Borsky, Amanda E, MPP, CAN

Harris, Daniel M, PhD

Johnson, Melanie B, MPA

Morrissey, Staci, BS

Myers, Ronald E, PhD

Sarfaty, Mona, MD

Stello, Brian, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Family MedicineComplexity of Using Multiple Data Sources forPopulation Management in Colorectal CancerScreening: The Experience of SATIS-PHI/CRCBrian Stello MDLehigh Valley Health Network, Brian.Stello@lvhn.orgAmanda E. Borsky MPP, CANLehigh Valley Health NetworkDaniel M. Harris PhDMelanie B. Johnson MPALehigh Valley Health Network, Melanie_B.Johnson@lvhn.orgStaci Morrissey BSLehigh Valley Health Network, Staci.Morrissey@lvhn.orgSee next page for additional authorsFollow this and additional works at: https://scholarlyworks.lvhn.org/family-medicinePart of the Primary Care CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtStello, B., Borsky, A., Harris, D., Johnson, M., Morrissey. S., Sarfaty, M., & Myers, R. (2011, July 22-24). Complexity of using multipledata sources for population management in colorectal cancer screening: The experience of SATIS-PHI/CRC. Poster presented at: The 2011Agency for Healthcare Research and Quality National Practice-Based Research Network, Bethesda, MD.AuthorsBrian Stello MD; Amanda E. Borsky MPP, CAN; Daniel M. Harris PhD; Melanie B. Johnson MPA; StaciMorrissey BS; Mona Sarfaty MD; and Ronald E. Myers PhDThis poster is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/family-medicine/3Complexity of Using Multiple Data Sources for Population Management in  Colorectal Cancer Screening: The Experience of SATIS-PHI/CRCl E H I g H  v A l l E y  H E A l T H  n E T w o R kBrian Stello MD,* Amanda E. Borsky MPP*,* Daniel M. Harris PhD*,* Melanie Johnson MPA,* Staci Morrissey BS,* Mona Sarfaty MD,*** Ronald Myers PhD*** *Lehigh Valley Health Network, Allentown, Pennsylvania; **CNA, Alexandria, Virginia; ***Thomas Jefferson University, Philadelphia, PennsylvaniaIntroduction The Systems Approach to Tracking and Increasing Screening for Public Health Improvement of Colorectal Cancer  (SATIS-PHI/CRC)•  a six-step, evidence-based, system-level  redesign of the way in which colorectal cancer (CRC) screening and follow-up are conducted in a community-based network of primary care practices.•  intended to assist primary care practices to better provide guideline-based preventive health care to their age-appropriate patients, who are at average risk for CRC and who are not up to date in their screening for it.•  intervention is intended to be conducted by a central entity, such as a health care delivery system, accountable care organization, or  insurer, affiliated with a network of primary care practices on behalf of and in conjunction with those practices. •  task funded by CDC through AHRQ’s ACTION program and implemented by the CNA Health ACTION Partnership, which included Thomas Jefferson University and Lehigh Valley Health Network. The task order was carried out  between Oct. 2007 and July 2010Methods The task was carried out in 15 practices of the Lehigh Valley Physician Hospital Organization  (LVPHO), whose practices  included•  Hospital-owned practices.•  Hospital clinics.•  Independent private practices.•  Private practices in a large group association.Eligible patients of each practice were invited to screen for colorectal cancer by colonoscopy or stool blood test (SBT) in accordance with 2008 guidelines published by the American Cancer  Society. Results of screening were tracked via the same data bases used to determine initial eligibility, supplemented by lab  reporting and chart review (both paper and  electronic).Research QuestionWhat complexities arise when implementing a multi-practice population screening task with data from  multiple sources?Step 3. Identify Eligible Patients. Develop patient list by  electronic records review and eligibility assessment.Organizational  Factors 1.  Claims data obtained for all practices from LVPHO required delays to account for periods of open-enrollment, where patients had the  opportunity to choose a new insurance product and/or practice. Requests for information needed to wait until the end of open  enrollment.2.  Billing and EMR data obtained from practices with a larger parent  organization required queuing data requests after priority  organization reports could be completed.Information  System  Factors1.  Queries to obtain population data to assess patient eligibility for CRC screening were not an existing part of the system, leading to a trial-and-error method to develop accurate data queries.2.  Operating systems in practices that were independent of a large parent organization did not have I/S support to develop queries,  resulting in a limited ability to capture patient data.3.  Data fields relating to CRC screening or CRC risk were absent,  coded in multiple places, or not coded for  tracking, limiting ability to report data on eligibility  status without manual chart audit.4.  