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Reliant
Medical Group
Atrius Health
iHT2 Health IT Summit, Boston MA
May 14th, 2014
Larry Garber, M.D.
Medical Director fo...
2
 Building the foundation for
transformation
 Efficiency improvements
 Quality improvements
 Safety improvements
 Re...
3
 Medical Director for
Informatics x 16 years
 Principle Investigator
for $3.5M AHRQ and
ONC grants for SAFE
Health and...
4
•300+ provider multi-specialty group practice
•30 specialties, including Occ Med & Behav Med
•23 sites in central Massac...
5
6
 Electronic Health Record
 Patient Engagement Tools (Personal
Health Record, Home monitoring, etc…)
 Health Informati...
7
 Completed rollout in 2007
 100% utilization by all physicians and staff
 Includes the MyChart Personal Health Record...
8
 Prescriptions – 22 years
 Lab Results – 16 years
 Transcribed Visit and Imaging Notes–15 yrs
 Immunizations, Health...
9
10
11
 Patients plug home health monitoring
devices (e.g. BP, weight, sugar, O2, etc…)
into home computer
 Automatically lo...
12
Mckesson &
Patient References
5 Hospitals
and 8 SNFs
CareEverywhere to
Other Sites
Reliant’s EHR &
Data Warehouse
Home ...
13
St. Vincent
Hospital
Reliant Medical
Group’s Epic EHR
Outside
Record Icon
in MedHost
Bedboard
blinks
CCD with
SVH MRN
A...
14
FCHP
Hospitals
Ref
Lab
PBM
Imaging
Centers
Solo
MD’s
Reliant
Medical
Group
15
 FCHP Claims  medication list and fill hx
 FCHP and Fallon Clinic claims/billing:
◦ Immunizations
◦ Health Maintenan...
16
17
Factor Criteria Points
DxCG Likelihood of Hospitalization Score
(Model 71)
Individual Patient Score >= 0.25
(90th Perce...
18
Risk Score Calculated with 2011CY data
Outcome Window = 1st 6 months 2012
19
20
 Have the right person do the work
 Use the right tools
 Re-use data whenever possible
21
In order of preference:
1. The computer (last note, history, results,
keyboard macros)
2. The patient (patient portal o...
22
 Chief Complaint(s)
 Allergies/Medications (including OTC)
 Preferred Pharmacy
 Pends medications that need renewal...
23
© 2014 Epic Systems Corporation
Decision Support built into documentation:
Payer/visit/patient-specific template
24© 2014 Epic Systems Corporation 24
25
Where do you start?
© 2014 Epic Systems Corporation
26
27© 2014 Epic Systems Corporation
28© 2014 Epic Systems Corporation
Automatically
Populates
29© 2014 Epic Systems Corporation
30
10 – 12% of Radiology orders at
Reliant were ordered incorrectly
and required changing
31© 2014 Epic Systems Corporation
32
33
34
35
 The total economic burden of diabetes
in the United States is estimated at
$245 billion, a 41% increase from 20071
 ...
36
No Clinical
Decision
Support
No change
with the
EHR!
37
 EHR guidelines automatically suggest testing
based on age, gender, diagnoses, meds,
smoking history, and existing ord...
38
Last date Next order
But doesn’t ask for an order if it’s not due or
already ordered
© 2014 Epic Systems Corporation
39
Barometer of
Actionable
Deficiencies
40
4141
4242
43
 Hypertension Control was 69%,
significantly below 90th Percentile of
73% for nation
44
45
 Graph of BP readings revealed peaks
every 10 mmHg
 Staff were rounding up to the next higher
multiple of 10
 Abnorm...
46
 Digital Cuffs
 Real-time alerts for abnormal readings
 Monitoring compliance with repeating
abnormals
 Nurse Blood...
47
48
49
50
Reliant had two patients where lung
nodules were incidentally found on
abdominal CT scans at other
institutions for div...
51© 2014 Epic Systems Corporation
52© 2014 Epic Systems Corporation
53
 More than 1200 patients currently
tracked in Pulmonary Nodule Registry
 Certified reminder letters for overdue
patie...
54
• 90,000 preventable life-threatening
or fatal ADEs in the elderly yearly
nationwide
• Warfarin is the most common caus...
55
 3 Days after hospital discharge,
medication claims data are reviewed
along with past and future labs
 Alerts sent to...
56© 2014 Epic Systems Corporation
57© 2014 Epic Systems Corporation
58© 2014 Epic Systems Corporation
59
 Automatically generated
 Automatically sent to Anticoag Clinic
InBasket
 Anticoag clinic makes sure follow-up INR
o...
