iHT2 Health IT Summit Boston 2013 – Larry Garber, Medical Director, Reliant Medical Group Case Study: "Maximizing the Value of an EHR: Beyond Meaningful Use Stage 1"
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iHT2 Health IT Summit Boston – Larry Garber, Medical Director, Reliant Medical Group Case Study: "Maximizing the Value of an EHR: Beyond Meaningful Use Stage 1" This session will provide the opportunity to explore how Reliant Medical Group began their journey into EHR and now, after receiving the 2011 HIMSS Ambulatory Davies Award, what it is they have done to capitalize on the EHR. Medical Director for Informatics, Larry Garber, MD stands behind belief that “The EHR enables patients to be more engaged in their health through improved communication with the provider team. The EHR also triggers alerts and automates processes to maintain consistent testing, education and follow up with the providers and patients to ensure higher quality, safer and more efficient care with better outcomes.” This presentation will share with the audience what Reliant Medical Group has done, and is continuing to do, that allows them to maximize the value of the EHR Learning Objectives: ∙ Understand how Reliant Medical Group effectively implemented the EHR ∙ Develop a deeper understanding of the various ways to best utilize EHR services ∙ Analyze both the pros and cons of implementing and using EHR
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iHT2 Health IT Summit Boston 2013 – Larry Garber, Medical Director, Reliant Medical Group Case Study: "Maximizing the Value of an EHR: Beyond Meaningful Use Stage 1"
- 1. Reliant Medical Group Atrius Health iHT2 Health IT Summit, Boston MA May 7th , 2013 Larry Garber, M.D. Medical Director for Informatics Reliant Medical Group/SAFEHealth
- 2. 2 Facilitating change Building the foundation for transformation Quality improvements Safety improvements Efficiency improvements Return on investment
- 3. 3 Medical Director for Informatics x 15 years Principle Investigator for $3.5M AHRQ and ONC grants for SAFE Health and IMPACT HIEs in Massachusetts Acting Chair, MAeHC Member ONC HIT Policy Committee’s HIE Workgroup and MA HIT Council Internist at Reliant (AKA Fallon Clinic) x 27 yrs
- 4. 4 •300+ provider multi-specialty group practice •30 specialties, including Occ Med & Behav Med •23 sites in central Massachusetts •200,000 patients with over 1 Million visits/year •Not affiliated with any hospitals •Not-for-profit •At financial risk for 70% of our patients •Member of Atrius Health
- 5. 5
- 6. 6 Successful HIT implementations need to: Provide value (Benefits > Cost) Fit into real-world workflows Earn the trust of the stakeholders
- 7. 7 Determine need for, and benefits of, EHR at all levels of the organization ◦ 17 site meeting with >half of MD’s + staff ◦ 7 Town Meetings attended by 25% organization ◦ Identified: 127 issues with paper-based records 100 benefits of an EHR 140 functional requirements for an EHR ◦ Management team (COO/CIO/CMIO/CFO/CHRO etc…) enumerated financial benefits
- 8. 8 Align incentives ◦ Food/beverages at all training classes ◦ CME/CEU credits for all training classes ◦ MD financial compensation for drop in productivity during go-live Frequently communicate EHR benefits to all users/stakeholders
- 9. 9 Listen to users/stakeholders!!! ◦ Make it easy for users to provide feedback ◦ Actively solicit feedback ◦ Remember that user complaints are typically opportunities to improve EHR Set reasonable expectations Deliver promptly on promises Market how much better your EHR is than others
- 10. 10
- 11. 11 3 Physicians 2 Nurses 1 Medical Assistant All were trained to become Epic-certified analysts Were able to envision and build clinically- useful and usable tools into EHR
