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Measured Outcomes - Medical informatics at Mayo Clinic

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					                                   ARRA 2009 Beacon Community Cooperative Agreement. Program HHS-2010-ONC-BC-004
                                                 Outcomes and Measures Capture Tool: 15 Day Reporting


                             Outcomes and Measures Capture Tool Instructions: 15 Day Reporting

Introduction

This tool's purpose is to provide a form where the objectives and measured outcomes of the awardees of the American Recovery and Reinvestment Act of 2009 Beacon
Community Cooperative Agreement Program may be recorded. This tool provides 2 data recording forms for awardees to complete; objectives and measured outcomes.

These elements of each Beacon Community program are defined below:

Objectives

Each community’s qualitative mission objectives that will establish the awardee community as a “Beacon” if completed. Objectives focus on a range of Beacon program goals,
ranging from specific health outcomes to HIT infrastructure issues. Each objective is supported by quantified measure outcomes. Beacon Awardees have typically outlined these
objectives in their grant application documentation. Documenting these objectives is the to be completed on the "Objectives" tab.

Measured Outcomes

Target community identified specific quantifiable health outcomes that define the community objectives above and serve as measurements for community performance. These
outcomes are the desired changes in care delivery and patient health resulting from HIT investments. Some of the measures identified by Beacon Communities are defined by
standardized quality measures such as those published by the National Quality Forum (NQF), others are specific to the beacon community. Documenting measured outcomes is
to be completed on the "Measured Outcomes" tab, where each outcome to be associated with the objective it supports. Each outcome must be associated with an objective.




Instructions
As a first step in the reporting process, it is important that Beacon Communities record their up-to-date contact information and other details necessary for the program. Please
use the included 'Contact Information' tab to record available details.

Each tab provides a table for the recording of objectives or Outcomes. Awardees should begin by recording their objectives such that outcomes can be associated to objectives
based on a finalized list. Awardees are to enter the details described in each column heading for the objective or outcome recorded in that row. Definitions of each field are on
the 'Defintions' tab. The associate of objectives to outcomes is accomplished in the Measured Outcomes tab, by selecting the appropiate objective ID numbers from a dropdown
for each outcome.

        Go to Defintions


SUBMITTING COMPLETED WORKPLANS
Please send your completed workplan templates to BeaconCommunityGrants@hhs.gov with a file name that indicates your Community’s name and that it contains the 15-day
reporting.


The data recorded in this document is the first component (i.e. 15 day reporting requriement) of Beacon Program Logic Model. The 60 day reporting tool will be based on the
data provided in this document:
                                                                        Fig 1. The 15 Day Reporting Tool




                                                        15 Day Objective Measured Outcomes Data Capture Tools

                                Logic Model Frame work                         Associated Capture Template                       Relationship Tracking
                                                                                                                                        Method

                                                                                                 Objectives Capture Form
                             Community Objectives      CO
                                                                                                                                       Association of Measured
                                                                                                                                       Outcomes to Objectives

                                                                                                          Measured
                             Measured Outcomes         MO                                                 Outcomes
                                                                                                          Capture Form
                                       ARRA 2009 Beacon Community Cooperative Agreement. Program HHS-2010-ONC-BC-004
                                                     Outcomes and Measures Capture Tool: 15 Day Reporting


                             Outcomes and Measures Capture Tool Instructions: 15 Day Reporting
Primary contact information - (Main Beacon Office)
Beacon information
    Organization name                                                                                     Mayo Clinic                enter name
    Street address                                                                                 200 First Street SW               e.g., 12 Main Street
    City                                                                                                  Rochester                  e.g., Springfield
    State                                                                                                 Minnesota                  pick from drop-down list
    Zip code                                                                                              55905-0001                 e.g., 01234-0000
    Website                                                                                        www.mayoclinic.org                e.g., www.myBeaconname.org
    DUNS number                                                                                            6471700                   9 digit Dun and Bradstreet Data Universal Numbering System number
Primary contacts
    Beacon primary contact name                                                                Lacey Hart, Project Manager           enter first and last name
    telephone number                                                                                 (507) 293-3780                  enter 10 digit phone number
    email address                                                                                 hart.lacey@mayo.edu                e.g., myname@myBeaconname.org


    Beacon secondary contact name                                                         Dr. C.M. Harper, Principal Investigator    enter first and last name
    telephone number                                                                                (507) 284-5350                   enter 10 digit phone number
    email address                                                                                  mharper@mayo.edu                  e.g., myname@myBeaconname.org


