Slide presentation on engaging physicians in medical information technology.

1. ACHIEVING PHYSICIAN BUY-
IN FOR EFFECTIVE IT
ADOPTION AND
ENGAGEMENT
SEPTEMBER 2009
Michael Wagner, MD FACP

2. Biographical sketch
Michael Wagner, MD
Mi h l W
Dr. Michael Wagner is currently the Chief of General Internal Medicine at Tufts Medical Center in Boston
Mass. He has been practicing internal medicine for 19 years as a primary care internist and hospitalist. He
p g y p y p
received his undergraduate degree from Connecticut College and medical degree from Georgetown
University School of Medicine. He completed his residency at Dartmouth-Hitchcock Medical Center in New
Hampshire. He is board certified in internal medicine and is a fellow of the American College of Physicians.
Dr. Wagner has held numerous appointments, including his current role as the Chief of General Internal
Medicine at Tufts Medical Center, CEO of EmCare Inpatient Services in Dallas Texas, Regional Medical
Director for Cove Healthcare in La Jolla Ca. and Residency Program Director in Internal Medicine at St.
Mary’s Hospital/University of Rochester in Rochester NY.
Dr Wagner has focused his career on building and managing effective physician practices in community and
academic settings. His has been involved in many IT projects from naval underwater warfare simulation to
electronic medical records and large database analysis.
Dr. Wagner currently manages the clinical division of General Internal Medicine which provides primary
care to 33,000 patients in downtown Boston. The division also has an inpatient/hospitalist program,
consultative service and concierge practice. Dr. Wagner is actively involved in teaching medical students
and residents. He serves on many hospital committees and task forces including the Institutional Review
Board.
In addition to his academic work, Dr. Wagner has extensive experience with community based physician
practices and hospitals. As the CEO of a national physician practice management company, he built and
managed over 60 hospitalist programs in 16 states employing 385 physicians.
Today Dr. Wagner will be sharing his experience and insights on achieving physician buy-in for effective IT
adoption and engagement.
Michael Wagner, 2009

3. Goals of Session
Review the context of primary care practice
environement
Outline the framework for an IT implementation
Lessons learned from an EMR implementation
Questions and discussion
Michael Wagner, 2009

4. A little more detail…
4
Disclosures
Chief, General Internal Medicine Tufts Medical Center
Founding Member, Phoenix Group
Biases
Clinical – Internal Medicine/Hospitalist
Organizational – Academic and community based physician
practices
i
Geography – Northeast, but with national view
Goal
Leave you with a few insights and methods
Outline the transformative nature of IT adoption
September 2009 M Wagner MD

5. Biases - National experience
p
Review and/or design hospitalist program
Work as hospitalist
Review and/or design primary care practice
5 Jan 2009 M Wagner MD

6. CURRENT STATE OF
PRIMARY CARE
Achieving Physician IT Adoption

7. Status report – Primary care physicians
p y p y
Physicians
Physicians’ Perspective study
Trends on where trainees are going
Burdens on primary care
Michael Wagner, 2009

8. Physician – Archetypes
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9. The Physicians’ Perspective: Medical
Practice in 2008
Study outline
Survey on physician perspectives mailed to:
>270,000 primary care physicians
50,000 randomly selected specialty physicians
Survey completed and reported in 2008
Sponsored by “The Physician’s Foundation” a non-profit
p y y p
company promoting physician practices and competed by
Merritt Hawkins and Associates
Results ~12,000 respondents
~12 000
Margin of error of about 1%
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

10. The Physicians’ Perspective: Medical
Practice in 2008
Morale
Physician rated their colleagues morale
Positive – 6%
Poor o Very Low – 42%
oo or Ve y ow %
Self rating
78% of physicians said medicine is either “no longer
no
rewarding” or “less rewarding”
Capacity
76% of physicians said they are either at “full capacity” or
“overextended and overworked”
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

11. The Physicians’ Perspective: Medical
Practice in 2008
Paperwork
p
Impact on time spent with patients
63% of doctors said non-clinical paperwork h
fd d l l k has
caused them to spend less time with their patients
Amount of time spent on paperwork
94% said time they devote to non-clinical
paperwork in the last three years has increased
ki h l h h i d
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

12. The Physicians’ Perspective: Medical
Practice in 2008
Government
“Declining i b
“D li i reimbursement” highest rated problem and 82% said their practices
” hi h d bl d id h i i
would become unsustainable if Medicare cuts are made
Reimbursement fails to cover costs
Medicaid – 65% of practices
Medicare – 36% of practices
Closed practices
Medicaid – 33% of practices
Medicare – 12% of practices
Finances
Health and profitable?
17% of physicians rated their practices
Would you retire?
45% of doctors would retire today if they had financial means
fd t ld ti t d th h d fi i l
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

