from the Beacon Project will inform change and innovation through the health care community. We must continue to work together, to cooperate, to innovate, to

redouble our efforts to improve the quality of health care and attain better economies in its delivery.

Now, and from now on, we must see that our solutions and success are sustainable.

Contents

Overview of the IC3 Beacon Project Successes

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Celebrating Success: IC3 Beacon Community Clinics 10 Celebrating Success: IC3 Beacon Project Partners

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Celebrating Success: Patient Engagement

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Celebrating Success: End of Life

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Celebrating Success: One Person at a Time

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Christie North, Beacon Project Champion: How it Happened The roots of the Beacon Project are deep at HealthInsight. For many years, our focus has been on devising ways to utilize the emerging field of Health Information Technology to improve the quality and reduce the cost for patients. When the Beacon opportunity

came along in 2009, the cooperative agreement behind it offered the funding and flexibility to attempt the impossible. Our goals were too ambitious, our benchmarks too high, our expectations too lofty.

We did not let any of that affect our determination to succeed. Our partners in

this process each brought high levels of expertise and ideas for solutions to challenges facing the healthcare system in Utah. University of Utah Department of Family and Preventive Medicine, Intermountain Healthcare, Utah Health Information

Network, and Utah Department of Health joined together with HealthInsight to lend expertise in devising and developing ways to use Health Information Technology to improve health for individual patients, improve health throughout the population, and reduce costs.

The Beacon Community came together under the

banner of “Improving Care through Connectivity and Collaboration,� or the IC3 Beacon Community.

The central focus for the project, diabetes care, was surrounded by secondary and supportive areas of

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focus: development of a Clinical Health Information Exchange (cHIE) and helping providers connect their offices to the exchange, promoting Meaningful Use of electronic health records (EHR), and improving technology options around population health and advanced care planning. The main thrust, improving diabetes care and reducing costs, involved recruiting primary care clinics in three Utah counties: Salt Lake, Summit, and Tooele.

Some clinicians saw the

benefit immediately and others required a little cajoling, encouragement and incentives, but scores of clinics joined the Beacon Community. Attempts to improve technology by promoting Meaningful Use of EHR and connection to the cHIE revealed barriers related to incompatible or incomplete EHR functionality. Our computer wizards went to work to develop software to solve virtually every problem, and all Beacon clinics have achieved Meaningful Use. Beacon Project facilitators worked with

clinics to gather,store and analyze data, and utilize that information to provide timely, appropriate patient care. While success was measured on many levels, benchmarks were established for eight diabetes measures—an ambitious number, and well beyond those of similar projects.

Clinics, and their patients, were aided and encouraged in taking the necessary steps to improve in every area, and the successes were many.

The IC3 Beacon Community developed numerous tools to help both clinicians and patients achieve success in diabetes care.

Healthier Living Events, Care4Life, Care Coordination, and Utah Diabetes Practice Recommendations represent some of these successes.

Countless hours of expertise went into the development and testing of the cHIE, which provides appropriate sharing of clinical data and other relevant information in a safe and secure environment, allowing providers to access community-wide clinical data for informed decision making for their patients. Likewise, a massive effort was launched to work with the 60 Beacon clinics and their EHR vendors to provide interfaces that give the clinicians access to the cHIE. UDOH worked with experts at the University of Utah and

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UHIN to design and build a technology solution for public health reporting for the mandated reportable conditions. University of Utah Health Care and Intermountain Healthcare have shared expertise and provided testing for the public health reporting system in Utah, which is now a model for other states.

The importance and encouragement of Advanced Care Planning was included in the overall Beacon project. An Electronic Physician Order for Life Sustaining Treatment (ePOLST) registry was created to house POLST

s su uc cc ce es ss se es s

documents securely online, allowing first responders in the field, emergency care physicians, and others in emergency care to access patient POLST forms instantly and electronically to guide care and treatment in accordance with patient wishes.

A rejuvenated Leaving Well Coalition, with Beacon Project support, has garnered community support to continue the work around end-of-life

conversations and created a comprehensive website to provide medical, legal, financial, and other information about end of life. Leaving-well. org also has an application for smart phones, with guides for working through the myriad issues surrounding end of life.

Another affiliated website, UtahHealthScape (UHS), also benefitted from the Beacon Project. UHS provides to consumers detailed information and unbiased quality measures for hospitals, clinics, and physicians throughout the state, accessible anytime via the Internet.

Throughout these pages you’ll read more about Beacon Project challenges, solutions and successes. The challenge from this day forward is sustainability—building on the success we’ve achieved by spreading that success to other diseases and conditions, more providers and clinics, more patients. While the Beacon Project is now complete, its work—our

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work—is not finished. For when it comes to utilizing technology to improve the quality of healthcare and reduce costs, there is, and always will be, more to do.

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Kim Bateman, MD: Critical Mass at a Critical Time

Dr. Kim Bateman, Medical Director for HealthInsight, led Utah efforts in healthcare reform based on the “Six Point Transformation of Healthcare” white paper. He helped convene the community to identify gaps in the healthcare

system and to ascertain the most urgent needs of the Utah community.

Fortunately, this coincided with the American Recovery and Reinvestment Act spearheaded by the administration of President George W. Bush and signed into law in 2009 by President Barack Obama.

This stimulus bill created the opportunity for the

Beacon Cooperative Agreement, and Dr. Bateman immediately saw the opportunity to further healthcare transformation dialogue in Utah.

The application process for the Beacon Project was a community effort and the launch in 2010 required the same collaboration Utah has become known for.

Dr. Kim Bateman realized the IC3 Beacon Community could provide impetus for ongoing efforts to encourage use of electronic health records (EHR) in a meaningful way, and to link those health records in what would become the Clinical Health Information Exchange, or cHIE.

“There was a lot of heavy lifting, and there were financial implications as well as time commitments for the providers,” Bateman says. “The Beacon Project helped get over some of those barriers and get critical clinician partners over the hump as well.”

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Dr. Bateman retired from HealthInsight and later returned to serve on the Board of Trustees. As the IC3 Beacon Project comes to a close, Dr. Bateman, Board Chair, reflects on the need for transformation he helped the community identify.

“It’s always difficult to get critical mass for projects like this. You can’t just get one clinic doing this—you have to get a bunch of them doing it, and doing it with a majority of their patients,” he says. “The Beacon Project helped us focus on a leading group of clinics who were already on the verge of doing these things,

and catalyzed the effort through funding and through a mutual clinical goal. Putting it all together was really magical.”

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The IC3 Beacon Project success is reflected in the successes of the clinics that are part of the Beacon Community. These clinics implemented Beacon Project solutions, and will be the driving force for sustaining improvements in clinical care into the future.

Beacon Project successes cover a broad spectrum, and we invite the healthcare community, and the community as a whole, to join us in celebrating the achievements of Beacon Community clinics.

Celebrating Success: IC3 Beacon Community Clinics

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Advanced Practice Medical Clinic Beacon Project success was a challenge for large clinics overflowing with staff members, assisted by financial incentives, and supported by large, technologically sophisticated healthcare networks.

Imagine the difficulties facing a small-town clinic led by a nurse practitioner.

But, no one told Brand Reynolds, FNP, it couldn’t be done, so he did it.

A Beacon facilitator worked with Advanced Practice Medical Clinic to, first, achieve Meaningful Use with electronic health records (EHR), then achieve diabetes care benchmarks as part of the Beacon

Project. The clinic now routinely provides an improved standard of care, offers patients informative clinical summaries, consistently records important data in patient EHR, and uses evidence-based guidelines to treat patients with diabetes routinely.

Mr. Reynolds continues to focus on gathering and recording quality measures for diabetes care to monitor and sustain his clinic’s progress in this area.

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Alpine Internal Medicine Clinic ROBUST CLIN I Cwas just the beginThat The Beacon Project shines so brightly on Alpine Internal Medicine they have to wear shades. Really. As part of achieving the goal to increase and properly document eye exams, the staff donned sunglasses—and passed them out to patients.

ning. Responding to challenges the staff perceived to achieving goals, their Beacon clinic coach provided a diabetic report card to engage patients and better involve them in their diabetes management. To help patients meet their blood sugar

control goals, medical assistants handed out measuring cups Beacon provided to assist with monitoring meal portion serving sizes. Then it was on to LDL testing and LDL control. Other education tools provided by Beacon

included handheld mirrors to remind patients to check their feet on a daily basis for any signs of blisters or wounds requiring special attention.

Despite initial barriers to utilizing the clinic’s EHR system, clinic staff members did meet goals for data entry and retrieval.

Connections to the Clinical Health Information Exchange were also established to enable the sharing of consented patient data.