There was no standard format for data organization or formatting for reports among the fifteen practices.Human   Factors1.  When appropriate data fields did exist, some data was absent (e.g. demographic data relevant to the task). When these fields required text entry, data were missing, “dirty” (i.e. of uncertain meaning) or lacking metadata (e.g. screening reported as “up to date,” but method of screening, or date, or result were missing).2.  When two databases were used for a practice, some data was found to be in conflict (e.g. two addresses for one patient). 3.  Patients names were duplicated due to subtle differences in data  entry (e.g. “John Doe” and “John A. Doe,” but with same DOB, SNN, and address).Discussion •  LVPHO is an open-model medical system involving multiple practices models, with each member or group using its own databases for managing patient care. •  Databases did not share a common operating  system, common coding, or common data entry guidelines. Many practices still use paper charts for the medical record. •  This resulted in a need to manually aggregate and clean population data to make it useful for SATIS- PHI/CRC. •  The practice entities and the multiple support systems each had their own internal timelines and priorities, changes in operating systems, and changes in per-sonnel, creating delays in any request for electronic records review or in preparing population mailings. •  Human factors at the practice level in entering billing and EMR data led to challenges in cleaning data or searching for data to determine patient eligibility and track results of CRC screening. •  These factors impacted the ability to access and  extract data from the various sources and systems, resulting in a time delay from the time data was  requested until it was prepared for implementation of the task. That delay was as long a six months for the development of the initial patient eligibility list.ConclusionsImplementation of a population intervention in an open-model medical system can be a time-intensive and  labor-intensive task due to the complex interaction of organizational factors, information system factors, and practice factors. Awareness of these complexities, and the time and support to manage them, may be keys to an organization’s ability to provide care based popu-lation data, as in an Accountable Care Organization model.ReferencesLeven B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, Dash C, Giardiello FM, Glick S, Johnson D, Johnson CD, Levin TR, Pickhardt PJ, Rex DK, Smith RA, Thorson A, Winawer SJ. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA A Cancer Journal for Clinicians. 2008 May-Jun;58(3):130-160. Harris D, Borsky A, Stello B, Sarfaty M, Myers R, Sifri R, Johnson M, Gratz N, Cocroft J, Kasper-Keintz M. Health care systems for tracking colorectal cancer screening tests: final report. [database on the Internet], update December 2010 [Rockville, MD] http://www.ahrq.gov/research/crcscreeningrpt/, last accessed 5/20/11.Harris D, Borsky A, Stello B, Sarfaty M, Myers R, Sifri R, Johnson M, Gratz N, Cocroft J, Kasper-Keintz M. Tracking and improving screening for colorectal cancer intervention: a systems approach. [database on the Internet] http://www.ahrq.gov/research/crctoolkit/, last accessed 1/5/11.Birtwhistle R, Keshavjee K, Lambert-Lanning A, Godwin M, Greiver M, Manca D, Lagacé C. (2009) Building a pan-Canadian primary care sentinel surveillance network: initial development and moving forward. Journal of the American Board of Family Medicine. 2009 Jul-Aug;22(4):412-22.Step 1. Recruit Practices  Obtain endorsement from all physicians to represent their practice and  contact their patients.Step 2. Conduct Academic Detailing Bring physician knowledge and physician/practice behavior in line with 2008 ACS guidelines for colorectal cancer screening and  follow-up.Step 3. Identify Eligible Patients Develop patient list and identify eligible patients by electronic  records  review and eligibility assessment.Step 4. Mail Screening Materials Mail screening invitation, information, and materials to eligible  patients on  behalf of the practice. Mail a reminder to initial non- respondents.Step 5. Track Screening Review electronic records review and audit charts to report  completed  screening tests.Step 6. Provide Feedback  Notify practices of screening results and recommended follow-up.Patient Outcomes: Screening by colonoscopy or stool blood test and follow up of positive stool blood tests.Figure 1. Steps for conducting SATIS-PHI/CRC. Steps 3 through 5  involved coordination of practices and multiple  support services.FindingsSteps 3, 4 and 5 (Fig. 1) involved coordination of the multiple practices and their support services by EPICnet, with complexities occurring at each step. These complexities created delay in implementation, resulted in errors that required correction, or required training and support of individuals engaged in the task. Complexities were apparent in three major areas:1.  