Presentation from the Massachusetts eHealth Institute Regional Health IT meeting in Worcester, MA in November, 2013. Featuring Larry Garber from Reliant Medical Group.

1. MeHI Regional Meeting – Worcester
November 4th, 2013
Reliant
Medical Group
Atrius Health
Larry Garber, M.D.
Medical Director for Informatics
Reliant Medical Group

2. 
Building the foundation for
transformation with an EHR and HIE

Safety improvements

Quality and outcome improvements

Efficiency and satisfaction improvements

Return on investment
2

3.  Internist
at Reliant
(AKA Fallon Clinic) x 27 yrs
 Medical
Director for
Informatics x 15 years
 Principle Investigator
for $3.5M AHRQ and
ONC grants for SAFE
Health and IMPACT HIEs
in Massachusetts
 Chair, MAeHC
 Member ONC HIT Policy
Committee’s HIE
Workgroup and Privacy
& Security Tiger Team,
and MA HIT Council
3

4. •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
4
4

5. 5

6.  100% utilization by all physicians and staff
 Includes the MyChart Personal Health Record for
patient engagement
6

7. 
Electronic (from legacy repository)

Manual Abstraction by dedicated team

Document Imaging (scanning/indexing)
7

8. 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

8

9. Allergies
 Family History
 Growth chart data
 Problem Lists

9

10. 
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)
10

11. 1.
2.
3.
Practice Management
(Registration/Scheduling/Billing) and
Clinical Results Repository
Paperless Telephone Messaging and
Prescribing
Computerized Physician Order
Entry/Documentation/Billing in Exam
Room
6 month gap between phases gave time
for users to become proficient
11

12. 12

13. 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
13

14. 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

14

15. CareEverywhere to
Other
Sites
to
49 Community MDs
1 Home Health
Agency
5 Hospitals
(8 SNFs 12/2013)
CCDs
Ancillaries
(Surescripts,
Quest Lab,
MUSE EKG,
Infinitt PACs +
Powerscribe)
Mckesson &
Vignette Document
Imaging
Reliant’s
EHR &
Data Warehouse
Transcription
and
Dragon
4 Payers
MA DPH
Immunization Registry
Patient References
Clark
Mailing
Service
48K Patients
Clinician
References
Health Coach
Disease Management
Registry
Appt Reminder IVR 15
15

16. 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

© 2013 Epic Systems Corporation
16

17. Hospitals
Solo
MD’s
Ref
Lab
FCHP
Imaging
Centers
PBM
Reliant
Medical
Group
17

18. 

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)
18

19. February 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)
19
19

20. 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

20
20

21. 
9/2011 –Selection Criteria:

16 Winning Pilot Sites:
◦ High volume of patient transfers with other pilot
sites
◦ Experience with Transitions of Care tools/initiatives
◦ 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 Facilities
21
21

22. 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

22
22

23. 
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) (golive 12/2013)
23
23

24. 
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 2014
24
24

25. Starting November 2013
 30 seconds after ED registration, Reliant’s
CCD is automatically loaded into ED’s EHR

ADT for
Reliant
Patients
St. Vincent
Hospital
Reliant Medical
Group’s Epic EHR
CCD with
SVH MRN
CCD with
SVH MRN
Outside
Record Icon
in MedHost
Bedboard
25

26. 26

27. 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

27

28. 
Special message in ED note triggers
copy of message to move to top of
note and routing to PCP InBasket
28

29. 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

29

30. 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

30

31. •
•
•
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.)
31

32. © 2013 Epic Systems Corporation
32

33. © 2013 Epic Systems Corporation
33

34. © 2013 Epic Systems Corporation
34

35. Automatically generated
 Automatically sent to Anticoag Clinic
InBasket
 Anticoag clinic makes sure follow-up INR
ordered

© 2013 Epic Systems Corporation
35

36. 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
36

37. 37
37

38. © 2013 Epic Systems Corporation
38

39. Where do you start?
© 2013 Epic Systems Corporation
39

40. 40

41. © 2013 Epic Systems Corporation
41

42. 42

43. Reliant had two patients where lung
nodules were incidentally found on
abdominal CT scans at other
institutions for diverticulitis and
appendicitis, and were not followedup until metastatic cancer was
diagnosed 1-2 years later
43

44. © 2013 Epic Systems Corporation
44

45. © 2013 Epic Systems Corporation
45

46. 


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
46

47. 47

48. 

1.
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
American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care.
2013;36(4):1033–1046.
48

49. 49

50. Just prior to patient visits
 During patient visits
 In between patient visits

50

51. 

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
© 2013 Epic Systems Corporation
51

52. 

Nurses automatically receive Epic InBasket
message 1 week prior to next visit
Records interval hx, educates and checks labs
© 2013 Epic Systems Corporation
52

53. Last date
Next order
But doesn’t ask for an order if it’s not due or
already ordered
© 2013 Epic Systems Corporation
53

54. Barometer of
Actionable
Deficiencies
54

55. 55

56. 56
56

57. 57
57

58. Lower Health
Care Costs
Reliant Medical Group’s
Medicare Diabetics’ Costs
are less than 96% of the
best group practices in
the nation!
58
58

59. 59

60. © 2013 Epic Systems Corporation
60

61. © 2013 Epic Systems Corporation
61

62. © 2013 Epic Systems Corporation
62
62

63. Have the right person do the work
 Use the right tools
 Re-use data whenever possible

63

64. 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 phone
4. The medical assistant that rooms patient
5. The doctor assisted by speech recognition
6. The doctor assisted by transcriptionist
7. The doctor typing
8. A scribe typing
64

65. 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

65

66. 
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
66

67. Payer/visit/patient-specific template
guides visit
© 2013 Epic Systems Corporation
67

68. © 2013 Epic Systems Corporation
68
68

69. 69

70. 70

71. 71
71
71

72. 64% “Very Satisfied”
with “Computers”
(AMGA Avg = 60%)
72
72
72

73. 73
73
73

74. 74

75. •
•
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
75

76. Payer/visit/patient-specific coding
guidance to physicians
© 2013 Epic Systems Corporation
76

77. Payer/visit/patient-specific coding
guidance to physicians
© 2013 Epic Systems Corporation
77

78. © 2013 Epic Systems Corporation
78

79. 
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
79

80. 
V codes can’t be used with regular visits

V codes must be used with preventive visits

E 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)
80

81. © 2013 Epic Systems Corporation
81

82. 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
82

83. © 2013 Epic Systems Corporation
83

84. © 2013 Epic Systems Corporation
84

85. © 2013 Epic Systems Corporation
85

86. Reliant’s RAF (HCC) Scores
$16 Million increased
revenue!
86

87. 87

88. 

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
88

89. Because of the EHR, HIEs,
clinical decision support,
and analytics, we improved
the quality, outcomes,
safety, efficiency of, and
satisfaction with, healthcare
delivery
89

90. Lawrence.Garber@ReliantMedicalGroup.org
90