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Barbara Rizzardi, MD ROBUST supportive staff. They’ve become very engaged in Dr. Rizzardi is the sole C L I N I C generating lists, and excelprovider in a busy Internal lent at facilitating reminders Medicine clinic. The chaland reviewing diagnoses.” lenges of a tight schedule and managing a practice Participation in the Beacon did not prevent her from Project was also inspiraachieving success with the tional. “[Their] enthusiasm Beacon Project. She gives helps me to be enthusicredit to her office staff. astic! I’m excited about “I’m not a team of one,” medicine and being part of she says. “I have a very a much bigger group,”

Rizzardi says. “Beacon participation promotes feelings of being part of a bigger network and community rather than feeling as though I’m all by myself, and I like that.”

Achieving EHR Meaningful Use proved a challenge, occupying staff time and

slowing productivity by as much as half for a time. But it proved worthwhile. “The advantage now is communicating with ease among ourselves and our patients, while tracking and improving deficiencies,” the doctor says. “I couldn’t have done it without the help of HealthInsight staff and my EHR vendor for meeting my quality measures.”

Dr. Rizzardi also reports improvements in patient’s diabetes care outcome measures, owing to easier tracking, recording, and increased documentation—all a result of Beacon Project participation.

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Coalville and Kamas Health Centers ROBUST CLIN C theI Beacon Project and

Serving two small towns and rural areas in Summit County, deep in Utah’s Wasatch Mountains, Coalville and Kamas Health Centers embraced

set out with the intention to meet every one of the project’s goals. And they found ways to do it, achieving significant success in improving diabetes care according to any measure and earning Robust Clinic designation in the process.

A physician with an affinity for computers adapted computer systems to allow the clinics’ EHR systems to interface with the Clinical Health Information Exchange as well as sending e-mails to providers,

medical assistants, and administrators to keep everyone informed and on board.

Patients were engaged with Healthier Living Days, free diabetes education and screening, and other activities.

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CopperView Medical Center ROBUST An engaged and enthusiastic front office staff memCLIN C berI contacted patients by telephone, by e-mail, and by mail to make appointments for screenings and exams, remind them of appointments, follow-up Two words define the sucafterward with results and cess of CopperView Mediencouragement, and to cal Center in achieving invite and remind patients Beacon Project success: of Healthier Living Days Patient Outreach. educational opportunities.

Diabetes patients visiting the clinic for other reasons were also screened for diabetes control measures. Providers received the same kind of contact, with weekly e-mail accountability messages comparing progress to goals, along with monthly motivational and informational e-mails from the team’s lead physician.

Steps were taken, with assistance from the HealthInsight Practice Analytics program, to improve the capabilities of the EHR and the clinic is on the way to achieving Primary Care Medical Home designation.

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Evolutionary Healthcare A “concierge medicine” or “retainer practice,” Evolutionary Healthcare focuses on personalized care and patient engagement. Increased involvement with patients allows providers to offer diabetes education and encourage self-management for diabetes patients.

Care4Life, developed by Voxiva and tested by the Beacon Project, proved an especially effective tool for Evolutionary Healthcare patients.

Automated text messages remind patients of appointments, to monitor blood sugar levels, check weight, engage in physical activity, plan meals, and offer positive feedback, encouragement, and motivation.

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Exodus Healthcare Network

Exodus Healthcare Network was a pioneer in the area of Group Diabetes Education classes to engage their patients, help them manage their disease successfully and

be reimbursed for this work. Through the Beacon clinical quality improvement project, achieving Meaningful Use benchmarks and improving foot and eye exam outcome measures demonstrated

early in the program the potential Exodus had for tackling the challenging Beacon measure goals.

Throughout the project, this team demonstrated how impactful a focused team-based effort can be on quality improvement measures. Utilizing similar

strategies, the Exodus team also tackled improving blood sugar (HbA1c) control, blood pressure control and nephropathy screening improvements with similar results. Based on their commitment to quality,

and their innovative group classes for diabetic patients, Exodus Healthcare Network was nominated to be a Fastrack Clinic the final year of the Beacon project.

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Foothill Family Clinic

Early successes with the Beacon Project and the potential to exceed expectations led to Fastrack Clinc status for Foothill Family Clinic. With a large population of patients with

diabetes, the opportunities for improvement were significant. Their Beacon Clinic facilitator encouraged increased screening, accurate reporting, information sharing, and improved technology utilization.

With increased enthusiasm and commitment, meeting nephropathy

screening objectives and blood sugar control benchmarks as measured

by HbA1c were achieved, signifying measurable improvements in patient care.

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Fourth Street Clinic ROBUST CLIN IC Salt Lake City and, for Finding any clinic, anywhere, with as many obstacles in its path to providing quality healthcare would be difficult, if not impossible. The Federally Qualified Health Center (FQHC), Fourth Street Clinic, serves the homeless population of

many patients, is their first and only chance for care and treatment. Owing to irregular diet, difficulty of obtaining and maintaining medication, inconsistent opportunities for care, and mental health complications, managing diabetes is a particular problem.

Still, Christina Gallop, MD, Medical Director, saw no reason the clinic could not achieve Beacon Project goals. And, according to the Beacon facilitator, the staff at Fourth Street Clinic took on the Beacon Project “with a roar.�

Working as a closely knit team, physicians, medical assistants, office staff, and the dietitian went to work and met Beacon Project goals quickly, all the while treating a challenging patient base with dignity and respect.

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Granger Medical Clinic Granger Clinic was a slow adopter of the Beacon vision. However, once they finally caught the wave, there was no stopping them. The patient population of this multi-office, multi-specialty clinic showed an alarming problem with LDL cholesterol, thereby qualifying for an intensely focused, rapid

cycle intervention program through the Office of the National Coordinator for Health Information Technology, targeting improvement for LDL control measures across their large patient population.

With almost daily support by their Beacon facilitator, Granger Clinic participated in weekly team meetings and weekly conference calls with national advisors and the other four sites across the country participating in this pilot project. At the clinic level, the performance of provid-

ers and medical assistants in meeting project goals was measured weekly and reported nationally to technical assistants engaged in the program.

Myriad strategies were employed to improve this difficult outcome measure including weekly education sessions on cholesterol control and monthly

Healthier Living Days with screening and education for patients.

The results have been phenomenal and demonstrate what can be achieved in record time when an entire clinic commits to a goal and tracks progress weekly. Everybody wins!

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Health Clinics of Utah ROBUST CLIN I C to quality health access As part of the Utah Department of Health, Health Clinics of Utah (HCU) uses data driven, evidence-based interventions to promote healthy lifestyles and behaviors; detect and prevent injury and disease; and improve

care for all people of Utah including the state’s most vulnerable populations. HCU clinics serve a diverse patient base with many challenging chronic diseases and socio-economic barriers to effectively managing their diabetes.

Yet, an integrated, engaged, and enthusiastic team of administrators, medical assistants, and providers completed mandatory training sessions provided by their

Beacon Clinic facilitator and coalesced as the “perfect team” to meet Beacon Robust Clinic goals. Captured on video for the Beacon 2011 Annual report, the Health Clinics of Utah Quality Improvement Team donned sports uniforms to highlight their team spirit and commitment to the Beacon vision. Go team!

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Healthfirst Family Medicine Their HealthInsight Beacon Facilitator was one of the first to enter when Healthfirst Family Medicine opened its doors. EHR Meaningful Use was achieved, and lessons learned through that process led to success in meeting Beacon Project guidelines.

EHR familiarity allowed the clinic manager to identify diabetes patients and remind them of appointments for screenings and check-ups. The system also alerted the clinic staff to problems, including a patient who visited a nearby hospital emergency

room regularly, owing to poorly managed diabetes.

After regular clinic visits and patient education, the emergency room visits

are no longer necessary and the diabetes is under control—so much so, in fact, that the patient who once had difficulty getting around now walks regularly, including walking to the pharmacy for prescribed medication.

Healthfirst Family Medicine’s success with the Beacon Project increased patient volume and earned the clinic a HealthInsight Quality Award.

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Holladay Family Practice

A primary care clinic with five physicians offering comprehensive care for patients of all ages, Holladay Family Practice

saw Beacon Project involvement as an opportunity to improve every facet of diabetes care and treatment. And that’s just what they did—setting and achieving ambitious goals and earning designation as a “can-do” clinic.

Among many achievements, Holladay Family Practice was one of the first Beacon Project clinics to connect to the

Clinical Health Information Exchange bi-directionally, sending and receiving clinical data to improve care at the clinic and contributing to improvements elsewhere on behalf of their patients.

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Intermountain Avenues Specialty Clinic

An organized and efficient clinic manager held providers and medical assistants accountable for their roles in meeting

Beacon Project goals, resulting in quick achievement of benchmarks for blood pressure screenings and nephropathy.

