ReliantMedical GroupAtrius Health

Maximizing the Value of an EHR: From

Foundation to the StarsMeHI Regional Meeting – Worcester

November 4th, 2013

Larry Garber, M.D. Medical Director for InformaticsReliant Medical Group

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Building the foundation for transformation with an EHR and HIE

Safety improvements

Quality and outcome improvements

Efficiency and satisfaction improvements

Return on investment

Overview

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Larry Garber, MDMedical Director for Informatics x 15 years

Principle Investigator for $3.5M AHRQ and ONC grants for SAFE Health and IMPACT HIEs in Massachusetts

Chair, MAeHCMember ONC HIT Policy Committee’s HIE Workgroup and Privacy & Security Tiger Team, and MA HIT Council

Internist at Reliant (AKA Fallon Clinic) x 27 yrs

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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 affiliated with any hospitals• Not-for-profit• At financial risk for 70% of our patients• Member of Atrius Health

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BUILDING THE FOUNDATION: ELECTRONIC HEALTH RECORD AND

HEALTH INFORMATION EXCHANGE (HIE)

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Reliant Medical Group’s EHR:

100% utilization by all physicians and staff Includes the MyChart Personal Health Record for

patient engagement

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Electronic (from legacy repository)

Manual Abstraction by dedicated team

Document Imaging

(scanning/indexing)

Data Conversion w/o MD/Staff

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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 (MUSE) – 15 years Allergies – 10 years Future Lab and Visit appointments – 1 year Over 100 Million Records Preloaded into EHR

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Allergies Family History Growth chart data Problem Lists

Manual Paper Chart Abstraction

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Standard for scanning legacy charts defined by clinicians•Handwritten notes (e.g. Pediatric CPEs)•Graphical results (e.g. PFTs, audiograms)•Outside reports (e.g. consultants, MRIs)

Indexing at multiple levels◦Patient Level (10 types, e.g. Advance Directive)◦Visit Level (20 types, e.g. Outside consults)◦Procedure Level (150 types, e.g. MRI of Breast)

Document Imaging

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Phased EHR Implementation1. Practice Management

(Registration/Scheduling/Billing) and Clinical Results Repository

2. Paperless Telephone Messaging and Prescribing

3. Computerized Physician Order Entry/Documentation/Billing in Exam Room

6 month gap between phases gave time for users to become proficient

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Ergonomic Exam Rooms

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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

www.youtube.com/watch?v=LZAqeJtpzEY&hd=1 LEVEL Used with permission of Kaiser Permanente

© 2004. The Permanente Federation LLC

LEVEL – Exam room etiquette

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Speech Recognition Mostly to document HPI and Medical Decision Making

Study showed higher quality notes and increased physician satisfaction with documentation & Epic

Hybrid notes are most efficient Notes signed in EHR improved 4 days 45 minutes

Average increase of 8 minutes/day/MD Saves $7,000/MD/year

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Mckesson &

Patient References

Reliant Medical Group’s Interfaces

5 Hospitals(8 SNFs 12/2013)

CareEverywhere toOther Sites

Reliant’s EHR & Data Warehouse

1 Home Health Agency

48K Patients

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

4 Payers

Health CoachDisease Management

Registry

Vignette DocumentImaging

to49 Community MDs

MA DPH Immunization Registry

Transcriptionand

Dragon

Clinician References

CCDs

Appt Reminder IVR

Clark Mailing Service

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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

Home Devices &

© 2013 Epic Systems Corporation

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At-risk claims data fed to clinic

FCHP

Hospitals

RefLab

PBM

ImagingCenters

SoloMD’s

ReliantMedicalGroup

Claims data

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FCHP Claims medication list and fill hx FCHP and Reliant 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)

Billing and Claims data

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Help Getting Connected to HIEFebruary 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of MA run by Reliant Medical Group:

Improving Massachusetts Post-Acute

Care Transfers (IMPACT)

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IMPACT Objectives & Strategies Update Consolidated CDA to better support transitions across the continuum of care

Develop software to acquire, view, edit, and send these data elements

Integrate and validate these tools in Worcester County

Measure outcomes

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IMPACT Pilot Sites 9/2011 –Selection Criteria:

◦High volume of patient transfers with other pilot sites

◦Experience with Transitions of Care tools/initiatives 16 Winning Pilot Sites:

◦St Vincent Hospital and UMass Memorial Healthcare◦Reliant Medical Group (formerly known as Fallon

Clinic) and Family Health Center of Worcester (FQHC)◦2 Home Health agencies (VNA Care Network &

Overlook VNA)◦1 Long Term Acute Care Hospital (Kindred Parkview)◦1 Inpatient Rehab Facility (Fairlawn)◦8 Skilled Nursing and Extended Care Facilities21

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Nursing Facility Pilot Sites

Beaumont Rehabilitation of Westborough Christopher House of Worcester Holy Trinity Nursing & Rehab Jewish Healthcare Center LifeCare Center of Auburn Millbury Healthcare Center Notre Dame LTC Worcester Rehabilitation & Health Care Center

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LAND & SEE Sites with EHR or electronic assessment tool

use these applications to enter data elements◦LAND (“Local” Adaptor for Network

Distribution) acts as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR (live since 10/2012)

Non-EHR users complete all of the data fields and routing using a web browser to access their “Surrogate EHR Environment” (SEE) (go-live 12/2013)

