Engaging Physicians In Information Technology


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Engaging Physicians In Information Technology

  2. 2. Biographical sketch Michael Wagner, MD Mi h l W Dr. Michael Wagner is currently the Chief of General Internal Medicine at Tufts Medical Center in Boston Mass. He has been practicing internal medicine for 19 years as a primary care internist and hospitalist. He p g y p y p received his undergraduate degree from Connecticut College and medical degree from Georgetown University School of Medicine. He completed his residency at Dartmouth-Hitchcock Medical Center in New Hampshire. He is board certified in internal medicine and is a fellow of the American College of Physicians. Dr. Wagner has held numerous appointments, including his current role as the Chief of General Internal Medicine at Tufts Medical Center, CEO of EmCare Inpatient Services in Dallas Texas, Regional Medical Director for Cove Healthcare in La Jolla Ca. and Residency Program Director in Internal Medicine at St. Mary’s Hospital/University of Rochester in Rochester NY. Dr Wagner has focused his career on building and managing effective physician practices in community and academic settings. His has been involved in many IT projects from naval underwater warfare simulation to electronic medical records and large database analysis. Dr. Wagner currently manages the clinical division of General Internal Medicine which provides primary care to 33,000 patients in downtown Boston. The division also has an inpatient/hospitalist program, consultative service and concierge practice. Dr. Wagner is actively involved in teaching medical students and residents. He serves on many hospital committees and task forces including the Institutional Review Board. In addition to his academic work, Dr. Wagner has extensive experience with community based physician practices and hospitals. As the CEO of a national physician practice management company, he built and managed over 60 hospitalist programs in 16 states employing 385 physicians. Today Dr. Wagner will be sharing his experience and insights on achieving physician buy-in for effective IT adoption and engagement. Michael Wagner, 2009
  3. 3. Goals of Session Review the context of primary care practice environement Outline the framework for an IT implementation Lessons learned from an EMR implementation Questions and discussion Michael Wagner, 2009
  4. 4. A little more detail… 4 Disclosures Chief, General Internal Medicine Tufts Medical Center Founding Member, Phoenix Group Biases Clinical – Internal Medicine/Hospitalist Organizational – Academic and community based physician practices i Geography – Northeast, but with national view Goal Leave you with a few insights and methods Outline the transformative nature of IT adoption September 2009 M Wagner MD
  5. 5. Biases - National experience p Review and/or design hospitalist program Work as hospitalist Review and/or design primary care practice 5 Jan 2009 M Wagner MD
  6. 6. CURRENT STATE OF PRIMARY CARE Achieving Physician IT Adoption
  7. 7. Status report – Primary care physicians p y p y Physicians Physicians’ Perspective study Trends on where trainees are going Burdens on primary care Michael Wagner, 2009
  8. 8. Physician – Archetypes y yp
  9. 9. The Physicians’ Perspective: Medical Practice in 2008 Study outline Survey on physician perspectives mailed to: >270,000 primary care physicians 50,000 randomly selected specialty physicians Survey completed and reported in 2008 Sponsored by “The Physician’s Foundation” a non-profit p y y p company promoting physician practices and competed by Merritt Hawkins and Associates Results ~12,000 respondents ~12 000 Margin of error of about 1% The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
  10. 10. The Physicians’ Perspective: Medical Practice in 2008 Morale Physician rated their colleagues morale Positive – 6% Poor o Very Low – 42% oo or Ve y ow % Self rating 78% of physicians said medicine is either “no longer no rewarding” or “less rewarding” Capacity 76% of physicians said they are either at “full capacity” or “overextended and overworked” The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
  11. 11. The Physicians’ Perspective: Medical Practice in 2008 Paperwork p Impact on time spent with patients 63% of doctors said non-clinical paperwork h fd d l l k has caused them to spend less time with their patients Amount of time spent on paperwork 94% said time they devote to non-clinical paperwork in the last three years has increased ki h l h h i d The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