- 12. 12 75-85% of an EHR project cost is fixed, largely independent of your software vendor ◦ PC Workstations, Servers, Networks ◦ Database licenses ◦ Other systems (e.g. Document Imaging) ◦ Interfaces/mapping/vocabularies ◦ Workflow analysis and system/template build ◦ Training/Support ◦ Drop in productivity/revenue Cheapest to most expensive EHR vendor will only change total cost by 5-10%
- 13. 13 Focus on desired outcomes Take a system-wide perspective, but remember specialty-specific needs Identify current state and rationale Eliminate waste (Do value stream mapping) Define/document future workflows Identify metrics for success Monitor metrics and solicit feedback Continually improve workflows Update policies and procedures
- 14. 14
- 15. 15
- 16. 16 Manual Abstraction by dedicated team ◦ Allergies ◦ Family History ◦ Growth chart data ◦ Problem Lists Document Imaging (scanning/indexing) ◦ Patient Level (10 types, e.g. Advance Directive) ◦ Visit Level (20 types, e.g. Outside consults) ◦ Procedure Level (150 types, e.g. MRI of Breast) Electronic (from legacy repository)
- 17. 17 Prescriptions – 22 years Lab Results – 16 years Transcribed Visit and Imaging Notes–15 yrs Immunizations, Health Maintenance, Disease Management – 15 years EKGs – 15 years Allergies – 10 years Future Lab and Visit appointments – 1 year Over 100 Million Records Preloaded into EHR
- 18. 18 1. Practice Management (Registration/Scheduling/Billing) 2. Clinical Results Repository 3. Paperless Telephone Messaging and Prescribing 4. Computerized Physician Order Entry/Documentation/Billing in Exam Room 6 month gap between phases 2-3-4 gave time for users to become proficient
- 19. 19 Recent college gradstrainersoptimizers Mandatory just-in-time hands-on training Mandatory dress rehearsal Go-live support by trainers for 2 weeks All-staff site meetings for open dialog Documentation summits – best practices Ongoing optimization ◦ 1:1 observation, plus remote into exam room ◦ Live lunches – demo best practices to “raise tide” ◦ Configure preferences/documentation tools
- 20. 20
- 21. 21 Completed rollout in 2007 100% utilization by all physicians and staff Includes the MyChart Personal Health Record for patient engagement
- 22. 22 22 5 Hospitals 25 Nursing Facilities Reliant’s PCPs & Specialists EHR & Data Warehouse 1 Home Health Agency 30K Patients Ancillaries (Rx/Lab/Rad…) 4 Payers MAeHC Quality Data Center
- 23. 23 Health Information Exchange (HIE) Live in Central Massachusetts since 2009 Patients give “opt-in” consent to exchange clinical data only between specific organizations where patient receives care No central clinical repository. Data flows from EHR to EHR. Sustainability is enabled by low operating expenses resulting from internally developed software and no RHIO
- 24. 24 Patients plug home health monitoring devices (e.g. BP, weight, sugar, O2, etc…) into home computer Automatically loads into Epic EHR via Microsoft HealthVault Batches readings, but sends critical ones © 2013 Epic Systems Corporation
- 26. 26 FCHP Claims medication list and fill hx FCHP and Fallon Clinic claims/billing: ◦ Immunizations ◦ Health Maintenance Dates (e.g. Mammo, Colonoscopy, CPE, etc…) ◦ Disease Management Dates (e.g. HA1c, Retinal Exam, Smoking status, etc…) ◦ Past Medical Hx (filtered for chronic & signif. dxs) ◦ Past Surgical Hx (filtered for significant procedures) ◦ Visit Hx (OV, CPE, Consults, ER, Hospital, SNF, LTC)
- 27. 27
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- 29. 29 Just prior to patient visits During patient visits In between patient visits
- 30. 30 EHR guidelines automatically suggest testing based on age, gender, diagnoses, meds, smoking history, and existing orders/results Staff draft orders & physician signs if they agree © 2013 Epic Systems Corporation
- 31. 31 Last date Next order But doesn’t display if it’s not due or already ordered © 2013 Epic Systems Corporation
