J Willis Hurst Internal Medicine Residency Program Show

End-of-Life Care Planning Improving Documentation of Advanced Directives in the Resident Clinic using Electronic

Improving Influenza Vaccination Rates in an Internal Medicine Resident Clinic J. Willis Hurst Internal

Improving Hypertension Control in the Patient Centered Medical Home J. Willis Hurst Internal Medicine

Improving Hepatitis C Screening in a Primary Care Internal Medicine Resident Clinic 1525 Clifton

Improving Counseling for Tobacco Cessation in a Resident Primary Care Clinic J. Willis Hurst

Improving the Documentation and Interventions of Obesity in a Resident Primary Care Clinic J.

Increasing Problem-Specific Educational Materials to Patients at the Emory Clinic J. Willis Hurst Internal

J. Willis Hurst Internal Medicine Residency Program Increasing End-of-Life Care Discussions, Including Code Status,

Best Foot Forward Improving Performance and Documentation of Diabetic Foot Exams in an Urban

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J. Willis Hurst Internal Medicine Residency Program Show Me the Sugars! Grady Health System, International Medical Clinic Sol Aldrete, MD, Roger Alvarez, DO, Jeremy Chow, MD, Juan Ortega-Legaspi, MD, Lori Randall, MD, Amy Salerno, MD, Danny Treiyer, MD, Aida Venado, MD Faculty Mentor: Nurcan Ilksoy Problem Tests of Change Measure Diabetes is a problem that disproportionately affects Hispanics in the United States, with a prevalence of 7. 9% compared to 5. 1% in White Americans (1). Not surprisingly, diabetes is one of the most common problems among the patients of the International Medical Center, most of whom are Spanish speakers. While it was evident that blood glucose logs could be invaluable in helping to attain optimal glycemic control, patients often had to create their own makeshift blood glucose log on blank paper. There was no process in place to make sure that there was a bilingual, three-meal glucose log available for our patients, and that the providers were having regular discussions of the blood glucose values with their patients. 1. 80% of clinic visits with insulindependent diabetics at the Grady International Clinic will have documented discussion of glucose log and a copy of blank log given to patient. 2. At 60% of visits, patient will bring glucose log (paper or glucometer). Goal time period: to accomplish this aim between October 2011 and April 2012. Result Placing glucose logs in clinic workroom for residents to use during appointments. Much higher rate of giving logs to patients but still inadequate rate of patients bringing in logs. Barriers What changes might result in an improvement? Physician Patient Lack of time Record BG log Bring log Multiple complaints No home BG Log recorded in chart Providing BG log Making copy for chart Staff System Need another intervention to remind patients to bring logs (possibly phone message) as well as more time for patients to have had prior appointments and been given logs. • Provider Factors: As seen in Figure 2 and 3, the largest barriers in discussing logs and patients bringing their logs, were the lack of initiation of discussion by the physician, and the failure to provide blood glucose logs. • Patient Factors: Figure 3 shows that patient factors such as forgetting to bring logs, noncompliance with glucose checks, and lack of supplies, also played a significant role. (1) http: //minorityhealth. hhs. gov/templates/content. aspx? lvl=2&lvl. ID=54&ID=3324 Aim Statement Test of Change What Was Learned Upload information to Epic Scheduling close f/u appointment Lessons Learned • Though physicians were close to meeting the 80% goal of having discussions about the glucose log, the percent of patients who brought their logs remained about 25%. • Despite the conversations taking place, in >50% of physician encounters, patients still were not given logs. • Physician discussions need to result in the reflexive supplying of a glucose log. • This seems to be area of change that can have the largest impact. Simple interventions, such as making logs more readily available in each room, or having nursing staff hand them out to diabetics, might improve the percent of patients who bring back logs. Meanwhile, patient-specific factors can be worked on at an individual level.

