Day in the life of a primary care for pdr net p pt version 4

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Presentation to Pharm EHR Summit, Philadelphia PA, 4/6/2011

Presentation to Pharm EHR Summit, Philadelphia PA, 4/6/2011

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  • Heartland Health is located in St. Joseph, MO (pop. 80,000) about 50 miles north of Kansas City. Composed of Heartland Regional Medical Center and Heartland Clinic. HRMC is a 300 bed hospital and Heartland Clinic is a combination of 30 clinics employing a little over 100 physicians of all specialties.Heartland Health is the proud recipient of last year’s Malcolm Baldridge National Quality Award.
  • Heartland Clinic of Platte City is one of the 30 Heartland Clinic clinics. It is a free standing clinic located just north of the Kansas City International Airport and 30 miles south of St. Joseph. It faces a totally different environment than other Heartland Clinics in that it is located in a suburb of Kansas City and most patients receive other medical services in 7 different hospitals in the Kansas City area instead of exclusively at HRMC.There 4 physicians (3.5 FTE) 2 Family Practice 1 Pediatric 1 Internal MedicineVarious specialists come down from St. Joseph on most days of the week to have half-day clinics Cardiology Podiatry Surgery Pain Management Endocrinology
  • Typical day involves a wide range of interactions with patients, staff, administration and colleagues. So how have we leveraged technology to help us?
  • First, it can work to simplify the location of information for the physician.We use a single electronic chart for both Inpatient and Outpatient patient recordsTwo sides of the same coinData entered once is immediately available across the entire spectrum of careShare problem lists, medications, labs, registration, everythingHeartland Health has completed certification for HIMSS Analytics Level 6 Award and is just short of achieving Level 7 status putting us in the top 2% of all health care organizations
  • Second: Eliminates paperWe’ve been “paperless” for over 2 years and here’s what’s changed:Dramatically changed the work flows Nurses don’t waste time pulling charts Administrative personnel don’t create paper charts Dramatically simplified and streamlined the process of seeing patientsDo most documentation at the point-of-careWeb portal exposes the chart to the patientIncrease productivity (we see the same number of patients with one less FTE per physician than clinics with paper charts)
  • Pushed work to the point-of-care like most other industriesBy simplifying the documentation work flow and doing it in the exam room in a way the patient can see the documentation being generated has:Decreased training time and effort (everyone using the same tools)Reduced the amount of redundant data entryIncreased the quality and quantity of the data collected during the visitCan be leveraged to increase patient through-put. Our overall cycle time (time from when a patient hits registers to discharge is now 40 minutes with 37 of those minutes spent with a provider instead of in the waiting room)Increases patient satisfactionPreliminary suggestions that it improves patient compliance and understanding
  • Point of care encourages us to continually improve exam-room technology.Are constantly experimenting with improving the point-of-care devices …. Goal is touch enabled living walls that can interact with both providers, patients and equipment … “living” exam rooms.
  • Standardized the patient visit to reduce variability, improve data accuracy and thoroughness and distribute work flow. Still labor intensive compared to what it could be.
  • Fourth, All communications movingas much communication to asynchronous, electronic forms as possible.Reduces interruptions.Improves communications and reduces mistakes.
  • No matter what automation is in place the physician is making a thousand decisions a day … does exhaust the mind.
  • ePrescribing has helped many of these decisions and new electronic features are preventing mistakes, call-backs and delays in patients getting the right medication. Still has room for improvement, though.
  • Having this information in advance helps us look intelligent and provides value added services for the patient
  • Decision support is complicated and, except for a significant chunk of ePrescribing, is still in the “gotcha” phase where a clinician has to make a decision and then get slapped. Negative reinforcer?
  • Interruptions are still the bane of the day and can undermine a well planned day. Technology is helping and we’re seeing a slight glimmer of hope in the horizon.
  • Meaningful use: Where would we be if the Eisenhower Administration had subsidized automobiles instead of putting in the Interstate system?Incentives help but the real value is in the interfaces to labs, pharmacies, hospitals, 3rd party payers, hospitals and other clinics … total cost of that dwarfs the cost of an office EMRNeed to make sure 3rd party payers push enrollees, their historical claims data to physicians … we just don’t know who we need to see and have to do the heavy lifting of de-novo data entry.Spend way too much time documenting minutia and as a result we miss the really important information. Requirements need to be more like they are in the UKOh, and wouldn’t it be nice if there was a unified set of regulations?People will continue to do what brings in the bacon until they can’t do it any more. Change always follows money.
  • Still, most of us are exhausted when we head home …. Only to be called several times during the intervening hours before the next day starts. Day is never really done.