13. The Physicians’ Perspective: Medical
Practice in 2008
Impact on physician workforce
An overwhelming majority of physicians – 78% – believe there is
a shortage of primary care doctors in the United States today
49% of physicians – more than 150,000 doctors nationwide –
said that over the next three years they plan to reduce the
number of patients they see or stop practicing entirely.
p y pp g y
11% said they plan to retire
13% said they plan to seek a job in a non-clinical healthcare setting
20% said they will cut back
10% said th will work part-time
id they ill k t ti
60% of doctors would not recommend medicine as a career to
young people
l
The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

14. Paperwork
p
Consult letters
Drug warnings
Medication substitutions
VNA forms
Oxygen orders
Notifications of PT-1 form
reauthorization requirements
Prior authorizations
Managed care patient lists
Refill authorizations
Letters from the division chief
Misc letters
Michael Wagner, 2009

17. Dissatisfaction with primary care
p y
17
Burden
Non-visit clinical work without support
Administrative paperwork
Technology 70
Compensation 60
50
Respect
40 General
G l
Role models Hospitalist
30 Subspecialty
Control 20
Medical school loans 10
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Source: Internal Medicine In-Training Examination Survey
M Wagner MD Jan 2009

18. Choices
18
Hospitalist Medicine Primary Care Medicine
The graduate
Michael Wagner, 2009

19. Choice: Primary Care vs. Hospital Medicine
Primary Care IM Hospital Medicine
Full time work commitment 18.75 days/month 15 shifts/month
Patient encounters per day 20-30 pts per day 15-18 pts per shift
Average compensation $150,000-$180,000/yr $180,000-$220,000/yr
Overhead Office, staff, equipment,
Office staff equipment Billing and medical
supplies, billing, medical malpractice
malpractice
Non-visit clinical work >100 documents/day Minimal
Administrative work Prior authorizations Inpatient payment
Referrals, FMLA, PT-1, denials
Disability forms, etc
Panel size 1,500 to 2,500 0
Schedule Monday - Friday On-off for blocks
Workday Controlled by schedule Controlled by patient
need, nursing, DC time
19 Michael Wagner, 2009

20. THE FUTURE STATE OF
PRIMARY CARE

21. Strategic analysis
Strategic Drivers Responses
Aging and chronic illness Increasing visit and non-visit
burden increase clinical work
Shrinking MD workforce Increasing ratio of patients
per primary care MD
Reduction in health care Application of evidence
dollars/patient based care to make quality
and utilization more uniform
Michael Wagner, 2009
21

22. Transition Strategic Drivers
1. Aging and chronic illness burden increase
analysis 2.
3.
Shrinking MD workforce
Reduction in health care dollars/patient
22
Accelerants
1.Investment
1 Investment
2.MD workforce
3.Hospital medicine
Current state Future state
General Internist The New Internist
Concerns
• Vi it f
Visit focus • L d of t
Leader f team
1.MD-Patient relationship
• Space and staff • Population focus
volume focused • Employed in larger
• Solo Wildcards organization
g
1.Retailization
2.Health Care reform
3.Information technology
Michael Wagner, 2009
Wagner
4.Remote monitoring
4R t it i
5.Non-physician providers
6.Organizational acceptance

23. The patient – physician relationship
p p y p
23
Minimal
Radiology
Anesthesia
Episodic What is the value of a continuous
relationship between a patient and
Consultants physician?
Hospitalist
Urgent care
g
ED
Continuous
Internist
Pediatrics
Family Medicine
Some specialty care
p y
Michael Wagner, 2009 Jan 2009

24. Levels of Patient Engagement
g g
Highly engaged
Engaged
Engaged with normal prompts
Fragmented engagement
g g g
Disengaged
g g
Michael Wagner, 2009

25. Deconstructing Primary Care
g y
25
1.Visit and non-visit work
2.Disease/condition care 1.Visit based work
management 2.Access is essential
3.Multidisciplinary teams 3.Physical space designed
for urgent care
4.Triage and collaboration
with ED and hospital for
transfers
Chronic Urgent
Care Care
Health
Screening
1.Non-visit work is substantial
2.Screening based on accepted
guidelines
3.Requires
3 Requires coordination with
specific screening services
(Mammo, Endo)
Michael Wagner, 2009

