Leadership Strategies for Information Technology in Health

Maximizing Effectiveness: Strategies for Improving Ambulatory CareUsing an EHR

Larry Garber, MDMay 15th, 2017

Leadership Strategies for Information Technology in Health Care

• Facilitating change

• Building the foundation for transformation

• Quality improvements

• Safety improvements

• Efficiency improvements

• Patient experience improvements

• Return on investment

Overview

Larry Garber, MD

• Medical Director for Informatics x 19 years

• Principal Investigator for $4M AHRQ/ONC/MeHIgrants for SAFE Health and IMPACT HIEs in Massachusetts

• Chair, MAeHC• Board, DirectTrust• Past member of ONC HIT

Policy Committee’s Interop Workgroup, JASON Task Force, Interoperability Experience Task Force Privacy & Security Tiger Team, and MA HIT Council

• Internist at Reliant x 31 yrs

Reliant Medical Group

•500+ provider multi-specialty group practice •30 specialties, including Occ Med & Behav Med•25 sites in central Massachusetts •300,000 patients with over 1 Million visits/year•Not affiliated with any hospitals•Not-for-profit•At financial risk for 70% of our patients

FACILITATING CHANGE

HIT Guiding Principles

Successful HIT implementations need to:

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

• Consumers overvalue current product’s benefits 2-3 times

• Sellers (innovators) overvalue new product’s benefits 2-3 times

• 4x-9x mismatch between what innovators believe consumers’ valuation is and what consumers actually value innovations

• EHR implementers (“sellers”) must ask EHR users (“consumers”) to assign value

Whose Value Is It?

Gourville, John T. "Eager Sellers and Stony Buyers: Understanding the Psychology of New-Product Adoption." Harvard Business Review 84, no. 6 (June 2006).

• 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• Get “people like me” already using same EHR to

talk about how great it is

Earning Trust

• 4 Practicing Physicians• 1 Nurse practitioner• 2 Nurses• 1 Medical Assistant• All were trained to become certified analysts• Added credibility and trust of EHR team• Were able to envision and build clinically-useful and

usable tools into EHR

Clinicians Embedded in IT

• Focus on desired outcomes• Take a system-wide perspective• 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

Workflow Redesign - Lean

Ergonomic Exam Rooms

• Let the patient look on• Eye contact with the patient• Value the computer as a tool• Explain what you are doing• Logoff and say you are doing so

https://www.youtube.com/embed/LZAqeJtpzEY?vq=hd1080LEVEL Used with permission of Kaiser Permanente © 2004. The Permanente Federation LLC

LEVEL – Exam room etiquette

• Bad EHRs, bad configurations, and insufficient training are all causes of failed EHR projects

• Mandatory, hands-on, user-specific– Job class (MD, nurse, MA, check-in/check-out)– Specialty

• Proficiency testing• Mandatory dress rehearsal confidence• Aggressive Support• Ongoing proactive optimization

Lots of Training and Support

BUILDING THE FOUNDATION

Pre-loaded Historical Data

• 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 yearOver 100 Million Records Preloaded into EHR

Merged with 74 more providers

• Epic to Epic conversion• 30+ Years of data. 65 Data types.• Patient level (nicknames, insurance, patient photo,

code status, problems, goals, allergies, family hx, preferred pharmacy, etc…)

• Encounter level (notes, scans, flowsheets…)• Order level (Rx, results, referrals, future…)Over 60 Million Records Converted into EHR

Mckesson &

Patient References

7 Hospitals+ 8 SNFs

toother Sites

Reliant’s EHR & Data Warehouse

1 Home Health Agency

~40% Patients

Ancillaries(Surescripts, Quest Lab, MUSE EKG,Infinitt PACs + Powerscribe)

4 Payers

SpecializedRegistry

1 ZOLL EMSto50+ Community MDs

MA DPH Immunization RegistryRx Monitoring Program

Transcriptionand

Dragon

Clinician References Appt Reminder IVR

Clark Mailing Service

Reliant’s Interfaces

to non-Epic Sites

IHE XCPDXCA

CDAs

• 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

• Expanding to be an Event Notification Service

SAFEHealth

• Patients plug home health monitoring devices (e.g. BP, weight, sugar, O2, etc…) into home computer

• Automatically loads into Epic EHR via

• Batches readings, but immediately sends critical ones

• Expanding to use iOS HealthKit as an aggregator

Home Monitoring Devices

© 2017 Epic Systems Corporation

At-Risk Claims Data Loaded

FHP

Hospitals

RefLab

PBMImagingCenters

SoloMD’s

ReliantMedicalGroup

• FHP Claims medication list and fill hx• FHP and Reliant claims/billing:

– Immunizations– Health Maintenance Dates (e.g. Mammogram, 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)