End-of-Life Care Planning Improving Documentation of Advanced Directives in the Resident Clinic using Electronic Medical Records J. Willis Hurst Internal Medicine Residency Program Grady Primary Care Center, Monday Purple Pod Salim Hayek, Ria Nieva, Frank Corrigan, Amy Zhou, Uma Mudaliar, David Mays, Michael Massoomi, Erika Heard, Reza Hassanyar, Dejuan White Faculty Mentors: Iris Castro, Nurcan Ilksoy Problem • End-of-life care planning has received and advocacy in recent years. JCAHO requires that hospital medical records document evidence of known advanced directives (AD) and provide information about advance care planning to all patients. Patient satisfaction is increased when AD are discussed in clinic. • Despite surveys showing patients prefer to discuss advance directives with their primary care doctor, many are completed during hospitalizations. Population based-estimates of completed advance directives range from 5% to 15%. • Discussing end-of-life care in the outpatient setting is perceived as challenging. One major obstacle reported by physicians is lack of time and effective reminders to address and document advanced directives. Aim Statement • Previously we assessed the effectiveness of emailmediated provider education and reminders in improving documentation of AD. This initial test of change (TOC 1) showed a slight (1%) and temporary increase in documentation of AD. • Using the electronic medical records (EMR) system EPIC we set to implement a reminder system for physicians to document AD in a select population of patients with chronic illnesses (see below), and assess the percentage of patients meeting criteria which have documented AD counseling within 6 months of the main test change: Adding “Advanced Directives Counseling” to the patient problem list (ADPL). • Patients must have one or more of the following characteristics/diagnoses: Age > 65, Congestive Heart Failure NYHA III, severe COPD (FEV 1<30%), AIDS, any diagnosis of malignancy, cirrhosis, ESRD, stroke. Tests of Change Methods and Measure Test of Change Yes No TOC 1 TOC 2 • A total of 588 patient charts were screened by 7 providers of Grady Clinics Purple Pod. • 157 met the predefined criteria for AD documentation. “Advanced Directives Counseling” was added to the problem list of 50% of patients who met criteria. • During the period of November 2011 -April 2012; 64 patients were seen in clinic; 38 had AD on their problem list, 26 did not. • 76% of charts with ADPL had documentation of AD. Only 11. 5% of those without ADPL had AD documented. TOC 3 What Was Learned Result • Provider education through email • Reminder emails • Distribution of handouts on advanced directives • Workshop on advanced directives discussion • Added “Advanced Directives Counseling” to problem list • Provided. ADVDISC summary template for rapid documentation Ineffective. Improvement in documentation rate temporary at best and highly dependent on physician’s personal motivation No effect on documentation Effective reminder, as well as easily accessible permanent record. Significantly increased documentation of AD Limitations TOC 1 TOC 2 TOC 3 Barriers to Documentation of Advanced Directives Data Collection • Sample size was relatively small and study of short duration. Will require longer term and larger population sample to assess sustainability of the improvement in documentation rate. • Study does not assess completion rates of official AD document completion. • No conclusion can be made on the impact of improved AD documentation on inpatient management Lessons Learned • EMR based reminders are effective in improving documentation rates of AD and may be applied for other purposes. • Obstacles remain, including the lack physicians’ initiative and knowledge in discussing AD, time limitations in the outpatient setting, as well as the unclear translation into changes in inpatient management. • Further research is needed to establish the sustainability of improved documentation over longer periods of time and in a larger population sample, as well as its impact on inpatient management.

Improving Influenza Vaccination Rates in an Internal Medicine Resident Clinic J. Willis Hurst Internal Medicine Residency Program General Internal Medicine at 1525 Clifton Rd. , Friday Resident Clinic Turang Behbahani, Vivian Cheng, Ed Clermont, Tina Constantin, Patrick Hall, Farah Khan, Freny Nirappil, Julian Raffoul, Nathan Spell Problem The number of seasonal influenza-associated deaths varies from year to year because flu seasons are unpredictable and often fluctuate in length and severity. The CDC estimates that from the 1976 -1977 season to the 2006 -2007 flu season, flu-associated deaths ranged from a low of about 3, 000 to a high of about 49, 000 people (1). In 2013, the CDC published a model to quantify the annual number of influenza-associated illnesses and hospitalizations averted by influenza vaccination during the 2006– 11 influenza seasons (2). Using that model the CDC estimated that vaccination resulted in 79, 000 (17%) fewer hospitalizations during the 2012– 13 influenza season than otherwise might have occurred. Especially in the primary care setting, providers are facing increasing difficulties to clarify "influenza -myths" as well as to identify burdens which keep patients from choosing or receiving the valuable vaccination. Aim Statement By January 1, 2014, 70% of more of all patients seen in the Friday resident clinic at 1525 Clifton Road will be vaccinated during their appointment (if not already completed). Tests of Change 1. Jan: Created standard process to let MD know patient’s status and wishes 2. Feb: Attending to review vaccine status during sign-out as detection and mitigation step. Barriers Measure Goal Actual - Lack of a standard process to address preventive care, in general, leading to creation of unique solutions to this problem - Perceived inability to influence patient wishes and misinformation - Relative little involvement of clinic staff Lessons Learned Standard process Attd review What changes might result in an improvement? - Doing an improvement project in isolation from the rest of the practice made it hard to create a standard way of checking vaccine status that would sustain itself - A standard process does not become the standard without effective training and reinforcement at first - Reliance on memory does not yield much improvement - We tended to make changes where we felt we had the most control, rather than trying to change patient beliefs, which was the greatest opportunity - Data collection should be built into the work flow or should come from a ready source References (1) Thompson MG et al. , Estimated Deaths Associated with Seasonal Influenza - United states 1976 -2006, Weekly, August 27, 2010 / 59(33); 1057 -1062 (2) CDC. Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2013– 2014. MMWR 2013; 62(No. RR-7).

