EHR Innovations for Improving Hypertension

Phase 1 Winners and Phase 2 Introduction Webinar (January 23, 2015)

The January 23, 2015 webinar presented the winners of Phase 1, Holly Dahlman of Green Spring Internal Medicine, and the team of Christopher Tashjian, Mary Boles, and Roseanne Matzek of Vibrant Health Clinics. The winners described their clinics’ hypertension control processes and answered questions from the audience. Finally, requirements for participation in Phase 2 of the challenge were presented.

Webinar Recording | Slides | Transcript coming soon

Download the Green Spring Internal Medicine Phase 2 Materials

Download the Vibrant Health Family Clinics Phase 2 Materials

Holly Dahlman, Green Spring Internal Medicine, LLC
Solution: EHR-Driven Practice Improvement – Hypertension Control
Description: Our practice was nominated by the Maryland Department of Health and Mental Hygiene to submit this innovation which is based upon three interventions: registry use to identify high-risk patients, DASH diet recommendation, and patient self-monitoring protocols which are facilitated by automation within the EHR.

Christopher Tashjian, Mary Boles, and Roseanne Matzek, Vibrant Health Family Clinics
Solution: On Our Way to Saving a Million Lives
Description: Vibrant Health Family Clinics, previously River Falls, Ellsworth and Spring Valley Medical Clinics, has worked diligently over the past few years to improve the care we provide to patients with chronic disease. Our focus has been not only on patients exclusively with hypertension but those that have multiple co-morbidities, including Diabetes and Ischemic Vascular Disease. Saving the lives of our patients by helping them learn about healthy lifestyle changes, good nutrition, setting goals, caring about themselves and adjusting medications is something we take great pride in. We have been Million Hearts Champions twice over the past two years. We started our improvement work with one clinic site and moved our interventions into our other two clinic sites, maintaining excellent blood pressure control for all patients with hypertension at a rate of 76% based on NFQ 0018 report data from July 31, 2013-August 28, 2014. We have actively shared our work with other clinical sites, most recently a clinic from Chippewa Falls, WI which is located about 50 miles away. Our work has also allowed us to be in a national collaborative group, the LEAP learning community, with a focus on creating a toolkit for other clinics looking to improve patient care.

The August 5, 2014 webinar introduced the EHR Innovations for Improving Hypertension Challenge and detailed the requirements for Phase 1.

Webinar Recording | Transcript

Critical Path to Reduce Cardiovascular Events via Practice-based Blood Pressure Control Improvements

• Practice is interested in and ready for Quality Improvement (QI) efforts
• Agreement on BP control as a QI priority
• Current BP-related information flow/workflow – and potential enhancements – are understood
• Tools/protocols to enhance care processes (order sets, registry reports, patient education /engagement) are implemented effectively
• Enhanced care processes yield improved BP control
• Improved BP control reduces CV morbidity/mortality

This Challenge will identify practices that have achieved at least the first five steps in this process – using electronic health record technology (EHR) to implement evidence-based clinical protocols in step four – and then drive widespread implementation of the clinical decision support (CDS) tools used by the practices.

Description: This Challenge will seek practices that have used clinical decision support (CDS) to implement the most clinically successful examples of an evidence-based blood pressure treatment protocol¹ and gather details about these tools and their implementation. In addition, the challenge will further reward organizations that can spread the successful tools for use by the most providers.

Challenge goal: Gather specific descriptions of CDS tools used by care delivery organizations to improvement in practice-wide blood pressure control (Phase 1), and identify models for quickly and widely spreading these to other practices (Phase 2). A comprehensive CDS approach supports these five protocol elements:

• BP measurement/recording
• BP follow-up
• Medications – initiation, titration
• Patient engagement
• Workup/referral for poor control

Participant activities by phase: In Phase 1 (three months), practices will document the CDS tools they used to implement an evidence-based BP control protocol, as well as describe the details and results of the implementation. In Phase 2 (nine months), practices and their partners will conduct, evaluate and document dissemination strategies for tools identified in Phase 1, emphasizing widespread, effective use of these tools by other practices.

Entry requirements: In Phase 1, practices must demonstrate high BP control levels and/or improvement to ensure that tools and strategies merit replication across practice settings. In Phase 2, submitters must demonstrate successful use of these tools in at least 2 additional practices.

Phase 1 Details:

1. Purpose:

• Identify CDS tools and approaches effectively used by individual practices to improve blood pressure so they can be spread to other practices.

2. Participants:

• A practice implementing the protocol must lead the submission. Practices are encouraged to form teams supporting their entry that include organizations such as a Regional Extension Center (REC), EHR developer, quality organization and/or professional society.