  12. 12. The Physicians’ Perspective: Medical Practice in 2008 Government “Declining i b “D li i reimbursement” highest rated problem and 82% said their practices ” hi h d bl d id h i i would become unsustainable if Medicare cuts are made Reimbursement fails to cover costs Medicaid – 65% of practices Medicare – 36% of practices Closed practices Medicaid – 33% of practices Medicare – 12% of practices Finances Health and profitable? 17% of physicians rated their practices Would you retire? 45% of doctors would retire today if they had financial means fd t ld ti t d th h d fi i l The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
  13. 13. The Physicians’ Perspective: Medical Practice in 2008 Impact on physician workforce An overwhelming majority of physicians – 78% – believe there is a shortage of primary care doctors in the United States today 49% of physicians – more than 150,000 doctors nationwide – said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. p y pp g y 11% said they plan to retire 13% said they plan to seek a job in a non-clinical healthcare setting 20% said they will cut back 10% said th will work part-time id they ill k t ti 60% of doctors would not recommend medicine as a career to young people l The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”
  14. 14. Paperwork p Consult letters Drug warnings Medication substitutions VNA forms Oxygen orders Notifications of PT-1 form reauthorization requirements Prior authorizations Managed care patient lists Refill authorizations Letters from the division chief Misc letters Michael Wagner, 2009
  15. 15. Dissatisfaction with primary care p y 17 Burden Non-visit clinical work without support Administrative paperwork Technology 70 Compensation 60 50 Respect 40 General G l Role models Hospitalist 30 Subspecialty Control 20 Medical school loans 10 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: Internal Medicine In-Training Examination Survey M Wagner MD Jan 2009
  16. 16. Choices 18 Hospitalist Medicine Primary Care Medicine The graduate Michael Wagner, 2009
  17. 17. Choice: Primary Care vs. Hospital Medicine Primary Care IM Hospital Medicine Full time work commitment 18.75 days/month 15 shifts/month Patient encounters per day 20-30 pts per day 15-18 pts per shift Average compensation $150,000-$180,000/yr $180,000-$220,000/yr Overhead Office, staff, equipment, Office staff equipment Billing and medical supplies, billing, medical malpractice malpractice Non-visit clinical work >100 documents/day Minimal Administrative work Prior authorizations Inpatient payment Referrals, FMLA, PT-1, denials Disability forms, etc Panel size 1,500 to 2,500 0 Schedule Monday - Friday On-off for blocks Workday Controlled by schedule Controlled by patient need, nursing, DC time 19 Michael Wagner, 2009
  19. 19. Strategic analysis Strategic Drivers Responses Aging and chronic illness Increasing visit and non-visit burden increase clinical work Shrinking MD workforce Increasing ratio of patients per primary care MD Reduction in health care Application of evidence dollars/patient based care to make quality and utilization more uniform Michael Wagner, 2009 21
  20. 20. Transition Strategic Drivers 1. Aging and chronic illness burden increase analysis 2. 3. Shrinking MD workforce Reduction in health care dollars/patient 22 Accelerants 1.Investment 1 Investment 2.MD workforce 3.Hospital medicine Current state Future state General Internist The New Internist Concerns • Vi it f Visit focus • L d of t Leader f team 1.MD-Patient relationship • Space and staff • Population focus volume focused • Employed in larger • Solo Wildcards organization g 1.Retailization 2.Health Care reform 3.Information technology Michael Wagner, 2009 Wagner 4.Remote monitoring 4R t it i 5.Non-physician providers 6.Organizational acceptance
  21. 21. The patient – physician relationship p p y p 23 Minimal Radiology Anesthesia Episodic What is the value of a continuous relationship between a patient and Consultants physician? Hospitalist Urgent care g ED Continuous Internist Pediatrics Family Medicine Some specialty care p y Michael Wagner, 2009 Jan 2009
  22. 22. Levels of Patient Engagement g g Highly engaged Engaged Engaged with normal prompts Fragmented engagement g g g Disengaged g g Michael Wagner, 2009
  23. 23. Deconstructing Primary Care g y 25 1.Visit and non-visit work 2.Disease/condition care 1.Visit based work management 2.Access is essential 3.Multidisciplinary teams 3.Physical space designed for urgent care 4.Triage and collaboration with ED and hospital for transfers Chronic Urgent Care Care Health Screening 1.Non-visit work is substantial 2.Screening based on accepted guidelines 3.Requires 3 Requires coordination with specific screening services (Mammo, Endo) Michael Wagner, 2009