Improving Hypertension Control in the Patient Centered Medical Home J. Willis Hurst Internal Medicine Residency Program Grady Green Pod Clinic Team Austin Chan, Maya Varthi, N. Thi Gunter, Patricia Hwang, Curtis Jamison, Bryant Chan, Arjun Nanda, Jessica Nave, Ravi Vora, Parth Joshi, Mahmoud Abdou, Danesh Kella, Greg Weston, Amirali Masoumi, Abhinav Koul, Abdullah Khan, Bradley Witbrodt, James Monaco, Vaishnavi Kundel, Yasamin Chowdhury, Danny Nguyen, Maria Lee, Anjan Deka, Phoebe Chi, Eric Shin, Aaron Gluth, Brian Heeke, Sandeep Krishnan, Anand Jain, Daniel Cucco, Vera Tate, Ula Abed Alwahab, Neal Bhatia, Kiran Valiani, Akshay Shetty, Shing. Yu “Cliff” Lin, Sara Turbow, Teresa Ingram, Katie Tipton, Robert Mc. Clung, David Dunhill, Valeria Cantos-Lucio, Joy Wortham, Shadi Yarandi, Nisha Joseph, Taylor Lebeis Faculty Mentors: Kalra, Girish L Doyle, Joyce P Bussey-Jones, Jada; Manning, Kimberly; Jones, Danielle Schneider, Jason S; Adhyaru, Bhavin; Ilksoy, Nurcan Green Pod Nurses and Staff Problem In our urban primary care center, a disproportionately large percentage of patients have uncontrolled hypertension compared to the general population. Moreover, among academic primary care clinics within the Grady Memorial Hospital Primary Care Center, a recent report revealed that our Green Pod practice ranked last in blood pressure control. In 3648 Green Pod patient encounters in June 2012, only 57. 2% had a SBP < 140 mm. Hg, compared to 65. 2%, 65. 4%, and 70. 4% in the Orange Pod, Purple Pod, and Yellow Pod clinics, respectively. Tests of Change What changes might result in an improvement? q Dec - To improve the accuracy of BP measurement and better identify patients who require intensification, at each visit, a manual BP is repeated in patients who are hypertensive, the physician is notified, and the value is recorded within the EMR. Figure 1. Fishbone diagram addressing barriers to effective BP control. q Feb – To improve patient adherence, the remark “For High Blood Pressure” is added to the sig line of prescriptions for antihypertensives. Three key barriers were addressed in our study: one physician factor, one nursing factor, and one patient-related factor. q Mar – Within our Epic EMR, a “dot phrase” reminder is added to the primary clinic note template that prompts physicians to address HTN. Additional Pitfalls Additional barriers contributing to suboptimal blood pressure control and possible decreased effectiveness of our interventions included: We sought to re-design our approach to hypertension management by identifying reasons for poor blood pressure control and devising interventions to help us more successfully treat our patients. 1. Erratic participation by providers 2. Time constraints within a busy primary care clinic Measure Figure 2. Percentage of return patients with SBP < 140 mm. Hg Aim Statement Among patients who have been seen in the clinic 2 or more times in the preceding six months, the percentage of visits with a systolic BP < 140 mm. Hg. Over 6 months, we aim to increase the percentage of Green Pod patients with hypertension who meet a systolic blood pressure goal of < 140 mm Hg to over 70%. n = return visits examined among Green, Orange, and Purple clinics. Baseline n = 292 TOC #1 n = 320 TOC #2 n = 268 n = 516 TOC #3 n = 594 n = 599 Note that these figures should not be compared to the percentages cited from the June 2012 report, which examined all patients. 3. Patient resistance to the addition of medication and physician uneasiness with intensifying therapy in the setting of possible non-adherence. 4. Limited patient finances and possible low literacy. Lessons Learned 1. Three simple, low-cost interventions showed varying degrees of benefit in helping our patients achieve BP control. 2. Utilizing support staff in the clinic appeared to be the most effective intervention, though the practice of preferentially obtaining manual BP assessments when the initial automated reading is high likely introduced some bias. 3. We were only partially able account for patients who were uncontrolled and then had meds changed. 4. Ensuring physician participation in a busy clinic setting without providing additional incentive was challenging.

