Jackson County Health Department

March 2019

Our activities in March included receiving and responding to 11 pregnant women referrals, continuing to reach out to additional OB/GYN practices, and resolving IT related issues.

10 internal referrals were generated from within health department programs to our lead case management visiting nurses.  One external referral was received from an EPIC EMR based practice.  Nurses followed up on all of these referrals, offering to complete the lead risk exposure assessment questionnaire.  Based on assessment results, at least two women consented to follow up with blood lead testing.  In both cases, the lead level was below 2 ug/Dl.  No further action is indicated at this level.

Jackson Health Network provider transformation specialists are continuing to educate both Epic EMR health system OB/GYN practices and independent OB/GYN practices not using the EMR on the referral opportunity and process.  One practice has communicated their desire to use their own EMR to make direct messaging referrals to the EPIC EMR to our medical director.  The details on how to accomplish this are in process.  Because other practices may not use an EMR at all, JCHD created a referral form that has been distributed to these practices in the hopes that a paper fax based referral can be completed.  That referral form is attached fyi.

One EPIC EMR based practice has reported making many referrals on virtually all of their pregnant women, but only one has been received to date.  We are engaged with Jackson Community Medical Record to identify and resolve the IT related issue in that office.

The current project director will transition out of the Jackson County Health Department mid-May 2019 to retirement.  A new project director  will be designated within egrams for the remainder of the project through the end of August 2019.  Richard Thoune will be available to report out to the CLEEC in early May on the project.

This report covers activities for the month of December 2018.

Demo:  Lead risk assessment questions have been moved and a template questionnaire developed.   The desired questions developed by the Health Department were shared with JCMR on 12/7.

Referrals by MAs to JCHD will go to Dr. Foust as medical director and be in his work que.  The system will default to making these referrals to Dr. Foust as provider at JCHD.  Permission to complete the referral to JCHD by the MA takes place in the referral function with a yes or no answer.

It will be helpful to develop a smartset phrase that JCHD RNs can access and use for charting/referral follow up purposes.

Educational Flyers:  Some problems have been encountered with uploading these documents into Epic and readability.  The JCHD developed flyer is available in MS Word format if it is helpful to have it in that form.  PDF form has been shared.  JCMR will continue to determine how, in what form, and where they can be placed and accessed for printing.  Tool kits for providers have been ordered from MDHHS and we will place these flyers in these kits for distribution also to appropriate provider offices.

Practice Education/Orientation/Training:  Superuser training is scheduled at the end of January and this project will be incorporated/included in that training event.  JCHD developed and shared a pre-operational education piece that can be used to alert and educate providers before the educational effort is launched.  JHN and JCMR to work together to fine tune content for this purpose.  January 2nd and 9th weekly Epic updates can contain this content.  A tip sheet with screen shots will be developed for January 9th.  Laurie Lewis will connect with JCHD RN staff to provide training and orientation for accessing the work que, note/visit charting, completion of the template questionnaire, lab work order entry and smartset development.

Going Live:  A go live date of January 14, 2019 is selected as this date.  Quarterly steering committee meetings will continue to be scheduled and held through 2019. 

This report covers activities for the month of November 2018.

Things moving a little slowly with the build out effort.  JCHD has been seeking a second demo of the EMR build since the earlier one we had in October, but could not get one scheduled now until December 7th.  Hoping we can get implementation going in January. 

This report covers activities for the month of September 2018.

• Positive urine tests for pregnancy can’t be built into the EMR to trigger the best practice advisory (BPA).  However, as long as all Medical Assistants are taught to complete the OB/GYN portion of vital signs at each visit, we would capture pregnancy status and the BPA would then be activated.
   
• Wording of BPA:  We settled on – “Advise all pregnant women to be screened for lead risk”.  A quick link to a one page or less document that provides an explanation for the screening will be built (into the BPA?) and available for print for patient education.  Staff will develop or provide a document for this purpose.  Other program eligibilities can be communicated to the patient by telephone once a referral to the health department takes place.  There may be some concerns about this work/workflow being within the scope of practice for MAs. 
   
