Best Practices for Optimizing Your EHR: Lessons from the Field

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American College of Physicians

Internal Medicine 2014

Best Practices for Optimizing Your EHR:

Lessons from the Field

Faculty

Moderator: Peter Basch, MD, FACP

Disclosure: Has no relationship with any proprietary entity producing health care goods or services consumed by or used on patients.

Panelist(s): Mitchell A. Adler, MD, JD, MPH, FACP

Thomas R. Yackel, MD, MPH, MS, FACP

1.ACP members will share experiences and perspectives on building effective, health IT-enabled practices. 2.How can workflow modifications maximize efficient and effective use of an EHR through the use of staff, patient, and clinical decision tools?

3.What general tips and tricks can enhance the use of the EHR (not vendor-specific)? 4.How to evaluate and use add-on EHR products, including registries?

Clinical questions to be addressed:

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Best Practices for

Optimizing Your EHR:

Lessons from the Field

IM 2014 – PN 033 – Saturday - 12 April 2014 Moderator

Peter Basch, MD, FACP

Panelists

Mitchell A. Adler, MD, JD, MPH, FACP Thomas R. Yackel, MD, MPH, MS, FACP

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Reminders

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Please put phones on silent/vibrate mode

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Please complete and return evaluations



Please hold your questions till the end of the

session

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Disclosure of Financial Relationships

Peter Basch

Has disclosed relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

ePocrates – Clinical Advisory Board

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Disclosure of Financial Relationships

Mitchell Adler Thomas Yackel

Have no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

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Peter Basch, MD, FACP

General internist in Washington, DC

Early adopter of EHRs, ePrescribing, etc.

Medical Director for EHR and Health IT Policy, Medical Director for MedStar Million Hearts® – MedStar Health

Chair, Medical Informatics Committee, American College of Physicians

Senior Fellow in Health IT Policy, Center for American Progress

Visiting Scholar in Health IT Policy, Engelberg Center for Healthcare Reform, Brookings Institution

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Mitchell A. Adler, MD, JD, MPH, FACP

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General internist in New York

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Chief Medical Information Officer at North Shore-LIJ Health System

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Member, Medical Informatics Committee, American College of Physicians

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EMR implementer, user, and optimizer since 1998

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Thomas R. Yackel, MD, MPH, MS, FACP

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General Internist at Oregon Health & Science University, Portland, OR

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Chief Health Information Officer and head of Clinical Informatics Department

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Member, Medical Informatics Committee, American College of Physicians

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Member, HIMSS Davies Award Selection Committee, 2010-2013

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Led enterprise EHR implementation 2006-2008

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Medical Informatics Curriculum – IM 2014 (Room 414 CD)

 Diagnosing EHR Pain: Can I Fix It? (PN 031)

 Thursday, 7:00-8:00 am

 Treating EHR Pain: Time to Replace It? (MTP 117)

 Thursday, 8:15-9:15 am

 Implementing eMessaging, Non-Visit Based Care, and Social Media to Engage Patients and Improve Care

(MTP 107)

 Thursday, 11:15 am-12:45 pm

 Preparing for Meaningful Use Stage 2 and Beyond (PN 003)

 Friday, 11:15 am-12:45 pm

 Best Practices for Optimizing Your EHR: Lessons from the Field (PN 033)

 Saturday, 11:15 am-12:45 pm

 Implementing Quality Measures and Clinical Guidance into the EHR to Improve Patient Care (PN 004)

 Saturday, 2:15-3:45 pm

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Clinical Questions / Learning Objectives

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ACP members will share experiences and perspectives on building effective, health IT enabled practices

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Enhancing your efficiency and effectiveness The role of workflow modifications

Optimizing staff

Inclusion of the patient / family member(s) General “tips and tricks”



How to evaluate and use add-on products, such as registries

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Why Is This Topic Necessary?

1

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Why is This Topic Necessary? – 2

Yarnell, et al., Am J Public Health 2003 April; 93(4): 635-641 Ostbye, et al., Ann Fam Med 2005 May; 3(3): 209-214 Yarnell, et al., Prev Chronic Dis 2009; 6(2): A59

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EHRs to the Rescue!

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Why is This Topic Necessary? – 3

American EHR Survey, 2010 – 2012

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Difficulty with improving care

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Difficulty returning to pre-EHR productivity

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Dissatisfaction with EHRs www.acponline.org

Rand Study on Physician Satisfaction

The Pros and Cons of Electronic Health Records

 Physicians approved of EHRs in concept and appreciated having better ability to remotely access patient information and improvements in quality of care.