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MA State Public HIE

Phase 1 – Send and Receive◦“Pushing” patient information using Direct◦Connect via EHR or Webmail◦Can use LAND & SEE to facilitate

connection◦Live since October 2012

Phase 2 – Search and Retrieve◦Building the Relationship Listing Service◦Cross-organizational query and retrieval

of patient records, starting in 201424

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Hassle-Free to ED

St. VincentHospital

Reliant MedicalGroup’s Epic EHR

Outside Record Icon in MedHost Bedboard

CCD with SVH MRN

ADT for Reliant

Patients

CCD with SVH MRN

Starting November 2013 30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR

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OTHER STRATEGIES TO IMPROVE PATIENT

SAFETY THAT ARE LIVE AT

RELIANT

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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

Improving Transitions of Care

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Special message in ED note triggers copy of message to move to top of note and routing to PCP InBasket

Direct ED to PCP Messaging

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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 appointments

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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

Alerts for monitoring of medications

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PROBLEM:• 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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Monitoring alert - warfarin renewal

© 2013 Epic Systems Corporation

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Dose alert - warfarin renewal

© 2013 Epic Systems Corporation

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Dose alert - warfarin renewal

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Automatically generated Automatically sent to Anticoag Clinic InBasket

Anticoag clinic makes sure follow-up INR ordered

Anticoag Clinic new antibiotic alert

© 2013 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

Improve Lab Testing Compliance

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Safety Improvement

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Anticoagulation Clinic Next INR alert

© 2013 Epic Systems Corporation

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Where do you start?

Identifying Abnormal Results

© 2013 Epic Systems Corporation

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Degrees of Abnormality

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Flag if Significantly Abnormal Result

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Safety Improvement

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PROBLEM:

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

44© 2013 Epic Systems Corporation

Fleischner Code, spawned from code in radiologists' dictation macro, triggers BPA…

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And auto-notifies Pulmonary Nodule Registry

© 2013 Epic Systems Corporation

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Results of Reliant's Registry

More than 900 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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STRATEGIES TO IMPROVE QUALITY OF

CAREAND OUTCOMES

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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. 2013;36(4):1033–1046.

PROBLEM:

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Just prior to patient visits During patient visits In between patient visits

Increase ordering of screening tests

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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

Ordering just prior to routine CPEs

© 2013 Epic Systems Corporation

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Nurses Call High-Risk Diabetics

Just Prior to Visit Nurses automatically receive Epic InBasket message 1 week prior to next visit

Records interval hx, educates and checks labs© 2013 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

MDs order during patient visits

© 2013 Epic Systems Corporation

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MAs call patients in between visits

Barometer ofActionable

Deficiencies

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EHR letters on patient’s birthday

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Quality Improvements

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Outcome Improvements

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

Lower Health Care Costs

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STRATEGIES TO IMPROVE EFFICIENCY AND PHYSICIAN PRACTICE STYLE

INDEPENDENCE AND SATISFACTION

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First Call Resolution by Nurses

© 2013 Epic Systems Corporation

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Defaults and Contingencies

© 2013 Epic Systems Corporation

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All info I need. Done in 1 click

© 2013 Epic Systems Corporation 62

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

Improve Note Creation

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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

Who should do the documentation?

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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

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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 Preference

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© 2013 Epic Systems Corporation

Payer/visit/patient-specific template guides visit

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CPE – Whole Enchilada – MD Finishes Note

© 2013 Epic Systems Corporation 68

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OV – Simple Templates and Enchiladas

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Reliant Productivity – Average All Sites

Proof that good planning works

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Employee Satisfaction

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Physician Satisfaction

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

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Patient Satisfaction

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RETURN ON INVESTMENT

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PROBLEM:• Reliant’s Charge Error Queues were

excessively large• Medicare Advantage RAF score was

1.06 yet DxCG was 1.13 and Potential RAF score (based on all prior diagnoses) was 1.4

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Payer/visit/patient-specific coding guidance to physicians

© 2013 Epic Systems Corporation

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© 2013 Epic Systems Corporation

Payer/visit/patient-specific coding guidance to physicians

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Double-checking with physicians in context of visit

© 2013 Epic Systems Corporation

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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 $300,000

The Result

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V codes can’t be used with regular visitsV codes must be used with preventive

visitsE 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

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Physician reminders for patient problems/diagnoses = Safety + $

© 2013 Epic Systems Corporation

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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

Result for Chronic Kidney Disease

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MD reminder to assess problems facilitates documentation…

© 2013 Epic Systems Corporation

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…and automatically adds correct diagnoses to encounter bill

© 2013 Epic Systems Corporation

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…and soon it will also add specific relevant data

© 2013 Epic Systems Corporation

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Reliant’s RAF (HCC) Scores

$16 Million increased revenue!

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EHR Total Cost and Benefit

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Reliant Medical Group has undergone a clinical practice transformation enabled by a properly configured, implemented and optimized EHR and HIE with analytics and clinical decision support

Using a talented team, user feedback, and reporting from the EHR, we have:◦ Eliminated steps that are no-longer necessary◦ Improved steps using EHR's ability to leverage patient and

medical information◦ Shifted work to lower-paid staff with physician-specific

preferences◦ Shifted work to the EHR◦ Creating new processes that were only possible because of the

Epic EHR and HIEs

Summary

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Because of the EHR, HIEs, clinical decision support,

and analytics, we improved the quality,

outcomes, safety, efficiency of, and satisfaction with,

healthcare delivery

Summary (continued)

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Questions?Lawrence.Garber@ReliantMedicalGroup.org