  24. 24. The New Internist - Role Expert in the care of the medically complex patient p y p p Manages patients with complex medical conditions across the spectrum of healthcare services and over time ti Team player Works in collaboration with a multidisciplinary and integrated team Nursing Social work Home based services Nutrition Michael Wagner, 2009
  25. 25. The New Primary Care Physician – practice structure Physician is part of the multidisciplinary team and is the medical leader Direct patient care Supervision of non-physician providers Clinical guidelines, protocol development Case review Practice is structured to support visit and non-visit clinical work Information technology Integrated EHR, e-prescribing, patient portal Staff For visit work focused on efficient patient flow For non-visit work – phone/electronic staff, case management Space S Practice supports lifestyle needs of providers Continuous professional development program Transfer of care relationships with specialists/hospitals th t provide a hi h l l T f f l ti hi ith i li t /h it l that id higher level of care (applicable to rural and community facilities) Michael Wagner, 2009
  26. 26. An Organizational Approach to Primary C Pi Care Align patients with your healthcare organization through effective primary care practices Create a platform for physician recruitment and retention by offering a stable employment structure. Align compensation program with value based health care Implement an electronic health record that is integrated with other information systems in order to p g y avoid duplication of data entry and facilitate access and transparency Quality integrated into clinical operations with appropriate staffing and support Reorganize staff to manage populations of patients in addition to managing visit based clinical work. Augment with multidisciplinary team members for niche issues such as home bound patients, hospice, etc. Reconfigure space to handle visit and non-visit clinical work non visit Reorganize physician work schedule to account for non-visit work and team participation Negotiate payer contracts to assume greater control over medical budget with appropriate risk/reward Michael Wagner, 2009
  27. 27. Review Primary care is on the cusp of a major change Current workloads and burdens are making the current practice structure non-sustainable In order to create sustainable models for primary care care, organizations or physician groups must rebuild the infrastructure supporting physicians IT can be transformative in this process How d H do you engage physicians t embrace an IT h ii to b implementation in the face of such a negative work environment? Michael Wagner, 2009 29
  29. 29. Components of an IT Implementation p p Providers/ Users Project Plan Operations Technology Michael Wagner, 2009
  30. 30. Technology - IT system invasiveness gy y Highly Invasive • Electronic Medical Records The more invasive the IT system is in terms • CPOE of daily workflow, the more MD engagement will  • Patient portal be needed to successfully implement the system y p y Invasive • Billing / Charge entry g g y • Managed care registries • Clinical information systems Minimally Invasive • Backend dictation systems • Patient scheduling systems • Order entry systems (non-CPOE) Michael Wagner, 2009
  31. 31. Organizational factors g What are the drivers for the IT system? Who is driving the program? Have those who will be effected be engaged? Have the goals of the project been clearly outline, including: What the system is designed to do? What the system is not designed to do or fix? Have resources been appropriately allocated? Michael Wagner, 2009
  32. 32. Organizational - Recheck g What are the intended and unintended consequences of the IT system? Let s Let’s recheck – do we have the right people and resources? Michael Wagner, 2009
  33. 33. Engagement is a state of mind… g g Respect Communication The engagement and attitude of the  Interests leaders/drivers of the IT implementation  leaders/drivers of the IT implementation will set the tone for the project.  A challenge  Concerns for the executive team driving this project will  be to use these qualities listed to the left when  Intelligence I lli interacting with the providers and staff using the  h h d d ff h new IT system. Data Michael Wagner, 2009
  34. 34. The Core Implementation Team p MD Operations Nursing IT Vendor Michael Wagner, 2009
  35. 35. Project p ( ) j plan(ner) Experience and organizational skills matter. Frequent organized meetings with project manager to hold participants feet to the fire. Action plans and minutes. Experience with successful implementation of same program in similar size organization. Good sense of humor humor. Michael Wagner, 2009