Special training sessions for medical assistants on cholesterol screening also

garnered results. Addition of a care manager improved patient contact for appointment and screening reminders, as well as appropriate referrals for care outside the clinic.

Providers and medical assistants at Intermountain Avenues Specialty Clinic continually monitored results from other Intermountain Beacon

Community clinics, using comparisons to motivate one another to higher accomplishments.

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Intermountain Cottonwood Internal Medicine Clinic

Beacon Project successes came early and often for Intermountain Cottonwood Internal Medicine Clinic.

Communicating Beacon Project goals through staff meetings—every staff meeting—was key to the success. Setting achievable goals encouraged medical assistants and

providers, and recognizing success helped maintain enthusiasm. Education updates, “tips visits,” statistical information and feedback, “Lunch and Learn” sessions provided by their HealthInsight Beacon Clinic Coach helped maintain focus at the clinic.

On a nuts-and-bolts level, a diabetes worksheet, consulted before patient visits, reminded medical assistants and providers to check for overdue or out-of-range tests and val-

ues, and to write orders to ensure inclusion of diabetes measures. Awareness and consistency proved crucial to success.

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Intermountain Holladay Clinic

What results when the Beacon Project meets providers, medical assistants, and clinic administrators who are involved, integrated, and motivated? Intermountain Holladay Clinic provides the answer.

Collaborative, but competitive, providers met weekly to challenge one another, share successes, and plan improvements.

Staff training included monthly luncheons with lectures on diabetes care, with similar get-togethers for providers.

Striving to meet Beacon Project objectives led to the development of a standardized form for eye examinations, which was made available to members of the Beacon

Community and beyond.

Use of this form at Intermountain Holladay Clinic increased documented eye exam outcome measure more than six-fold.

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Intermountain Internal Medicine Associates All it took was a small success with documenting and recording foot examinations to convince physicians and support staff at Intermountain Internal Medicine Associates that the Beacon Project could pave the way to improved care for diabetes patients.

With assistance from their Beacon clinic facilitator, once foot exams were properly entered into the EHR, the value became evident. From there, it was on to making other

diabetes management tools part of the clinic’s standard operating procedure, with LDL cholesterol monitoring next in line. Assignment of a clinic care manager furthered progress, along with the introduction of the Intermountain Healthcare “diabetes bundle,� where

five measures are evaluated. Significant improvements in eye, foot, and LDL processes for care of patients with diabetes have resulted.

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Intermountain Medical Tower Family Practice

Intermountain Medical Tower Family Practice worked hard to standardize clinical processes, rally

providers, and involve medical assistants. Those efforts, along with the appointment of a care manager, resulted in achieving goals for improving and documenting eye care, foot care, and LDL cholesterol screenings.

Under the direction of the care manager, medical assistants tracked diabetes patients meticulously, contacting them with

reminders for screenings and appointments, and ensuring that patient information is properly entered into EHR. Learning sessions and other training activities solidified

improvements and lead to continuing advances in providing quality care for patients with diabetes.

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Intermountain Salt Lake Clinic Effective, efficient, economical care for diabetes patients is not a one-size-fitsall proposition. The flexibility of Beacon Project strategic interventions allowed clinics to achieve success on their own terms, as evidenced

by Intermountain Salt Lake Clinic. Patient engagement within their

parent company’s culture involves a personalized primary care team, an embodiment of the Patient Centered Medical Home concept. The team is comprised of healthcare

providers, with a physician directing care managers and health advocates, working together for the well-being of the patient. The team organizes patient information, contacts patients, tracks patient treatment, and ensures follow up.

The clinic’s version of patient engagement proved effective in meeting Beacon Project goals for diabetes care. Beacon Project clinical measures, overlapped with another of Intermountain Healthcare’s clinical initiatives, the “diabetes bundle,” which includes HbA1c screen-

ing and control, LDL screening and control, blood pressure control, nephropathy, eye exams, and foot exams. Intermountain Salt Lake Clinic achieved success on all those measures, and, in fact, by any measure.

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Intermountain South Jordan Clinic Significant and shifting barriers complicated Beacon Project implementation at Intermountain South Jordan Clinic. From upheaval related to building remodeling to administrative staff changes, the road to success proved a difficult one.

Still, the physicians, medical assistants, and administrative staff rose to the occasion and reached the clinic’s goals for documenting LDL values, foot care, and eye care, with

significant improvements in nephropathy screening. Charts and graphs measuring progress were posted in clinic work areas, success stories were circulated, and other measures taken to keep clinic staff engaged and involved.

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Intermountain South Sandy Clinic Intermountain South Sandy Clinic developed a clear vision of how to increase eye exam tracking and results reporting for diabetes patients. A fivestep process divided the task among staff members, with each taking ownership and responsibility for success.

Compliance? Complete.

The team achieved 100% participation in reaching Beacon Project goals for eye examinations. Teamwork proved the key—

along with education and training delivered by their Beacon facilitator.

The clinical staff invited providers to an informational meeting to explain the program and their role in it.

Among many measurable results were increased appointments with the clinic’s certified diabetes educator. In addition to implementing a teamwork approach within the clinic, they shared their valuable lessons learned with other Beacon clinics!

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Intermountain Southridge Clinic

Clinic quality improvement teams all need a champion to keep them motivated and on track with the current goals and aims. Usually it’s a provider champion but in some cases it is another

healthcare professional. A newly hired care manager saw the Beacon Project as an opportunity to make a difference—

and took it. Increased focus and improved clinical processes were among the results. So were setting, and meeting, ambitious goals for blood pressure and LDL screening.

Intermountain Southridge Clinic also increased their outreach efforts to their patients with diabetes by sending them reminders for appointments for care

and screening. There was also an increase in opportunities for diabetes education of staff and patients.

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Intermountain West Jordan Clinic

The clinic manager made Beacon Project success a personal goal. By working one-on-one with each

provider in the clinic, the manager marshaled individual strengths and characteristics to implement the project and achieve objectives.

First on the agenda were eye and foot screenings of diabetes patients during every visit—regardless of reason—and correctly entering that information in the EHR. Upon achieving those

goals, providers and medical assistants were encouraged to go to work on LDL screening and control, and that goal, too, was reached.

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Jordan Meadows Medical Center ROBUST CLINIC Getting information into the Clinical Health Information Exchange is crucial to its value in contributing to improved health care. Jordan Meadows Medical Center stands out as an example of how to gather that information.

Front office staff, beginning right at the reception desk, took the lead on establishing the clinic as a leader.

The consent form, allowing patient information to be entered in the Clinical Health Information Exchange, became simply one more step in the patient paperwork process. Most patients gladly signed, and most questions and concerns were

easily addressed owing to training by Utah Health Information Network. Those who seemed hesitant were encouraged to take the form home, study it, and contact the clinic or the Utah Health Information Network with questions.

Once embraced by clinic staff, the enrollment process proved much easier than anticipated.

And the staff is confident the rewards of more and better health information will prove significant.

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Jordan Ridge Family Medicine

Jordan Ridge Family Medicine was an early adopter of quality improvement as a result of the Beacon Program.

After the clinic’s providers and staff attended one of the first Beacon

learning sessions, they established several Plan-DoStudy-Act (P-D-S-A) Cycle Quality Improvement tests of change to immediately

establish, implement and document workflow improvements. The clinic has

been able to maintain high level changes, winning a SelectHealth quality award for their excellent diabetes clinical outcomes.

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People’s Health Clinic Among the discoveries of the Beacon Project is the fact that success has many faces. Even a clinic considered “unconventional” by most measures plays an important role in diabetes treatment and can achieve success with the demanding Beacon Project measures.

Few clinics in the Beacon Community compare to Park City’s People’s Health Clinic. This non-profit, community supported clinic utilizes volunteers to provide high-quality medical services to uninsured

individuals and families.

Two part-time physicians, a full-time clinic manager, and a part-time volunteer coordinator oversee as many as fifty volunteer physicians, nurses, medical assistants, and other support staff. In a recent year, 6,100 volunteer hours were logged, 3,000 of

which were provided by licensed medical professionals, providing care and treatment for more than 9,500 patients. The People’s Health Clinic is supported by local governments, private foundations, donors, and community fundraising projects.

The People’s Health Clinic is committed to providing improved patient care and outcomes utilizing the models and tools provided by the Beacon program. They were particularly grateful for the patient teaching tools available in Spanish.

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Riverton Family Health Center ROBUST and eager to engage.

