How to Implement an EHR and HIE that Actually
How to Implement an EHR and HIE that Actually Improve the Quality, Safety (Formerly known as Fallon Clinic) and Efficiency of Healthcare Larry Garber, MD DISCLAIMER: The vi ews and opinions expressed i n this presentation are those of the author a nd do not necessarily represent official policy or position of HIMSS. Conflict of Interest Disclosure Larry Garber, MD Has no real or apparent conflicts of interest to report. © 2012 HIMSS Learning Objectives • Identify diverse sources of clinical data that can be used to populate EHRs • Detail mechanisms to minimize "information overload" • List multiple strategies for using EHRs to ensure that appropriate tests are ordered, and that ordered tests are performed Overview • Keys to a successful EHR implementation • Quality improvements • Safety improvements • Efficiency improvements • Return on investment Reliant Medical Group (Formerly known as Fallon Clinic) •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-for-profit •At financial risk for 60% of our patients •Not affiliated with any hospitals Establish Champions Early • Identify, fund and train both physician and nurse champions • Define value of EHR at all levels – All MD‟s + staff determine clinical/operational benefits (real users, not just “managers”) – All Senior Management - financial benefits Thanks to a highly talented & dedicated team! Extensive Communication • Continually remind everyone of the value of EHR, especially when road gets bumpy • Many presentations, early and often, with Senior Management involvement to show their support • FAQ to clarify details of vision & scope • Status reporting – EHR vendor & internal • Newsletters • All-staff kick off – have some fun 9/19/2007 9 Communication is 2-Way • Feedback directly through implementation team/trainers and Help Desk • Surveys – Before and after – Involve MDs and staff – lets them know that you‟re listening • Most complaints are actually opportunities to improve the system Minimize Disruption at Sites • Phased implementation – Maximal increments of change that don‟t interrupt operations – Gives time to become proficient with skills before taking on new tasks at next phase • Speech recognition software – Easiest documentation tool to learn • Data conversion from the paper chart that doesn’t involve physicians or staff – Doesn‟t take time away from busy MD‟s and staff – No juggling paper and EHR charts in exam room Pre-loaded With Historical Data # of Years # of Records Prescriptions 22 32 Million Lab 16 30 Million Imaging 14 2 Million Notes 14 11 Million Visits 15 20 Million Total 95 Million Pre-loaded With Historical Data • Immunizations, Health Maintenance, Disease Management – 15 years • Allergies – 10 years • EKGs – 15 years • Future Lab and Visit appointments – 1 year • Manually abstracted Family History, Growth Charts, and Problem Lists • Scanned other relevant tests and notes EHR Data Sources • Reliant Medical Group (Fallon Clinic) transcribed visit notes and imaging reports • Reference lab results • Inbound interfaces from a home health agency and 5 hospitals (lab, imaging, notes), including SAFEHealth.org Health Information Exchange (HIE) • Reliant Medical Group (Fallon Clinic) billing • FCHP claims At-risk claims data fed to clinic Hospitals Solo MD’s Ref Lab FCHP Imaging Centers PBM Reliant Medical Group Billing and Claims data 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/ECF) Ergonomic Exam rooms Effective Training and Support • Recent college gradstrainersoptimizers • Mandatory just-in-time training • Hands-on training, 1 computer per user • User-specific classes – Job class (MD, nurse, MA, checkin/checkout) – Specialty • LEVEL exam room etiquette (with permission of Kaiser Permanente) • Mandatory dress rehearsal Effective Training and Support • • • • Go-live support by trainers for 2 weeks All-staff site meetings Documentation summits Optimization team – Direct observation and 1-on-1 training – Live lunches – System improvement STRATEGIES TO IMPROVE QUALITY Ordering just prior to routine CPEs • Guidelines suggest testing based on age, gender, diagnoses, meds, smoking history, and existing orders/results • Staff draft orders & physician signs if they agree © 2012 Epic Systems Corporation Ordering in between patient visits Barometer of Actionable Deficiencies Quality Improvements Reliant Medical Group 23 Reliant Medical Group’s Medicare Diabetics’ Costs are less than 96% of the best group practices in the nation! STRATEGIES TO IMPROVE PATIENT SAFETY Monitor meds at time of renewal Automatically Populates © 2012 Epic Systems Corporation Improve Lab Testing Compliance • 