Organizational: complexities involving to the function of an  organization and its priorities as related to the task or the  involved practices.2.  Information Systems: complexities relating to I/S personnel, data systems and data components necessary to the task.3.  Human Factors: complexities relating to the knowledge,  experience, and performance of people acting on behalf of  the task in the implementation phase, in patient screening, and in the tracking phase.Note: While the same software product may have been installed in multiple organizations, its coding and customization was unique to each organization.Figure 2. Data sources for identifying the patient population in  SATIS-PHI/CRCEMR Billing Claims1. Centricity Physician Office     (hospital-owned) 2. Next Gen (hospital-owned) 3. Next Gen (large group-owned) 4. Next Gen (private practice)1. IDX (hospital owned) 2. IDX (hospital owned,          but outsourced) 3. Private practice  systems1. LVPHOFigure 3. Elimination of patients from the initial electronic  records review to develop the colorectal cancer screening  intervention  registry.Initially eligible patients (15 Intervention Practices) 10,063Patient ineligible due to conflicting or absent information in the elec-tronic record review (EMR, billing, claims). For example, conflicting  addresses when two data sources were used; absent demographics such as DOB.328Patients ineligible due to information discovered on manual chart  review. For example, evidence of screening or high risk discovered in chart but not documented in appropriate data fields; data fields com-pleted but lacking appropriate metadata context such as screening method.73Patients ineligible due to self-report of up-to-date screening or high risk.1,342Patients ineligible due to returned mailings ,i.e. address in registry deemed to be inaccurate55Total number of patients eliminated due to above factors 1798Total number of eligible patients after above elimination. (Note: an additional 300 eligible patients chose to opt out of screening).8,265Step 4. Mail Screening Materials. Mail screening invitation,  infor mation, and materials on behalf of the practice. Mail a  reminder to initial non-respondents.Organizational  Factors1.  Contracted mail services provider queued CRC patient mail-ings behind other competing prioritized mail.Information  System Factors1.  Information Systems Factors were minimally at issue in this step.Human  Factors1.  Due to time lag, practice personnel required a “booster” to  remind them of task processes for the practice and its  patients, including support for patient questions about screening and support in helping patients  successfully screen for CRC.2.  New practice personnel required orientation to the task.Step 5. Track Screening. Review electronic records review and  audit charts to report completed screening tests.Organizational  Factors1.  Billing and EMR data obtained from practices with a larger parent  organization once again required queuing data requests behind priority  organization reports.2.  One parent organization initiated a change in its EMR operating system, placing practices in transition between systems as task results were  being tracked.3.  One practice underwent a change in its practice affiliation during the  results phase. Information  System Factors 1.  For the practices that changed their EMR operating system, recent data relating to task results needed to be obtained from “archived” EMR and combined with the current EMR.2.  Personnel who had previous run queries related to the task had left their jobs, resulting in the need to orient new personnel to the task. Often, this required re-developing the information queries.Human   Factors1.  In all practices, results received for both SBT and colonoscopy needed to be entered manually into appropriate data fields or flowsheets.  Some data received from an outside source was never entered into the  appropriate field or flowsheet, and needed to be captured by manual chart audit. 2. I n some paper charts, flowsheets did not exist.3.  When screening data was entered In practices using an EMR, some data was entered in error, was incomplete, or was missing metadata (e.g. SBT completed, but no result; colonoscopy  completed, but no date or  diagnosis). Table 1. Sources for tracking results of screening, by number of practices using each source. Results in 10 practices with EMR and 5 practices with paper charts were confirmed by chart audit.0 2 4 6 8 10 12 14 16Lab Reports (STB results)EMRBillingClaimsManual Chart Audit (EMR)Manual Chart Audit (paper chart)

Complexity of Using Multiple Data Sources for Population Management in Colorectal Cancer Screening: The Experience of SATIS-PHI/CRC

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1002&context=family-medicine

Complexity of Using Multiple Data Sources for Population Management in Colorectal Cancer Screening: The Experience of SATIS-PHI/CRC

Abstract

Similar works

Full text

Available Versions

Lehigh Valley Health Network: LVHN Scholarly Works