That CLIN I Centhusiasm soon When Riverton’s Beacon translated to results. facilitator hosted diabetes care “learning meetings” All effective quality imat Riverton Family Health provement teams are led Center, their conference by committed provider room overflowed with parchampions and Riverton ticipating staff. Twenty or was no exception to the more staff members, from rule. In addition, clinic physicians to medical asmanagement offered sistants to office personincentives to the clinical nel would show up, ready support staff and to

the providers for achieving Beacon goals. Medical assistants developed protocols to gather and record appropriate information from every diabetes patient on every visit—even if unrelated to diabetes—and kept physicians informed and advised. Administrative

staff regularly monitored Electronic Heath Records to ensure information was documented properly for full credit for the clinical work performed. The EHR system was also utilized to send automated voice mail messages to patients to remind them to schedule screening and control appointments.

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saging system paid for itself by increasing our appointment load and reducing our no show rate, which improved the bottom line as well as our patient quality measures,” reported Aaron Monson, Practice Administrator.

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Salt Lake ROBUST Community Health Centers Among Beacon Community participants CLIN I C group visits were utilizing Group visits represent Salt Lake Community another facet of Patient Health Centers. Growing engagement methods numbers of patients with implemented by Beacon diabetes inspired the Project clinics to encourclinics to find a more effiage and facilitate selfcient approach to patient management of diabeeducation. Clinical teams tes, and are successful formed and included in activating both providproviders, medical ers and patients. assistants, and health

educators. An office manager planned the group visits with assistance from their Beacon facilitator.

Some twenty patients attended two, two-hour sessions. Led by the clinical team, patients discussed diabetes myths and facts. Each patient

set a self-management goal at the visit and received individual assistance and education from the clinical team in how best to achieve that goal.

Lab tests and screenings were conducted, office visits scheduled, and EHR updated during the group visit.

Innovation and flexibility are hallmarks of the Beacon Project, with success demonstrated in many ways, including group visits at Salt Lake Community Health Centers.

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St. Mark’sROBUST Family Medicine A registered nurse and CLIN I C assistant at the medical clinic received specialized The Beacon Project training from HealthInsight successes of this clinic, to increase understanding under the leadership of Dr. in a variety of patient-enJohn Berneike, are many. gagement and education Perhaps most significant is topics to provide comthe clinic’s piloting a newly prehensive assistance developed Beacon Diabefor high-risk diabetes tes Self-Management Care patients. Data collected in Coordination Program. the clinic’s EHR were

used to closely monitor diabetes indicators.

Increased emphasis on patient engagement and involvement paid identifiable dividends, including marked improvement in HbA1c blood glucose levels. Other benefits include improved staff involve-

ment and satisfaction through engaging with patients on a deeper level and feeling “ownership” in the patient care management process.

The motivated team is sold on care coordination.

“This is the kind of thing that is very appropriate to the way we practice medicine,” Dr. Berneike

says. “This program helps us to truly engage our patients. This should be the norm in primary care, and hopefully will be, as we continue to transform health care.”

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Utah Eye Associates, the Diabetic Eye Center

The Utah Eye Associates Diabetic Eye Center was founded and owned by David Masihdas, O.D. Dr. Masihdas was one of several specialists in the Beacon project who successfully completed

Meaningful Use attestation and participated in the Beacon project in several different ways. Utah Eye Associates served as half of a pilot project with another primary care provider to establish an electronic referral system, a requirement of Meaningful Use Stage 2.

Dr. Masihdas also was able to improve his response rates back to physicians regarding retinopathy status among diabetes patients.

In addition, Dr. Masihdas participated as often as his patient schedule would allow in the Beacon “Healthier Living Days�,

providing retinal eye exams for patients with diabetes who attended the event, something many of these patients had never had before. Dr. Masihdas is a tireless educator on the risks of blindness caused by uncontrolled diabetes.

He crusades to prevent this unnecessary tragedy.

The Diabetic Eye Center in Salt Lake City is dedicated to providing comprehensive eyecare to patients with diabetes.

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CLINIC

ROBUST

clinic

ROBUST

IC3 BEACON PROJECT CLINIC 72

Wasatch ROBUST Internal Medicine CLINIC

From quality care to enthusiastic participation in the Beacon Project, Wasatch Internal Medicine makes diabetes treatment a priority. A nurse practitioner on staff specializes

in diabetes care, and serves as care coordinator for other diabetes patients at the clinic as well as her own.

A Robust Clinic, Wasatch Internal Medicine set ambitious Beacon Project goals, and met them.

Sticky notes, posters, and flyers paper the walls with reminders of goals, progress reports, success stories, achievements, initiatives, reminders, and

encouragement. According to their Beacon facilitator, when it comes to the Beacon Project at Wasatch Internal Medicine, “They are totally committed to the Beacon goals.�

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CLINIC

ROBUST

clinic

ROBUST

IC3 BEACON PROJECT CLINIC 74

West Valley Family & Preventive Clinic ROBUST CLINIC

Educating and motivating diabetes patients is paramount in managing diabetes, so it follows that effective self-management on the part of patients is important in achieving Beacon Project success.

Tan Tran, MD and his staff at West Valley Family & Preventive Medicine have found success in patient engagement through persistence.

Rather than write off difficult or uncooperative patients, Family & Preventive Medicine goes the extra mile. No matter the time involved, the provider and his staff educate patients, going so far as to draw pictures and offer

detailed explanations.

Listening to patients is a priority, understanding their concerns and questions and offering the information they need, from diet and nutrition to fitness and weight control to testing and medication. If diabetes patients missed appointments for

screenings or examinations, the office staff was on the phone to reschedule, then calling again with reminders. Patience, caring, and hard work— that’s the story behind Beacon Project success at West Valley Family & Preventive Medicine.

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The IC3 IC3 Beacon Beacon Community is is aa comcommunity in in the the truest truest sense sense of the word. No No single single organization organization could could have have devised the solutions solutions or or achieved the successes we have enjoyed. But But the the combined expertise and and collective commitment commitment of of our partners partners pushed pushed the the Beacon Project Project to to soaring soaring heights. Now, Now, sustainabilsustainability is the challenge, challenge, and and these organizations organizations will will continue to collaborate collaborate to to achieve even more. more.

Celebrating Success: IC3 Beacon Project Partners

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Utah Department of Health

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Improving Technology for Improved Public Health Reporting Preventing and controlling disease, with emphasis on communicable disease, is one of the many important roles of public health departments throughout the United States. The success of these efforts relies on timely and accurate information from health-care providers and laboratories.

While the public health system, from the Centers for Disease Control to state and local health departments, have made great strides in limiting the incidence and spread of many diseases, advancements are hindered by slow, cumbersome, manual data collection and reporting processes.

The typical reporting process in Utah involves the laboratories, hospitals, and clinics identifying the occurrence of specific diseases, ‘Reportable conditions’, collecting and sending relevant information on the seventy-two conditions

that are currently reportable in Utah to either one of twelve local health departments or the Utah Department of Health.

With the advent of Electronic Health Records (EHR) came the opportunity to increase the ease, speed, and accuracy of disease reporting.

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Public Health Surveillance Use PUBLIC HEALTH ENTITIES

REPORTING ENTITIES Define And Publish Reporting Specifications HIE Lab Information System

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However technological barriers seemed prohibitive, along with economic obstacles to fund efforts to overcome those barriers.

The Beacon Project afforded an opportunity to clear some of the hurdles.

HealthInsight partnered with the University of Utah, the Utah Department of Health, and Utah Health Information Network to develop software and systems that leverage the state-wide Clinical Health Information Exchange (cHIE) to implement automated detection and transmission of public health reports to the state health department.

Day Care Clinical Information System School Nursing Home General Public Other Physician Nurse Lab Tech Computer Other

Access Specifications Detect Reportable Events

ELR ELR Case Reporting

Public Health Official

Create a Public Health Report Transmit Report to Public Health Department

Local Regional Tribal State

Receive Public Health Report

CDC

Investigate Reported Events

WHO

Implement Control Measures (Individual and Population-based) Monitor and Report Trends and Alert About Health Threats

Investigator

Clinical and Surveillance Team

System Architecture

Clinic Apelon DTS

Laboratory

Hig

Terminology Server

OPEN CDS

Hospital

Decision Support Service

Drools Guvnor Rules Manager

PH Reportable Conditions Knowledge

UTAH cHIE OpenCDS Knowledge Repository

Virtual Health Record

Data Warehouse Reportable Conditions Log

Drools Expert

PUBLIC HEALTH

Rules Engine

HL7 vMR

hlights

Medical Record Data Standard

MIRTH CONNECT INTERFACE

UT-NEDSS Statewide Surveillance System

The Beacon Public Health Reporting Team started the ball rolling by developing “logic” to detect four reportable diseases The project involved numerous technically challenging requirements, including source mapping, data flow and conversion, report compilation, and design of system architecture.

Development was successful, testing is complete, and, while many details remain, the process is being integrated into the cHIE data warehouse and, upon completion, will allow virtually instant reporting and dissemination of reportable disease information, and more.

Other states—none of whom had even contemplated such a comprehensive process—are eager to share in the success.

