Wednesday, May 06, 2009

Quality improvement, year 3

Our quality of care for preventive services continues to improve. We have 9,985 eligible services. We provided 87.75% of these services, compared to 73.53% last year, an increase of over 14%. It was interesting, because quality of care went up for every service, for every physician. We also went from 9 physicians to 12. Part of the improvement was better, more consistent data entry by everyone, and part is an actual increase in services; I can't know which is which, but I have no doubt that there is an actual increase in services.

Pap smears went from 74% to 89%; mammograms from 74% to 88%, and influenza vaccinations for the elderly from 71% to 85%.

Our Fecal Occult Blood (FOB) screening program has now started. We were able to extract a list of patients with Colorectal cancer or Inflammatory Bowel Disease for every physician (through ICD codes); these lists were then faxed to each physician for verification. Our data entry person has now entered a code in all Cumulative Patient Profiles to exclude those patients from screening. Every practice knows about the code, so patients newly diagnosed can be excluded in the future.

My colleagues have been good about entering colonoscopies consistently and in the right area of the CPP; we generated lists of all patients with colonoscopies <5>

We will then cross check the remaining patients with the paper lists of FOBT (from lab billing data) that the Ministry of Health recently sent us; we mailed FOBT letters last year as a trial, and this worked, so once all the data entry is done and cross-checked, we'll go ahead with mailing patients overdue for this screen. Our FHN administrator will notify everyone ahead of time, so all practices have time to prepare (order extra FOB kits, make sure that everyone knows to put in a lab req when patients come in to pick up the kit etc); we also email a copy of the letter template to every physician for approval prior to mailing. This will enable us to monitor FOBT from now on and to add FOBT to our regular 3 monthly mailings. I expect this to be completed by July or August, with the first mailing going out then.

Here is the letter to patients:


Our records show that you are due for a Fecal Occult Blood (FOB) screening test. FOB screening has been found to decrease the risk of dying of cancer of the lower bowel, and should be done every two years.

Please come to the office to pick up your FOB kit. You do not need to make an appointment for this.
If you have had a colonoscopy in the previous 5 years, then you do not require this test. Please inform the office if a colonoscopy has been done.

FOB screening is an important part of keeping you healthy; more information on early detection of lower bowel cancer can be found at

As your Family Physician, I appreciate the opportunity to work with you to prevent illnesses and enhance your health.

We are now at 14 physicians in my FHN; we'll add our two new colleagues to the preventive program this summer, which will bring us to just over 15,000 rostered patients. We will also get data auditors to cross check the paper lists to make sure that patients who are rostered on the EMR are shown as rostered on the Ministry lists. We'll do a cross check for patients who already have two letters mailed, to make sure that they have not had an overlooked service. You have to maintain your database, and double check things. As well, during the summer, all patients with two reminder letters and still no response get an extra phone call, as we hire summer staff for this.

We are also getting data entry for our diabetes registry; this adds reminders to look at the flowsheets every 3 months. Several physicians in my group have been looking at overdue reminders, and have called to remind these patients to come in. I thought this was a good idea, so we had a look and found 6 diabetics who had not come in for over 6 months. My secretary called all of them, and four have booked appointments.

As a test, I had data entry done for all my diabetics for last date of retinopathy check (for eyes) and neuropathy (foot exams). I was able to generate a list of overdue retinopaties (>2 yrs)--17 patients--and these are now all getting a reminder letter; as well as overdue foot exams--14 patients--and these now all have an alert in the chart. My nurse saw a diabetic in for another reason, noticed the alert, did a foot exam and marked it as completed. The system now shows me the list with that exam completed, and the date it was done.

I think that our system is slowly maturing, and I have evidence that we are using EMR capabilities to improve quality. I think this is what you should be able to achieve by the third year of EMR.

The last two filing cabinets have now been emptied; all paper charts are gone from the front. I put the filing cabinets on Craigslist yesterday, and sold them today. Paper charts have no place in this clinical setting.