 However, for many physicians, the current state of EHR technology significantly worsened professional satisfaction in multiple ways.

 Aspects of current EHRs that were particularly common sources of dissatisfaction included poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information, and degradation of clinical documentation.

Friedberg MW Et. Al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, 2013. http://www.rand.org/pubs/research reports/RR439.

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Inefficiency Correlated With…

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Less time in training

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Less time in understanding processes in their offices

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An implementation approach such as this… www.acponline.org

Efficiency Correlated With…

Previously efficient with paper records

Training and demonstrated proficiency with EHR

Focused on workflow Optimization of staff (not just themselves) www.acponline.org

Optimizing Your EHR…

Necessary, but not sufficient

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Technology better able to accelerate efficient processes

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Technology less likely to fix bad processes

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If poorly implemented and poorly used – very

likely to make bad processes even worse

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Optimization of Effectiveness and Efficiency

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Understanding processes and workflow Re-engineering processes workflow and process

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Optimizing existing technology

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Planning for / implementing additional technology (where needed)

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Taxonomy of Optimization

When

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Pre-visit

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Visit

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Post-visit (between visits) What / How

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People

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Workflow

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Technology www.acponline.org Taxonomy of Optimization – Example: Pre-Visit When Pre-visit What / How People

On-time (staff, patients)

On-time PLUS (you!)

Workflow

Front-desk – pre-visit form(s)

Technology Portal

Other secure mobile technology

Having all technology ready for you

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Example of Optimization – Embedding Million Hearts® into Practice

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THIS IS NOT ROCKET SCIENCE!

Million Hearts® Simply Asks for a More Consistent Application of What We Know

(AND PERFECTION ISN’T REQUIRED TO MAKE A DIFFERENCE)

• Of the ~2M heart attacks and strokes occur each year, achieving the 2017 goals would reduce the number of new heart attacks / strokes by 10% per year

• Over 5 years – prevent 1M new heart attacks / strokes

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A Clinical Program to Provide Consistently Better CV Care for our Primary Care Patients

 All MedStar primary care sites will have information available about Million Hearts® and MedStar's partnership efforts.

 Every adult patient who receives care from a MedStar primary care provider will be appropriately screened for high blood pressure and high cholesterol and will also be encouraged to discuss Million Hearts®with their PCP and have their cardiac risk assessed.

 Every adult patient who should be on aspirin (without allergy or contraindication ) will be encouraged to take aspirin.

 Every adult patient will have evidence-based goals set for their BP and cholesterol results; those with elevated BP and/or cholesterol will be optimally treated towards those goals.

 Every adult patient will be assessed for smoking, and if they smoke, they will be optimally managed towards cessation.

 Every adult patient will be provided with an individualized end-of-visit summary – showing their current ABCs “report card,” and reasonable steps they could take to further reduce their risk of heart disease and stroke.

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Leveraging the EHR to Make Awareness and Adherence to the “ABCS” Easier…

What Nobody Sees… (Unless They Choose To)

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Form that opens in the background of all adult medicine visits

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Auto-calculates

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Our Approach to Avoid “Alert Fatigue” – Embedded Protocols Targeted to PCP Providers – ONLY Prompts When Necessary Information is Missing, Out of Date, or When a Goal is Unmet

This approach used for all protocols – but for Million Hearts® we lead with a “global” prompt, and we pre-check it – such that it auto-cascades if goals are unmet www.acponline.org

Our Approach to Make Doing the Right Thing Easier AND Reduce Documentation Burden  ‘ABCs’ prompts show protocol AND relevant prior information in the EHR  The prompts also contain most all reasonable actions – adding / changing meds, creating referrals, etc. Checkbox choices also create documentation in the note AND structured data for future analysis and reporting.

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Example of the Prompt Cascade – When All of the ‘ABCS’ Goals are Unmet

Patient Engagement – Poster in Reception Area and Personalized ‘ABCS’ Report to Patients

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How Are We Doing 1 yr into this 5 Yr Plan? Already Surpassing All 2017 Targets!