Tens of thousands of public health and information technology professionals saw a glimpse of the system when Beacon Project personnel presented it at the 2013 HIMSS—Healthcare Information and Management Systems Society—conference.

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Intermountain Health Care

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Improving Clinical Decision Support through Data Exchange Free exchange of clinical data is widely recognized as crucial to reducing healthcare costs and improving quality. So it is no surprise that devising methods to create information flow for support of clinical decision making was an important goal of the Beacon Project from the outset.

It would be a big job: difficult, time-consuming, and requiring unparalleled technological expertise. Intermountain Healthcare offered all that and more—including an eager willingness

to rise to the challenge.

Sid Thornton, Medical Informatics Director, led an Intermountain team that evaluated the many and varied EHR systems in use within the Beacon Community, navigated technological barriers to two-way information exchange, devised a viable patient authorization

protocol, and developed reliable, secure, and sustainable infrastructure requirements that will carry Beacon Project improvements far into the future.

partners

Highlights: Objective: Patient authorization and consent.

Hig

hlights

Numerous laws, rules, and regulations at both the federal and state level attempt to control the sanctity of patient information. Processes developed to manage this labyrinth—without compromising patient privacy or inhibiting the flow of desirable information—included an informed Opt In procedure for patients as well as safeguards to ensure the right information is available only to the right people under the right circumstances.

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Most patient files and visits contain valuable information not included in the database. By educating patients about the Health Information Exchange and encouraging consent, continuing increases in the amount of collected data were achieved across a range of clinical visits.

Intermountain Health Care

Objective: Create a patient identity process and link patient data over time.

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Beacon Project participants, including Intermountain Healthcare and the Utah Department of Health, worked with the state legislature to create a patient identification system that would track and accurately record patient data from various providers and make that information available through the Utah Health Information Network and Care Connectivity Consortium.

Objective: Create real-time information exchange.

In conjunction with a private technology partner, Intermountain Healthcare developed a method to make Clinical Health Information Exchange data available to providers in real-time while consulting with patients. The process was implemented and tested through the exchange of diabetes data for care coordination.

Hig

Into the Future:

hlights

Making improvements achieved through the Beacon Project sustainable into the future is essential. A number of initiatives are underway to improve the flow of patient care information.

Among these are:

Create “intelligent� features to flag data relevant to each patient encounter.

Develop methods to allow easy, seamless access to the Clinical Health Information Exchange for existing and emerging EHR systems and Meaningful Use requirements.

Further streamline patient consent and accessibility processes.

Continue and expand collaborative efforts such as Health Information Network, Clinical Health Information Exchange, Care Connectivity Consortium and others to increase the speed of development and implementation of clinical data exchange programs.

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175 lbs.

University of Utah Community Clinics

TARGET WEIGHT

10 units INSULIN DOSAGE

2200 CALORIES

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Your Days Are Numbers

A New Model EXERCISE:

30 minutes Imagine that you’ve just been diagnosed with diabetes. You’re angry and resentful of all the changes the disease will bring to your life. Your anxiety level rises as different numbers start swirling through your mind.

It all seems overwhelming, especially because the one number that sticks with you is 15.

That is the average time you will have with your physician every 3 months to figure out how to manage your diabetes. The rest of the time you’re on your own.

BLOOD PRESSURE

140/90

15

minutes

AVERAGE TIME SPENT WITH PHYSICIAN

This outdated model of care is still the normal practice for most health systems despite the fact that it causes patients frustration, depression, and often a paralyzing inability to manage their symptoms.

Yet managing diabetes requires a well-crafted plan, current information, and a proactive approach to diet and exercise.

University of Utah Community Clinics tackled this problem head on by developing a new model of care—a better way to help patients increase their self-management skills and arm them with powerful tools needed to confidently manage their present condition and to maintain behavior change over time. With funding support from the IC3 Beacon project, a Care Management Program was implemented.

The Nuts And Bolts Of The Care Management Program CARE MANAGER + PATIENT

A Good Care Manager Is A: Sounding Board Coach Motivator Connection to Resources

Two together The University of Utah Community Clinics created a Care Management Program that partners patients with their own personal care manager.

Care managers have one-on-one meetings with patients to assess individual situations, to develop strategies, and to arm patients with the tools and resources needed to best manage their diabetes

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Assessment Tools > Patient Activation Measure (PAM) Both initial and ongoing assessment through the PAM tool is a key component of the Care Management Program. Proper assessment of a patient’s strengths, weaknesses, progress, and struggles

is vital in the effort to develop and implement effective management strategies. > PHQ-9 Depression adds complexity and difficulties to the lives of patients with chronic health concerns.

The PHQ-9 tool helps to identify depression, so that it doesn’t become a barrier to self-management.

University of Utah Community Clinics

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The Nuts And Bolts Of The Care Management Program Connection to Resources

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Care managers work Self-Monitoring Tools The Care Management Program empowers patients to track their own progress via paper or our innovative online portal tools that include tracking charts for blood sugar levels, weight, blood pressure, and exercise.

closely with each patient’s physician and other care team members, including pharmacists, dietitians, diabetes educators, nursing staff, and other specialists. Through care managers, patients are supported with the information and expertise they need to more effectively manage their diabetes.

Transitions Navigator As the clinic-based Care Management Program gained positive results and improved outcomes, it became apparent that hospital transitions could be better managed as well. Patients are often overwhelmed with information as they leave the hospital and need some help before they go home, so that they can stay as healthy as possible.

> Improve their preparation for discharge To help patients make the transition out of the hospital, the University developed an innovative, hospital-based role of Transitions Navigator.

Transition Navigators work with patients to:

> Ensure proper follow through on treatment guidelines, medication, and follow-up appointments > Facilitate communication with care managers, primary care providers

partners

MANAGER

TEAM OF SPECIALISTS

Transitions Navigation Impact July 2012 - March 2013

20%

en d help

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ion,

oviders

89

n=1,147 discharges

40%

60%

80%

100%

68% 39% 79% 57% 9% 19% “No Shows� to follow up appointment Attended scheduled appointments Coordinated plan of care at discharge Transitions Navigation

No Transitions Navigation

Transitions Navigator

Patients that moved from one PAM level next higher level.

Patients that moved from one PAM level to to thethe next higher level.

Patients had improvement over baseline A1c Patients had anan improvement over baseline A1c Patients with improvement LDL Patients with improvement in in LDL Patients with improvement weight and BMI Patients with improvement in in weight and BMI Patients with improvement blood pressure Patients with improvement in in blood pressure

+12% Discussion of of changing habits Discussion changing habits +12% +43% +43% Setting personal goals Setting personal goals +9% +9% Helping to to make changes Helping make changes +9% Discussing things causing stress Discussing things causing stress +9%

Improved clinical outcomes

The increased self-management skills patients develop through the Care Management Program have improved clinical outcomes.

A New Set Of Numbers

pilot pilot clinic clinic

Patient experience scores for care management activities increased.

A better patient experience

pilot clinic

are Management Program e pilot clinic to eight other pilot ENGAGING PROVIDERS assessment, self-monitoring clinic ld with providers to introduce them to themeetings Care Management Program.

As to introduce them to the Care Management Program. were held with providers ds of patients across the Clinic-specific ts to care managers, they providers saw improvement in their patients and quickly began referring to care managers, they saw improvement in their patients and quickl network. ram. became champions for the program.

+16% its +16% +12% Discussing depression +43% DiscussingSTRENGTH health monitoring +20% GROWING ring +20% re Management Program Over a 15-month period, Management Program +9% Help in managing care the Care +9% +9% pilot clinic to eight other successfully expanded from the pilot clinic to eight other tress +9% pilot ssessment, self-monitoringclinics, bringing the program’s assessment, self-monitoring clinic s of patients across the tools, and resources to hundreds of patients across the etwork.

University of Utah Health Care network.

Beacon: Beacon: This This material material was was prepared prepared by (UU) by pressure (UU) as part as part of our of work our work as the as IC3 the Beacon IC3 Beacon Community, Community, under under grant grant #90BC00006 #90BC00006 ith improvement in blood Patients with improvement in blood pressure 30% fromfrom the Office the Office of the of National the National Coordinator, Coordinator, Department Department of Health of Health and and Human Human Services.

Services. el.that moved from one PAM level to the next higher level.

SSCM: This This project project was was supported supported by grant by grant number number R18HS020106 R18HS020106 fromfrom the Agency the Agency for Healthcare for Healthcare Research Research and and Quality.

Quality. hadSSCM: an improvement over baseline A1c ENCE PATIENT EXPERIENCE The The content content is solely is solely the responsibility the responsibility of the ofA authors theBETTER authors and and doesdoes not necessarily not necessarily represent represent the official the official viewsviews of the of Agency the Agency for for Healthcare Healthcare Research Research andactivities and Quality.