Improving Hepatitis C Screening in a Primary Care Internal Medicine Resident Clinic 1525 Clifton Road Emory Clinic Friday Team Freny Nirappil MD, Vivian Cheng MD, Tina Constantin MD, Edward Clermont MD, Patrick Hall MD, Michael Lava MD, Rachel Anquez MD Faculty Advisor: Nathan Spell III MD Background Aim Statement By April 12, 2013, 80% or more of patients born between 1945 -1965 seen for a visit in the Friday resident clinic at 1525 Clifton Rd. will have been screened for hepatitis C infection. Fishbone Diagram 0, 3 0, 28 Tests of Change 0, 28 Test of Change #2 0, 25 Ratio of patients screened In 2012, the CDC recommended that everyone born between 1945 and 1965 should get screened for Hepatitis C is the leading cause for liver transplantation in the United States, and up to 75 -80% of patients infected with HCV can go on to develop chronic infection. Given the morbidity associated with this illness, we sought to improve our screening for HCV. Measures of Screening 0, 21 0, 2 0, 15 0, 1 0, 05 0 Baseline 8/4/12 10/26/12 TOC #1 12/21/12 2/8/13 What was learned Provider reminder sticky sheet on computers Easy to miss on computer screens Reminders are easy to overlook and short lived Pre-test patient information handout given to each Friday clinic patient Many patients did not receive the handouts, so screening wasn’t done. We needed a better implementation plan to increase adherence Barriers to screening TOC #2 2/22/13 4/12/13 Test of Change # 2 Tally Sheet Reasons why screening is Prior to After Test of not done intervention Change #1 Patient refuses |||| Lack of prior records | || Not MD priority / awkward || || Not patient priority ||| MD forgets to mention / consider |||| || MD forgets to order ||| || Too little time to explain |||| MD unaware of recommendation | Concerns about insurance | coverage / cost Result |||| | |||| • It is difficult to screen patients who have acute visits as opposed to those coming in for a physical as acute visits do not usually require bloodwork. • Reminder systems relied solely on the physician to implement screening. • We did not have enough PIP conferences to discuss ongoing issues with the project. Lessons Learned More frequent evaluations of the success of our tests of change would have allowed for more prompt corrections to those changes. Lasting change is easier to accomplish when focusing on larger issues because it forces the individual to focus on the system as a whole in order to implement appropriate steps towards establishing long-lasting change. The narrow focus of our clinical question may have limited the progress of our project specifically because it focused on one small step in the process of improving screening within our clinic.

