Through the collaborative effort at Naval Hospital Oak Harbor (NHOH) to improve the quality of care for our patients, our IT Staff here at NHOH, developed a web-based application called “The Bridge” to help manage our HEDIS patients. This invaluable tool is helping NHOH improve patient care and our Healthcare Effectiveness Data Information Set (HEDIS) scores.
As a disease prevention tool, The Bridge is used to increase screening for breast, colon, and cervical cancers. Health care providers also are able to manage chronic conditions such as diabetes, depression, and hyperlipidemia by tracking lab values, medication management, and patient appointments. With preventive health screenings and effective management of chronic conditions, we are helping improve quality of life for all beneficiaries and support force health protection.
The initial concept of The Bridge was to display HEDIS information; however, a care plan feature (Images 6-8) was added to improve patient care and meet the guidelines outlined by the National Committee for Quality Assurance (NCQA). This improvement was instrumental in allowing our Medical Home Port teams to achieve the NCQA documentation requirements and led to NHOH achieving NCQA 2012 Level 3 accreditation. The Bridge was also recommended as a Joint Commission Best Practice during the August 2012 survey for NHOH.
The Bridge application evolved to simultaneously view patient medical data from different inpatient and outpatient Electronic Health Record (EHR) Systems (Image-4) Composite Health Care System (CHCS), Essentris, CarePoint, S3 and Mammography Reporting System (MRS Live) in one application without the need to open up multiple EHR’s just to see a single patient's information. Business rules are also applied to the data. In the case of our HEDIS data, due and overdue screening exams are highlighted as shown in Image-1 and Image-2.
The Bridge is designed to provide easy access and efficient navigation of patient medical information. Staff members continue to come up with innovative ways to use The Bridge. Improving the health of our beneficiaries through preventive screenings and better management of chronic illnesses will ultimately lead to lower health care costs for our MTF.
Overview of the images: (Patient info has been covered up in the screen shots except in the pages where “Doe, Jane” is being shown, this data is actually the address and phone numbers here at NHOH)
Image-1: This is a screen shot of the main page of The Bridge. Part of the NCQA requirements is that providers and staff members have easy access to Clinical Practice Guidelines, references and links.
Image-2: This screen shot is what a staff member sees when they click the “Diabetes” button (on the left side of the page) under the “Care Point Action List.” Displayed are the HEDIS eligible patients from CarePoint. For this metric, we have 553 patients who are monitored and tracked. The list is displayed alphabetically, but it can also be sorted out by clicking on the column headers.
Image-3: The majority of the staff uses this page, as it provides detailed patient information for a single health care provider. In this view, the HEDIS eligible patients who are scheduled for an appointment in the next 14 days for Dr. Warren are displayed. As you can see, we have 6 patients that can be contacted to schedule a well- woman appointment, offer a consult to General Surgery for colonoscopy, or direct the patient to radiology for a walk-in mammogram allowing us to maximize the patient’s visit while at NHOH. Prior to implementation of The Bridge, we did not have an efficient process to look ahead and see which scheduled patients were due for labs, screenings, or follow-up appointments.
Image-4: When a staff member clicks on a patient in the search list (Image-2 or 3), the screen below is displayed (the patient and demographic information in this screen shot is fictitious). The data displayed in the patient’s HEDIS section comes from CarePoint. (As a current project, the data in this section will soon include the date of when the last mammogram reminder letter was sent to the patient) One of our goals with The Bridge is to reduce the use of FMP/SSN and use the patient’s DoD ID as much as possible. However, this is a challenge since much of the data from other EHRs still use the FMP/SSN. The Bridge allows a patient search using the Last 4, and it will display the FMP/Last 4 as a cross-reference against those EHRs (e.g. AHLTA) which do not yet use the DoD ID.
Image-5: This screen shot shows the “Care Plan” tab which allows the provider to access and choose various care plans (Diabetes, Asthma and Depression). This feature was added because existing EHRs did not have or provide for the creation of Care Plans.
Images-6: This screen shot shows the Diabetes Care Plan template. Currently, some of the fields in this form/template are auto populated by data that is either in CarePoint or CHCS. We are looking at how to incorporate AHLTA macros to populate even more of the fields. The ultimate goal is for the staff members to document the patient information in only one place, and have that data available in other forms. The data entered into the care plan template is saved in the SQL database which can be used to provide a patient’s care plan history or populate a new diabetes care plan for the patient. Once the care plan is completed, the provider can print it by selecting the appropriate team (Cascade or Olympic) print button. The printed copy is then given to the patient as per NCQA requirements.
Image-7: This screen shot shows the Print to Clipboard button and care plan document. This feature was added because the providers wanted to be able to paste the care plan into the patient’s AHLTA record.
Image-8: This is a screen shot of the printed Care Plan that is given to the patient.