Quality. re management with improvement in LDL increased.

Patient experience scores for care management activities increased. with improvement in weight and BMI Discussing s +12% +16% Discussiondepression of changing habits+16%+12% Discussing depression with improvement in blood pressure Discussing health monitoring +43% +20% Setting personal goals +43% Discussing health monitoring +20% Help in managing +9% +9% +9% +9% Helping to make care changes Help in managing care IENCE ess +9% Discussing things causing stress +9% care management activities increased.

ad an improvement over baseline A1c Patients had an improvement over baseline successfully successfully manage manage their their condition, condition, soso they they can can live live the the lifelife they they want want toto live. live. A1c 64% OMES ith improvement in LDL Patients with improvement in LDL 63% skills patients through the Care Management have ntithProgram havedevelop improvement in weight and BMI PatientsProgram with improvement in weight and BMI 55%

toto provide provide patients diagnosed with with diabetes diabetes the the support, support, resources, resources, and confidence confidence they they need need to to hat moved from patients one PAMdiagnosed level to the next higher level.

Patients that moved from one and PAM level to the next higher level.

41% NUMBERS

MES IMPROVED CLINICAL OUTCOMES Based onon a strong a strong foundation foundation and and bolstered bolstered byProgram by itsits initial initial success, success, the the Care Care Management Management Program Program Program have t skillsBased patients develop through the Care Management have The increased self-management skills patients develop through the Care Management improved clinical willwill continue continue toto refine refine and and expand expand tooutcomes. to meet meet changing changing patient patient expectations expectations and and needs. needs.

Our Our goal goal is is

UMBERS

A NEW SET OF NUMBERS

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This This forward-thinking forward-thinking strategy strategy helps helps to to ensure ensure thethe program’s program’s viability viability and and sustainability sustainability asas health health care care transitions transitions outout of of a volume-based a volume-based model. model.

ENGAGING ENGAGING PROVIDERS PROVIDERS Clinic-specific Clinic-specific meetings meetings were were held held with with providers providers to to introduce introduce them them to to thethe Care Care Management Management Program.

Program.

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+16% +16% Discussing depression Discussing depression +20% Discussing health monitoring Discussing health monitoring+20% +9% +9% Help in in managing care Help managing care

AA BETTER PATIENT EXPERIENCE BETTER PATIENT EXPERIENCE Patient experience scores forfor care management activities increased.

Patient experience scores care management activities increased.

41% 41% 64% 64% 63% 63% 55% 55% 30% 30%

IMPROVED IMPROVED CLINICAL CLINICAL OUTCOMES OUTCOMES The The increased increased self-management self-management skills skills patients patients develop develop through through thethe Care Care Management Management Program Program have have improved improved clinical clinical outcomes. outcomes.

AANEW NEWSET SETOF OFNUMBERS NUMBERS 90

University of Utah Community Clinics

ses of in the Management Program were built to operate in a value-based erate a Care value-based n and bolstered by its initial success, the Care Management Program by its initial success, the Care Management Progr Based on a strong bolstered vironment.

This forward-thinking strategy helps tofoundation ensure theand program’s re the program’s

PROVIDING VALUE held providers to introduce them were to thebuilt Care Management Program.

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As nts to care managers, theycare saw improvement their environment. patients and quickly ronment.

This forward-thinking strategy helps toinensure the program’s delivery and payment This forward-thinking strategy helps to ensure the program’s patients and quickly ogram. alth care transitions out of aviability volume-based model. as health care transitions out of a volume-based model. and sustainability

clinic

cussing health monitoring +20% +9% lp in managing care

successes pilot clinic

Impressive them to the Care Management Program. As w improvement in their patients and quickly

Outcomes

Growing strength

Over a 15-month period, the Care Management ogram were built to operate in a value-based Program successfully strategy helps to ensure the program’s expanded from the pilot lume-based model. clinic to eight other clinics, bringing the program’s assessment, self-monitoring tools, and resources success, the Care Management Program ent expectations and needs. Our goal is to hundreds of patients resources, and confidence they need toacross the University of Utah Health Care network.

life they want to live.

Providing value Engaging providers Clinic-specific meetings were held with providers to introduce them to the Care Management Program. As providers began referring patients to care managers, they saw immediate improvement and quickly became champions for the program.

The infrastructure and processes of the Care Management Program were built to operate in a value-based care delivery and payment environment.

This forward-thinking strategy helps to ensure the program’s viability and sustainability as health care transitions out of a volume-based model.

Based on a strong foundation and bolstered by its initial success, the Care Management Program will continue to refine and expand to meet changing patient expectations and needs. Our goal is to provide every patient diagnosed with diabetes the support, resources, and confidence they need to successfully manage their condition, so they can live the life they want to live.

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successful

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Innovation Advisor Program In Utah, diabetes accounts for 1 in every 10 hospital admissions and more than 30% of all costs of care. Sarah Woolsey, MD, medical director for HealthInsight, was among the inaugural group of 72 experts across the country selected for the Centers for

Medicare & Medicaid Services (CMS) Innovation Advisors Program.

The initiative, launched by the CMS Innovation Center in October 2011, is helping health professionals deepen skills that will drive improvements in patient care and reduce healthcare costs. Working with some of the more mature users of EHR, the

Beacon team was able to show that with proper funding and training, primary care clinics can reduce costs by using registered nurse care managers and medical assistants to provide care coordination, systematic screening, and improved documentation of diabetes care.

A pilot program was launched in one of the Beacon clinics who dedicated staff to the medical assistant-led model

Through this program, clinical staff developed a better understanding of how to assist patients to

based on the tenets of the Association for Healthcare Research and Quality (AHRQ). This pilot was effective, affordable, and sustainable. The AHRQ model encourages the clinical staff to function as a team and engage with diabetes patients on a deeper level than the typical office visit allows.

overcome the barriers to managing their chronic disease. Preliminary results have indicated patients who benefitted directly from this pilot experienced positive outcomes including improved care, greater satisfaction with the care received, reduced healthcare costs and improved health.

partners

Next Steps:

Patients enrolled in the pilot included some of the most challenging patients and yet many saw significant improvements in control measures, approaching the clinic’s “usual care� levels as well as community thresholds.

Beacon Project clinics are showing significant improvements in diabetes treatment through this effort and a variety of other interventions. The Care Coordination model is a recommended next step for further gains. Selected clinics are being offered training and assistance in developing systems to address the 20% of the diabetes population receiving care who offer the greatest challenge for disease management.

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Utah Health Information Network

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cHIE: Health information at the right time by the right people

The Utah Health Information Network (UHIN) is a non-profit, broad-based coalition of Utah healthcare insurers, providers, the state of Utah and other interested parties.

The mission of the Utah

Health Information Network (UHIN) is to reduce healthcare costs and improve quality and access for the community by assuring that providers, payers, and patients can exchange information electronically.

The Utah cHIE (clinical Healthcare Information Exchange) has been operating for four years.

Patients benefit: Medical history is available to their healthcare providers anytime, anywhere Data available means: > Improved quality of care; information at hand means fewer errors > Reduction in duplicate tests

Data is secure and private; access requires authentication

Clinicians benefit:

Best possible decisions for care, which results in safer, improved quality of care, fewer medical mistakes, and reduced occurrences of duplicate tests

With secure, electronic access to patient medical information anytime anywhere

More information available without the use of fax machines, or massive storage facilities

Patients must consent to have their data made available to providers

partners

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Community benefit: Availability of information means community cost of care is reduced through appropriate use of testing and treatment Actionable information available to those who need it and are legally able to access it

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Key elements of cHIE: 1) Gathering patient consent. Experience has shown that when it is easy to provide consent, the majority of people in Utah see the benefit of having their medical information available to their providers electronically and enthusiastically participate.

2) As a first step towards connection, providers use the cHIE VHR tool to access patient medical information.

3) The final step is providers connecting their office based EHR to the

cHIE to exchange clinical data. UHIN has developed cHIE interfaces with many EHR systems to send, receive or transmit data bi-directionally, with more connecting every day as the EHR vendors develop the necessary interfaces to enable this level of data sharing.

All Beacon clinics have access to cHIE data through one of these mechanisms with the goal being statewide bi-directional connectivity by 2014.

Challenged by the technical complexity of connecting multiple (19) disparate EHR systems to the cHIE, the progress that has been made to date in this compressed

time frame is laudable and benefits are already being realized in the state. As more providers connect and more of the population consents, improved health and anticipated cost savings will soon become visible to all. There really will come a day in the near future when fax machines are no longer necessary pieces of medical equipment and patients will no

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longer have to complete lengthy questionnaires about their medical history for each physician that they visit.