Improving Counseling for Tobacco Cessation in a Resident Primary Care Clinic J. Willis Hurst Internal Medicine Residency Program Grady Primary Care Center, Friday Purple Pod Jane Titterington, Robert Kung, Zahi Mitri, Jeff Chen, Kyle James, Jenna Kay, Wendy Neveu, Reema Dbouk, Anthony Gamboa, Faculty Mentors: Sanjukta Chatterjee, Nurcan Ilksoy Problem and Background • Cigarette smoking is the leading preventable cause of mortality in the United States, responsible for over 400, 000 deaths annually 1. • Up to one-half of all tobacco users can be expected to die from a tobacco-related disease 2. • The economic burden of tobacco use is estimated to be $197 billion per year 1. • Smoking cessation is associated with clear health benefits and should be a major health care goal 3. • Screening all patients for tobacco use and providing all smokers a brief smoking cessation intervention is one of the three most cost-saving clinical preventive services 3. • Less than half of all patients (48. 7%) report receiving advice from health professionals to quit 4. Outcomes Result Test of Change #1 – Nurses: Screened patients for tobacco use during triage. - There was a significantly increased rate of screening for tobacco use amongst all clinic patients. 100, 0% - Documented with triage vital signs. #2 – Physicians: -There was a significantly “Tobacco counseling” section increased rate of smoking added to standard progress note cessation counseling by template. physicians - Documented in progress note. 20, 0% • Most common physician barriers were: forgetting to address smoking status, not having enough time to address it or having too many other active medical problems to address, or failure to document in the progress note that tobacco cessation counseling occurred. • Lack of patient education materials was also a barrier to proper counseling. • RN barriers included lack of documentation of screening for tobacco use during triage, as well as having patients roomed before triage could occur. 10, 0% Lessons Learned 0, 0% • Screening for tobacco use by clinic nurses increased when incorporated into routine triage procedures. • Tobacco cessation counseling occurred significantly more frequently when providers were prompted by a standardized progress note template. Documentation of intervention was also more likely to be completed. • Having patient education materials readily available appeared to promote tobacco cessation counseling by providers, and ensured patients left clinic with specific resources to help them quit smoking. 90, 0% 80, 0% 70, 0% 60, 0% 50, 0% Test of Change #1 40, 0% Test of Change #2 and #3 30, 0% #3 - Patients: Receive tobacco cessation handout containing the Georgia tobacco quit hotline number. and information on tobacco cessation classes at Grady. Barriers - Patients left the clinic visit with information to obtain more tobacco cessation counseling with resources to help them quit smoking. OCT NOV RN screening DEC MD counseling What changes might result in an improvement? Potential problem or barrier Fishbone Diagram Aim Statement MD forgot to discuss smoking status Lack of time Forgets to discuss nt n ia tem ff ys ta l. S ita sp Ho An cil lar y. S Not documented Count 13 MD forgot to document smoking in history 3 MD did not document counseling in progress note 9 Tired of counseling MD had too many active issues at current visit 9 Other more urgent concerns MD had no time to address 4 Not disclosing smoking status RN Did not add smoking status to triage vitals Only wants treatment Counseling Prior status not updated Not triaged tie ic Forgets to document Other more urgent issues 2. We aim to improve tobacco cessation counseling rates to greater than 80% of our population of current smokers, as measured by both documentation in clinic notes; as well as by including tobacco cessation resources in the patient’s after visit summary by May 2012. Pa ys Ph 1. We aim to screen 100% of our Friday Purple Pod patients for current tobacco use with corresponding documentation in EPIC by January 2012. JAN Lack of counseling materials No template in Epic Not in problem list in Epic 23 RN sent to room before triage and screening 1 RN reviewed but did not update smoking status 5 Patient tired of repeated counseling 7 Smoking cessation not a priority to patient 7 Patient just wants treatment and not counseling 1 Patient discouraged by repeated attempts that failed 5 Tobacco use not automatically placed on problem list 5 Counseling materials not readily available 4 References (1) MMWR Morb Mortal Wkly Rep. 2008 Nov 14; 57(45): 1226 -8. (2) http: //whqlibdoc. who. int/publications/2011/9789240687813_eng. pdf (3) Maciosek MV et al. Am J Prev Med 2006; 31: 52. (4) MMWR Morb Mortal Wkly Rep. 2011 Nov 11; 60(44): 1513 -9.