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 Improving Transitions of Care • 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 Identifying Abnormal Results Where do you start? © 2012 Epic Systems Corporation Degrees of Abnormality Flag if Significantly Abnormal Result © 2012 Epic Systems Corporation Auto-notify Pulmonary Nodule Registry © 2012 Epic Systems Corporation Anticoag Clinic new antibiotic alert • Automatically generated • Automatically sent to Anticoag Clinic InBasket • Anticoag clinic makes sure follow-up INR ordered © 2012 Epic Systems Corporation Safety Improvements 34 STRATEGIES TO IMPROVE EFFICIENCY “1-Click” Radiology Orders © 2012 Epic Systems Corporation Efficiency Improvements 37 MD Productivity – All Sites EHR Go-live 38 RETURN ON INVESTMENT 63% Reduction in Transcription 40 41 41 Summary EHRs and HIEs properly implemented can truly improve the quality, safety, and efficiency of healthcare delivery Questions? Larry Garber, MD [email protected] (Formerly known as Fallon Clinic) Special thanks to Epic, our great EHR partner! Electronic Health System The Foundation for Building a Successful Solo Medical Practice DISCLAIMER: The vi ews and opinions expressed i n this presentation are those of the author a nd do not necessarily represent official policy or position of HIMSS. Conflict of Interest Disclosure James F. Holsinger, MD Has no real or apparent conflicts of interest to report. © 2012 HIMSS Who is Doctor Holsinger ? • B.S. cum laude, Fairleigh Dickinson University • MBA, New York University • Sales management, Corn Products International • Sales and Marketing Executive, H.J. Heinz Company • Owner and manager of a independent bookstore • M.D., Ross University • Family Medicine Residency, Southern Illinois University • Chief Resident, Southern Illinois University • Board Certified, Family Medicine • 2 terms as Chief of Staff, Keokuk Area Hospital • Director, Keokuk Health Systems • Medical Director, Lee County Juvenile Detention Center • Medical Director of 3 local nursing homes • Known in the community as ―the doctor who listens‖ What do we do? 350 Cumulative Number of Individual Patients Treated 2,369 2,816 3,170 3,369 300 3,602 250 200 150 1,880 1,360 Age Distribution of Active Patients - 2012 Female Male 100 826 50 270 0 2003 - 2004 2005 2006 2007 2008 2009 2010 2011 Age Operate a solo family medicine practice which opened in July 2003 Started practice with no patients Practiced obstetrics from 2003 through 2006 Treat an active patient base of over 1,400 with approximately 4,100 clinic visits per year Aging population base Payer mix by volume: 56% who have commercial insurance, 23% from Medicare, 11% for Industrial/Disability, 6% for the private payers, uninsured or the indigent and 4% from Medicaid. Fully utilize an electronic health system in a paperless clinic What else do we do? Operate a separate business - Compass Consulting, managed by Kathy Holsinger, our Business Process Engineer - Owns our 4,000 square foot clinic - Attracts specialty providers to our rural community - Rents space to additional full and part-time providers - Offers a full range of business and management services to other providers - Offsets our capital investment and lowers operating costs for all providers - Serves a range of specialties such as urology, cardiology, podiatry, audiology, women‟s health and other family medicine providers Where are these services offered? Iowa, ―A Place to Grow‖ - One rural America practice site located in Keokuk, Iowa A shrinking community population of about 20,000 On the Mississippi River sharing borders with Illinois and Missouri State ranks 43rd in Medicare reimbursement County has highest rate of unemployment in the state Why are we here today ? To learn how an electronic health system can provide the foundation on which to build a successful and profitable solo medical practice. Session Objectives—At the conclusion of this session, participants will understand how to: align clinic staff process with the EHR process. shift from reactive medicine to preventive medicine. identify and use key performance indicators to build a financially successful solo practice. A vision and objective are critical to building a successful practice Defining a business vision and objective: - Are tools for effective communication with staff Provide a roadmap Provide focus Help prioritize both day-to-day and project work Give us benchmarks for measuring our success Our vision: To become a sustainable preventive care practice. Our objective: To create a profitable, state-of-the-art medical practice that delivers the highest level of quality in patient care. Key Industry Indicators Helped Us Evaluate Our Clinic Staffing