For more information and to stay updated on the progress UHIN and the cHIE are making, visit www.mychie.org.

Utah Diabetes Prevention and Control Program

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Utah Diabetes Practice Recommendations As part of the Beacon Project’s goals of improving diabetes care and reducing associated costs, HealthInsight’s Medical Director, Sarah Woolsey, MD, worked with a panel of professionals organized by the Utah Diabetes Prevention and Control Program

of the Utah Department of Health, to develop clinical guidelines to help healthcare providers more effectively screen, diagnose, and manage diabetes.

Available in a booklet hand-delivered by HealthInsight facilitators to all Beacon providers, and online, where they have been downloaded

hundreds of times, the guidelines build upon and complement national and regional diabetes protocols. Basic information about diabetes, screening guidelines, insulin therapy, cardiovascular complications, foot care, nephropathy, eye care, and depression are among the topics

covered. Also included are teaching aids to help educate patients about self-management, medications, foot exams, monitoring glucose levels, caring for feet, healthy eating, and smoking cessation.

The panel updates and revises the recommendations annually. HealthInsight intends continuing involvement in, and support of, this important initiative in partnership with UDOH.

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Regional Extension Center

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Meaningful Use HealthInsight served as the Regional Extension Center (REC) for the states of Utah and Nevada. Like Beacon, REC is overseen by the Office of the National Coordinator for Health Information Technology (ONC).

Since Meaningful Use attainment was an ONC

priority it became a goal for both programs and collaboration between the two proved essential to success. As part of the process, EHR vendors participated in cross clinical trainings sponsored by REC and Beacon, which allowed users to influence further software enhancement features that were critical for quality improve-

ment reporting purposes with a focus on Diabetes Mellitus Type 2. The multiclinic trainings allowed independent clinics to develop local relationships enabling the sharing of best practices with regard to workflow and EHR use, helping each other to improve patient care delivery in the community.

Another benefit of this collaboration was that clinics achieving Meaningful Use while working on Beacon diabetes outcome measure improvement were able to see the relevance of

Meaningful Use requirements as they relate to improving patient care.

The rationale becomes very clear when program priorities are aligned!

The IC3 Beacon project recruited over 60 clinics that utilized 19 different EHR, which complicated the

partners

OVER

60 CLINICS

UTILIZING

19

101

DIFFERENT EHR

ASSISTING OVER

600 PROVIDERS

process exponentially as staff from both REC and Beacon helped our clinics learn to maximize the capabilities of their EHR to enable goal attainment for both programs. How much simpler it would have been if there had been only a few EHR in the system to work with.

Throughout the course of the Beacon project, over 600 providers were assisted by HeathInsight teams and attained Meaningful Use. Since REC will continue for an additional six months post Beacon, many more providers are expected to attain Meaningful Use by February of 2014.

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It is estimated that more than 90% of care for chronic diabetes occurs outside the doctor’s office. So, it is essential that patients be educated, motivated, and aided in effective diabetes management. The IC3 Beacon Community developed, tested, and implemented several programs and tools to achieve success, and as those programs and tools spread throughout the healthcare community, those successes will grow, lowering costs and improving diabetes care for all patients while setting the stage for improving care for other chronic conditions.

Celebrating Success: Patient engagement

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Healthy Living Events Educating and motivating patients with chronic conditions to manage their disease is, in itself, a chronic condition. It is a challenging, never-ending task for healthcare providers treating patients with diabetes. As part of the Beacon Project, HealthInsight partnered with other organizations involved in

diabetes care to initiate an innovative, efficient, and effective way to engage patients, provide tools to help them manage their diabetes, and inspire them to increase their efforts to maintain optimal health.

Held at participating Beacon clinics, “Healthier Living Days” generated enthusiasm among both

patients and clinic staff, teaching the former how to manage diabetes, and the latter how to easily and effectively engage with patients. From white cotton socks to portioncontrol measuring cups, to “healthy-plate” placemats to sun glasses, to mirrors

for foot exams, and more, Healthier Living Days offered participants many useful tools to help manage their diabetes. As part of the incentive to participate, providers joined in, encouraging patients to get their screenings while in the office, often at reduced or no charge.

All activities were provided

in a festive atmosphere where patients were encouraged to talk to the staff about their concerns, challenges and goals for health. These clinic events were well received and appreciated by the patients who participated. Not only were patients appreciative, but also many took action

engagement

as a result of these events, which led to improved measures including blood pressure, cholesterol and HbA1c screenings and control. Skeptics at some clinics were soon won over, and many requested additional Healthier Living Days. Thanks to Beacon Project participants, about 383 patients at 14 clinics benefitted from 25 Healthier Living Days.

Healthier Living Days would not have been nearly as successful without the participation and support of our corporate sponsors: Utah Diabetes Specialty Center, whose staff provided advice and free samples of glucometers and orthotic devices for patients with diabetes.

Novo Nordisk for providing their dietitian who counseled patients on weight management at no charge.

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Harmon’s Grocery Store who also provided nutritionists to advise patients on food choices, food preparation tips, food shopping guidelines and reading labels.

Dr. David Masihdas, of the Diabetes Eye Center of Salt Lake City, who provided dilated eye exams for patients at Healthier Living Days.

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Care4Life Despite the comprehensive and ambitious goals originally proposed for the Beacon Project, it became evident that one crucial element was missing: Patient engagement. With chronic diseases, such as diabetes, the vast majority of care management takes place outside the

doctor’s office. So, the success of any diabetesfocused program is almost wholly dependent on the program’s adaptability to and integration with the daily lives of patients.

Beacon Project participants at HealthInsight went to work to devise and develop economical ways to make effective,

reliable, and sustainable diabetes management information and tools accessible to patients.

Emphasis was given to patient-centered interventions that could lower the cost of care.

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Among the results is Care4Life. This innovative project utilizes a communication channel that has become ubiquitous in our culture: the mobile phone text message.

Throughout the day, Care4Life participants receive text messages from “Paula” reminding them

to engage in a number of health-related tasks of their choosing: check their blood pressure, take medications, check blood sugar levels, monitor their weight, attend doctor appointments, and the like. They also received motivational messages, tips for healthy living, progress toward goals, and positive feedback.

Most important, the type

and timing of messages is individualized and personalized, and could be adjusted anytime. Participants received the kind of reminders and information they found most helpful, the frequency and timing of messages, and other variables. And, the system is interactive, allowing participants to respond and report to “Paula.”

Approxmiately 450 patients used the Care4Life program. EHR can identify patients most likely to benefit from the program, and providers can enroll patients or refer them online to take advantage of the selfmanagement program.

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UtahHealthScape If consumers are to play a role in managing healthcare costs—which they must—they need access to information that will allow educated, considered decisions. Participation in the Beacon Project allowed HealthInsight to offer this kind of valuable information via UtahHealthScape.org.

An interactive, online resource, UtahHealthScape provides information about the availability and quality of health care in Utah. Detailed listings of physicians, clinics, hospitals, nursing homes, and home health agencies are searchable by a variety of categories and provide actionable information, such as whether a

physician speaks another language and a clinic has weekend office hours.

Quality of care measures are based on objective, well-vetted national datasets. The creation of summary scores makes

this information easier to understand for healthcare consumers, with the option to drill down through a series of layers to see greater detail. The site also includes basic information on common health conditions and concerns, with links to more detailed sources.

Many in the local community have long recognized the value of making quality information about health care available to the public, to further educate, engage, and empower patients and families. The Beacon Project, through the creation of UtahHealthScape, makes this aim a reality for today and the long term.

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Stanford Self-Management Program

Because half of all people with diabetes also suffer from other chronic diseases or conditions, interventions that help patients approach a variety of chronic conditions are sorely needed.

To serve this need, HealthInsight professionals looked to the Chronic Disease Self-Management Program developed

by Stanford University, which teaches approaches and strategies to help individuals tackle a range of conditions.

The program, which is supported by 20 years of research showing improved outcomes and lower costs, is conducted through in-person workshops as well as virtual

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format (online) and promoted during clinicbased Healthier Living Days. In a series of six, two-to three-hour workshops, trained facilitators, usually patients with chronic disease themselves, cover topics such as managing symptoms,

diet, physical activity and exercise, medication management, and effective communication with medical providers.

Participant engagement and social support contribute to the success of the program.

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Fostering healthy discussions surrounding the end of life can benefit all.

Not only are those approaching death honored as the healthcare system respects their wishes concerning the care associated with passing, families and other loved ones are relieved of the burden of making decisions with limited information. Successful Beacon Project initiatives made great strides in end-of-life care, and set the stage for future improvements.