Improving the Documentation and Interventions of Obesity in a Resident Primary Care Clinic J. Willis Hurst Internal Medicine Residency Program Grady Primary Care Center, Monday Orange Pod Kobina Wilmot MD, Justin Cheeley MD, Jessie Torgerson MD, Jia Shen MD, Anita Saraf MD, Jenny Luke MD, Meena Prasad MD, Thomas Runge MD, Arash Harzand MD, Hassan Imam MD, Jessica Mc. Dermott MD, Faculty Mentors: Jada Bussey-Jones MD, Stacie Schmidt MD , Nurcan Ilksoy MD Problem Aim Statement We aim : • To continue to improve documentation of BMI in problem list to 75% by March 2012. • To have at least 50% of patients documented with obesity (BMI >30) to have an intervention of exercise, diet, or obesity referral by March 2012 in Orange Pod Monday clinic. Percentage of Obesity Documentation in Problem List by Physicians in Monday Orange Pod Per Month Percentage of BMI Documentation in Obese patients by Physicians in Monday Orange Pod Per month Ratio of Obesity Addressed in Plan by Physicians in Monday Orange Pod Per Month 120% 1, 2 120% 100% 1 100% Test of Change Result Height added to nursing triage template to be able to calculate BMI Significant improvement in documentation and sustainability observed What Was Learned Interdisciplinary team work with system change made the process sustainable. 80% Documentation of obesity on increase documentation on the Periodically reminders are the problem list needed. Also new physicians in clinic need to be accounted for. 0, 8 60% 0, 6 40% 2 ch ry ar nu a 0 M Ja be m ce '1 2 '1 11 r' '1 De ob er '1 Oc t em be r t' Se pt gu s Au 1 11 1 '1 ly ch ar M br Fe Ju '1 1 '1 ua ry ry nu a Ja er Oc t ob ch ar '1 0 '1 2 M ry nu a Ja be m ce De ob Oc t '1 11 r' '1 er '1 be r em Se pt Au gu st '1 1 '1 ly ch ar Ju '1 1 M ua ry br Fe ry nu a '1 '1 0 '1 Ja er ob 1 0, 2 1 0% 1 0, 4 1 20% Oc t July '11 August '11 September '11 October '11 December '11 January '12 March '12 Obesity Clinic Referral Results Ratio of Diet intervention in Obesity Plan by Physicians in Monday Orange Pod Per Month 35 30 Number of Patients 0, 8 0, 7 0, 6 0, 5 30 25 20 13 15 10 4 5 4 6 3 1 Initial informative email and flyers encouraging obesity plans & obesity clinic referral program Increase trend in obesity documentation in problem list and interventions described in problem list Visual reminders and site to send patients increases interventions for patients with obesity Another informative email sent Continual trend upward in documentation in problem list and interventions Once again reminders help but not enough for reliable process improvement 3 nd ed r ot he at te de cli ne d t ye d le al tc an s w no ng ro w no nu m ct ne on isc nu m be rd ow sh Barriers di d no t 0, 2 be r ed ss la tc 1 s to 0, 3 er 0 0, 4 ve y, • Making BMI more visible in EMR • Time for physicians to make and offer specific education on diet and exercise • Assuring patients who are referred to obesity clinic have message sent to and received by clinic scheduler • Patients referred to obesity clinic actually are able to be reached to attend sessions • Enough sessions are available to accommodate the large number of obese patients in our primary clinic ou ts ur 0, 1 le d 0 July '11 August '11 September '11 October '11 December '11 January '12 fil • Obesity is defined as a BMI of >30. • More than 1/3 (35. 7%) of U. S. adults are obese. The rate in Fulton County is 23. 2%, in Dekalb County 27. 4%. • Obesity is an increasing problem. Currently, >30% of the population is obese in 12 states. In 2000, no state had an obesity rate >30%. • The average hospital length of stay for obese patients is 60% longer than for normal weight individuals nationwide. • The annual cost of obesity in Georgia is $2. 4 billion (or $250 per Georgian each year), including direct health care costs and lost productivity. • Obesity places patients at greater risk for diabetes, heart disease and some types of cancer. It is the #2 cause of preventable death in the United States. • After increasing obesity documentation in our clinic last year, we noted that despite documentation, interventions were often not addressed. The obesity clinic instituted by Dr. Schmidt became an additional resource to obese patients this year, in addition to nutrition classes and diet/exercise education by the health care practitioner. Tests of Change Measure March '12 Outcome What changes might result in an improvement? Process Improvement Chart with possible interventions for improvement of outcome Patient arrives Nursing enters biometric data BMI documented and reviewed by MD Obesity entered on problem list Lessons Learned Obesity plan initiated - BMI reference - BMI autopopulated with. phrase charts displayed in clinic rooms - Circulating periodic reminders to MDs to document obesity - MD education of obesity plan options: • Diet/exercise • Nutritionist referral • Obesity Clinic referral • EMR has facilitated BMI as being listed as part of a patient’s vital signs for each visit, helping to prompt a response for an abnormal BMI • Though BMI is automatically calculated in EMR, obesity is still often overlooked by providers as a separate medical problem • If obesity is listed as a separate problem, an intervention is often proposed • Nutrition and obesity clinic referrals offer concrete actions providers can take to address obesity. Diet and education handouts may be helpful for providers to more readily access.