  • 1. Day in the Life of a Primary Care Physician
    Presented by Dr. David Voran, M.D.
    April 6, 2011
    Heartland Clinic
  • 2. 2
    Heartland Health
  • 3. Heartland Clinic of Platte City
    Free standing clinic
    30 miles away from hospital
    Located in suburb of Kansas City
    3.5 physician FTE
    1,000-1,200 visits/moth
    Specialists visit periodically
  • 4. Typical Day
    20-24 patient visits
    Mini meetings
    1-3 procedures
    Exam room operative or diagnostic
    1 meeting
    Staffing, billing, marketing or professional
    20-40 asynchronous messages
    Nurses, patients colleagues
    10-15 interruptions
    Pharmacies, phone calls, detail reps
    So how does technology help?
  • 5. 5
    Single EMR
    Patient List
  • 6. One Place for all Visits
  • 7. Integrated HIE
  • 8. 8
    Ditched Paper … What’s Changed?
    Paper chart pulls
    Eliminated 6-8 hours of work/week/nurse
    Paper chart creation
    Chopped 8 hours of clerical work
    Saved $32 in material cost per patient
    Point-of-care documentation
    Instant access instead of 24-48 hour delay
    Saving $20-$30K per physician per year
    Electronic patient access
    Eliminated 1-2 hours of phone conversations per day
    Quick access to results (36 hours)
  • 9. Point-of-care documentation
    Use flexible templates
    Over 500 that can be combined in unlimited ways
    Most work done with patient at provider’s side
    Increased transparency
    Increased accuracy
    Nurses and Physicians contribute equally
    Information carries forward
    Eliminates redundant documentation
    Improves quantity and quality of clinical information
    Simplifies work flow and training
    Significantly streamlined workflow
  • 10. POC Technology
    Push as much technology to the point of care as possible
    Device is as much for the patient as the provider
    Used as a “window to the world”
    notebook > tablet > standard workstations > expanded large screen workstations > multi-touch wide-screen devices
  • 11. Clinic Visit Interview
    Standardized “SOAP”
    What the patient says
    What we see and measure
    Prescriptions, orders, education and follow up
    Templates provide structure and consistency distribute work to even the patients
  • 12. 12
    Message Center
    All communication in one location
    Incoming Paper converted to digital documents at the door
    Reduced workflow variability
    Can now manage incoming information
  • 13. Decisions, Decisions, Decisions
    What to ask?
    What to examine?
    What to include?
    What to exclude?
    ~40% uncertainty
    What tests to order?
    What to prescribe?
    25 - 50 decisions each visit
    625 - 2,500 a day
  • 14. Prescribing
    ePrescribe – Uses CPOE interface
    Part of the documentation process
    Launched from the template
    Actions rendered as text in the note
    Usually done at the point of care
    Can get outside information before decisions are made
    Can tell which meds are on formulary before ordering
    List of various medications available with generic components
    Shows alternatives
    Dramatically reduces interruptions and increases productive time in the exam room
  • 15. Real Decision Support
  • 16. Have more to do ….
    Pharmacy selection should be smarter
    Many pharmacies identified by number
    Lack of maps
    Entering zip codes don’t help as nearby zip codes not listed
    Product status
    Dither out products that are no longer available
    Indicate relative prices
    Diagnostic orders
    “Gotcha” discern support
    Alert fires AFTER selection
    Should act like formulary notification
    Indicator to AVOID selection
    Lack of condition-based prescription recommendations
    Make a diagnosis > produce a list of orders and medications indicated for this diagnosis
  • 17. InterruptionsThe biggest bane
    Not easy to recover from many of them
    Interruptions are more than lack of timely decision support
    Technology has eliminated more than half
    Patient portal
    Electronic messaging
    Many pharmacies still resorting to telephones and faxes
    Electronic communications preferred
    Good news is that the industry is slowly catching on
    Long way to go
  • 18. About that trip…
    Meaningful Use
    Feds missed the boat
    Should be building highways instead of buying cars
    Very little benefit from the incentives
    Much larger costs are interfacing EMRs to the all of the other systems involved in the care of a person
    However, every little bit helps
    Need to have similar mandates for 3rd party payers
    Too much emphasis on documentation
    Concerned about the leaves instead of the trees
    Should do more to help us manage the forest
    Conflicting mandates between different regulatory branches
    ePrescribe EXCEPT for scheduled medications (What the #I@*?)
    Everyone will still follow the money
    Ride the RVU and fee-for-service wave until it crashes
    Need some reward for those of us that are voluntarily “falling on our swords”
  • 19. At the end of the day