Celebrating Success: End of Life

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ePOLST: Respecting Patients to the End Among the most important aspects of end-of-life care planning, in addition to Advance Directives, is the Physician Order for Life Sustaining Treatment, or POLST. This form is signed by physician and patient after in-depth conversations about patient values and end-of-life care wishes. It outlines

in detail what treatments and procedures the patient does and does not want provided by emergency responders and hospital personnel should the patient be unable to communicate during an emergency. Since it is a physician order, POLST gives patients the most control possible over medical decisions during

a medical emergency and is more immediate and imminent than Advance Directives and other preparations. End-of-life experts say the POLST form is important, but the conversations with physician and family that lead to the completion of the form are what really

matter. Nor is creation of a POLST form a one-time thing; following every new diagnosis or change in medical condition, end-oflife specialists recommend a patient’s POLST be updated to accommodate those changes. And, anytime the patient changes their mind from what they recorded originally, a new form should be created.

Until now, the POLST form has existed only on paper. Unfortunately, paper POLST forms are often unavailable at the very time they are needed most. Hence, the need for an electronic POLST, or ePOLST—an idea long in the planning, but short in implementation owing to lack of funding.

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The Beacon Project provided the funding required to design the technology, set up the database, create the user interfaces and other technical requirements to make ePOLST possible.

With ePOLST, an electronic version of a patient’s POLST form is held in a Utah Department of Health secure database

and can be readily accessed by paramedics, emergency physicians, and other appropriate care providers who can then comply with the patient’s documented wishes with a clear conscience. ePOLST is accessible anywhere there is an internet connection for computers, tablets,

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smart phones, and other electronic devices. EMS providers have been trained in the use of the ePOLST and are very excited about this advanced way to accommodate patient’s wishes around end of-life-care.

Thanks to Beacon Project support of ePOLST, the system is ready to go to work—a decade ahead of estimates of when

it might have debuted without that support.

Educational programs are underway throughout Utah for medical professionals involved in endof-life care to train them in use of the ePOLST system. Utah’s program will be the first of its kind and is rapidly becoming a model for other states wishing to implement similar initiatives.

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Leaving Well Coalition: Raising End-of-Life Care to a Higher Level Death, in our culture, is an uncomfortable subject.

Most people don’t care to discuss it. But, when it comes to leaving this life with peace of mind, talking about the care leading up to one’s death is of utmost importance. The Leaving Well Coalition exists for many reasons, but dominating them all is

a desire to allow each of us to die with dignity and with respect for our wishes concerning medical treatment and intervention when the time comes.

Long-time champion of quality end-of-life care and the Leaving Well Coalition, Julien Puzey, put an exclamation point on her beliefs by showing the way with her own end of life. Puzey asked Christie North, a HealthInsight colleague also involved in end-of-life advocacy, to

document her death from cancer in microscopic detail in a journal, which became a magazine article, to publicize and educate healthcare professionals and the public about end-of-life issues.

This included her decision to not have additional chemotherapy and to experience a natural death at home, attended by loved ones. “Not everyone’s cup of tea,” North says, “but a strong brew nevertheless.” And an important one.

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Inspired by Puzey’s example and with Beacon Project support, the Leaving Well Coalition found renewed vigor and determination. The coalition has goals to ensure the vital conversations occur and are documented, and supports the development and continued availability of the electronic POLST process.

The most visible result of the coalition efforts is www.Leaving-Well.org.

This comprehensive website seeks to bring end-oflife conversations to the forefront by creating an environment where talk about death and dying can be more comfortable, more informed, and more

likely to occur. Informative articles on virtually every aspect related to end of life are either within the site or through direct external links to other reliable sources. Much of the information originates with, or is created by, members of the Coalition.

You’ll find forms and documents, including POLST and Advance Directive forms on the site and links to the ePOLST. Financial information and legal information are also available. Part of the site is information about hospice centers, palliative care, and funeral planning.

“The Leaving Well Coalition exists to ensure every person in Utah has the opportunity to live well to the end of life by sharing the conversation about their values, making their wishes known and receiving the end-oflife care they desire.”

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The IC3 Beacon project is all about teamwork. Truly, none of the achievements this initiative realized could have occurred without the dedication and commitment of large groups of people from many different organizations and professions working together. However, by chronicling a few individual stories of patients and providers within these pages, we can demonstrate the impact this program has had on individual lives.

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On a Personal Level: John Berneike, MD Health Information Technology can be imagined as a two-sided coin. On one side is the clinical perspective, understanding how information can improve the quality of patient care as well as add efficiencies and economies in providing care.

On the other side are the technological challenges

associated with gathering, storing, retrieving, and analyzing data relevant to the complexities of human health.

No matter how you flip such a coin, it will come up John Berneike, MD, every time.

A physician with St.Mark’s Family Medicine, Dr. Berneike has been a Beacon

Project champion in many ways. His clinic was designated a Robust Clinic early in the project, achieved admirable results by every measure and served as the pilot clinic for the Beacon Project’s Care Coordination program. Health Information Technology is of particular interest to Dr. Berneike. With undergraduate training in computer

engineering, he worked as a software engineer and development manager for a major computer company for nearly a decade.

That education and experience were not forgotten when Berneike became a doctor. He manages the computer network and EHR system at his clinic, has been actively involved

with Utah’s Clinical Health Information Exchange (cHIE) operated by the Utah Health Information Network (UHIN), has served as a physician representative on the UHIN Board for many years, and was elected Vice-Chair of the Board and Chair of the Clinicians Committee.

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Dr. Berneike’s many Beacon Project successes led to his representing Utah at a White House Town Hall Meeting in 2012, where he met with senior administration officials and fellow healthcare providers to discuss challenges and opportunities in using health information technology to improve health care.

Adding to the honors, Dr. Berneike was named as a Health IT Fellow by the Office of the National Coordinator for Health Information Technology. The prestigious group is comprised of 28 practicing healthcare professionals who work to improve patient care through innovative technology in their practices.

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On a Personal Level: Gene Burton

Understanding patients is at the core of care coordination—effectiveness requires overcoming barriers and including individual values and preferences.

Among the patients who helped Beacon Project personnel appreciate the importance of this simple fact was Gene Burton, a patient at St. Mark’s Family Medicine Clinic.

During a follow-up visit for diabetes care, Gene saw his doctor and then met with a medical assistant trained in care coordination to develop a plan to

improve self-care and better control his blood sugar levels and other lab measures.

Sensing a problem, the medical assistant asked Gene if anything else was bothering him. Gene reluctantly admitted experiencing chest pain whenever he exerted himself.

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consulted with Gene’s doctor, then arranged a cardiac stress test. The cardiologist, on seeing the result, ordered emergency cardiac stent placement.

The procedure revealed that Gene’s heart was ninety percent occluded— a condition called “the widow maker.” The doctor believed Gene would have died that weekend

had the medical assistant not spent the time, and employed the training, to find out what was really happening with his health.

Care coordination worked for Gene Burton.

As a result, he’s still alive to talk about it.

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On a Personal Level: Sydney Firkins Managing diabetes takes a concerted effort on the part of providers and patients. With engaged providers, care coordination, and Care4Life, that effort is paying off for patient Sydney Firkins.

Communicating with her clinical care team at St. Mark’s Family Medicine Residency and Utah HealthCare Institute is at

the core of her success.

“They’ve been right there, working with me, making sure I stay right on level.

We’ve talked about my diabetes situation, how to control my diabetes and bring it under control so that I am able to function normally,” Sydney says.

“If they didn’t care about

me, then I probably wouldn’t care about myself, either—I would just go along trying to do my own little patch-up job instead of doing it the organized way. I noticed my blood sugars had started to lower themselves. Also, I was starting to lose the weight.”

Care4Life, Voxiva’s interactive text messagebased reminder and motivational program being tested by the IC3 Beacon program, helped her stay on track as well.

Sydney says, “Care4Life helped me to keep going, to have confidence in myself. It was just knowing that Care4Life was there, that they care about me.”

From education to inspiration to organization, the Beacon project’s successes count—for providers, for diabetes patients like Sydney, and for the community.

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On a Personal Level: James Davidson

Spending eleven hours a day behind the wheel of a big rig, eating truck stop food, and intermittent sleep in motel rooms are not conducive to controlling diabetes.

Despite persistent encouragement—nagging— from his physician at West Valley Family & Preventive Clinic and his wife, James Davidson simply could not generate the will to comply with a care plan.

But losing his driving permit due to elevated cholesterol and blood

sugar levels gave James the incentive to succeed.

His doctor and others at the clinic took the time to understand James and to help James understand diabetes and how to manage it. And if James missed an appointment, the staff at the clinic kept after him until he rescheduled—and showed up.

Among the many changes that led to success for James was better eating habits. “Greasy spoon” restaurants are still a reality of life on the road, but portion control and avoiding snacks are also

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a reality for James. He reports feeling better, his diabetes is under control, and James is more confident than ever that he will be around for his kids.