Increasing Problem-Specific Educational Materials to Patients at the Emory Clinic J. Willis Hurst Internal Medicine Residency Program Elizabeth Wiles DO, Paul F. La Porte MD Ph. D, Emory Hsu MD, Ross Deppe MD, Samantha Shams MD, Blake Anderson MD and Naveen Bellam MD MPH Faculty Mentor: David Propp MD The Emory Clinic at 1525 Clifton Rd, Emory University School of Medicine, Atlanta, GA Problem In 2012, the Center for Medicare/Medicaid Services (CMS) created the objective to use Electronic Health Records (EHR) to provide at least 10% of patients with electronically generated educational resources as part of their meaningful use criteria. Given a possible cost savings of $289 billion dollars from improved medication compliance alone, providing problem specific resources in a timely and appropriate fashion has potential to improve patient satisfaction and compliance in regards to their medical plans. 60, 00% Patients receiving Education 50, 00% Results Analysis Compared to CMS Objective as well as against Primary AIM Statement 40, 00% Percentage 1/100 Physicians do not always effectively communicate medical problems or treatment plans to their patients and retention of education performed by the physician issue even among highly educated patients. Difficulty with understanding medical disease has been hypothesized to contribute to lower compliance with medication and activity regimens, increased calls to nursing staff, higher repeat visits, and worse medical outcomes. Statistical Measures and Analysis Baseline period (Prior to Test of Change): Rate = 8. 0% Likelihood of 8. 0% rate below CMS 10% rate? ; p = 0. 097 - It cannot conclusively be stated say that we were not already meeting “Meaningful Use” criteria 30, 00% 20, 00% 10, 00% Pretest Patients receiving Education Test of Change 1 Test of Change 2 8, 01% Baseline Study Data 37, 44% Chi-Squared Statistics Chi-square table for TOC 1 Pretest TOC 1 TOC 2 Handout Patient cross. Materials Yes No Total check % Provided 34 85 35 Before 34 390 424 8. 02% After 85 142 227 37. 44% Total diff 29. 43% Patients In Study Period 424 0. 0801 Chi-square table for TOC 2 Handout 69 cross 0. 5072 Yes No Total check % Before 85 142 227 37. 44% After 35 34 69 69 50. 72% diff 13. 28% 227 0. 3744 2 nd test of change vs 1 st test of change: Handout rate 37. 4% (before) vs 50. 7% (after) % change over 1 st test of change period = 13. 2 (-0. 1 -26. 7) LR 1. 35 (1. 02 -1. 80) p = 0. 0491 - Based on a p-value of less than 0. 05, it can be stated there was a measurable difference between test of change 2 and 1 (i. e. MA reminders)… p = 0. 0491 - The LR is significant compared to the p-value (double-checked with a different procedure) possibly due to separate calculations in software Tests of Change Test of change (TOC) 1: Educating physicians regarding use of standardized computer-based education format and use of a desktop reminder at each computer. MD Factors Nursing Factors Not remembering to provide / print education via depart process Time constraints not allowing for nursing reminder Checking out patients without nursing assistance Acute visit time constraint Lack of insight To increase patient education handouts by 30% during the study period Nov 1 2013 -Feb 14 th 2014 (compared to July-October 2013), through entering education related to patient diagnoses in General Clinic note. 2 nd test of change: Handout rate 8. 0% (before) vs 50. 7% (after) % change over pretest period = 42. 7% (30. 6 -54. 7) LR = 6. 32 p < 0. 0001 - 50. 7% rate compared to CMS 10% goal; p << 0. 0001 - During test of change 2, we can conclusively say we met our target of 30% absolute increase in handouts (CI is between 30. 6 -54. 7) Cause and Effect Analysis Forgetting to offer educational resources Aim Statement 50, 72% 1 st test of change: Handout rate 8. 0% (before), 37. 4% (after) % change over pretest period = 29. 4% (22. 6 -36. 2%) LR = 4. 67 p < 0. 0001 - 37. 4% rate compared to CMS 10% goal; p << 0. 0001 - During test of change 1, it cannot conclusively say we met our target of 30% absolute increase in handouts (CI is between 22. 6 -36. 2) Providing Patient Education Clicking on “Patient Education” opens all available educational resources based on diagnosis code, or per prompted search Ease of Use Can not read Patient feeling education Is unnecessary Krames Database having appropriate education related diagnoses Implemenation Time and Time to Print Resources Patient factors System factors Test of change 2: Require nurses reminders during their portion of the patient depart process if we had not chosen education for the patient using the above computer selected format. Barriers 1. Full schedules, clinic time constraints, or PCPs writing notes at the end of clinic did not benefit from computer-based educational templates. 2. There remains minimal incentive to create additional templates. 3. While desktop reminders were useful at first, physical notes could be lost , misplaced, or ignored. 4. Nurses had variability in providing reminders due to the multitude of patient tasks and multiple residents in clinic. 5. Patient illness complexity may not have had appropriate EMR-specific resource (i. e. providing education on PEG tube use, or proper explanation of more rare diseases). Lessons Learned A multifactorial and team-based approach can lead to improved patient awareness and education at a time cost not overly detrimental to clinic flow. Cost-effectiveness may be theorized to be appropriate and beneficial in improving patient outcomes; however, we do not have financial data to support this assertion. Importantly, focusing our intervention on an existing element not requiring any modification to the resident workflow was a key to success.