60
 IVR calls to remind patients of upcoming
lab tests just prior to “expected date”
 Alerts when patient calls or is se...
6161
62
63
64
65
Avg. Massachusetts FFS: $13,000+
Avg. Massachusetts ACO: $12,000+
Atrius Health ACO: $10,700
Annual Cost Per Patient (A...
66
With thoughtful use of the
EHR, HIEs, clinical
decision support, and
analytics, you can
improve the quality,
outcomes, ...
67
Lawrence.Garber@ReliantMedicalGroup.org
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Health IT Summit Boston 2014 – Case Study “Beyond MU Stage 2: Maximizing the value of your HER” with Larry Garber, Medical Director of Informatics, Reliant Medical Group

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Health IT Summit Boston 2014 – Case Study “Beyond MU Stage 2: Maximizing the value of your HER” with Larry Garber, Medical Director of Informatics, Reliant Medical Group

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Health IT Summit Boston 2014 – Case Study “Beyond MU Stage 2: Maximizing the value of your HER” with Larry Garber, Medical Director of Informatics, Reliant Medical Group

  1. 1. Reliant Medical Group Atrius Health iHT2 Health IT Summit, Boston MA May 14th, 2014 Larry Garber, M.D. Medical Director for Informatics Reliant Medical Group/SAFEHealth
  2. 2. 2  Building the foundation for transformation  Efficiency improvements  Quality improvements  Safety improvements  Return on investment
  3. 3. 3  Medical Director for Informatics x 16 years  Principle Investigator for $3.5M AHRQ and ONC grants for SAFE Health and IMPACT HIEs in Massachusetts  Chair, MAeHC  Member ONC HIT Policy Committee’s HIE Workgroup and Privacy & Security Tiger Team, and MA HIT Council  Internist at Reliant (AKA Fallon Clinic) x 28 yrs
  4. 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, member of Atrius Health & ACO •At financial risk for 80% of our patients •Winner of HIMSS Davies Award for implementing HIMSS Stage 7 EHR 4
  5. 5. 5
  6. 6. 6  Electronic Health Record  Patient Engagement Tools (Personal Health Record, Home monitoring, etc…)  Health Information Exchange  Clinical Decision Support  Healthcare Analytics and Reporting Tools
  7. 7. 7  Completed rollout in 2007  100% utilization by all physicians and staff  Includes the MyChart Personal Health Record for patient engagement
  8. 8. 8  Prescriptions – 22 years  Lab Results – 16 years  Transcribed Visit and Imaging Notes–15 yrs  Immunizations, Health Maintenance, Disease Management – 15 years  EKGs (MUSE) – 15 years  Allergies – 10 years  Future Lab and Visit appointments – 1 year Over 100 Million Records Preloaded into EHR
  9. 9. 9
  10. 10. 10
  11. 11. 11  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 © 2014 Epic Systems Corporation
  12. 12. 12 Mckesson & Patient References 5 Hospitals and 8 SNFs CareEverywhere to Other Sites Reliant’s EHR & Data Warehouse Home Health Agency Patients Ancillaries (Surescripts, QS1, Quest Lab, MUSE EKG, Infinitt PACs + Powerscribe) 4 Payers Health Coach Disease Management Registry Vignette Document Imaging to Community MDs MA DPH Immunization Registry Transcription and Dragon Clinician References, Intranet CCDs Appt Reminder IVR Clark Mailing Service
  13. 13. 13 St. Vincent Hospital Reliant Medical Group’s Epic EHR Outside Record Icon in MedHost Bedboard blinks CCD with SVH MRN ADT for Reliant Patients CCD with SVH MRN 30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR
  14. 14. 14 FCHP Hospitals Ref Lab PBM Imaging Centers Solo MD’s Reliant Medical Group
  15. 15. 15  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)
  16. 16. 16
  17. 17. 17 Factor Criteria Points DxCG Likelihood of Hospitalization Score (Model 71) Individual Patient Score >= 0.25 (90th Percentile) 3 Hospital Admissions or ED Visits Three or More in past 12m 3 Behavioral Health (Psychiatric, Substance Abuse, Dementia) Active Diagnosis (Enc or Prob List) 2 CHF or COPD or CKD Active Diagnosis (Enc or Prob List) 1 Poly-pharmacy (Exclude topical & supplies) 14+ active medications on current EPIC medication list 1 Maximum Score 10 Risk Level Flag Score % Total Low 0 58% Medium 1 - 2 26% High 3 – 7 13% Very High 8 - 10 2%
  18. 18. 18 Risk Score Calculated with 2011CY data Outcome Window = 1st 6 months 2012
  19. 19. 19
  20. 20. 20  Have the right person do the work  Use the right tools  Re-use data whenever possible
  21. 21. 21 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
  22. 22. 22  Chief Complaint(s)  Allergies/Medications (including OTC)  Preferred Pharmacy  Pends medications that need renewals  Full Social and Family History  Vital signs  Rooming note  Loads MD’s note template & pastes last CPE  Review of Systems and Health Risk
  23. 23. 23 © 2014 Epic Systems Corporation Decision Support built into documentation: Payer/visit/patient-specific template
  24. 24. 24© 2014 Epic Systems Corporation 24
  25. 25. 25 Where do you start? © 2014 Epic Systems Corporation
  26. 26. 26
  27. 27. 27© 2014 Epic Systems Corporation
  28. 28. 28© 2014 Epic Systems Corporation Automatically Populates
  29. 29. 29© 2014 Epic Systems Corporation
  30. 30. 30 10 – 12% of Radiology orders at Reliant were ordered incorrectly and required changing
  31. 31. 31© 2014 Epic Systems Corporation
  32. 32. 32
  33. 33. 33
  34. 34. 34
  35. 35. 35  The total economic burden of diabetes in the United States is estimated at $245 billion, a 41% increase from 20071  Reliant’s Diabetes HbA1c Screening Rate and Control Rate did not change significantly with EHR implementation 1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. 2014;36(4):1033–1046.