• The JCHD pool to whom referrals will be made in the EMR in basket will consist of two registered nurses.
   
• The template for completing the lead risk assessment in EPIC has not yet been completed. Expected to be completed this week.
   
• Jackson Community Medical Record has responsibility for Core and Community Connect sites and would capture screen shots and provide training of medical practice staffs, with support from JHN Provider Servicing Specialists.
   
• Request the build team schedule another demo when these changes/additions have been completed, within the month of October. 
   
• JCHD staff shared copies of recently issued policies from MDHHS’ Epidemiology and Population Health Division on dissemination of individual blood lead test results.  MDHHS will continue to consider any test result of 4.5 – 4.9 to represent an EBLL for children under six years of age and will round up to 5.  This is based on a CDC Advisory Committee on Childhood Lead Poisoning Prevention recommendation.    Because this approach will create confusion between patients, JCHD, and health care provider messages, JCHD will continue to look up actual lead testing results from WIC testing logs, MCIR, MIWIC and EPIC to identify the actual tested result versus using a rounding result of 5 from state provided systems before initiating reach out for case management services with families. 

This report covers activities for the month of July 2018.

• Identify relevant ICD 10 diagnosis codes.  The JCMR build team indicates that the most efficient way to quickly identify a pregnant woman for referral purposes is to capture her status in the vitals status section of the EMR.  Pregnant status would be identified as a result of a point of care urine test in a practice or through a laboratory ordered blood test.  Clarification is being obtained regarding whether a positive urine test result is accepted as pregnant for recording in the vitals status section versus a blood test.  Dr. Foust will consult with his practice partners on this item.  Point of care tests are entered by medical assistants and entering a positive test would need to generate a pop up window within EPIC rules that results in a consent based referral to the Health Department.  Laboratory ordered blood tests are not ordered by medical assistants and they would never see them or the result.  A way to crosslink positive blood tests recorded in the lab module to the pop up consent needs to be developed.  This functionality is intended to be present in family medicine and OB/GYN practices in the community using EPIC.  Non-EPIC user practices will be addressed in at a later point in time.
  
  Update:  Dr. Foust has confirmed that providers consider a urine test at point of care with order entry to be confirmation of pregnancy.  Some providers may also accept a home pregnancy test result.  He anticipated that an ordered blood test for pregnancy would be the exception and not the rule.  Therefore, cross linking positive blood tests in the lab module to the pop up consent does not appear to be necessary.  Cross linking should take place with a POC urine test order result.
   
• Obtain and share lead risk assessment tools used by others.  JCHD had responsibility to complete this item.  Three sourced resources were used to build a draft questionnaire.  Illinois Department of Public Health, Minnesota Department of Health, and ACOG.  The Health Officer cross referenced all three and pulled content not contained in one or more tools into one combined tool.  That draft tool is attached.  As discussed in the Project Steering Committee on 8/3/18, some minor small edits to the questionnaire will be completed and then submitted to the build team.  The decision was made that the questionnaire will be entered into EPIC as a template and completed by the Health Department through the referral process, avoiding an additional burden on already busy practices.
  
  Update:  Build of the template is nearly complete.
   
• Map the desired lead risk assessment, testing and referral process.  The JCMR Build Team will demonstrate this mapping through a scheduled demo in the near future.
  
  Update:  Demo to be scheduled in September/October with key staff.
   
• Scope and define tasks necessary to place a best practice alert/advisory and lead risk assessment template in EPIC.  As described above, the vital status section will be used to record pregnant status for women.  JCMR is no longer pursuing creation of a best practice alert/advisory for this purpose.  JCMR will use the lead exposure risk screening questionnaire for template purposes.  Responses to the questions will be recorded and saved in EPIC.
   