3. Duration: 3 months

4. Required to submit:

• Provide data on BP control rate and/or improvement, as well as data on hypertension prevalence in the practice (prevalence data is collected to better understand the organization’s hypertension screening results, but is not used for review)
  • Submission requires more than 70% BP control (<140/90) in hypertension patients; specifications used to determine this rate must be the same as that used for PQRS #236/NQF #0018 and/or
  • Significant improvement over time in BP control: Provide the percent of the patient population whose BP rate was improved over a specified period. Each submission will be evaluated based on the percent improvement and time period but no specific threshold for these must be met as a part of submission requirements.
  • Information about the patients affected by the CDS interventions to help describe the Challenge’s reach and effects, including:
    • Size of the practice’s patient population and hypertension prevalence;
    • Aggregate demographic information on the patient population (e.g., disparities); and
    • Specialty and demographic information about the practice (e.g., number/type of providers, setting [rural vs. urban], type [academic vs. community])
• Describe Protocol elements addressed (use structured narrative; we encourage but do not require that submitters address all five elements):
  • BP measurement/recording (e.g., use of documentation templates, highlighting abnormal BPs in EHR)
  • BP follow-up and patient recall (e.g., use of registry reports)
  • Medication selection and titration (e.g., use of order sets)
  • Patient engagement (e.g., use of patient education and goal setting tools, templates for documenting and responding to home BP readings, patient reminders for medications/appointments)
  • Workup/referral for poor control (e.g., reference information, hypertension-specific consult order forms)
• Describe EHR/HIT tools used to implement protocol (generic description; screenshots optional) and details about deployment so that others can replicate it
  • Order sets, registry reports, documentation templates/tools, medication protocols, patient engagement/education tools, referral templates, reminders, etc.
  • Tool descriptions can include generic version of intervention (e.g., contents of order set, documentation template, rule), screenshots, and/or implementable artifacts
    • We encourage, but do not require, use of the format described in the HL7 CDS Knowledge sharing implementation guide (also called the ‘Health eDecisions’ format)
• Describe how the tools are deployed in workflow
  • Use CDS/Quality Improvement worksheets for standard presentation/replication (e.g., similar to QI case example within the CDS/QI resources recently provided by ONC²)

Phase 2 Details:

1. Purpose:

• The ultimate goal is that many organizations (e.g., professional societies, developers, quality organizations, RECs) spread use of the effective tools and related workflows from Phase 1 to many additional practice settings.
• Phase 2 submitters will develop and implement strategies for disseminating the CDS interventions recognized from Phase 1 as having the greatest value for BP control.
• Organizations with the greatest spread results and further spread potential will be selected for recognition, including a single winner, from the Phase 2 Challenge component.

2. Participants:

• Phase 2 Challenge applicants can include any organization or collaboration that is able to widely spread successful use of EHR/CDS-enabled BP treatment protocols using tools recognized during Phase 1. Phase 2 submitters need not have participated in Phase 1.³

3. Duration: 9 months

4. Required to submit (see Phase 2 submission form):

• Evidence that the tools and artifacts were implemented, or implementation is underway, in at least 2 other practices or provider groups
  • As part of describing the spread strategy, submitters must describe the CDS tools that were used to implement the hypertension control protocol; the format for this is based on that from Phase 1, and also includes any modification made to the tools so they could spread. We encourage, but do not require, use of the format described in the HL7 CDS Knowledge Sharing Implementation Guide (i.e., the ‘Health eDecisions’ format).
• Results from spreading CDS tools to other practices: ideally blood pressure control/improvements similar to that achieved from the tools in Phase 1, but, at a minimum, compelling evidence of significant value from tool implementation.
• Evidence of intent from other practices (i.e., in addition to those practices covered in 4.a above) to replicate the BP protocol approach using the CDS tools.
• Information about the patients affected by the CDS interventions, including:
  • Size of practice’s patient population and hypertension prevalence;
  • Aggregate demographic information on the patient population (i.e., disparities); and
  • Specialty and demographic information about the practice (e.g., number of providers, setting [rural vs. urban], type [academic vs. community]).

  This information will help define the Challenge’s reach and effects; the Challenge is intended to affect many different practices sizes and types.

• Practice deployment strategy summary and critical success factors for spreading CDS tool implementation to enhance BP control.