Model Percentage of Total Operating Costs for Family Medicine 1 All other 15% Malpractice insurance 5% Office expense 7% Lab 4% Wages, Benefits and Payroll Tax 52% Clinical supplies 6% Office Space 11% - Total overhead costs are generally between 52-57% of practice revenue1 The national average support staff to FTE physician ratio is 5.362 Average annual work RVU‟s for family practice is 4,6003 1 - Medical Economics Continuing Survey, 2003 2 - Physician Practice, “Benchmarks For Your Practice”, February 16, 2011 3 - Physician Compensation and Production Survey‟; 2008 Report Based on 2007 Data (MGMA) Our Staffing Model Indicates We Surpass Industry Benchmarks National Average 1 => 5.36 FTE / provider Our Clinic => 2.38 FTE / provider Reception & Scheduling 1 FTE Document Management Billing and Collections 1 FTE 0.75 FTE Cost of Overhead % of Overhead 100% 80% 60% 40% 20% 0% 31% 2008 23% 22% 23% 2009 2010 2011 Our Clinic Patient Encounter (Charting) Patient Management (Order Follow-up ) Family Practice Median Laboratory CLIA Moderately Complex 8000 6000 3 Full time providers 1 FTE 1 FTE Work RVU’s 7281 6771 6201 5920 2009 2010 2011 4000 2000 0 3.40 FTE 2008 Dr. Holsinger 1 - Physician Practice, “Benchmarks For Your Practice”, February 16, 2011 Family Practice Median How Do You Exceed the Industry Standards? Reception & Scheduling - Purchase a best-in-class EHS system - Fully align staff with EHS process modules Document Management 0.75 FTE 1 FTE - Strictly use system as designed versus forcing your view of the process on the system Patient Encounter (Charting) Billing and Collections Patient Management (Order Follow-up ) - Train all front office staff in all front office tasks 1 FTE Laboratory Management 3 Full time providers 1 FTE 3.40 FTE 1 FTE - Train all back office staff in all back office tasks - Utilize medical assistants who are trained in all functions - Hire one business process engineer to drive process improvements - Actively seek out ways to make the job easier through use of the EHS - Ensure that ALL work is “value-added” for the clinic or the patient - Eliminate or automate as much in-going and out-going paper as possible by challenging the status-quo with others (nursing homes, durable medical equipment suppliers, local employers, etc) Is Our Lean Staffing Model Sacrificing Quality of Care? - In 2008, we were asked to participate in CMS‟s 9th Scope of Work Prevention Project - Initial benchmarks revealed we exceeded both state and national compliance rates Project Start 07/31/2008 Centers for Medicare and Medicaid Services 9th Scope of Work Prevention Project Breast Cancer 100.0% Screening 80.0% 61.5% 60.0% 26.0% 26.4% 40.0% 20.0% 0.0% % of Compliance Colon Cancer Screening 48.1% 14.0% 19.7% Influenza Vaccination 32.7% 27.0% 28.3% Pneumococcal Vaccination 41.1% 26.0% 24.7% Our assessment: - Our staffing model did not sacrifice quality of care - We had an opportunity for improvement - This initiative was our tool to shift from reactive medicine to preventive medicine A Preventive Care Practice Takes More Work than Reactive Care Reactive Care: July 2003 – September 2008 - We used only the basic functions of our EHS for managing patient care - Relied on the staff to assure routine health maintenance was performed - We did not formally measure key performance indicators for the clinic Preparing for the transition: July – September 2008 - We shared our clinic vision and objective with employees Initiated the culture of eliminating “non-value added” work Created front-office and back-office champions Established and communicated key performance indicators for the clinic Established a bonus system for employees based on personal performance, financial performance of the clinic, success with PQRS and e-prescribing and continuous improvement with the CMS Prevention Project Improved Quality Results & Bonus Drive Shift to Preventive Care The Journey: September – December 2008 - The staff began to actively use the EHS clinical reminder module - The staff used clinician‟s day out of clinic to call patients for the cancer screenings and vaccinations and other health maintenance needs - Regularly reported our key performance indicator results to the staff - Paid a bonus to all full-time and part-time employees The Journey: 2009 - The clinic achieved continuous improvement in 4 consecutive quarters of the CMS Prevention Project - The staff assumed the leadership role of CMS Prevention Project - The staff would „tattle‟ on the non-compliant patient prior to Dr. Holsinger seeing the patient - The staff was now using nearly every EHS interface available - The staff was actively seeking ways to improve their work process - Expanded