  36. 36. Where to find Physician Leadership? y p Michael Wagner, 2009
  37. 37. Physician factors y Role of physician leadership Nurturing future physician leaders Scoping out your doctors Avoid A d Nattering nabobs of negativism Technocrati Disorganization Go for the silent, and usually appreciative, middle Train h T i the trainer model of education i d l f d i Behind the scenes lobbying, education and occasional deals Michael Wagner, 2009
  38. 38. Physician Types y yp Michael Wagner, 2009
  39. 39. Levers for transition What is broken? What will be fixed? What is in it for me? How will this help the practice? How will this help patients? Michael Wagner, 2009
  40. 40. Strategies for Success g Have clear objectives that penetrate clinical work flows Respect existing clinical work flows, but seize on opportunity to re-work and fix what is recognized as broken Listen carefully to physician concerns and incorporate suggestions when feasible – be gracious Focus on the silent majority and build a system that will work for them Provide options and choices. Developing 3-4 well p p g worked out clinical work flows is better than forcing one solution on everyone or keeping the 20 different ways it is done todayy Michael Wagner, 2009
  41. 41. Essential components p Engagement g g Planning that involves all parties Training g Adjusting clinical volumes during implementation Pre-loading data g Train the trainer model and super users Phasingg High touch and presence during GO-LIVE Have Fun! Michael Wagner, 2009
  42. 42. AN EXAMPLE
  43. 43. Tufts Medical Center - GMA Michael Wagner, 2009
  44. 44. The daily bag y g Michael Wagner, 2009
  45. 45. The ask Michael Wagner, 2009
  46. 46. The choice Michael Wagner, 2009
  47. 47. Transition Drivers 1. Risk management analysis 2. 3. 3 4. Drug recalls Reports for Boston Public Health Department R f B P bl H l h D On-call access to patient data 49 Accelerants 1. MD leadership 2. Investment Current state – Future state – Paper based EHR records Concerns 1. MD-Patient relationship 2. Time 3. Productivity Wildcards 4. Computer skills 1. Vendor support 2. IT support 3. Administrative bandwidth 4. MD revolt 5. Patient acceptance 6. Budget hawk Michael Wagner, 2009 Michael Wagner, 2009
  48. 48. Timeline 1999- Realization - practice must have EHR April 2000 – Presentation to system RAC Summer 2000 - Rejection by system RAC Fall 2000 – Project approved under hospital RAC process Late 2000 – Vendor selected – Medicologic “Logician” product Early 2001 – Project planning process begun with weekly and bi-weekly meetings Summer 2001 – Final testing – training begins g g g August 2001 – GO LIVE January 2002 – Physician order entry initiated Michael Wagner, 2009
  49. 49. Implementation team p MD Operations Nursing IT Vendor Michael Wagner, 2009
  50. 50. Functionality y Appointment lookup – passive Note writing – with options Order entry Results reporting Lab Rad Path Medication management Meds Prescriptions (does not meet e-prescribing standard) Phone call management ED and hospital notifications Michael Wagner, 2009
  51. 51. Creating options – Note generation g p g Form  Transcription Quick Text Free form Components Final Note i Fi l N in Electronic Medical Record Michael Wagner, 2009
  52. 52. Paper records p Paper based records Destinations 1. 1 Clinic chart 2. Medical Record 3. Provider copy Office visit Our traditional view of what the output of an office visit has narrowed our concept of a “medical record”. We have tended to focus on the note as the physical structure that must be reproduced in electronic format. Michael Wagner, 2009
  53. 53. EMR – not just a p y note writer j pretty Data repository Destinations • Notes • Patients • Labs / Rads • CHIN/Hub • Phone notes • Hospital(s) • Orders / sets • Registries • Medications • Research • P4P reporting However, an EMR is the foundation of a data repository and p p y practice structure for effective medical management of individual patients and population of patients. Michael Wagner, 2009
  54. 54. Loading the EMR g Demographic data is easily added t EMR il dd d to through an interface from scheduling system Michael Wagner, 2009
  55. 55. Clinical data is added Sample reports p p manually and requires constant attention to ensure work is being done. Michael Wagner, 2009
  56. 56. Flu season 2001 In 2001, for the first time, we could track the actual number of flu shots given and who got the shots in real time time. Michael Wagner, 2009