    Beacon primary contact name                                                         Dr. Chris Chute, Co-Principal Investigator
    telephone number                                                                                 (507) 284-5506
    email address                                                                                   chute@mayo.edu

    Beacon primary contact name                                                         Dr. Doug Wood, Co-Principal Investigator
    telephone number                                                                               (507) 266-3626
    email address                                                                              wood.douglas@mayo.edu

    Beacon Award/Finance Speclialist                                                   Brian Wernecke, Award/Finance Speclialist
    telephone number                                                                               (507) 538-3782
    email address                                                                             wernecke.brian@mayo.edu

    ONC GMO name                                                                                                                     enter first and last name of ONC Grant Management Officer
    telephone number                                                                                                                 enter 10 digit phone number
    email address                                                                                                                    e.g., name@hhs.gov


    ONC PO name                                                                                                                      enter first and last name of ONC Project Officer
    telephone number                                                                                                                 enter 10 digit phone number
    email address                                                                                                                    e.g., name@hhs.gov


Additional contact information - (Beacon Sub-Recipient Office)
Sub-Recipient information
    Organization name                                                                            Olmsted Medical Center              enter name
    Street address                                                                                 210 Ninth Street SE               e.g., 12 Main Street
    City                                                                                                 Rochester                   e.g., Springfield
    State                                                                                                Minnesota                   pick from drop-down list
    Zip code                                                                                            55904-0001                   e.g., 01234-0000
    Website                                                                                      http://www.olmmed.org/              e.g., www.organization.org
    DUNS number                                                                                                                      9 digit Dun and Bradstreet Data Universal Numbering System number
Primary contacts
    Sub-Recipient primary contact name                                                      Dr. Barbara Yawn, Co-Investigator        enter first and last name
    telephone number                                                                                 (507) 288-3443                  enter 10 digit phone number
    email address                                                                                 byawn@olmmed.org                   e.g., myname@organization.org


    Sub-Recipient secondary contact name                                                 Susan Schuett, Chief Information Officer    enter first and last name
    telephone number                                                                               (507) 287-2757                    enter 10 digit phone number
    email address                                                                               SSchuett@olmmed.org                  e.g., myname@organization.org


Additional contact information - (Beacon Sub-Recipient Office)
Sub-Recipient information
    Organization name                                                               Olmsted County Public Health Services (OCPHS)    enter name
    Street address                                                                             2100 Campus Drive SE                  e.g., 12 Main Street
    City                                                                                             Rochester                       e.g., Springfield
    State                                                                                            Minnesota                       pick from drop-down list
    Zip code                                                                                        55904-0001                       e.g., 01234-0000
    Website                                                                                                                          e.g., www.organization.org
    DUNS number                                                                                                                      9 digit Dun and Bradstreet Data Universal Numbering System number
Primary contacts
    Sub-Recipient primary contact name                                                      Mary Wellik, Public Health Director      enter first and last name
    telephone number                                                                                  507-328-7500                   enter 10 digit phone number
    email address                                                                            wellik.mary@co.olmsted.mn.us            e.g., myname@organization.org


    Sub-Recipient secondary contact name                                                                                             enter first and last name
    telephone number                                                                                                                 enter 10 digit phone number
    email address                                                                                                                    e.g., myname@organization.org


Additional contact information - (Beacon Sub-Recipient Office)
Sub-Recipient information
    Organization name                                                                                  Winona Health                 enter name
    Street address                                                                                 855 Mankato Avenue                e.g., 12 Main Street
    City                                                                                                  Winona                     e.g., Springfield
    State                                                                                                Minnesota                   pick from drop-down list
    Zip code                                                                                            55987-0001                   e.g., 01234-0000
    Website                                                                                    http://www.winonahealth.org/          e.g., www.organization.org
    DUNS number                                                                                                                      9 digit Dun and Bradstreet Data Universal Numbering System number
Primary contacts
    Sub-Recipient primary contact name                                                      Mike Allen, Chief Financial Officer      enter first and last name
    telephone number                                                                                  507-457-4156                   enter 10 digit phone number
    email address                                                                               mallen@winonahealth.org              e.g., myname@organization.org


    Sub-Recipient secondary contact name                                                Rachelle Schultz, Chief Executive Officer    enter first and last name
    telephone number                                                                                 507-457-4156                    enter 10 digit phone number
    email address                                                                             rschultz@winonahealth.org              e.g., myname@organization.org