26. The New Internist - Role
Expert in the care of the medically complex patient
p y p p
Manages patients with complex medical conditions
across the spectrum of healthcare services and over
time
ti
Team player
Works in collaboration with a multidisciplinary and
integrated team
Nursing
Social work
Home based services
Nutrition
Michael Wagner, 2009

27. The New Primary Care Physician – practice structure
Physician is part of the multidisciplinary team and is the medical leader
Direct patient care
Supervision of non-physician providers
Clinical guidelines, protocol development
Case review
Practice is structured to support visit and non-visit clinical work
Information technology
Integrated EHR, e-prescribing, patient portal
Staff
For visit work focused on efficient patient flow
For non-visit work – phone/electronic staff, case management
Space
S
Practice supports lifestyle needs of providers
Continuous professional development program
Transfer of care relationships with specialists/hospitals th t provide a hi h l l
T f f l ti hi ith i li t /h it l that id higher level
of care (applicable to rural and community facilities)
Michael Wagner, 2009

28. An Organizational Approach to
Primary C
Pi Care
Align patients with your healthcare organization through effective primary care practices
Create a platform for physician recruitment and retention by offering a stable employment
structure. Align compensation program with value based health care
Implement an electronic health record that is integrated with other information systems in order to
p g y
avoid duplication of data entry and facilitate access and transparency
Quality integrated into clinical operations with appropriate staffing and support
Reorganize staff to manage populations of patients in addition to managing visit based clinical
work. Augment with multidisciplinary team members for niche issues such as home bound patients,
hospice, etc.
Reconfigure space to handle visit and non-visit clinical work
non visit
Reorganize physician work schedule to account for non-visit work and team participation
Negotiate payer contracts to assume greater control over medical budget with appropriate
risk/reward
Michael Wagner, 2009

29. Review
Primary care is on the cusp of a major change
Current workloads and burdens are making the current
practice structure non-sustainable
In order to create sustainable models for primary care
care,
organizations or physician groups must rebuild the
infrastructure supporting physicians
IT can be transformative in this process
How d
H do you engage physicians t embrace an IT
h ii to b
implementation in the face of such a negative work
environment?
Michael Wagner, 2009
29

30. FRAMEWORK FOR
ENGAGEMENT

31. Components of an IT Implementation
p p
Providers/
Users
Project
Plan
Operations Technology
Michael Wagner, 2009

32. Technology - IT system invasiveness
gy y
Highly Invasive
• Electronic Medical Records The more invasive the IT system is in terms
• CPOE of daily workflow, the more MD engagement will
• Patient portal be needed to successfully implement the system
y p y
Invasive
• Billing / Charge entry
g g y
• Managed care registries
• Clinical information systems
Minimally Invasive
• Backend dictation systems
• Patient scheduling systems
• Order entry systems (non-CPOE)
Michael Wagner, 2009

33. Organizational factors
g
What are the drivers for the IT system?
Who is driving the program?
Have those who will be effected be engaged?
Have the goals of the project been clearly outline,
including:
What the system is designed to do?
What the system is not designed to do or fix?
Have resources been appropriately allocated?
Michael Wagner, 2009

34. Organizational - Recheck
g
What are the intended and unintended
consequences of the IT system?
Let s
Let’s recheck – do we have the right people and
resources?
Michael Wagner, 2009

35. Engagement is a state of mind…
g g
Respect
Communication The engagement and attitude of the
Interests leaders/drivers of the IT implementation
leaders/drivers of the IT implementation
will set the tone for the project. A challenge
Concerns for the executive team driving this project will
be to use these qualities listed to the left when
Intelligence
I lli interacting with the providers and staff using the
h h d d ff h
new IT system.
Data
Michael Wagner, 2009

36. The Core Implementation Team
p
MD
Operations Nursing
IT Vendor
Michael Wagner, 2009

37. Project p ( )
j plan(ner)
Experience and organizational skills matter.
Frequent organized meetings with project manager
to hold participants feet to the fire.
Action plans and minutes.
Experience with successful implementation of same
program in similar size organization.
Good sense of humor
humor.
Michael Wagner, 2009

38. Where to find Physician Leadership?
y p
Michael Wagner, 2009

39. Physician factors
y
Role of physician leadership
Nurturing future physician leaders
Scoping out your doctors
Avoid
A d
Nattering nabobs of negativism
Technocrati
Disorganization
Go for the silent, and usually appreciative, middle
Train h
T i the trainer model of education
i d l f d i
Behind the scenes lobbying, education and occasional
deals
Michael Wagner, 2009

