Electronic Medical Records for the Physician Practice Strategies for Navigating the Quagmire

1. Electronic Medical Records for the Physician PracticeStrategies for Navigating the Quagmire Kevin Kennedy, MHS, CPHQ, CPHIT Director of Quality Improvement October 24, 2008

3. Institute of Medicine Reports • “To Err is Human, Building a Safer Health System” (1999) • “Crossing the Quality Chasm: A New Health System for the 21st Century” (2001)

4. Institute of Medicine Report “To Err is Human…” Top 10 Causes of Death in 1998 • Heart Disease 724,269 • Cancer 538,947 • Stroke 158,060 • Lung Disease 114,381 • Medical Errors 98,000* • Pneumonia 94,828 • Diabetes 64,574 • Motor Vehicle 41,826 • Suicide 29,264 10. Kidney Disease 26,295 * Estimated

5. “The Right Care forEvery Person Every Time.” Stephen Jenks MD, Former DirectorQuality Improvement GroupOffice of Clinical Standards and Quality Centers for Medicare and Medicaid Services

6. Electronic Medical Records (EMR) Avoid Medical Errors • Availability of records • Enhance communication • Provide decision support • Reduce medication errors • Improve quality measures • Provide economic benefit? Bates, David MD, Family Practice News, October 15,2004

7. Medicine is a Very “Communication Intensive” Industry Enhanced communication between physicians, settings, and patients can: • Coordinate chronic disease management and medications • Improve quality of referrals and consults • Avoid medical errors that lead to liability

8. Electronic Medical Records • “At the turn of this century, . . .the average industry was investing $8,000 per employee on computer technology, health care was spending $1,000. • By now, if you belong to a frequent shopper club, your grocery store almost certainly has far more computerized data than your healthcare provider..."

9. Electronic Medical Records "With almost three-quarters of physicians in solo or small-group practice settings, it is critical to recognize not only the financial barriers, but the greater need for technical assistance in implementing electronic health records, compared with physicians in larger healthcare settings with existing support systems. . .” Anne-Marie Audet, Vice President The Commonwealth Fund

10. Primary Objectives • Describe EMR basics • Discuss the six stages involved in adopting an EMR system • Assessment, planning, selection, implementation, evaluation, and improvement • Share our experiences with clinics in Nevada and Utah

11. “I just don’t see how doctors can stay in the game unless they are somehow plugged into an electronic medical record” Tufts-New England Medical Center, CEO, The Boston Globe, Feb. 10, 2006

12. HIT vs. EMR/EHR • Health information technology (HIT) is a general concept • Electronic medical record (EMR)/electronic health record (EHR) is a specific concept relating to systems having the ability to capture data from various sources for clinical decision support at the point of care

13. The Burning Platform for EMR Systems • During the 1990’s, EMR system adoption was usually limited to larger organizations • Currently, 20 to 30% of outpatient clinics use EMR systems (20% in NV and 30% UT) • Estimated that 50 to 60% over the next several years • Small outpatient practices expected to be fastest growing sector for EMR system adoption

14. What Are Benefits of EMR Systems? • Improved care • Views of entire medical histories • More efficient workflow – reduce the paper chase • Generate patient specific reminders • Reference medical research and protocol data at the point of care to enhance diagnostic and treatment plans

15. What are the Benefits of EMR Systems? • Reduction of errors • IOM report • Coding confusion, illegible documentation, poor information management contribute to errors • EMR systems improve documentation and communication and assist in managing critical information

16. What is the Business Case?

17. Return on Investment (ROI) • The amount of time it will take your practice to re-coup the dollars spent on the EMR project. • Process of confirming that the system is delivering anticipated benefits. • Is it required? No, But it will help in demonstrating, evaluating, and assessing the success of the project.

18. Financial Benefits • Reduction in Costs • Storage space • Transcription services • Staff time pulling and filing paper records

19. Reduction in Costs • Some vendors state an ROI is possible within 12 months while others state over three years • Low hanging fruit is reduction in transcription costs • Potential staff reduction or reallocation • If average physician needs four FTEs for support, this number can be reduced by at least one FTE with an EMR

20. Increased Revenues • Many providers down-code to prevent claims from being denied • EMRs assist providers in coding to assure that the correct codes are used with support documentation • More accurate coding can decrease claims denials, increase reimbursement rates, and improve cash flow via shorter billing-to-payment cycles • EMR is vital tool for improved reimbursements through pay-for-performance initiatives

21. The Big Picture

22. “The impact and expectation of cost-justifying patient safety IT initiatives using a traditional ROI must evolve to focus beyond the financial benefit. It must encompass overall patient safety, patient satisfaction, and employee andphysician satisfaction benefit categories” L.M. Newell “Who’s Counting Now? ROI for Patient Safety Initiatives”, Journal of Healthcare Information Management