Comments
                                                    Additional stakeholders listed in grant submission.
                                                  ARRA 2009 Beacon Community Cooperative Agrmt. Program HHS-2010-ONC-BC-004
                                                                      Outcomes and Measures Capture Tool



                                                                                               Definitions

Objectives Capture Form Definitions
Field                                        Definition                                                                                                                           Example
ID                                           Numerical Identification for each objective                                                                                          1
                                             The high level category the objective can be classified under. Can be one of three options: Quality, Population Health, Cost. 'Cost'
                                             objectives are defined as trying to reduce operational costs or patient treatment costs. 'Population Health' objectives aim to
Outcome Category                                                                                                                                                                  Quality, Population Health, Cost.
                                             improve overall general population health metrics. 'Quality' objectives seek to improve care quality, operational and administrative
                                             process quality, etc.
                                                                                                                                                                                  Deploy cost-effective, community-wide HIT infrastructure to
Description                                  The text entry of the objective
                                                                                                                                                                                  support the full range of care-coordination needs for 12 million.
Start Date                                   Estimated start date of the objective time frame limited to 4/1/2010 to 12/31/2013                                                   6/6/2012
End Date                                     Estimated end data of the objective time frame limited to start date tp 12/31/2013                                                   9/6/2012
Notes                                        Any additional notes relating to the source or intent of the obective


Measured Outcomes Capture Form Definitions

Field                                        Definition                                                                                                                           Example
ID                                           Numerical Identification for each measured outcome                                                                                   4
                                                                                                                                                                                  Register all participating HCOs and 51,000 patients in a secure e-
Target Outcome                               Text description of the goal, measured outcome and target date. (SMART- specific, measurable, achievable, realistic and timely)      messaging system
Clinical Focus (if applicable)               For clinical measures, clinical condition addressed.                                                                                 Diabetes, mental health, smoking cessation, etc.
                                             The community population targeted or affected by the outcome. Specifically, the population refers to the subject of the outcome
Target Population                            description. Include information such as age and gender if applicable.                                                               Diabetic patients 18-65 years of age.
Target Population Size                       An estimate of the number of people affected by this Outcome                                                                         100,000
Measure Name/ID                              Name of published measure if applicable                                                                                              NQF 0059
Reporting Timeline                           Schedule for measurement.                                                                                                            Monthly, quarterly,etc. Or 3, 6, 12 months.
                                             Source of the data used in the outcome, and a description of any calculation required to determine the measured outcome if           Utah State Medicare, 2007. Determined by averaging the values of
Data Source & Calculation Description        applicable                                                                                                                           figures A, B, C.
Baseline Value                               the intial or current state value of the measure identified                                                                          500 Patients

Notes                                        Any additional notes relating to the source or intent of the outcome

Related Objectives                           A drop down list where the objective(s) supported by this measured outcome can be identified                                         1,3,8
                                                                                                                                    ARRA 2009 Beacon Community Cooperative Agrmt. Program HHS-2010-ONC-BC-004
                                                                                                                                                        Outcomes and Measures Capture Tool


Usage Instructions


Please use the table below to record community objectives. Each field should be completed. To enter an objective please begin by clicking on first empty row (ID=1), and selecting from
the dropdown provided or by entering text as needed. Clicking on the column headings will show a brief reminder of the defintion of the field. Full defintions and examples can be
accessed on the definitions tab or by clicking on the link below. Please note that entries into the date columns are limited to 4/1/2010 to 12/31/2013
         Go to Defintions




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  1   Cost                                                              Reduce total costs per patient related to healthcare utlization                                                                     4/1/2010        3/31/2013
  2   Cost                                                      Reduce ED /hostpital visits                                                                                                                 4/1/2010        3/31/2013
  3   Quality                                                   Improve Patient reported functional status                                                                                                  4/1/2010        3/31/2013
  4   Quality                                                   Improve Disease metrics through adherence to treatment plan                                                                                 4/1/2010        3/31/2013
  5   Population Health                                         Increase Asthma Action Plan (AAP) availability                                                                                              4/1/2010        3/31/2013
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                                                                                                                                                             ARRA 2009 Beacon Community Cooperative Agrmt. Program HHS-2010-ONC-BC-004
                                                                                                                                                                                 Outcomes and Measures Capture Tool