our quality focus by participating in Wellmark Blue Cross Blue Shield quality program The Journey: 2010 We are a Preventative Care Practice CMS 9th Scope of Work Prevention Project 92.0% 100.0% 75.0% 50.0% 25.0% 0.0% Breast Cancer Breast Cancer % of Compliance 81.8% 95.3% Colon ColonCancer Cancer Screening Screening Project Start (07/31/2008) 95.6% Influenza Influenza Vaccination Vaccination Pneumococcal Pneumococcal Vaccination Vaccination Project End (11/30/2010) - Exceeded state and national benchmarks by a factor of 2-3 times - Achieved very similar results in BCBS program; 17 of 18 measures ranked as level 3 (highest level) with 1 measure ranked a Level 2 - Embraced fully a culture of continuous improvement by measuring and using results in our work to provide a consistently high quality of care The Journey: 2011 Meaningful Use Attestation on April 24 Meaningful Use Core Measures Meaningful Use Menu Set 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% Attestation Target Current - Dr. Holsinger was the 54 th physician in the U.S. to achieve Meaningful Use - Our EHS is the foundation for us to earn incentives from Meaningful Use, PQRS and other pay-for-performance programs which exceeded $35,000 in 2011 - Preparing for CMS 10 th Scope of Work and other continuous improvements - Have paid equal or higher bonuses every year since 2008 Establishing Key Performance Indicators is an Invaluable Tool Key Performance Indicator Electronic filing success rate Support staff /physician Overtime % Overhead % Total visits* Charges / visit* Expense / visit Net revenue / visit* Visits / support staff A/R over 120 days % Co-pays collections % Electronic claims % Gross collections % Net collection % Days in AR - Gold Standard > 97% <5 < 3.5% < 32% > 3900 > $225 < $141 > $80 > 960 < 21% > 95% > 90% > 55% > 98% < 42 days 2003 2004 2005 2006 2007 2008 2009 2010 2011 89.9% 70.3% 83.5% 77.4% 96.0% 97.7% 98.3% 98.8% 3.25 3.04 2.74 2.66 3.53 3.44 3.35 2.52 0.8% 0.3% 0.2% 0.2% 47% 33% 31% 29% 24% 31% 23% 22% 23% 634 2,440 3,163 3,626 3,915 4,820 4,412 4,110 4,104 3.42 186 10% 26% 94% 123 751 1,040 1,321 1,474 1,367 1,284 1,226 1,628 19% 27% 39% 30% 20% 16% 6% 8% 58% 88% 96% 98% 97% 99% 99% 99% 100% 57% 52% 55% 57% 54% 48% 49% 48% 99% 98% 99% 99% 98% 96% 98% 99.9% 83 71 85 45 34 36 20 24 Measure only what is meaningful for your practice Make report easy to understand Use measures which relate directly to employees‟ work processes Your EHS should be able to generate results for your key indicators Report progress and actively promote activities which will generate business improvement Gold Standard Source: Physician Revenue Cycle Gold Standard Study, 2008 Gateway EDI and LarsonAllen (*) – Gold Standard adjusted for 1 physician versus multiple physicians - Holsinger estimate Our EHS is the Foundation for Achieving our Vision and Objective Our vision: To become a sustainable preventive care practice Our objective: To create a profitable, state-of-the-art medical practice that delivers the highest level of quality in patient care. Our EHS: - Allows us to operate with low staffing cost by aligning our staff with the EHS process Attracts other providers to our clinic resulting in lower overall costs for all providers Greatly improves quality of patient care and lends itself to profitable Preventive Care Quickly generates clinic and business results in order to measure our opportunities and successes Our People: (Staci, Merle, Ashley, Sheila, Katie, Britina, Mary Ann and Tiffany) - Make our clinic a fun place to work - Are fully committed to quality of patient care and continuous improvement - Have utilized our EHS to make our dream come true – We thank each of you Questions? What does our EHS do ? ―Provides easy access to patient charts which saves time‖. Staci Medical Assistant ―Gives us accessibility, searchability and legibility‖. Merle B.B.A. Finance ―Enhances efficiency and accuracy in our medical practice‖. Ashley Certified Medical Assistant ―Enhances ability to accomplish patient care efficiently‖. Sheila Registered Nurse ―With a click of the mouse, you can view all patient information‖. Katie Registered Nurse ―Provides quality patient care, education, teaching opportunities, and service‖. Britina Certified Medical Assistant ―Saves time with having all the information in one place‖. Mary Ann Registered Nurse ―It is fast, efficient, easily used and makes everything simpler‖. Tiffany Certified Medical Assistant Contact Information: James F. Holsinger M.D. or Katherine G. Holsinger 1603 Morgan Street, Suite 3 Keokuk, IA 52632 Phone: 319.524.4300 e-mail: [email protected] [email protected]
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