Monitoring inbaskets with feedback to providers enhances the timeliness of patient care

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Background: The adoption of Electronic Health Records (EHRs) has changed the workflow for providers. The “inBasket” feature supplants telephone and email communications, replaces paper results review and has become the way to track incomplete encounters. Failure to promptly complete medical records leads to unread notes and impairs multidisciplinary communication. Also, unclosed encounters lead to potential penalties and uncollected fees. One benefit of the inBasket, is that it can be monitored. Methods: We created a report that tracked EPIC inBasket activities by provider including numbers of open charts, unchecked results, phone calls, incomplete dictations and orders needing cosign. The report shows the number and length of time each activity has been delinquent. In December 2015 we began emailing automated reports to all providers with their monthly results. In January 2016 we began an enforcement process for providers with >50 open charts: 30 days to complete charts or practice would be closed to new patients; if >50 remained after 30 days providers had 60 days before complete suspension from practice. We modeled the financial impact of chart closure by creating a weighted average by payor of fees collected per visit. For charts that would have been delinquent beyond payor filing deadlines this represents actual increased revenue. For charts that would have eventually been closed before the filing deadline this represents earlier revenue capture. Results: See table. Conclusions: Inbasket monitoring with structured feedback to providers led to improvement in the number of open charts, the focus of corrective action. We did not see consistent improvements in the other inbasket metrics. Future work will involve a similar approach to all inBasket metrics. Closing charts also has a significant financial impact; we estimate that $483,049 in fees that could have been lost due to exceeding payor deadlines became collectable. [Table: see text]

An EPIC electronic decision support tool to identify percentage of patients with stage IV thoracic or gastrointestinal malignancy who would benefit from concurrent palliative care but do not currently receive it

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Background: In 2016 ASCO updated its guideline for early integration of palliative care (PC) into standard oncologic care for all “inpatients and outpatients with advanced cancer.” PC has been shown to improve quality of life, align care at the end of life with patient preferences, and reduce health-care utilization. In preparation for the expansion of our palliative care service into ambulatory disease-based practices at Smilow Cancer Hospital at Yale-New Haven, we sought to create a decision support tool (DST) in the EPIC Electronic Health Record (EHR) that would identify patients for PC referral. Methods: This DST identifies patients with a GI or thoracic malignancy who have had an ICD-10 diagnosis of metastatic or stage IV disease, have not had a palliative care visit in the last 6 months, and are not enrolled in hospice. If the patient meets criteria, the DST will remind providers that “this patient meets ASCO and IOM criteria for concurrent palliative care with oncologic care ” and offers a one-click option to place the referral. To understand the volume of patients this DST would refer, we ran it silently in the EHR background from 7/15/16 through 9/1/16. We tracked how many patients were seen in the clinics, how many were eligible, and how many were referred to PC. Results: See table. Conclusions: Our silent BPA indicated that only 5% of patients eligible for a palliative care consult received it at baseline; this matches national data, which suggests that most patients who would benefit from PC do not receive it. This DST has the potential to dramatically improve PC referral rates and increase adherence with ASCO and IOM guidelines. We plan to move the DST into the live clinical EHR in 2017 after the integrated PC clinics are open. We anticipate that once our BPA is activated, we will see a dramatic increase in the number of eligible patients referred to palliative care. [Table: see text]