40. Physician Types
y yp
Michael Wagner, 2009

41. Levers for transition
What is broken? What will be fixed?
What is in it for me?
How will this help the practice?
How will this help patients?
Michael Wagner, 2009

42. Strategies for Success
g
Have clear objectives that penetrate clinical work flows
Respect existing clinical work flows, but seize on
opportunity to re-work and fix what is recognized as
broken
Listen carefully to physician concerns and incorporate
suggestions when feasible – be gracious
Focus on the silent majority and build a system that will
work for them
Provide options and choices. Developing 3-4 well
p p g
worked out clinical work flows is better than forcing one
solution on everyone or keeping the 20 different ways it
is done todayy
Michael Wagner, 2009

43. Essential components
p
Engagement
g g
Planning that involves all parties
Training
g
Adjusting clinical volumes during implementation
Pre-loading data
g
Train the trainer model and super users
Phasingg
High touch and presence during GO-LIVE
Have Fun!
Michael Wagner, 2009

44. AN EXAMPLE

45. Tufts Medical Center - GMA
Michael Wagner, 2009

46. The daily bag
y g
Michael Wagner, 2009

47. The ask
Michael Wagner, 2009

48. The choice
Michael Wagner, 2009

49. Transition Drivers
1. Risk management
analysis 2.
3.
3
4.
Drug recalls
Reports for Boston Public Health Department
R f B P bl H l h D
On-call access to patient data
49
Accelerants
1. MD leadership
2. Investment
Current state – Future state –
Paper based EHR
records
Concerns
1. MD-Patient relationship
2. Time
3. Productivity Wildcards
4. Computer skills 1. Vendor support
2. IT support
3. Administrative bandwidth
4. MD revolt
5. Patient acceptance
6. Budget hawk
Michael Wagner, 2009 Michael Wagner, 2009

50. Timeline
1999- Realization - practice must have EHR
April 2000 – Presentation to system RAC
Summer 2000 - Rejection by system RAC
Fall 2000 – Project approved under hospital RAC process
Late 2000 – Vendor selected – Medicologic “Logician”
product
Early 2001 – Project planning process begun with weekly
and bi-weekly meetings
Summer 2001 – Final testing – training begins
g g g
August 2001 – GO LIVE
January 2002 – Physician order entry initiated
Michael Wagner, 2009

51. Implementation team
p
MD
Operations Nursing
IT Vendor
Michael Wagner, 2009

52. Functionality
y
Appointment lookup – passive
Note writing – with options
Order entry
Results reporting
Lab
Rad
Path
Medication management
Meds
Prescriptions (does not meet e-prescribing standard)
Phone call management
ED and hospital notifications
Michael Wagner, 2009

53. Creating options – Note generation
g p g
Form
Transcription Quick Text Free form
Components
Final Note i
Fi l N in
Electronic Medical Record
Michael Wagner, 2009

54. Paper records
p
Paper based records
Destinations
1.
1 Clinic chart
2. Medical Record
3. Provider copy
Office visit
Our traditional view of what the output of an office visit has narrowed our
concept of a “medical record”. We have tended to focus on the note as
the physical structure that must be reproduced in electronic format.
Michael Wagner, 2009

55. EMR – not just a p y note writer
j pretty
Data repository Destinations
• Notes • Patients
• Labs / Rads • CHIN/Hub
• Phone notes • Hospital(s)
• Orders / sets • Registries
• Medications • Research
• P4P reporting
However, an EMR is the foundation of a data
repository and p
p y practice structure for
effective medical management of
individual patients and population of patients.
Michael Wagner, 2009

56. Loading the EMR
g
Demographic data is
easily added t EMR
il dd d to
through an interface
from scheduling system
Michael Wagner, 2009

57. Clinical data is added
Sample reports
p p manually and requires
constant attention to
ensure work is being
done.
Michael Wagner, 2009

58. Flu season 2001
In 2001, for the first time, we could track the actual
number of flu shots given and who got the shots
in real time
time.
Michael Wagner, 2009

