Tennessee Primary Care Association Tracks 101: Basic Training - - PDF document

1 Tennessee Primary Care Association

Tracks 101: Basic Training 10/29/18 – 10/30/18

i2iTracks Basics Training: Day 1

Monday, October 29 10:00 a.m. – 5:00 p.m.

Introductions

• Let’s get to know each other!
• What is your name?
• What is your position title – and what do you really do?
• What is an interesting fact about yourself?

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i2iTracks Agenda

Introduction Section 1: Data Accessibility Tools Section 2: Proactive Care Tools Section 3: Analytics & Business Intelligence

Goals

• Confident in creating and using huddle report
• Confident in creating and modifying schedules and

protocols

• Confident in creating and validating patient search
• Confident in being able to run canned or imported

reports and validate results

• Confident in use of EDD to validate data

i2iTracks Introduction

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What is i2iTracks?

Population Health Management System

What is Population Health Management?

The coordination of care delivery across a population to improve clinical and financial outcomes

Population Health Management Features

Data Accessibility to Support High Quality Care Proactive Care

Supports care teams with tools for efficient patient visits Helps care teams plan for daily resource needs

Analytics & Business Intelligence

Provides reports and dashboards for outcome statistics Challenges you to become “the best” in a measurable way Financial Performance Improves expense management (e.g., staff productivity) Maximizes revenue potential (new revenue streams)

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Section 1: Data Accessibility to Support High Quality Care

Technical Info - Data in i2iTracks

Data comes into Tracks through interfaces

• Practice Management System Data: Patient Demographics, Visit

Information (CPT, ICD), Appointment Data

• EHR Data: Vitals, Labs, Medications, Problems, Allergies,

Immunizations, Custom Data

• Other Interfaces: Direct labs, Text Messaging, other interfaces for

specific customers/payers/etc.

Viewing Population Data: Patient Search Easy way to identify populations that need care

• Who needs a flu shot?
• Who needs to come in for a well child visit?
• Who has lab test results that are consistently out of

range?

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Viewing Population Data: Patient Search Actionable Patient Lists

• Send a letter/e‐mail/text message
• Setup a follow‐up or recall
• Print a form – Patient Visit Summary
• Print or Save Reports (excel, html, other formats)

Find a population! Let’s go into Tracks and find a population….

• Patients seen for Diabetes in the last 1 year
• DM Patients that belong to a specific provider
• Missing HbA1c tests

Viewing your Data

View Patient Specific Data through the Patient Information screen View “like” data types (Medications, Problems, Labs, Vitals…) through the External Data Diagnostics tool

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Patient Information Where does the data come from?

Knowing where your data is being stored in your EHR is vital!

External Data Diagnostics

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Class Exercise Look up a Patient:

• Who is their PCP?
• When was their last charge?
• What was their primary Diagnosis?
• Are they currently taking aspirin?
• What was their most recent blood pressure?
• What was their most recent HbA1c result?
• When was their last flu vaccine?

Class Exercise

Open the External Data Diagnostics tool

• How many patients have had a CPT of 99213?
• Who prescribed Lisinopril 5 MG tabs to the first

patient on the list?

• What is the highest weight that was recorded?
• Is that patient a smoker?
• How many occurrences has ICD10 code E11.9 been

used? When was the last visit date?

Creating your own Populations

Review of Simple Searches

Searches are made with FILTERS and FIELDS

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Search Filters

Filters: Your Search Criteria - WHO Each filter narrows down your population. The more filters that you use, the shorter your patient list will be…

Search Fields

Fields: The data you want to include in the resulting patient list. - WHAT Fields

Creating a Search

First, ask yourself a few questions:

• What population do you want to identify?
• How will this Search be used?
• WHO is the population we want to view? (FILTERS)
• WHAT information do you want to see about this

population? (FIELDS)

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Creating a Search Let’s create a search together!

• Patients with Diabetes
• Filters:
• Active
• Data Elements > Problems > Diabetes Type 1 or 2
• Fields:
• ID, Name, Age, PCP
• Last HbA1c Result and Last Result Date

Let’s Create a More Advanced Search

Patients that have Diabetes OR had an HbA1c > 9 in the last 2 year Filters:

• Data Elements > Problems > Diabetes
• Visit History > Labs > Had a HbA1c test in the last 2

years with value > 9 Fields:

• ID, Name, Age, PCP
• Last HbA1c Result and Last Result Date

Advanced Filter Criteria

Use advanced logic operators

AND

Include ‘this’ AND ‘that’