J. Willis Hurst Internal Medicine Residency Program Increasing End-of-Life Care Discussions, Including Code Status, in a Resident Run Urban Community Primary Care Clinic Orange Pod Wednesday/Friday Team, Grady Primary Care Center Rekha Thammana, MD, Andrew Ip, MD, Nurcan Ilksoy, MD, Shelly-Ann Fluker, MD, Dominique Cosco, MD Fofie Akota, MD, Stephen Berger, MD, Matthew Darrow, MD, Kendrick Gwynn, MD, Racha Halawi, MD, Elisa Ignatius, MD, Moise Jean, MD, Emma Johns, MD, Poonam Kalidas, MD, Christine Kirlew, MD, Enoch Kotei, MD, Song Li, MD, Jason Perry, MD, Nikita Patel, MD, Priyesh Patel, MD, Roshan Patel, MD, Deep Shah, MD, Sana Shah, MD, Yoo Shin, MD, Geoffrey Southmayd, MD, Komal D’Souza, MD, Xiao Jing Wang, MD, Andrew Webster, MD Problem • Tests of change • Dot phrase added (TOC 1) • To help providers remind about having code-status or advanced-directive discussions • Surveys passed in waiting room (TOC 2) • Allows patients to ask provider questions about end-of-life-care • Many elderly patients (defined as >65 years of age) do not have advanced directives on file • Discussing code status and endof-life care is difficult given time constraints in our clinic visits • Residents have trouble initiating conversations about end-of-life care What changes might result in an improvement? Aim Statement PHYSICIAN • We aim to increase the number of end-of-life care discussions, including code status documentations, in Grady Orange Pod patients older than 65 years, to 50% by April 2014 Acknowledgement We would like to thank the nurses and support staff of the Orange Pod Primary Care clinic for their assistance with the project. Barriers Measure I do not know how to initiate discussion Not enough time I forget Assigned patients are too young Patients not prepared to discuss topic has not heard of 'code status' or AD Would like to discuss with family first End-of-Life care discussion has not been documented Lack of continuity with patients SYSTEM • No standardized method to initiate code status discussions or end-of-life • Forgetting to implement dot phrase • No easy way to document code status in EPIC chart Lessons Learned • Education of providers on palliative care discussions PATIENT Does not want to discuss • Not enough time! – patients often come in with a large agenda or have multiple chronic medical diseases Not enough time in clinic visit Inadequate reminder system • Need for easier documentation methods in EPIC for advanced directives or code status • Education of patients to help facilitate discussions in outpatient visits • Physicians have little time to discuss, thus other methods must be implemented (nurse or group visits)

Best Foot Forward Improving Performance and Documentation of Diabetic Foot Exams in an Urban Resident Primary Care Clinic J. Willis Hurst Internal Medicine Residency Program Grady Primary Care Center, Wednesday Purple Pod James Mac. Namara, Matthew Dudgeon, Heather Batchelor, Annie Massart, Rahul Maheshwari, Jeffery Hedley, Maria Klimenko, Pooja Kotadia Faculty Mentor: Nurcan Ilksoy Problem • Many diabetic patients present to the primary care clinic and go without consistent foot exams. • The American Diabetes Association recommends clinicians perform a comprehensive foot examination annually on patients with diabetes to identify risk factors for ulcers and amputation and perform a visual inspection of the feet at each visit. 1 • Lavery, et al demonstrated a combined minor and major amputations reduction from 12. 89 to 6. 18 per 1000 patients per year with a diabetes foot prevention program. 2 Others have shown significantly improved outcomes as well. 3 Measure Increased focus on diabetic foot exam on individual level Monofilaments made available in clinic by faculty First visit with pt, MD defers RHM til next visit Placing concise but complete explanation of diabetic foot exam guidelines and techniques in rooms Improved level of exams, but fell off over time Need consistent method to help provider keep foot exam a priority Improved Equipment is percentage of exams important for performance of exam Initially improved Need consistent performance, but method to help last data points provider keep foot indicates decline exam a priority Barriers What changes might result in an improvement? Aim Statement • Our aim was to increase the documentation of last complete diabetic foot exams and current inspection for known diabetic patients at Purple Pod Wednesday Primary care clinic visits by 50% by March 30 th, 2014. 1. Boulton, et al Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008 Aug; 31(8): 1679 -85 2. Lavery La, Wunderlich RP, Tredwell JL. Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Res. Clin. Pract. 2005; 70(1): 31– 37. 3. Ozdemir, et al Population-based screening for the prevention of lower extremity complications in diabetes. Diabetes Metab Res Rev. 2013 Mar; 29(3): 173 -82 Test of Change Result What Was Learned • Not enough publicity of the foot exam techniques and guidelines • Inconsistent documentation amongst providers’ exams and assessments • Patient do not like having shoes off while waiting for provider • Patients unaware of need for foot exams • Limited Monofilaments, no tuning forks available in clinic Future Directions First visit with pt, MD defers RHM til next visit • A persisting method of encouraging exams is needed with involving nursing staff • A concise and complete dot phrase and may promote consistency amongst providers • Providing patients with information so they can advocate for the exam • Ensuring appropriate equipment is in every exam room