- 33. 33
- 34. 3434
- 35. 35
- 36. 36 ER and hospital Discharge Notes file into EHR as well as InBasket of PCP and Case manager ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge which also go to physician InBasket
- 37. 37 Hospital ADT monitored for hospital discharges 3 Days later, EHR checks to see if follow-up appointment took place or is scheduled If none, an InBasket message is automatically sent to PCP’s appointment secretary
- 38. 38 3 Days after hospital discharge, medication claims data are reviewed along with past and future labs Alerts sent to PCP’s InBasket suggesting dose checking, monitoring or discontinuation
- 39. 39© 2013 Epic Systems Corporation Automatically Populates
- 40. 40© 2013 Epic Systems Corporation
- 41. 41© 2013 Epic Systems Corporation
- 42. 42© 2013 Epic Systems Corporation
- 43. 43 Automatically generated Automatically sent to Anticoag Clinic InBasket Anticoag clinic makes sure follow-up INR ordered © 2013 Epic Systems Corporation
- 44. 4444
- 45. 45 IVR calls to remind patients of upcoming lab tests just prior to “expected date” Letters to patients who no-show labs ◦ If 25% overdue (e.g. 1 month late on a 4 mth f/u or 3 months late on a 1 year f/u) ◦ Letter automatically sent to patient from EHR
- 46. 4646
- 47. 47© 2013 Epic Systems Corporation
- 48. 48© 2013 Epic Systems Corporation
- 49. 49
- 50. 50© 2013 Epic Systems Corporation
- 51. 51© 2013 Epic Systems Corporation
- 52. 52© 2013 Epic Systems Corporation
- 53. 53 Have the right person do the work Use the right tools Re-use data whenever possible
- 54. 54 In order of preference: 1.The computer (last note, history, results, keyboard macros) 2.The patient (patient portal or forms) 3.The nurse triaging problem on phone 4.The medical assistant that rooms patient 5.The doctor assisted by speech recognition 6.The doctor assisted by transcriptionist 7.The doctor typing 8.A scribe typing
- 55. 55 MA rooms patient and always enters: Chief Complaint(s) Allergies/Medications (including OTC) Preferred Pharmacy Pends medications that need renewals Full Social and Family History Vital signs Rooming note Review of Systems and starts MD’s note
- 56. 56 No Enchilada ◦ MA does their own rooming note ◦ MD does their own note from scratch Half Enchilada ◦ MA loads rooming note + template for MD note ◦ MD does “Make me the author” and finishes note Whole Enchilada ◦ MA loads rooming note + template for MD note ◦ MA copies last physical exam from last CPE ◦ MD does “Make me the author” and finishes note
- 57. 57© 2013 Epic Systems Corporation
- 58. 58© 2013 Epic Systems Corporation
- 59. 5959
- 60. 60
- 61. 61
- 62. 62 © 2013 Epic Systems Corporation
- 63. 63 © 2013 Epic Systems Corporation
- 64. 64 © 2013 Epic Systems Corporation
- 65. 65 Increased Medicare Advantage HCC coding compliance rate over 3 years: 20% 45% 84% with a corresponding revenue increase by >$2 Million/year, shared between payer and Reliant Medical Group
- 66. 66
- 67. 67 Reliant Medical Group’s Medicare Diabetics’ Costs are less than 96% of the best group practices in the nation! Lower Health Care Costs 67
- 68. 68 Clinical Practice Transformations are enabled by properly configured, implemented and optimized EHRs Transformations can involve: ◦ Eliminating steps that are no-longer necessary ◦ Improving steps using EHR's ability to leverage patient and medical information ◦ Shifting work to lower-paid staff with physician-specific preferences ◦ Shifting work to the EHR ◦ Creating new processes that are only possible because of EHRs and HIEs
- 69. 69 EHRs and HIEs truly can improve the quality, safety, and efficiency of healthcare delivery
Editor's Notes
- MAeHC = Massachusetts eHealth Collaborative
- The Three “U’s” of successful HIT: Useful Usable You trust it!