Usage Instructions


Please use the table below to record Measured Outcomes. Each field should be completed. To record an outcome please begin by clicking on first empty row (ID=1), and select from the dropdown provided or by entering text as
needed. Clicking on the column headings will show a brief reminder of the defintion of the field. Full defintions and examples can be accessed on the definitions tab or by clicking on the link below. Related objectives may be
selected by using the drop down by pressing the arrow appearing to the right of the cell when the cell is selected. To select multiple objectives, select each objective from the drop down one by one. Each new objective selected
will be automatically appended to the list. To delete, simply select the cell and press 'delete' on your keyboard.
         Go to Defintions




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  1   Reduce Healthcare costs/patient                                                                                Diabetes                                   Adults [Age 21-75]                                               22800    TTLCost-DM                       Yearly               Payer Claims Data               TBD                                             1
  2   Reduce Healthcare costs/patient                                                                                Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    TTLCost-ASA                      Yearly               Payer Claims Data               TBD                                             1
  3   Reduce ED/Hospital visits by 10%                                                                               Diabetes                                   Adults [Age 21-75]                                               22800    ED-DM                            Yearly               EHR                             TBD                                             2
  4   Reduce ED/Hospital visits by 10%                                                                               Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    ED-ASA                           Yearly               EHR                             TBD                                             2
  5   Increase Physical & Emotional Well being scores                                                                Diabetes                                   Adults [Age 21-75]                                               22800    QL-DM                            Quarterly            EHR                             TBD                                             3
  6   Increase Physical & Emotional Well being scores                                                                Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    Asthma APGAR                     Quarterly            EHR                             TBD                *APGAR Attached              3
  7   Decrease # of days absent from school                                                                          Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    NQMC:001616                      Quarterly            SelfReported/SchoolRecord       TBD                                             3
  8   % Diabetic Patients with Blood Pressure <140/90                                                                Diabetes                                   Adults [Age 21-75]                                               22800    NQMC:004243                      Quarterly            EHR                             TBD                                             4
  9   % Diabetic Patients with LDL <130                                                                              Diabetes                                   Adults [Age 21-75]                                               22800    NQMC:000599                      Quarterly            EHR                             TBD                                             4
 10   % Diabetic Patients with HgbA1C > 9mg%                                                                         Diabetes                                   Adults [Age 21-75]                                               22800    NQMC:004236                      Quarterly            EHR                             TBD                *APGAR Attached              4
 11   Decrease poor control outcomes requiring therapy changes (APGAR Score of 3 out of 6)                           Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    Asthma APGAR                     Quarterly            EHR                             TBD                *APGAR Attached              4
 12   Decrease inadequate control outcomes requiring action (APGAR Score of 4+ out of 6)                             Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    Asthma APGAR                     Quarterly            EHR                             TBD                *APGAR Attached              4
 13   Increase the total number of Asthma Action Plans (AAP) updated and on file in schools                          Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    AAP #                            Monthly              EHR                             TBD                                             5
 14   Increase the overall % of students with Asthma condition that have an Asthma Action Plans (AAP) on file.       Asthma                                     Pediatric [School Age ~5-18yrs]                                   5530    AAP %                            Monthly              EHR                             TBD                                             5
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Scoring Patient ASTHMA and linking to algorithm

Interpretation of APGAR score:
a. Score of 2 or 3---Inadequate control requiring action
b. Score 4 or more--Poor control requiring therapy change

Scoring:
A = activities
           Never = 0 1-2 time = 1          3 or more times = 2
P = persistence of symptoms
           Daytime
              None = 0      1-2 days = 1        3 or more days = 2
           Nighttime
              None = 0      1-2 nights = 1       3 or more nights = 2
Simply add the scores for a total of 0 to 6.

All other questions are used to gather information about problems related to control

Case: (an example of training case)

              Score is 2 with 1 for activities and 1 for daytime symptoms.
              No major exacerbations.
              Cigarettes and mold may asthma worse but can usually avoid
              Is taking short acting beta agonist 2 times per day
              Is not taking inhaled steroids except on prn basis
              Does not think the steroids help and short acting beta agonist wears off

Summary from ASTHMA---inadequate control, seems to be avoiding triggers but not adhering to therapy as prescrib

Go to algorithm—
      Address issues of adherence—why not adhering—cost, misunderstanding, fear of steroids, does not likely dail

             Address issues of inhaler technique—is the SABA being delivered?

Decide on changes---agreement to try ICS daily for 3 weeks, SABA—prn using newly learned proper inhaler techniq
t adhering to therapy as prescribed---seems to have them backwards.


 of steroids, does not likely daily medications, other?




ly learned proper inhaler technique, and return visit in 3 weeks for reassessment.

				
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