  36. 36. 36 No Clinical Decision Support No change with the EHR!
  37. 37. 37  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 © 2014 Epic Systems Corporation
  38. 38. 38 Last date Next order But doesn’t ask for an order if it’s not due or already ordered © 2014 Epic Systems Corporation
  39. 39. 39 Barometer of Actionable Deficiencies
  40. 40. 40
  41. 41. 4141
  42. 42. 4242
  43. 43. 43  Hypertension Control was 69%, significantly below 90th Percentile of 73% for nation
  44. 44. 44
  45. 45. 45  Graph of BP readings revealed peaks every 10 mmHg  Staff were rounding up to the next higher multiple of 10  Abnormal readings were not rechecked
  46. 46. 46  Digital Cuffs  Real-time alerts for abnormal readings  Monitoring compliance with repeating abnormals  Nurse Blood Pressure Clinics  Pharmacist review of patients with poor BP control and diabetics not on ACE/ARB  Report cards showing site-specific performance
  47. 47. 47
  48. 48. 48
  49. 49. 49
  50. 50. 50 Reliant had two patients where lung nodules were incidentally found on abdominal CT scans at other institutions for diverticulitis and appendicitis, and were not followed- up until metastatic cancer was diagnosed 1-2 years later
  51. 51. 51© 2014 Epic Systems Corporation
  52. 52. 52© 2014 Epic Systems Corporation
  53. 53. 53  More than 1200 patients currently tracked in Pulmonary Nodule Registry  Certified reminder letters for overdue patients, those that refuse testing, and patients who leave our network  No patients with follow-up failures in 4 years
  54. 54. 54 • 90,000 preventable life-threatening or fatal ADEs in the elderly yearly nationwide • Warfarin is the most common cause of preventable life-threatening or fatal ADEs • 1.4% of Reliant’s levels overly thin (Gurwitz JH, Garber LD, Bates DW, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289:1107-1116. 2003.)
  55. 55. 55  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
  56. 56. 56© 2014 Epic Systems Corporation
  57. 57. 57© 2014 Epic Systems Corporation
  58. 58. 58© 2014 Epic Systems Corporation
  59. 59. 59  Automatically generated  Automatically sent to Anticoag Clinic InBasket  Anticoag clinic makes sure follow-up INR ordered © 2014 Epic Systems Corporation
  60. 60. 60  IVR calls to remind patients of upcoming lab tests just prior to “expected date”  Alerts when patient calls or is seen that they have overdue labs that have been ordered already  Letters to patients who no-show labs ◦ If 25% overdue (e.g. 1 month late on a 4 month f/u or 3 months late on a 1 year f/u) ◦ Letter automatically sent to patient from EHR
  61. 61. 6161
  62. 62. 62
  63. 63. 63
  64. 64. 64
  65. 65. 65 Avg. Massachusetts FFS: $13,000+ Avg. Massachusetts ACO: $12,000+ Atrius Health ACO: $10,700 Annual Cost Per Patient (Age 65+) (12 months ending March 2014) © 2014 Atrius Health, Inc. All rights reserved.
  66. 66. 66 With thoughtful use of the EHR, HIEs, clinical decision support, and analytics, you can improve the quality, outcomes, safety, and efficiency of healthcare delivery
  67. 67. 67 Lawrence.Garber@ReliantMedicalGroup.org

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