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

ReliantMedical GroupAtrius Health

iHT2 Health IT Summit, Boston MA

May 14th, 2014

Larry Garber, M.D.

Medical Director for Informatics

Reliant Medical Group/SAFEHealth

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Building the foundation for transformation

Efficiency improvements

Quality improvements

Safety improvements

Return on investment

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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

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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, member of Atrius Health & ACO

•At financial risk for 80% of our patients

•Winner of HIMSS Davies Award for implementing HIMSS Stage 7 EHR

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Electronic Health Record

Patient Engagement Tools (Personal Health Record, Home monitoring, etc…)

Health Information Exchange

Clinical Decision Support

Healthcare Analytics and Reporting 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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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

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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

© 2014 Epic Systems Corporation

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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

Imagingto

Community MDs

MA DPH

Immunization Registry

Transcription

and

Dragon

Clinician

References,

Intranet

CCDs

Appt Reminder IVR

Clark

Mailing

Service

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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

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FCHP

Hospitals

RefLab

PBMImagingCenters

SoloMD’s

Reliant

Medical

Group

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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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Factor Criteria Points

DxCG Likelihood of Hospitalization Score (Model 71)

Individual Patient Score >= 0.25 (90th Percentile)

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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

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Maximum Score 10

Risk Level Flag Score % Total

Low 0 58%

Medium 1 - 2 26%

High 3 – 7 13%

Very High 8 - 10 2%

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Risk Score Calculated with 2011CY data

Outcome Window = 1st 6 months 2012

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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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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

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© 2014 Epic Systems Corporation

Decision Support built into documentation:Payer/visit/patient-specific template

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Where do you start?

© 2014 Epic Systems Corporation

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AutomaticallyPopulates

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10 – 12% of Radiology orders at Reliant were ordered incorrectly and required changing

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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.

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No Clinical

Decision

Support

No change

with the

EHR!

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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

© 2014 Epic Systems Corporation

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Last date Next order

But doesn’t ask for an order if it’s not due or already ordered

© 2014 Epic Systems Corporation

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Barometer of

Actionable

Deficiencies

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4141

4242

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Hypertension Control was 69%, significantly below 90th Percentile of 73% for nation

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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

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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

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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

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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

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• 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.)

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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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Automatically generated

Automatically sent to Anticoag Clinic InBasket

Anticoag clinic makes sure follow-up INR ordered

© 2014 Epic Systems Corporation

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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

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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.

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With thoughtful use of the EHR, HIEs, clinical

decision support, and analytics, you can

improve the quality, outcomes, safety, and efficiency of healthcare

delivery

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[email protected]