09 Jul OP Care Plans: Why Each Practice Needs to Be Part of their Own Solution
By Dr. Sue Kressly
It’s really rewarding to see so many colleagues realizing the power behind the EHR and embracing it as a robust tool, not just an electronic word document. Creating a note, which reflects the work performed at an office visit, is much of what pediatric team members do every day. However, using the power of OP to improve patient care is our opportunity to make a difference in our communities.
As practices develop strategies to recall patients, close gaps in care and improve their quality measurement performance, they often ask us “Why can’t OP just give me a care plan for asthma, anxiety, ADD or my special needs kids?” The answer to this question is centered around three key elements: evidence-based care guidelines, practice implementation preferences and approaches, and flexibility of OP.
Unlike adult medicine, where there are well-studied evidence based guidelines for common chronic diseases, pediatrics has less-well researched and published algorithms for pediatric concerns. Bright Futures is perhaps the most widely accepted evidence-informed guideline that all pediatric practices should follow in order to deliver preventive care according to best practices so that every child has an optimum chance at a bright future. As such, OP has incorporated some of the basic components of Bright Futures into a preventive visit care plan. This care plan can be used to identify patients who are missing well visits, based on the Bright Futures schedule. Yet, there are practice nuances for how to prioritize and when to incorporate individual elements of Bright Futures.
For example, while the current version of Bright Futures schedule suggests maternal depression screening at the following periodicity: by 1 month, 2 months, 4 months, and 6 months, individual practices have chosen to implement them in their practice at a 1 week, 1 month and 2 month visit only. In addition, the tool used to do the screening (PHQ2, PHQ9, Edinburgh), how it is implemented (through CHADIS, OP surveys, on papers and scanned into documents) is highly variable. An “out of the box single solution” is impossible to create and allow individual implementation nuances at the practice level.
When you look at chronic disease management, like asthma, it gets even more complicated. First, you have to decide how your practice defines asthma and how you document asthma in OP in a way that the computer can use to drive care plans and recalls. Do all of your providers add it to the problem list and use SNOMED codes? If so, which ones? Do your providers use the severity scoring in the problem list to note whether the asthma is mild intermittent or moderate persistent? Do you want your care plans to include all severities of asthma or only the ones that are moderate and severe persistent? Do you want them to include all ages or just those children over 2?
How often does your practice see children with chronic asthma? Every 3 months? Every 6 months? Does the well visit count? Do you do spirometry, pulse ox, or an asthma screening tool like ACT? How do you do asthma action plans in your office, and where do you record it?
So many questions to answer, so many ways to practice appropriately and so many ways to document and create an implementation workflow. So, what is a practice to do? Firstly, decide on what conditions you wish to focus on first. Pick one or two to start, but certainly no more than three. You may want to make your well visit care plans more robust as a place to start. Try to standardize screenings, fluoride varnish, lead testing, etc.
Next, all providers in the practice must agree on the periodicity, documentation workflow implementation. This is often the hardest. However, you can’t recall a population of patients according to your practice care plans, if different providers want to perform different tasks at different ages or intervals. You have to agree on what screening tools you are going to use (the ACT?), at what intervals, who is going to perform the work and how you will document it. If you aren’t sure, or can’t agree, look for evidence-based guidelines (the AAP has some, but they are often “broad guiding principles” and not a specific algorithm). Not sure of OP documentation best practices? Invest in some time with a training specialist. Ask colleagues on the listerv, but please be forewarned…not everyone uses OP according to best practices and there are often unintended consequences of doing so. (For example, using diagnostic tests to record procedures can distort your metrics for discrete data for diagnostic tests in PMCH and MU reporting and can result in billing gaps depending on workflow.)
After you have come to consensus and know exactly what you want to do, for example: see all patients 5 years of age or older who have any level of ‘persistent’ asthma as defined by SNOMED codes 426979002, 427295004, or 426656000 on the problem list as an active problem (not tracking) every 3 months using the visit template called “asthma recheck” (which will also be used and billed separately at a well visit), and will perform an ACT every 3 months, an updated asthma action plan every 3 months performed using OP’s integrated tool, asthma education every 3 months, and spirometry every 6 months, THEN then designing your care plan and recall process can begin.
Each practice must do the difficult work above in order to have a functional and robust care plan for their patients. Each practice must be part of their own solution. When the practice work is complete, then engage someone who has expertise in OP care plan SQL capabilities (contract time with an OP specialist, hire an external SQL resource, or perhaps someone in your office possesses SQL knowledge and interest) to work out the specifics. While physicians are very bright and often think we can learn anything, I would argue this is not the best use of our time and expertise. I let this work to the specialists, while I go see a few more patients to pay for this work to be done correctly so my patients and practice can benefit from improved care.