- >MD Champion needs to be paid in order to cut back on their clinical hours, but not too much. You need someone who’s technologically savvy enough to be completely immersed in the details of the project. At the same time, (s)he needs to be clinically respected. >Nurse champion needs to understand the workflows of the staff >In 2001, Fallon Clinic conducted 17 site meetings with almost half of its physicians along with many nurses, medical assistants, and practice managers, identifying 127 challenges with the current delivery of healthcare, including issues such as notes and results being misfiled and the paper medical record not always being available for appointments. During each of these meetings, the physicians and staff spontaneously concluded that an EHR would solve many of those problems. >Continuing the participatory principles used in determining the need for an EHR, over 300 physicians & staff attended seven “town meetings” to discuss the EHR and identify 140 EHR functional requirements. >Healthcare Information Technology Evaluation Committee (HITEC) was a multidisciplinary team of physicians, staff, managers and senior management that identified over 100 hard and soft benefits of an EHR
- The productivity drop was less than expected, and most physicians actually took home more money as a result of this incentive. However, this added compensation did help cover physicians for the additional hours that they put in for training and working after-hours.
- The EHR is something that they should feel good about
- 3 MDs, 2 nurses, 1 MA
- Balancing act between adjusting the workflow to match the EHR functionality vs. modifying the EHR functionality to match the ideal workflow. System-wide perspective is how: What you do impacts others in your apartment What your dept does affects other departments in your organization What your organization does affects other organizations in the healthcare system How everything effects the patient
- This perception is in part due to poor placement of the computer, and perhaps poor etiquette using the computer The Cost of Technology A Piece of My Mind | June 20, 2012 Elizabeth Toll, MD Author Affiliations: Departments of Pediatrics and Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island ( [email_address] ). JAMA . 2012;307(23):2497-2498. doi:10.1001/jama.2012.4946 Acknowledgment : With sincere thanks to Thomas G. Murphy, MD, and Dori B. Murphy, WHNP, for their help in preparing this essay and to A. G., age 7, artist.
- Notice small keyboard, keyboard tray, size of monitor, monitor arm. Mention outlet covers.
- Doesn’t take time away from busy MD’s and staff No juggling paper and EHR charts in exam room Scanned: Handwritten notes (e.g. Pediatric CPEs) Graphical results (e.g. PFTs, audiograms) Outside reports (e.g. consultants, MRIs) MOVE - Make Our Volumes Electronic – mostly MD’s and nurses Images mix seamlessly with electronic results, so you don’t have to look in other places to find things. Consults are further indexed to specialty so they can be found using filters.
- Maximal increments of change that don’t interrupt operations Phases 1 and 2 were Big-bang Phase 2 used to get MDs and staff used to navigating around the system to find things. Phase 3 taught physicians and staff to use all of the components of the EHR, including documentation, ordering/prescribing, as well as messaging. 6 months between phases 3 and 4. This enabled physicians to master these functions in the comfort of their offices without patients looking over their shoulders. “ Big Bang” Pros: Avoid running two parallel systems (especially for Practice Management). Get to the goal quicker, realize the gain sooner. Take the “Pain” all at once and get it done. “ Big Bang” Cons: Support required, personnel and costs. Disruption and impact to the business. No room for error if old system is turned off, conversions and interfaces must be right. Think through contingency, can be hard (if not impossible) to turn back. “ Phased Roll Out” Pros: Allows end users to learn some and build on it. Allows old system to be a fall back while verifying conversions and interfaces (don’t underestimate the difficulty of converting an old EMR). Reduces the support load, limited resources can do limited sites or function at a time. “ Phased Roll Out” Cons: Confusion on which system to use. “ Slow Pain”, “let’s get this over with”, “Why do I have to wait to use…”. Cost of running two systems.
- 96% of Fallon Clinic MDs Achieve Meaningful Use during first 3 months of 2011.
- Notice to MyChart Tethered PHR patients and HealthVault for home monitoring devices MAeHC = Massachusetts eHealth Collaborative
- Federated Edge Proxy-Server Architecture with Consent Engine and EMPI Trusted organization hosts the central EMPI in their data center in order to save money. Just need a Data Use and Reciprocal Support Agreement (DURSA) in order to establish trust and baseline requirements for HIPAA and state regs (e.g. minimal requirements for authenticating users).