Diabetes AND HbA1c <9 Female AND Abnormal Pap AND Recall completed

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Advanced Filter Criteria

Use advanced logic operators

OR

Include ‘this’ OR ‘that’

Age 65+ OR (i2i) Diabetes Tracking Patients with Obesity Diagnosis OR BMI >30 OR Obesity

Each OR “starts the search over again”

Patients with Obesity Diagnosis Patients with BMI >30 Patients with Obesity Advanced Filter Criteria

• Use advanced logic operators
• NOT (but exclude)
• Include ‘this’ NOT ‘that’
• Active AND NOT had a Visit in the last 3 years
• Diabetics AND NOT had a HbA1c test in last 6 months

Advanced Filter Criteria

• Use advanced logic operators
• Parentheses
• Include ‘this’ and (either ‘that’ or ‘that’)
• Active and (had a visit in the last 3 years OR have an

appointment this week)

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Advanced Filter Criteria

Look at a few examples: Caution:

Active Status

• nly applies to

the Visit!

Search Exercise

Time to build some Searches!

• Patients with Diabetes who have had one visit in the past
• ne year
• Patients with Diabetes who have had one visit in the past
• ne year who are female
• Patients with Diabetes who have had one visit in the past
• ne year who are female and whose most recent HbA1c

test done in the last 1 year was >9. Search Exercise

• Patients with Diabetes who have had one visit in the

past one year who have not had a Diabetes Education in the last one year

• Patients with Diabetes who have never had an HbA1c

test over 7.

• Active Patients Age 50+ with Diabetes or Patients

Age 65+ with Asthma

• Active Patients with a Visit in the Last Year who are

Age 50+ with Diabetes or Patients Age 65+ with Asthma

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Questions?

Section 2: Proactive Care Tools

Agenda

1:15 – 4:00 p.m. Section 2: Proactive Care Tools Chapters 4, 7, 8, 9, 25, 30 Team Leads, Supervisors, Lead Providers, QI

• i2iTracks Today
• Pre-Visit Planning
• Morning Huddle – At-a-glance report
• Schedules/Alerts
• Patient searches for “Protocols”
• Patient Visit Summaries – detailed report
• Data Elements/Patient Profiles

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i2iTracks Today Your own personal dashboard that helps you monitor the tasks, reminders, reports, etc. that are meaningful to you.

Customizable by User

i2iTracks Today Setting up Default Tracks Today Customizing Tracks Today Pre-Visit Planning

• Get prepared for your day’s appointments!
• Tracks Pre-Visit Tools
• Morning Huddle Report
• Schedules/Alerts
• Protocols
• Patient Visit Summaries

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Morning Huddle Report Easy to use report/summary Identifies outstanding care needs

What care needs are

• utstanding for my

patients who have an appointment today?

iTi Care Team Huddle Report Easy to use report/summary Identifies outstanding care needs Enhanced information at your fingertips Schedules/Alerts

• Schedules are typically defined by Evidence-Based

Guidelines from entities such as HRSA / UDS / MU – Ultimately Schedules are decided by YOUR health center

• Schedules can be set on:

– Procedures / Referrals – Immunizations – Labs – Educations

• Warning – Do not create

Alert Overload!! – Too many alerts drives providers away from tool

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Schedules/Alerts Setup > Data Element Manager Schedules/Alerts Educations > Edit > Schedules > Add/Edit Schedules/Alerts Educations > Edit > Schedules > Add/Edit

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Protocols

Allows patient searches to show up as care alerts

• n Morning Huddle Reports, Care Team Huddles,

Visit Summaries, and Patient Information

Patient Visit Summaries Patient Visit Summaries are a customizable ‘at- a-glance’ summary of the patient’s medical condition. When/How to Use a Visit Summary Before the Visit

• Day of care planning

During the Visit

• Share progress with patient
• Reminder of care items that are due

After the Visit

• Education material for the patient to take

home

17 Diabetes Tracking Type

Diabetes Profile Diabetes Data Elements

Let’s Explore our Diabetes Profile

Each Indicator can be customized to meet the needs of your care model. Schedules are created for proactive alerts

Diabetes Data Elements

Diabetes Data Elements

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Diabetes Data Elements A Profile contains the list of the associated Data Elements for our Diabetes care model.

Diabetes Profile Diabetes Data Elements Diabetes Tracking Type

Diabetes Profile Diabetes Data Elements

i2iTracks Basics Training: Day 2

Tuesday, October 30 9:00 a.m. – 4:00 p.m.