Intervention 2012 Baseline

2017 Target

MedStar Health – November 2013

Aspirin for those at high risk 47% 70% 86% Blood pressure control 46% 70% 71% Cholesterol control 33% 70% 77% Smoking cessation Smoking prevalence 23% 21% 70% 19% 76% 13% (down 11% from 2012) www.acponline.org

What Makes Million Hearts® Possible? Compelling / understandable

Built into office workflow

Optimized EHR

Automates

Goal setting

Algorithms for determining need for information, consideration of treatment

At goal status

Individualized information for patients

Actionable information displays

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Panelists – Drs. Adler & Yackel

Walk us thru a visit / multiple visits – pointing out practical “optimization opportunities”

Comments on optimization taxonomy

How to evaluate the need / benefits of technology add-ons

Provide examples from your experience of best practices for optimizing efficiency and effectiveness

How can we collectively share / adopt best practices for health-IT enabled care optimization

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Lifecycle of Optimization – Questions to ask before beginning an optimization…

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What are we optimizing for?

Efficiency? For whom? (provider, staff, patient)

Quality and Safety?

Patient experience?

Privacy? Compliance?

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What are our biggest goals and opportunities?

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What problems are we trying to solve?

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Early Optimization Efforts

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Assembled 2 “optimization teams” of 5 FTE that “returned” to practices 1-2 years after go-live to address issues

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Included scheduling/patient access, billing, clinical workflow, and trainers

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Optimization Oversight Committee assembled metrics, reviewed plans, made decisions on scope and timing

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Rollout Status

As of Monday 11/15/10

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Meaningful Use Metrics

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Efficiency Metrics

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“Issues Addressed” became a major measure of success

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Results were mixed at best…

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Optimization 2.0 – revamping the “team”

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Optimization team was disbanded

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IT resources returned to their individual

“teams”

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Reorganization to assign IT resources to a portfolio of practices

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IT resources got to know their practices, working on issues continuously

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Participated in institution-wide topic-driven “optimizations”

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Identifying a problem

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Optimization 2.0 – Improving

communication with referring providers

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Problem: Referring providers told us our practice was a “black hole”

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Diagnosis: Workflow and tools were studied to determine the underlying problems

Creating letters fell to providers Time consuming, extra work Optional

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Implementation: Designed with vendor, implemented within the practice

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Results continuously measured and fed back

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AutoLetter was born!

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A letter was automatically queued up for the provider to the appropriate referring provider(s) and PCP(s)

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Consultants can use the default letter or edit on their own

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Letters automatically sent when the visit is finalized

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Consultants could “delete” the

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Results – First Live Department

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Optimization 2.0 – The approach

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Leadership was engaged to determine what

needed to be improved based upon anecdotes which lead to data collection

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The workflow was studied and the requirements for a “solution” were determined

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Implementation was conducted

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Results continuously measured

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Lifecycle of Optimization: Is the EHR really the “problem”?

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The EHR is frequently identified as the “problem” but root cause analysis often shows there are workflow problems

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EHR may shine a bright light on previously

loosely coupled workflows

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Workflow analysis with focus on underlying assumptions and documentation of “standard work” an early step in diagnostic stages of optimization effort

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Lifecycle of Optimization: How do we implement the solution?

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Disrupting existing workflows is hard for everyone

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Expect some people to “lose” with the changes (especially in big organizations)

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Standardize communication, update

documentation

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Optimization will put your change management system to the test

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Lifecycle of Optimization: How do you know if it worked?

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From the start make sure your goals are measurable

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If you’re not willing to measure it, consider how important it really is

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Take the time to “prove” the benefits of optimization

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Optimization is expensive; benefits must be demonstrated to ensure ongoing resource commitment

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Lifecycle of Optimization

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Set a goal

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Perform diagnosis

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Implement the solution

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Enhancing EMR Usability

with

Work Flow Improvements

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Radiology Report Delivery

Pre-Optimization

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Radiology Report Delivery

Post-Optimization

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Lab Result Delivery

Private Offices

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Lab Result Delivery

Clinic Pre-Optimization

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Lab Result Delivery

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Questions???

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ACP Resources

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AmericanEHR Partners (www.americanehr.com)

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ACP Practice Advisor (www.practiceadvisor.org)

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ACP Physician & Practice Time Line

(http://www.acponline.org/running_practice/physician_practice _timeline/)

ACP Running a Practice

(http://www.acponline.org/running_practice/technology/)

MGMA/ACP Collaboration – Benchmarking & Resources (http://www.mgma.com/industry-data/participate/acp-mgma-resources)

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Where to find answers to your questions at IM 2014

College Resource Center Briefings in the Exhibit Hall

Tools for Practice Improvement

Thursday, 4:05 pm

Friday, 3:55 pm

Saturday, 1:05 pm

Tools to Meet Federal Requirements and Reporting

Friday, 4:05 pm

Saturday, 12:55 pm

ACP staff experts will be on hand to answer questions and discuss concerns.