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"

ReliantMedical GroupAtrius Health

iHT2 Health IT Summit, Boston MAMay 7th, 2013

Larry Garber, M.D. Medical Director for InformaticsReliant Medical Group/SAFEHealth

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Facilitating change

Building the foundation for transformation

Quality improvements

Safety improvements

Efficiency improvements

Return on investment

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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, MAeHCMember ONC HIT Policy Committee’s HIE Workgroup and MA HIT Council

Internist at Reliant (AKA Fallon Clinic) x 27 yrs

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•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

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Successful HIT implementations need to:

Provide value (Benefits > Cost) Fit into real-world workflows Earn the trust of the stakeholders

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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

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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

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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

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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

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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%

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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

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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)

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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

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1. Practice Management (Registration/Scheduling/Billing)

2. Clinical Results Repository3. Paperless Telephone Messaging and

Prescribing4. Computerized Physician Order

Entry/Documentation/Billing in Exam Room

6 month gap between phases 2-3-4 gave time for users to become proficient

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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

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Completed rollout in 2007 100% utilization by all physicians and staff Includes the MyChart Personal Health Record for

patient engagement

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5 Hospitals

25 NursingFacilities

Reliant’s PCPs & Specialists EHR & Data Warehouse

1 HomeHealth Agency

30K Patients

Ancillaries(Rx/Lab/Rad…)

4 Payers

MAeHC Quality Data Center

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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

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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

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ReliantMedicalGroup

Claims data

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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)

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Just prior to patient visits During patient visits In between patient visits

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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

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Last date Next orderBut doesn’t display if it’s not due or

already ordered

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Barometer ofActionable

Deficiencies

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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

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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

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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

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AutomaticallyPopulates

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Automatically generated Automatically sent to Anticoag Clinic InBasket

Anticoag clinic makes sure follow-up INR ordered

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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

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Have the right person do the work Use the right tools Re-use data whenever possible

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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 phone4.The medical assistant that rooms patient5.The doctor assisted by speech recognition6.The doctor assisted by transcriptionist7.The doctor typing8.A scribe typing

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MA rooms patient and always enters:Chief Complaint(s)Allergies/Medications (including OTC)Preferred PharmacyPends medications that need renewalsFull Social and Family HistoryVital signsRooming noteReview of Systems and starts MD’s note

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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

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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

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Reliant Medical Group’s Medicare Diabetics’ Costs are less than 96% of the best group practices in the nation!

Lower Health Care Costs

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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

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EHRs and HIEs truly can improve the quality,

safety, and efficiency of healthcare delivery

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Lawrence.Garber@ReliantMedicalGroup.org