23. Satisfaction • Provider – Leave the office earlier – Access patient information remotely – Better understanding of the practice operations – More time spent caring for patients – Less time spent chasing charts, paper, and resources

24. Satisfaction • Staff – Cleaner workflows – less waste – Better understanding of roles and responsibilities – Leave the office earlier – More advanced skill sets • Patient – More information about the office visit – Better access to health information – Better organized office

25. EMR System Technical Options • Interfaced practice management (PM) and EMR systems vs. integrated • Terms often used interchangeably although difference can be significant • Interfaced – independent applications that talk to each other • Integrated – share common master files • All modules usually come from a single vendor or two closely linked vendors

26. Hosting Options • Application Service Provider (ASP) • Lease EMR application and network, hardware and IT maintenance services • Beneficial for smaller practices lacking IT expertise • Significantly reduces initial investment

27. Hosting Options • On Site • Clinic purchases software license, network servers, operating systems and employ or contract for maintenance • System backups completed on site • Security issues are clinic’s responsibility

28. So, how does a clinic even begin the process?

29. Challenges of EMR Transition • Failure to plan properly • The horror stories - systems going down • Problems with vendors • Change is difficult • Investing in EMR but not fully utilizing the product

30. The Six Stages of EMR Migration

31. Stage 1 - Assessing Your Readiness • Challenges and financial impacts involved in successful EMR implementation can’t be ignored • Critical that physicians and management evaluate whether your practice is ready to take on the challenges

32. Assessing Readiness • Decision-Maker Buy-In • Does everyone agree on the goals and expectations for the EMR system? • Do you have a physician champion?

33. Assessing Readiness • Staff Buy-In • Is your staff capable and enthusiastic about installing an EMR system? • Will the key staff members have the patience and willingness to be involved in the transition?

34. Assessing Readiness • The Learning Curve • Can your practice afford the financial impact of reduced patient volume for a 2-3 month period? • Will the physicians have the time and patience for an EMR system transition period?

35. Assessing Readiness • Practice Management Integration • Have your physicians and management carefully considered the differences between an interfaced and integrated system? • What is your level of satisfaction with your current PM system? Are you willing to trade it for a new integrated system?

36. Practice Tasks During Assessment • Assess current workflow • Begin/continue regular staff meetings • Assign physician champion • Organize EMR selection team

37. Stage 2 - Practice Tasks During Planning • Write down the clinic goals and priorities (these should be agreed upon previously) • Translate goals into available EMR system functions and features • Address concerns of staff with lower levels of readiness • Develop a timeline and project plan

38. How to Select an Electronic Medical Record System “A natural tendency might be to call a few vendors.. and ask them for a demo. Stop. Unless you want the vendors to control the selection process, you need a plan.” K. Adler, Family Practice Management, February 2005

39. Stage 3 -Vendor Selection • Use translated goals list of functions and features – your rating system • Create a clinic-specific case scenario • References and sites visits – don’t skip! • Additional hardware and support plans • Negotiating a contract

40. Partners for Patients ElectronicHealth Record Market Survey American Academy of Family Physicians Center for Health Information Technology

43. Stage 4 - Implementation • Workflow analysis – have a plan for changes (roles, scanning, handoffs, etc.) • Data conversion, interfaces, testing • Recovery and security planning • Training – iterative and “super users” • Go-live – modify workload

44. Major Workflows Associated with the Patient Visit • Scheduling • Check-in/registration • Authorizations • History and physical • Provider’s SOAP process (Subjective/Objective/Assessment/Plan) • Labs/imaging/medication orders • Referrals • Checkout • Billing

46. Stage 5 - Evaluation • Workflow analysis – identify problem areas • Additional training/learning • Check progress towards initial goals • Using data in your EMR to improve care • Ongoing checks – all staff (workarounds?)

47. Stage 6 - Improvement • Workflow analysis • Identify bottlenecks, possible role redesign • Using data to check progress • First step is checking data integrity – never perfect • Next – set goal(s) and track progress • Find “best practices” internally and externally • Use the EMR to its capacity

48. Experiences Thus Far“The transition is a process NOT an event” • Difficult to generate specific ROI but it is possible to have a general idea of ROI • Sometimes too many choices with EMR vendors – one size does not fit all • Clinics find it challenging to use 100% of system capacities

49. Summary • EMR is a valuable tool to improve outcomes • EMR helps to deal w/complexity of decisions being made under time constraints • EMR can help reduce medical errors and liability risk

50. Discussion