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Reliant Medical Group Atrius Health iHT2 Health IT Summit, Boston MA May 14 th , 2014 Larry Garber, M.D. Medical Director for Informatics Reliant Medical Group/SAFEHealth
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ReliantMedical GroupAtrius Health
iHT2 Health IT Summit, Boston MA
May 14th, 2014
Larry Garber, M.D.
Medical Director for Informatics
Reliant Medical Group/SAFEHealth
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Building the foundation for transformation
Efficiency improvements
Quality improvements
Safety improvements
Return on investment
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Medical Director for Informatics x 16 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
Internist at Reliant (AKA Fallon Clinic) x 28 yrs
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•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, member of Atrius Health & ACO
•At financial risk for 80% of our patients
•Winner of HIMSS Davies Award for implementing HIMSS Stage 7 EHR
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Electronic Health Record
Patient Engagement Tools (Personal Health Record, Home monitoring, etc…)
Health Information Exchange
Clinical Decision Support
Healthcare Analytics and Reporting Tools
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Completed rollout in 2007
100% utilization by all physicians and staff
Includes the MyChart Personal Health Record for patient engagement
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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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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
© 2014 Epic Systems Corporation
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Mckesson &
Patient References
5 Hospitals
and 8 SNFs
CareEverywhere to
Other Sites
Reliant’s EHR &
Data Warehouse
Home Health
Agency
Patients
Ancillaries
(Surescripts,
QS1, Quest Lab,
MUSE EKG,
Infinitt PACs +
Powerscribe)
4 Payers
Health Coach
Disease Management
Registry
Vignette Document
Imagingto
Community MDs
MA DPH
Immunization Registry
Transcription
and
Dragon
Clinician
References,
Intranet
CCDs
Appt Reminder IVR
Clark
Mailing
Service
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St. Vincent
Hospital
Reliant Medical
Group’s Epic EHR
Outside
Record Icon
in MedHost
Bedboard
blinks
CCD with
SVH MRN
ADT for
Reliant
Patients
CCD with
SVH MRN
30 seconds after ED registration, Reliant’s CCD is automatically loaded into ED’s EHR
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FCHP
Hospitals
RefLab
PBMImagingCenters
SoloMD’s
Reliant
Medical
Group
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FCHP Claims medication list and fill hx
FCHP and Fallon Clinic 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)
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Factor Criteria Points
DxCG Likelihood of Hospitalization Score (Model 71)
Individual Patient Score >= 0.25 (90th Percentile)
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Hospital Admissions or ED Visits Three or More in past 12m 3
Behavioral Health (Psychiatric, Substance Abuse, Dementia)
Active Diagnosis (Enc or Prob List) 2
CHF or COPD or CKD Active Diagnosis (Enc or Prob List) 1
Poly-pharmacy (Exclude topical &supplies)
14+ active medications on current EPIC medication list
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Maximum Score 10
Risk Level Flag Score % Total
Low 0 58%
Medium 1 - 2 26%
High 3 – 7 13%
Very High 8 - 10 2%
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Risk Score Calculated with 2011CY data
Outcome Window = 1st 6 months 2012
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Have the right person do the work
Use the right tools
Re-use data whenever possible
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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
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Chief Complaint(s)
Allergies/Medications (including OTC)
Preferred Pharmacy
Pends medications that need renewals
Full Social and Family History
Vital signs
Rooming note
Loads MD’s note template & pastes last CPE
Review of Systems and Health Risk
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© 2014 Epic Systems Corporation
Decision Support built into documentation:Payer/visit/patient-specific template
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Where do you start?
© 2014 Epic Systems Corporation
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AutomaticallyPopulates
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10 – 12% of Radiology orders at Reliant were ordered incorrectly and required changing
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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.
2014;36(4):1033–1046.
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No Clinical
Decision
Support
No change
with the
EHR!
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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
© 2014 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
© 2014 Epic Systems Corporation
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Barometer of
Actionable
Deficiencies
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4141
4242
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Hypertension Control was 69%, significantly below 90th Percentile of 73% for nation
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Graph of BP readings revealed peaks every 10 mmHg
Staff were rounding up to the next higher multiple of 10
Abnormal readings were not rechecked
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Digital Cuffs
Real-time alerts for abnormal readings
Monitoring compliance with repeating abnormals
Nurse Blood Pressure Clinics
Pharmacist review of patients with poor BP control and diabetics not on ACE/ARB
Report cards showing site-specific performance
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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
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More than 1200 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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• 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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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
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Automatically generated
Automatically sent to Anticoag Clinic InBasket
Anticoag clinic makes sure follow-up INR ordered
© 2014 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
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Avg. Massachusetts FFS: $13,000+
Avg. Massachusetts ACO: $12,000+
Atrius Health ACO: $10,700
Annual Cost Per Patient (Age 65+)
(12 months ending March 2014)
© 2014 Atrius Health, Inc. All rights reserved.
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With thoughtful use of the EHR, HIEs, clinical
decision support, and analytics, you can
improve the quality, outcomes, safety, and efficiency of healthcare
delivery
