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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)