Billing and Claims data

Good Planning Works

STRATEGIES TO IMPROVE QUALITY

• Just prior to patient visits (CPEs)• During patient visits• In between patient visits

Increase ordering of screening tests

• EHR guidelines automatically suggest testing based on age, gender, diagnoses, meds, and existing future orders/results

• Scheduling staff sends order and notifies provider who can edit or cancel if they disagree

Ordering Just Prior to CPEs

© 2017 Epic Systems Corporation

Last date Next order

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

Ordering During Visits

© 2017 Epic Systems Corporation

Alerts Ensure Proper Screening

© 2017 Epic Systems Corporation

Patient-specific explanation of screening issues

Ordering at Patient’s Birthday

Quality Outcomes

Lung Cancer Screening:• CMS-compliant orders increased from 5% to 80%

• CT denials now close to zero

• More lung CT screens being done– 34% of eligible patients offered lung CT– 40% of those patients accept order

Quality Improvements

Quality Improvements

32

Quality Improvements

Quality Improvements

34

• Identify all patients near-due or overdue for tests, procedures and/or appointments based on Standing Order Guidelines– Health Maintenance– Disease Management– Prior abnormal test result

• Identify who needs order vs. reminder

• Place orders and/or notify patients using their preferred communication method

Population Health Approach

Patients appear on the reports of only one group based on level of patient complexity:

Population Health Hierarchy

Dividing the work

CareManagers

Disease Managers

Health Coordinators

Standing Order Reporting Workbench

of Flagged Patients

Health Maintenance

Registry

Disease Management

Registries

Abnormal Results

Registries

Standing Order Workbench

Care Managers

Disease Managers

Health Coordinators

Care Managed Patients

Disease, but not Care Managed Pts

All other patients

Monthly Physician Feedback

Population Health Outcomes

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

2014 2015 2016 (Q1&2)

Diabetes Composite OutcomesPo

p H

ealt

h

2016: 90th%-tile in 90% of Healthcare Quality Measures

(21/23 HEDIS measures)

STRATEGIES TO IMPROVE PATIENT SAFETY

St. Vincent Hospital &Milford Regional Med Ctr

Reliant MedicalGroup’s EHR

Outside Record Icon in MedHost Bedboard

blinks

CCD with Hospital

MRN

ADT for Reliant

Patients

CCD with Hospital MRN

90 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR

Improving Transitions of Care

ED Registration

Reliant Med Group

PCP

Care Manager

SAFEHealthMPI/RLS/SEND/GET

CCD to EMS

Dispatchers

Paramedics

CCD Patient Summary

EMS Database

MA Prescription Monitoring Program

PMP Query

Planned for Summer 2017

IMPACT 2.0

• ER and hospital Discharge Notes file into EHR as well as InBasket of PCP and Care manager

• ER and hospital lab/rad/procedure notes file silently into EHR, EXCEPT for those resulted after discharge which also go to physician InBasket

Improving Transitions of Care

• CDA from hospital after discharge is parsed:

– Immunizations (e.g. Newborn Hep B, Tetanus, Pneumococcal, Flu) are automatically loaded into Epic

– High-risk meds (anticoag, opiates, diabetic) automatically trigger message to pharmacist for education

Improving Transitions of Care

• 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

Alerts for Follow-up

• 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

Alerts for Monitoring of Meds

Monitor meds at Renewal

© 2017 Epic Systems Corporation

AutomaticallyPopulates

Dose alert - warfarin renewal

© 2017 Epic Systems Corporation

© 2017 Epic Systems Corporation

Dose alert - warfarin renewal

• Automatically generated• Automatically sent to Anticoag Clinic InBasket• Anticoag clinic makes sure follow-up INR ordered

Anticoag Clinic New Abx Alert

© 2017 Epic Systems Corporation

© 2017 Epic Systems Corporation

Anticoag Clinic Next INR Alert

Safety Improvements

53

• 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 mth f/u or 3 months

late on a 1 year f/u)– Letter automatically sent to patient from EHR

Improve Lab Test Compliance

Safety Improvements

55

Where do you start?

Identifying Abnormal Results

© 2017 Epic Systems Corporation

Degrees of Abnormality

© 2017 Epic Systems Corporation

Flag if Significantly Abnormal

Auto-Populate Registry

© 2017 Epic Systems Corporation

Canned text macro

Embedded code in canned text macro

© 2017 Epic Systems Corporation

Interface engine recognizes embedded code and spawns an extra result component with the code

Auto-Populate Registry

© 2017 Epic Systems Corporation

EHR recognizes extra result component with the code which triggers inclusion in registry

Auto-Populate Registry

The Results

• More than 2000 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 known follow-up failures in 6years

• Use similar process for Lung-RADS and Mammography BI-RADS

EHRs Save Lives

STRATEGIES TO IMPROVE EFFICIENCY AND

PHYSICIAN PRACTICE STYLE INDEPENDENCE

First Call Resolution by Nurses

© 2017 Epic Systems Corporation

Defaults and Contingencies

© 2017 Epic Systems Corporation

All info I need. Done in 1 click

© 2017 Epic Systems Corporation

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

Improve Note Creation

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

Who should do documentation?

