EMR Applications in Primary Care SWVTC Medical Technology Summit Nick Ulmer, MD CPC Principal Consultant, ProTime, LLC Director, Quality and Compliance,

EMR Applications in Primary Care

SWVTC Medical Technology Summit

Nick Ulmer, MD CPCPrincipal Consultant, ProTime, LLC

Director, Quality and Compliance, Preserve Health, PA Lead Physician, Doctors Care Urgent/Family Care Centers

Objectives

Understand office efficiencies gained by implementation of an electronic health record

• operational flow

• coding and documentation.

Understand how with this “tool”• patient satisfaction was enhanced

• clinical delivery of healthcare improved

Realize the most common pitfall in EMR use

Where is SC?

South Carolina

Palmetto Tree and Crescent Moon Carolina Wren Myrtle Beach, Hilton Head, and Charleston Governor Mark Sanford and Argentina…… House of Rep Joe Wilson--- “You lie!!” Fox News Sept 19: “14 WF bags 14’ gator”

Where is Laurens/Clinton?

The Family Healthcare Center, PA

1991, 6.5 FTE providers, full-scope Family Medicine practice, ~18K patients, privately owned

Decision to make a change after 10 years• “Lost” charts and chart chasing

• Paper costs (charts, transcription paper, etc.)

• “Sticky note” toxicity

• “Can’t keep up”……hire more staff?

• Second storage building full

The “tool” to address our needs

System efficiencies Staffing ratios Data mining Billing, coding and documentation Patient satisfaction/healthcare delivery

System efficiencies

Messaging • Sticky pads piled up

• The “busyness” of office faded Eliminated paper inefficiencies & costs

• No more lost charts

• No more ‘can’t read’ inquiries from pharmacy

• Cut supply costs by more than $10,000 in one year

• eRx efficiency was huge

System efficiencies

Scheduling• Emails after hours/during day via web portal

• 7 AM and 1 PM each day • Non urgent appointment needs

• Refill requests

• Phone congestion plummeted

Information dissemination• Output functions to perform multiple tasks at once

Faxing and attaching directly into EMR system from subspecialists/hospitals

Staffing concerns

Staffing full time equivalents/provider

• FHC vs. MGMA (all family practice types)*

• 3.23 vs. 3.57 (6.5 FTE)

• Prior to EMR we were above MGMA*

• 2 FTE left, 1 FTE position eliminated

• Able to keep up with work load

Data mining

Birthday cards….? Clinical Trials participation Patient recruitment - targeted

• Gardacil, Menactra

• IPPE (Welcome to Medicare)

Drug recalls (Bextra and Vioxx)

Billing, coding and documentation

Higher levels for providers Better overall documentation Ease of reading notes Templates allow better care by setting up

exams to meet quality standards of care• Team involved in patient care after EMR

Physician billing/order entry

Patient satisfaction/healthcare delivery

eRx efficiencies: time saver, “wow” factor Lab information exchange Templates set up to augment quality of care Patient educational material: user/system defined After hours phone dialogue

• Chart access Satellites (much lower cost for expansion)

• Second clinical office started and access at 3 NH

• Student health clinic

Return on Investment - FHC

Transcription cost• 2000 $65,848

• 2001 $62,145 (EMR in 10-2001)

• 2002 $26,691

• 2003 $15,553

• 2004 $ 6,636

• 2005 $ 2,923

• 2006 $ 0 (any needed done in house)

Return on Investment - FHC

Staffing• Below MGMA by 1.6 FTE

Coding and Documentation

Research

Return on Investment - FHC

Corporate market • Quality wellness emphasis (reminders)

• Data tracking and reporting

• Executive physicals

Return on Investment - FHC

Family time• Convenience of doing charts at home

• I used to do them pre-EMR nightly, cut back to once a week to catch up (2-3h on Sunday afternoon)