• Phase I submission period: July 7-October 6, 2014
• Phase I review period: October 7-October 21, 2014
• Phase I winners announcement, tools posted: October 27, 2014
• Phase II submission period: October 28, 2014-July 31, 2015
• Phase II review period: August 1-August 15, 2015
• Phase II winners announcement: August/September, 2015

Phase 1 will have up to 4 winners, each of whom will receive a $5,000 prize. Other Phase 1 submitters who provide CDS tools that reviewers select for spread during Phase 2 dissemination efforts will receive non-monetary recognition (e.g., Honorable Mention). Phase 1 practices may be recognized in different categories (e.g., practice type, size) based on submissions received.

Phase 2 will have a single winner of a $30,000 cash prize. Other Phase 2 submitters, whose CDS tool dissemination and implementation strategies the reviewers deem commendable, will receive non-monetary recognition (e.g., Honorable Mention). Phase 2 recognitions may be categorized into different spread organization types based on submissions received (e.g., REC, quality organization, specialty society, vendor).

Phase 1

• BP Control (<140/90) among hypertension patients
  • BP control rate: specifications used to determine this rate must be the same as that used for PQRS #236/NQF #0018) and/or
  • BP control rate improvement: percentage point increase in BP control rate over a specified time. Submissions will be evaluated based on the percent improvement, if this is provided by submitters, but no specific threshold must be demonstrated as a part of submission requirements.
• Comprehensiveness and innovation in addressing the protocol elements using EHR or other HIT
• CDS tool implementation description detailed enough so that others could replicate it
• Ease with which others could implement the same approach (e.g., if the strategy required a high degree of custom development that cannot easily be shared, then it would be harder for others to replicate)

Phase 2

• Number of practices in which the CDS interventions were implemented, or implementation is underway
• Number of practices expressing interest in replicating the CDS-enabled protocol implementation approach in addition to those that actually implemented it during Phase 2
• CDS tool implementation spread efforts resulting in demonstrated BP control improvements. Absent actual BP control improvements, demonstration of compelling evidence that CDS tool implementation has made a positive impact on BP care processes and/or that BP control improvements are likely.
• Comprehensiveness and innovation in supporting BP protocol elements with CDS tools.
• Likelihood that the submitter’s approach to spreading the CDS tool-enabled BP protocol implementation can be further replicated beyond Phase 2.

Review Panel

Reviewers will identify the most effective, replicable approaches to EHR/HIT-enabled practice-wide BP control in Phase 1, and the most promising approaches to spreading such implementation widely in Phase 2. We anticipate a broad review panel, similar for both phases and including ONC/CDC/other federal staff, societies, CDS and hypertension subject matter experts, and organizations engaged in earlier Million Hearts work (e.g., see here) or Medical Home care coordination efforts.

Ownership of intellectual property is determined by the following:

• Each entrant retains title and full ownership in and to their submission. Entrants expressly reserve all intellectual property rights not expressly granted under the challenge agreement.
• By participating in the challenge, each entrant hereby irrevocably grants to Sponsor and Administrator a limited, non-exclusive, royalty-free, worldwide license and right to reproduce, publically perform, publically display, and use the Submission to the extent necessary to administer the challenge, and to publically perform and publically display the Submission, including, without limitation, for advertising and promotional purposes relating to the challenge.

In order for an entry to be eligible to win this Challenge, it must not use HHS’ or ONC’s logos or official seals in the Submission, and must not claim endorsement.

Eligibility Rules for Participating in the Competition

To be eligible to win a prize under this challenge, an individual or entity—

(1) Shall have registered to participate in the competition under the rules promulgated by the Office of the National Coordinator for Health Information Technology.

(2) Shall have complied with all the requirements under this section.

(3) In the case of a private entity, shall be incorporated in and maintain a primary place of business in the United States, and in the case of an individual, whether participating singly or in a group, shall be a citizen or permanent resident of the United States.

(4) May not be a Federal entity or Federal employee acting within the scope of their employment.

(5) Shall not be an HHS employee working on their applications or submissions during assigned duty hours.

(6) Shall not be an employee of Office of the National Coordinator for Health IT.

(7) Federal grantees may not use Federal funds to develop COMPETES Act challenge applications unless consistent with the purpose of their grant award.

(8) Federal contractors may not use Federal funds from a contract to develop COMPETES Act challenge applications or to fund efforts in support of a COMPETES Act challenge submission.

An individual or entity shall not be deemed ineligible because the individual or entity used Federal facilities or consulted with Federal employees during a competition if the facilities and employees are made available to all individuals and entities participating in the competition on an equitable basis.

Entrants must agree to assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from my participation in this prize contest, whether the injury, death, damage, or loss arises through negligence or otherwise.

Entrants must also agree to indemnify the Federal Government against third party claims for damages arising from or related to competition activities.

ONC reserves the right to cancel, suspend, and/or modify the Contest, or any part of it, for any reason, at ONC’s sole discretion.