From the 2019 HVPAA National Conference
Dr. David Broome (Cleveland Clinic Foundation), Dr. Erin Covert (Cleveland Clinic Foundation), Dr. Jennifer Ohtola (Cleveland Clinic Foundation), Dr. Rabel Rameez (Cleveland Clinic Foundation), Dr. Ashley Wood (Cleveland Clinic Foundation), Dr. Leon Zhou (Cleveland Clinic Foundation), Dr. Catherine Fleischer (Cleveland Clinic Foundation)
As of August 2018, only 70.7% of patients under the care of FRAME A, G10 POD B and C resident clinics were on medically appropriate statin therapy for prevention and treatment of cardiovascular disease as defined by the ACO guidelines.
To increase compliance with ACO guidelines in the prevention and treatment of cardiovascular disease in patients seen in FRAME A, G10 POD B and C resident clinics by 15% between August 2018 through March 2019.
We established a pre-intervention process map and fishbone diagram to identify problems areas as well as opportunities for intervention. We then established a decision matrix illustrating the frequency and impact of each problem as well as ease of fixing it, the highest scoring areas for possible intervention were a lack of a standardized dot phrase in our notes as well as absence of “stain choice” in the “health maintenance” tab. Since our request to make changes to our EMR system, EPIC was not successful, we decided to focus our efforts on resident education as well as development of a dot phrase.
The dot phrase was embedded into our clinic notes and would allow us to F2 through the various options, it would also pull in the last lipid panel in the system, go through a decision tree allowing us to go through the various patient groups with indications for statin use as per ACO guidelines. Data collection was via the electronic dashboard in EPIC.
By educating residents and including a standardized dot phrase, we were able to increase compliance with appropriate statin use as identified by ACO guidelines, by 12.4%.
Indications for statin use outside of hyperlipidemia are easily missed. By embedding a standardized dot phrase in our notes, we were able to make sure appropriate statin use was addressed in all new physicals and established follow ups. Although we did not meet our target of 15%, we did see a significant improvement of 12.4%. Other areas to target would be an EPIC change to allow for appropriate statin use to be a part of the “health maintenance” tab. Since residents see their patients every 5 weeks, a longer follow up might have shown a greater change as well. In patients who are counseled about statin use but refuse them, the system does not yet allow for providers to document refusal after counselling but does allow for intolerance or allergies to be an exception, addressing this might help decrease the denominator and increase the overall percentage of patients on appropriate therapy.
Benefits of statin use for primary and secondary prevention of cardiovascular disease in the populations outlined by the ACO guidelines is well established in literature. Using a standardized dot phrase was an easy and efficient way of addressing appropriate statin use in all our patients, however, further interventions and longer follow ups would be necessary to meet out goal.