• Less work after hours• HUGE learning curve

Preserve Health, PA at The Cliffs

Background• Primary care medical practice, north of Greenville, SC

• Rural location

• Service to • The Cliffs Community residents

• (4000, many part-time)

• The Cliffs Community, Inc. employees/dependants• (800+ employees)

• Residents of the rural surrounding area

• Opened July 7th, 2008• “Model without statistics”

Objectives

Prevention first model of healthcare• Emphasize

• Dietary compliance

• Exercise adherence

• Stress reduction

• Evidence based medical care

• Patient centered approach• Goal setting, accountability

• Consider alternative medical therapies where appropriate

The Team Approach

Mirrors the “Medical Home” model• TransforMed initiative

• Endorsed by AAFP, AAP, ACP, AOA

Integrated team of medical providers• Dedicated to optimizing one’s ability to

achieve maximum quality of life

• Empowering the patient to make decisions for sustainable wellness

The Team Approach

Human touch, but high tech• Electronic medical record

• Allscripts Professional EMR system

• Team has full utilization of this product• Data collection

• Benchmark to national, internal standards

• Team approach for competition among communities

• Marketing to area to show attention to detail and determination to be outstanding in this area

• Communication

• Patient management

The Team Approach

Physician is leader• Total oversight, but weekly meetings with

clinical team

Clinical Advocate• RN who is manager of patient clinical data

• Reporting, follow-up of diagnostic studies

• Facilitate scheduling

• High touch when needed

The Team Approach

Wellness Advocate (hourly, as needed)• Wellness Coach

• Health Education, 4 year degree

• Works with patient for goal setting, vision casting

• Coordinates care with rest of team, directs patient to other ancillary providers as needed, works closely with Clinical Advocate (the right hand, left hand theory)

• Works in concert with Wellness Counselor as support and accountability individual

Registered Dietitian (hourly, as needed)• Dietary visits encouraged (2-3), more so if there is clinical

need (i.e., DM)

The Team Approach Cognitive Behavioral Therapist (hourly, as needed)

• Called a “Licensed Wellness Counselor”

• Meets to encourage sustainable change in patients lives

• Patient needs to see benefit and needs to have the “want to” to change (Wellness Advocate)

• Encourage two sessions

• Positive psychology type of sessions more than disease management (manage stress, maintain focus in life)

Exercise Science (hourly, as needed)• Functional medicine and exercise prescriptions

Staff nurses (medical office assistants, LPNs)

The Team Approach

Part time staffers• RD, CBT, Wellness Coach

Back office heavy approach• For 2 providers:

• 2 nurses per provider, 1 shared nurse (5)

• 2 lab/x-ray trained staffers (2)

• 1 front office, 1 billing, 1 manager (3)

All with EMR access• Make recommendations for provider to advise upon

• Tracking for improvement and allows accountability

The “back office heavy” model in action

One person to “check-in” • Answers phone

• Billing will jump in if busy

• Hopefully record updated from home via portal Nurse assigned a room

• Takes patient back

• Updates database

• Collects the copay

• Begins to collect clinical history

• Nurse signals provider to come in

• Provider does visit or uses nurse as scribe

The “back office heavy” model in action

Nurse (cont.)• Completes visit by scheduling needed tests,

getting follow-up appointment

• Escorts patient out.

Second nurse is doing the same type of process in adjacent room

Third nurse is floating (shared with second provider)

The “back office heavy” model

Perception• Satisfaction is 99.5% “exceeded

expectations”

• Patients are never “alone”

Telemedicine

Pilot project arrangement with Wake Forest Consider integration into a Smart Home

project• USC School of Medicine Senior Smart Program

• Floor sensors, bed alarms, home monitors w/alarms

Distance healthcare impact• Follow-up care

• Underserved areas

• Corporate work site wellness models

Plans

Use EMR to decrease staff strain• Kiosks for check-in

• On-line bill payment, appointment requests, data updates

#1 problem………?

Customization

contact me

Nick Ulmer, MD [email protected]

864-684-4248