MA rooms patient and always enters:• Chief Complaint(s)• Allergies/Medications (including OTC)• Preferred Pharmacy• Pends medications that need renewals• Full Social and Family History• Vital signs• Rooming note• Review of Systems and starts MD’s note

Adult Comprehensive Physicals

• 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

EHR Knows Each MD’s Prefs

Template guides visit

© 2017 Epic Systems Corporation

Payer/visit/patient-specific

CPE – Whole Enchilada

© 2017 Epic Systems Corporation

OV – Simple Templates

“1-Click” Radiology Orders

© 2017 Epic Systems Corporation

Efficiency Improvements

Employee Satisfaction

77

Physician Satisfaction

78

64% “Very Satisfied” with “Computers” (AMGA Avg = 60%) in 2010

Physicians Continue to Like It!

Press-Ganey 2015 EHR Usability Score Reliant's EpicFavorable (agree or strongly agree) 83%Score (scale of 0-4) 3.18National Clinical Physician Average 2.00% Above National Average 59%

Strongly disagree=0, Disagree=1, Neutral=2, Agree=3, Strongly agree=4

EHR

IMPROVING PATIENT

EXPERIENCE

Patient Satisfaction

81

Patient Check-in

• Check-in from home generates barcode

• Swipe barcode at kiosk (or full check-in at kiosk)

• Kiosk silently takes photo of patient• Photo is visible to Medical Assistant

in EHR so they can approach correct patient in waiting room

• Photo is automatically deleted at check-out

Planned for Summer 2017

Any Room for Any Patient

•eFLAGs integrated with EHR identify which physician’s patient is in room and their status (e.g. with MD, waiting for nurse, or waiting for cleaning when motion sensor sees no more activity)

•Monitor in room automatically displays physician-specific photos and patient-specific education while patient waits for physician

Patients Continue to be Happy

RETURN ON INVESTMENT

86

63% Reduction in Transcriptionduring first 4 years

100% Reduction in Transcriptionsince adding Dragon

© 2017 Epic Systems Corporation

Payer/visit/patient-specific coding guidance to physicians

© 2017 Epic Systems Corporation

Payer/visit/patient-specific coding guidance to physicians

Double-checking with physicians in context of visit

© 2017 Epic Systems Corporation

• Our Medicare Wellness coding compliance rate by physicians has increased:– 10% in Feb 2011 – 98% in Feb 2012

• This has:– reduced provider frustration with the documentation

and coding processes– reduced billing rework– reduced patient complaints– improved revenue by $600,000

The Result

Z codes can’t be used with regular visits

Z codes must be used with preventive visits

V, W, X, and Y Codes can never be primary

• This has reduced the charge review work queue 90% from $4 million (27,993 claims) to $557,000 (2526 claims)

Primary Dx – LOS Mismatch

© 2017 Epic Systems Corporation

Physician reminders for patient problems/diagnoses = Safety + $

© 2017 Epic Systems Corporation

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

Chronic Kidney Disease

MD reminder to assess problems facilitates documentation…

© 2017 Epic Systems Corporation

…and automatically updates documentation and adds correct diagnoses to encounter bill

© 2017 Epic Systems Corporation

ReliantMedical Group

1

1.05

1.1

1.15

1.2

1.25

1.3

1.35

1.4

2010 2011 2012 2013 2014

SmartformBPAs Smartform and Abstract

RAF (HCC) Scores$20 Million in increasedannualrevenue!

EHR Total Cost and Benefit

Does not reflect increased revenue from HCC initiatives

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

Lower Health Care Costs

98

Total Medical Expense

20-25% less in TME than network

30% lower ER and hospital admission rates than Medicaid network

20% less on a PMPM basis than network

Employees who receive their care at Reliant cost - 17% less in TME

Despite Sicker PopulationCompared with an 11 million person benchmark community

• Clinical Practice Transformations are enabled by properly configured, implemented and optimized EHRs

• Transformations should be goal-oriented• 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

Summary

• Measure to make sure that you've achieved your goals

• EHRs and HIEs truly can improve the quality, safety, efficiency of, and satisfaction with, healthcare delivery

Summary (continued)

Questions?Lawrence.Garber@ReliantMedicalGroup.org