- No separate patient consent because this is part of Treatment, Payment and Operations and we are at Financial Risk. Downloads occur weekly It’s the “Poor Man’s HIE”
- PMHx from ICD9 codes PSHx from CPT codes
- 15% drop in productivity Returns to normal after 2 weeks ! Mention the extra hours
- Also reduces ADEs by encouraging monitoring
- Also helps with health maintenance and Disease Management
- produce, on a weekly basis, a report that identifies all patients, with a Fallon Clinic PCP, between the age of 50 to 75 inclusive, who will be having a birthday in the next week and have services for which they are near-due or overdue, but not currently scheduled/ordered. additional exclusionary criteria (nursing home (filter by Nursing Home PCP), hospice status (exclude any pt’s with hospice flag), dementia (see below), receiving chemotherapy, etc...), active Fallon Clinic patient, Alive Also helps with health maintenance and Disease Management
- Note that it wasn’t enough to just implement the EHR. Had to also turn on CDS
- Remember, we don’t own any hospitals.
- Here are all of the strategies for medication monitoring: Reminders for ordering labs related to medication monitoring: o When placing a new order – October 2012 o Pre-CPE – SmartSet directs staff to order the correct lab monitoring for lipid meds, diabetic meds, thyroid meds, seizure meds, and diuretics – (Holden/Westboro/NLA 11/10/2010, May St 1/2/2011, Plant 1/22/11, Auburn 2/23/11, Webster 3/31/11, Millbury/Milford 4/13/11, Spencer 9/24/11) o At time of renewal – Manually since 2006. Automated January 2012 (Westborough pilot, Wed., Jan. 25, 2012; Live at all sites, Wed., Feb. 15, 2012) Reminders to go to the lab for tests that have been ordered: o On After Visit Summary when ordered during that visit – Since 2006 o Automated Telephone reminder – Since 2006 (General reminder when associated with an office visit, which has a brief mention to get lab tests at end), and the specific lab test reminder for non-visit-associated labs on March 8, 2010 o Lab no-show letter – Since October 1, 2008 o BPA Alert during visit that patient should go to lab for labs already ordered – May 5, 2012 o On After Visit Summary if ordered during prior visit – June 1, 2012? o Visible in MyChart with expected date – June 4, 2012
- Here are all of the strategies for medication monitoring: Reminders for ordering labs related to medication monitoring: o When placing a new order – October 2012 o Pre-CPE – SmartSet directs staff to order the correct lab monitoring for lipid meds, diabetic meds, thyroid meds, seizure meds, and diuretics – (Holden/Westboro/NLA 11/10/2010, May St 1/2/2011, Plant 1/22/11, Auburn 2/23/11, Webster 3/31/11, Millbury/Milford 4/13/11, Spencer 9/24/11) o At time of renewal – Manually since 2006. Automated January 2012 (Westborough pilot, Wed., Jan. 25, 2012; Live at all sites, Wed., Feb. 15, 2012) Reminders to go to the lab for tests that have been ordered: o On After Visit Summary when ordered during that visit – Since 2006 o Automated Telephone reminder – Since 2006 (General reminder when associated with an office visit, which has a brief mention to get lab tests at end), and the specific lab test reminder for non-visit-associated labs on March 8, 2010 o Lab no-show letter – Since October 1, 2008 o BPA Alert during visit that patient should go to lab for labs already ordered – May 5, 2012 o On After Visit Summary if ordered during prior visit – June 1, 2012? o Visible in MyChart with expected date – June 4, 2012
- This is when we converted the Anticoag Clinic from paper to Epic
- Includes Cancellations without rebooking.
- Calls are 2 weeks before expected date. Letters are delayed 2-weeks on average due to monthly batching of letters
- Similar to how the Mammogram codes and alert works
- In additions to those above, including prescription refill process
- MAs always update CC/Meds/Allergies/Preferred Pharmacy/Pends Refills/SocialHx/FamilyHx/Vitals/Rooming note
- MAs always update CC/Meds/Allergies/Preferred Pharmacy/Pends Refills/SocialHx/FamilyHx/Vitals/Rooming note
- No unfinished work in MA note. MD starts new note.
- Break-even would have been after 7 years. With MU, break-even was after 6 years.