59. Flu 2009
Flu Surge Data
Administrative and Logician
Data
9/23/2009 8:22
9/14 9/15 9/16 9/17 9/18 9/19 9/20 9/21
Human resources Goal Average Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday
Administrative staff out 0 1 1 1 3 3 3
Nursing staff out 0 0 0 0 1 0 0
MD staff out
MD t ff t 0 0 0 0 0 0 1
Practice capacity Urgent care capacity at 8AM 25 18 26 29 32 37 20
Appointments scheduled at 8 AM 244 411
Appointments completed 381 323 285 355 237 363
Historical daily
average*
Volume
V l
Phone notes 318 313 381 290 303 319 270 16 4 387
Office Visit notes 260 282 302 313 275 304 215 287
ED visits of patients in Logician 26 28 29 25 29 30 31 25 25 22
Hospital admissions of patients in Logic 11 14 22 14 14 15 18 5 9 15
Ordering Chest xrays 10 9 14 7 9 9 4 8
Flu shots (highlighted cell is to date)
Flu shots (highlighted cell is to date) >5000 1213 200 39 19 56 16 105
E&M codes with URI/Flu ICD9 code
*Average from 9/10/2008 ‐ 9/11/2009
In 2009, we can use a combination of information sources to prepare for a
possible flu surge Most of the data comes from our EMR
surge. EMR.
Michael Wagner, 2009

60. Typical questions to answer from the EMR
How many patients do we have in the practice?
How many seen in past three years?
How many diabetics?
What is average A1C?
How has highest A1C?
By PCP
How many diabetics?
How many have met process measures?
How many are meeting outcome measures?
Of the patients coming in today:
Who is diabetic?
What interventions need to be completed?
Michael Wagner, 2009

61. LESSONS LEARNED

62. Creating a platform for sustainability
g p y
Issues
Issues •Upgrades
•Note structures Technology
•Problems
•User defined •Interfaces
tables
bl
•Patient lists
•Problem lists Issues
•Medication lists p
•Specialized
•Training and re- training
training •Providers tables
•New feature
Clinical work Product development,
development
flows customization testing and
integration
Michael Wagner, 2009

63. General Internal Medicine
One f
O of many practices at Tufts
ti t T ft
Tufts MC
Medicine Pediatrics Surgery
GMA Cardiology GI Renal … Gen Peds Ped GI … …
GMA has 60,000 visits,
but 240,000 visits were
happening in other clinics
Michael Wagner, 2009

64. Snapshot of work generated in the
EMR
Total number of Average number Ratio compared Number compared to
documents since per day for all of to office visit average volume of 20
Document type January 2008 GMA volume patients per day
Office Visit 63,932 256 1.00 20
Coumandin 9,058 36 0.14 3
Phone Note 75,103 300 1.17 23
Rx Refill
e 20,861
0,86 83 0 33
0.33 7
Letter - Results 39,310 157 0.61 12
Medication list 14,845 59 0.23 5
External Correspondence 18,726 75 0.29 6
Internal Correspondence 10,241 41 0.16 3
Other letter 39,543 158 0.62 12
Lab Report 258,036 1,032 4.04 81
Imaging Report 17,115 68 0.27 5
Pathology Report 4,052 16 0.06 1
Hospital Admission* 3,530 14 0.06 1
Emergency Report* 9,002 36 0.14 3
Totals (excluding office visit) 519,422 2,078 8 162
Other notes* 87,631 351 1.37 27
Based on Tufts GMA EMR data from January 15, 2008 to January 15, 2009
Michael Wagner, 2009

65. Electronic work generated
g
Michael Wagner, 2009

66. Avalanche of data
By the end of the week the
physician will have reviewed in
excess of 700 electronic
documents plus mail, fax and
email
Michael Wagner, 2009

67. IT overload and lack of integration
g
Logician / Centricity Clinic electronic health record
Soarian
S i Hospital li i l information
H it l clinical i f ti
PatientKeeper Physician billing system
RelayHealth Patient portal
QuantiaMD Physician education website
RCO/Envision Patient scheduling system
Standing Stone Warfarin management system
Dr. Quality Quality reporting website
Bed Board/ADT Inpatient bed tracking system
NEQCA registry Managed care quality monitoring
Mail Tradition mode of communication
Email General communication
Fax Legacy system
Phone Legacy system
Intranet (phone book, Up to Date) Information resources
Veriphy
p y Radiology critical result reporting
gy p g
SoftMed/ESA Electronic signature for dictations
Michael Wagner, 2009

68. Lessons earned
Like the field I showed earlier, an EMR needs constant
tending. The work flows may be automated, but the field
and hardware get old, broken and fail to keep up with the
changing landscape. Patient, problem and medication lists
need to be updated constantly.
dt b d t d t tl
Decisions must be made up front on who and how the
product will be maintained. Some of that maintenance will
need to b done by clinical people, so i
d be d b li i l l invest accordingly.
di l
Information systems are popping up everywhere and there
is little integrative analysis being done when a new system is
selected and implemented. The end result is clinicians
interacting in a fragmented digital landscape. Which will
only worsen physician satisfaction and increase patient risk
Michael Wagner, 2009

69. THANK-YOU