  57. 57. Flu 2009 Flu Surge Data Administrative and Logician  Data 9/23/2009 8:22 9/14 9/15 9/16 9/17 9/18 9/19 9/20 9/21 Human resources Goal Average Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Administrative staff out 0 1 1 1 3 3 3 Nursing staff out 0 0 0 0 1 0 0 MD staff out MD t ff t 0 0 0 0 0 0 1 Practice capacity Urgent care capacity at 8AM 25 18 26 29 32 37 20 Appointments scheduled at 8 AM 244 411 Appointments completed  381 323 285 355 237 363 Historical daily  average* Volume V l Phone notes  318 313 381 290 303 319 270 16 4 387 Office Visit notes 260 282 302 313 275 304 215 287 ED visits of patients in Logician 26 28 29 25 29 30 31 25 25 22 Hospital admissions of patients in Logic 11 14 22 14 14 15 18 5 9 15 Ordering Chest xrays 10 9 14 7 9 9 4 8 Flu shots (highlighted cell is to date) Flu shots (highlighted cell is to date) >5000 1213 200 39 19 56 16 105 E&M codes with URI/Flu ICD9 code *Average from 9/10/2008 ‐ 9/11/2009 In 2009, we can use a combination of information sources to prepare for a possible flu surge Most of the data comes from our EMR surge. EMR. Michael Wagner, 2009
  58. 58. Typical questions to answer from the EMR How many patients do we have in the practice? How many seen in past three years? How many diabetics? What is average A1C? How has highest A1C? By PCP How many diabetics? How many have met process measures? How many are meeting outcome measures? Of the patients coming in today: Who is diabetic? What interventions need to be completed? Michael Wagner, 2009
  60. 60. Creating a platform for sustainability g p y Issues Issues •Upgrades •Note structures Technology •Problems •User defined •Interfaces tables bl •Patient lists •Problem lists Issues •Medication lists p •Specialized •Training and re- training training •Providers tables •New feature Clinical work Product development, development flows customization testing and integration Michael Wagner, 2009
  61. 61. General Internal Medicine One f O of many practices at Tufts ti t T ft Tufts MC Medicine Pediatrics Surgery GMA Cardiology GI Renal … Gen Peds Ped GI … … GMA has 60,000 visits, but 240,000 visits were happening in other clinics Michael Wagner, 2009
  62. 62. Snapshot of work generated in the EMR Total number of Average number Ratio compared Number compared to documents since per day for all of to office visit average volume of 20 Document type January 2008 GMA volume patients per day Office Visit 63,932 256 1.00 20 Coumandin 9,058 36 0.14 3 Phone Note 75,103 300 1.17 23 Rx Refill e 20,861 0,86 83 0 33 0.33 7 Letter - Results 39,310 157 0.61 12 Medication list 14,845 59 0.23 5 External Correspondence 18,726 75 0.29 6 Internal Correspondence 10,241 41 0.16 3 Other letter 39,543 158 0.62 12 Lab Report 258,036 1,032 4.04 81 Imaging Report 17,115 68 0.27 5 Pathology Report 4,052 16 0.06 1 Hospital Admission* 3,530 14 0.06 1 Emergency Report* 9,002 36 0.14 3 Totals (excluding office visit) 519,422 2,078 8 162 Other notes* 87,631 351 1.37 27 Based on Tufts GMA EMR data from January 15, 2008 to January 15, 2009 Michael Wagner, 2009
  63. 63. Electronic work generated g Michael Wagner, 2009
  64. 64. Avalanche of data By the end of the week the physician will have reviewed in excess of 700 electronic documents plus mail, fax and email Michael Wagner, 2009
  65. 65. IT overload and lack of integration g Logician / Centricity Clinic electronic health record Soarian S i Hospital li i l information H it l clinical i f ti PatientKeeper Physician billing system RelayHealth Patient portal QuantiaMD Physician education website RCO/Envision Patient scheduling system Standing Stone Warfarin management system Dr. Quality Quality reporting website Bed Board/ADT Inpatient bed tracking system NEQCA registry Managed care quality monitoring Mail Tradition mode of communication Email General communication Fax Legacy system Phone Legacy system Intranet (phone book, Up to Date) Information resources Veriphy p y Radiology critical result reporting gy p g SoftMed/ESA Electronic signature for dictations Michael Wagner, 2009
  66. 66. Lessons earned Like the field I showed earlier, an EMR needs constant tending. The work flows may be automated, but the field and hardware get old, broken and fail to keep up with the changing landscape. Patient, problem and medication lists need to be updated constantly. dt b d t d t tl Decisions must be made up front on who and how the product will be maintained. Some of that maintenance will need to b done by clinical people, so i d be d b li i l l invest accordingly. di l Information systems are popping up everywhere and there is little integrative analysis being done when a new system is selected and implemented. The end result is clinicians interacting in a fragmented digital landscape. Which will only worsen physician satisfaction and increase patient risk Michael Wagner, 2009
  67. 67. THANK-YOU