Continuing Certification (CC)

Diplomate: Kathryn Cillessen, MD

Abstract: The VA North Texas implemented a CROC (Clinical Reminder Order Check) to activate when a prescription for Lithium was ordered and no Lithium level was found in the system in the last six months. The goal was to improve the percentage of patients meeting the minimal lab monitoring guidelines. Once a lab order was placed a letter was mailed to patients needing labs and the Lab staff were educated to look for old orders. While the percentage of patients having the lab done within 6 months improved there were many lab orders placed but not completed. Additional work on the process for education of patients and staff is needed.

Diplomate: Anthony M. Dunnigan, MD

Abstract: Faced with low personal health record (PHR) sign-up and engagement, including a general lack of understanding of PHR features among both patients and staff, and lack of a clear, consistent process for patient sign-up, a project was led to increase sign up, firmly operationalize key processes, and add value to the PHR for both patients and staff. Key data gathered included PHR activation rates by each ambulatory center, communication rates, rates of online scheduling, and patient satisfaction. Clinical leaders were placed in the business ownership role, and through biweekly meetings reviewed data and helped drive the success of the project.

Diplomate: Michael Hwa, MD, FACP

Abstract: Electronic Health Records (EHR) adoption is growing rapidly. >95% of acute care hospitals and >90% of office-based physicians have adopted EHR’s. Computerized Physician Order Entry (CPOE) and Clinical Decision Support (CDS) tools have been shown to improve outcomes, but alert fatigue is an increasing concern. Alert fatigue is the phenomenon of end users becoming desensitized due to an excessive number of false positive alerts, leading to dismissing potentially clinically relevant alerts. At Santa Clara Valley Health and Hospital Systems Medication Warnings are the highest firing CDSS tool. For CY 2018, for every 100 medication orders placed, there were 110 warnings. We undertook a quality improvement project involving a multidisciplinary team to systematically evaluate medication warning data in our institution. Using standard tools in our EMR we reduced warnings by ~30% over a 1-year period.

Diplomate: Julie Massey, MD, MBA

Abstract: Our sepsis project was divided into two parts: Early identification and treatment upon presentation to the Emergency Department and Early identification and treatment in the Inpatient setting. Each initiative included implementation of an alert in the electronic medical record (EMR) and development of subsequent defined protocols and pathways for diagnostic evaluation and treatment. The project required development of education for clinical staff on sepsis, review and revision of order sets, implementation of new workflow processes, and measurement and monitoring performance on key metrics through development and dissemination of dashboards. The sepsis initiative resulted in improved mortality rate and reduced complications, length of stay and direct cost of care.

Diplomate: Matthew Rafalski, MD FAAFP

Abstract: My project consisted of looking at several aspects of in-line, context-aware clinical decision support (ICA-CDS), implemented in a commercial EHR at a community health center non-academic practice to improve screening practices. I was able to demonstrate ICD-CDS can effectively improve and maintain routine periodic screening rates for depression in an undiagnosed population. I also showed this technique is intuitive to produce the same improved screening rates in a different population with a different screen (falls risk screen).

Diplomate: Rachel Sherman, MD

Abstract: Fecal occult blood testing is an accepted screening test for colorectal cancer particularly in patients who refuse colonoscopy. At the James J. Peters VA in 2014, 25% of our screening FOBTs were inappropriate and in the Veterans Health Administration system-wide results were similar at 26% (Powell JGIM 2016). The aim of the project was to determine if an electronic template in the VA’s electronic health record, CPRS, would reduce the rate of inappropriate screening FOBT orders. The template was instituted in 2015 in addition to the preexisting clinical reminder as the only option of ordering screening FOBT tests. Patients were selected through chart review of all FOBTs pre-template (10/14-12/14 n=112) and post-template (10/15-4/16 n=96). The proportion of screening FOBT tests which were inappropriate pre-template was 25% and post-template 7% (p=001). Use of the template was associated with appropriate FOBT ordering by logistic regression (p<0.001).