• Develop mock up BPA and lead risk assessment template.  The build team has moved away from the best practice alert/advisory approach.  The addition of the template will be reviewed through a scheduled demo.
   
• Build referral order in EPIC.  Good progress is being made in development of the pop up consent window for referral.  It will also be demonstrated.
   
• Determine where to place patient consent for referral. 
   
• Build record of patient consent for referral.  After a positive test is recorded, EPIC rule notifies the medical assistant of eligibility for referral to the Health Department.  The window will contain a box that can be checked to record consent.  While this consent could be included in an after visit summary (AVS) normally printed out for each patient visit, it was not viewed as critical to include it in the AVS. 
   
• Review, refine, and approve BPA and template build.  The build team will obtain any approvals required through the submission of a local enhancement request.  The vital status section changes and template will be placed into the service system next week for approval.
  
  Update:  The build is almost complete.  The alert has been created and the referral SmartSet/SmartGroup will appear for Jackson County practices.   Working to tie up just a few small details and configure the referral workqueue so that the referrals are routed to the correct pool.

July 2018

• Identify relevant ICD 10 diagnosis codes.  The JCMR build team indicates that the most efficient way to quickly identify a pregnant woman for referral purposes is to capture her status in the vitals status section of the EMR.  Pregnant status would be identified as a result of a point of care urine test in a practice or through a laboratory ordered blood test.  Clarification is being obtained regarding whether a positive urine test result is accepted as pregnant for recording in the vitals status section versus a blood test.  Dr. Foust will consult with his practice partners on this item.  Point of care tests are entered by medical assistants and entering a positive test would need to generate a pop up window within EPIC rules that results in a consent based referral to the Health Department.  Laboratory ordered blood tests are not ordered by medical assistants and they would never see them or the result.  A way to crosslink positive blood tests recorded in the lab module to the pop up consent needs to be developed.  This functionality is intended to be present in family medicine and OB/GYN practices in the community using EPIC.  Non-EPIC user practices will be addressed in at a later point in time.

• Obtain and share lead risk assessment tools used by others.  JCHD had responsibility to complete this item.  Three sourced resources were used to build a draft questionnaire.  Illinois Department of Public Health, Minnesota Department of Health, and ACOG.  The Health Officer cross referenced all three and pulled content not contained in one or more tools into one combined tool.  That draft tool is attached.  As discussed in the Project Steering Committee on 8/3/18, some minor small edits to the questionnaire will be completed and then submitted to the build team.  The decision was made that the questionnaire will be entered into EPIC as a template and completed by the Health Department through the referral process, avoiding an additional burden on already busy practices.   

• Map the desired lead risk assessment, testing and referral process.  The JCMR Build Team will demonstrate this mapping through a scheduled demo in the near future.

• Scope and define tasks necessary to place a best practice alert/advisory and lead risk assessment template in EPIC.  As described above, the vital status section will be used to record pregnant status for women.  JCMR is no longer pursuing creation of a best practice alert/advisory for this purpose.  JCMR will use the lead exposure risk screening questionnaire for template purposes.  Responses to the questions will be recorded and saved in EPIC.

• Develop mock up BPA and lead risk assessment template.  The build team has moved away from the best practice alert/advisory approach.  The addition of the template will be reviewed through a scheduled demo.

• Build referral order in EPIC.  Good progress is being made in development of the pop up consent window for referral.  It will also be demonstrated.

• Determine where to place patient consent for referral. 
• Build record of patient consent for referral.  After a positive test is recorded, EPIC rule notifies the medical assistant of eligibility for referral to the Health Department.  The window will contain a box that can be checked to record consent.  While this consent could be included in an after visit summary (AVS) normally printed out for each patient visit, it was not viewed as critical to include it in the AVS. 

• Review, refine, and approve BPA and template build.  The build team will obtain any approvals required through the submission of a local enhancement request.  The vital status section changes and template will be placed into the service system next week for approval.