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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

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

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