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Application of a Primary Headache Diagnosis

Algorithm to EMR

Marielle Kabbouche, MD, FAHS

Professor of Child Neurology and Headache Medicine

Cincinnati Children’s Hospital Medical Center

Headache Center

Rationale for the algorithm : Standardization

� Variation amongst providers in diagnosing primary HA disorders: • 41% of patients coming to ED were diagnosed with: Non-specific Headache disorder

• 58%: received Migraine Diagnosis

Dr. Vinson et. al: Annal of Emergency Med: 41(1): 90-97.2003

� Variation amongst providers in regards to treatment:• Affects care delivery and cost:

• Physician use of higher resources in the ED was associated with increased LOS and did not reduce return visits to ED

Practice variation such as this may represent an opportunity to improve health care quality and decrease costs!!

Jain Stabnam &al.: Physician practice variation In Pediatric ED and it’s impact on resources use and quality of care : Dec2010, volue26 Issue12: 902-908

Diagnosis Standardization is an essential first step to improve headache treatment, outcomes, as well as

controlling costs!

Measurement: How Success is Defined

Clinical outcomes:

�More then 80% of encounters with appropriate diagnosis of migraines using the ICHD-3 criteria was assigned

�More then 80% of encounters where appropriate imaging and labs were ordered based on diagnosis.

Process outcome:

�More then 80 % of encounters where algorithm was correctly followed

�Process is sustainable

Financial outcome:

�Direct effect: • Less then 20% of patients receiving unnecessary tests & procedures

�Long term effect: • Evaluating cost of HA care in pediatrics (NV vs. FU, chronic vs. intermittent)

• Showing cost control (this may take time)

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% Algorithm Followed

83%

94.10%100%

75%

83.30% 82%

94%

0%

20%

40%

60%

80%

100%

120%

March April June July August September November

Algo followed

4 Pts

New Neuro residents?

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Appropriate Tests Ordered

83%

94.10%100%

87%

100% 100%

90%

0%

20%

40%

60%

80%

100%

120%

March April June July August September November

Appropriate Tests

Correct Diagnosis

72.20%

82.30%

100%

65%

83.30%90% 89.20%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

March April June July August September November

Correct Diagnosis

N:4

Outpatient Headache Evaluation cost :

long term evaluation needed to show cost effectiveness

$462.28

$524.35 $533.00

$660.00

$678.00

$400.00

$450.00

$500.00

$550.00

$600.00

$650.00

$700.00

Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17

Headache Diagnosis

Charge Per Case (OP only)

More Chronic patients seen In

the fall: HA seasonal Disease

Pkalanis &al.: Seasonal variation in ED referral among pediatric headache patients.

Headache Sept2016:56/8:1344-7

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Application of the headache diagnostic algorithm into

EMR ( EPIC )

2 entry points:

1- Patient entry: tablet given at registration with questionnaire. Questions answered are automatically syncing to the patient’s EPIC visit

2- Flowsheet in EPIC visit for that day where provider can review the entry and make changes if necessary when interviewing the patient

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• 1- Full Description of headache with severity mild –moderate to severe, frequency, worsening with exercise, ?waking up from sleep

• 2- Questions about acute treatments, preventive treatments

• 3- frequency of use of acute medications

• 4- PedMIDAS/MIDAS

• 5-Review of system, past medical history, family history

48 Questions for new visit . Takes 10-15 minutes to fill up

•Click on Flowsheets section > "Headache New Visit Questionnaire" or "Headache Follow-up Visit Questionnaire".

Review unvalidated patient answers, make changes to answers as necessary, file flowsheet rows to validate a

Click on Flowsheets section > "Headache New Visit Questionnaire" or "Headache

Follow-up Visit Questionnaire".

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Review unvalidated patient answers: unvalidated patient answers have an icon and are cross hatched.

Make changes to patient answers as necessary:

File flowsheet: When all rows are reviewed and any changes made, hover near the

date/time at top of flowsheet, left-click and select from the drop down "File Selected".

This will highlight all rows and file the flowsheet.

If the information in validated flowsheet rows for the Headache New Visit Questionnaire is

answered according to the headache diagnosis algorithm, alerts may fire to help provide best

practice diagnosis or ordering guidelines. These will vary depending on the patient answers.

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Populate your note with validated flowsheet answers using newly created .neunew (new visit)

and .neufu (follow up visit) headache templates.

Type .neunew (or .neufu)

OR : Select the headache with links version

These templates have been enhanced to populate the note with validated

flowsheet information.

Historical Average charges adjusted to current pricing

3/1/15-2/29/16

Adjusted for Price Increases

Clinic 141.25 $148.83

Labs 557.5 $587.44

Radiology 3030 $3,192.70

Total 3728.75 $3,928.97

Current Average charges

3/1/16-6/30/17

Clinic $153.24

Labs $597.25

Radiology $2,934.25

Total $3,684.74 $3,684.74

Decrease $244.23

% Decrease 6.22%