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Security/Access Privileges i2i Community High quality support & service are available through the Community Portal. With access to the Portal, you can begin to log cases detailing your questions or concerns with i2i products. Disease Management Population Management Strategies – Creating a Tracking type for a population of focus – Correspondence – Configuration and Utilization – Follow-ups and Recalls (Brief Introduction) Reporting – Measuring the Outcomes of the Tactical Solutions – Health Registry Report – Canned Reports

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Disease Management

“A system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.”

Care Coordination

Exploring Tracking Types

• Let’s explore a few Tracking Types…
• Diabetes
• Tracking Type
• Profile
• Data Elements

Tracking Types

• Tracking Types are used to group ‘like’ patients

together allowing you to:

• Follow the same guidelines for care
• Foundation for proactive care

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Preconfigured Tracking Types

• Women’s Health
• Pap Tracking
• Mammogram Tracking
• Perinatal Tracking
• Childhood Immunizations

Other Tracking Types

• i2iTracks allows you to create an unlimited number of

Tracking Types for the disease or condition of your choice – built to your specifications… or you can use

• ne of our Tracking Types Templates.
• Diabetes
• Preventive Care

What’s in a Tracking Type

• A Tracking Type includes a profile of health indicators
• Each indicator can be customized to meet the needs of

your care model.

• Includes schedules that will remind you of what is

due

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Proactive Care Tools

Now that we understand how to build our care model – we can start to use i2iTracks Proactive Care Tools

Follow-Ups

• Monitors your efforts and reminds you to follow-

up with patients for outstanding care needs

• Electronic ‘To-Do’ list
• Two ways to manage:
• Individual Patient‐level follow‐up
• Global follow‐up with the Follow‐Up Manager

Follow-Up Types

• General Follow-Up
• Women’s Health Follow-Up
• Disease Management Follow-Up
• Referral Management Follow-Up

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Questions?

Section 3: Analytics & Business Intelligence

• Agenda
• Health Registry Reports
• UDS/MU/Other Standard Reports
• Population Health Analytics
• Reports
• Dashboards

Section 3: Analytics & Business Intelligence

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Health Registry

• Easy Disease Management Report
• Limited to ONE Population of Patients
• View Statistics
• Drill down to the patient level
• Customizable features

Standard Reports

• UDS Clinical Tables
• Meaningful Use
• Indian Health Services
• GPRA
• Diabetes Health Status
• Other standard Reports

Data Element Manager

• Centralization of all i2iTracks data mappings in one library

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Data Element Mapping Uses

• Reports and Dashboards
• Patient Searches
• Disease Management
• Preventive Care Tracking
• PopIQ

Data Element Benefits

• Makes setup easy
• Saves time and resources
• More accurate and consistent data across reports
• Built-in mapping automation tools

Understanding Data Element Details For further training:

• i2i University Course
• Professional Service time with Anne Enright, Population

Health Consultant

• Technical Assistance with Ashley Pasquariello, TPCA

Data Analyst

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Report Mapping Standard Reports need to be MAPPED before using them. Mapping is all about defining ‘equivalents’. Mapping means to take all the different codes (CPTs and ICD9) and other types of EHR/external data used to identify a visit, a procedure, medication or a diagnosis and assign them all to one indicator in i2iTracks. Why MAP?

• Custom or unique codes
• Data stored in different places in EHR
• Templates
• Orders
• Data may be stored differently
• Free text fields
• Dropdown menus
• Check boxes
• Funders and Payers may have different requirements for

the same elements Default Mappings Auto-mapped data elements have been mapped based

• n industry standard reporting guidelines, primarily the

standard codes recommended by the National Library of Medicine Value Set Authority Center (https://vsac.nlm.nih.gov/#). Please review the mappings and map your own internal

• r non-standard codes.

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It’s time to run your UDS Report!

Review your mappings Print your report Review for accuracy, missing data, potential mapping issues, etc. Standard Report Exercise Population Health Analytics: Create Custom Reports and Dashboards How are they different from standard reports and searches?

• Multiple populations on one report
• More in depth filtering options
• For example – AGE can be defined as
• Age as of the end of the reporting period
• Age as of the beginning of the period
• Current Age
• Age as of a specific date

Importing Reports and Dashboards Even without training, you have access to a library of iPHA reports and dashboards that you can just IMPORT right into Tracks. Let’s import a report together!

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Implementation Planning Discussion

• Review of Expectations Met/Unmet
• Review of Homework – Planning for webinars
• Building a successful Tracks Implementation Plan
• Draft Practical Implementation Strategy
• Tools for Use in Next 90‐180 days
• Staff and Access Privileges (set up security)
• Strategy needs by: daily | weekly | monthly | etc.
• Documentation needs: policies, procedures, workflows,

and next steps Questions?