Running Head: TINY TOWN CLINIC CASE ANALYSIS 1
Tiny Town Clinic Case Analysis:
Hybrid Delivery Model for Physical Therapy Services
Laurie Burke, Celia Dolinta and Harry E. Scher
Texas Woman’s University
Author Note1
Laurie Burke, The Houston J. and Florence A. Doswell College of Nursing, Texas
Woman’s University; Celia Dolinta, The Houston J. and Florence A. Doswell College of Nursing,
Texas Woman’s University; Harry E. Scher, The Houston J. and Florence A. Doswell College of
Nursing, Texas Woman’s University.
1 Alphabetical order
TINY TOWN CLINIC CASE ANALYSIS 2
Table of Contents
Tiny Town Clinic Placement in the Micro/Meso/Macro Systems Conceptual Framework………3
Services Needed for Tiny Town Clinic with Rationale………………………………………… 4 Finances…………………………………………………………………………………………..20 Current Revenue and Sources…………………………………………………………...20 Potential Funding Sources……………………………………………………………….21 Proposed Budget………………………………………………………………………...21 Current Workflow in Tiny Town Clinic………………………………………………………... 22 Measurable Outcomes from EHR, PT and Telehealth Services to Document Quality of Care... 23 Outcome A - EHR - Demographic Data Entry on 80% of All Patients ………………..26 Outcome B – Physical Therapy – Glycosylated Hemoglobin on Diabetics……………..26 Outcome C – Telehealth – Weight Loss and Glycosylated Hemoglobin………………..26 Decision Regarding Recommended Products and Rationale for Selection……………………... 28 Electronic Health Record………………………………………………………………..28 Physical Therapy Equipment……………………………………………………………30 Telehealth Equipment…………………………………………………………………...30 Project Management Plan……………………………………………………………………….. 30 Summary Document of Recommendations…………………………………………………........35 References………………………………………………………………………………………. 36
TINY TOWN CLINIC CASE ANALYSIS 3
Appendices……………………………………………………………………………………… 42 Appendix A – Physical Therapy Advisement Form…………………………………….42 Appendix B – Physical Therapy Consultant Recommendations………………………..48 Appendix C - High Performing Clinical Microsystem………………………………… 53 Appendix D - Listing of Recommended equipment for Tiny Town Clinic…………… 54 Appendix E - Tiny Town Clinic Patient Flow Chart………………………………….. 55
TINY TOWN CLINIC CASE ANALYSIS 4
Tiny Town Clinic Case Analysis: Hybrid Delivery Model for Physical Therapy Services
Tiny Town Clinic (TTC) is the only healthcare facility in Tiny Town. It is located
approximately 45 miles to the nearest clinic. The clinic serves a community of 2,818 and meets
the primary healthcare needs of the local population as well as those who are temporarily
relocated to the area for employment purposes. A nearby border patrol station brings illegals to
the clinic for medical clearance prior to their being sent to a holding facility. There are also
patients who obtain primary care services at the clinic as their primary care provider is located an
excessive distance from their homes in Tiny Town.
Tiny Town is an example of a microsystem. It provides front line health care services
to a significant number of people in the community. The clinic is part of a larger health system.
There is no business manager on site at TTC. Billing functions are facilitated at a remote
location. It is also known that a business/clinic manager is not listed as a clinic employee for the
clinic. (Handouts provided on blackboard regarding TTC). This clinic is also part of a
mesosystem, defined as when two or more clinical or supporting microsystems are joined
(Godfrey & Nelson, 2011). Front line health care facilities need a system for referral for the
patients who may need urgent care specialty care. These referral sites and specialty providers
then become part of the mesosystem that supports TTC. The individual departments and service
providers that are available for TTC fit into a larger organization known as a macrosystem, which
can be a hospital, a multispecialty group practice, or integrated health system (Nelson et al.,
2008). In the case of TTC, the macrosystem is likely to be a hospital or an integrated health
system.
TINY TOWN CLINIC CASE ANALYSIS 5
Needed Services for Tiny Town with Rationale
Personal health portal. Jorch (2007) reports that the patient portal is a secure web site
that displays health records. Patient portals provide a direct communication link with doctors and
nurses. The use of a patient portal in TTC provides the clinic staff the ability to preregister
patients while providing access lab results, writing prescriptions, and billing for services rendered.
Jorch (2007) notes that the biggest challenge of implementing the patient portal is developing
secure communication so that sensitive medical information cannot be accidentally divulged.
MyChart from EPIC is one of the examples that has an integrated the patient portal. MyChart
gives patients controlled access to the same Epic medical records that providers use via browser
or mobile app (iOS and Android). EPIC (2014) noted that the self-serve online functions may
activate patients to improve their own health, reduce the cost of customer service and provide a
vital communication link to support accountable care. MyChart allows patients to access the test
results, view upcoming appointments and complete pre-visit questionnaires. It also provides an
interface that allows patients to schedule appointments, view paperless statement and pay bills,
upload photos, update medications and allergies, and refill prescriptions. A unique software
feature provides a secure messaging function that provides an electronic patient-to-provider
communication tool. While viewing medical records, MyChart provides documents on a wide
array of education topics. The software is also programmed to send patients electronic chronic
disease alerts that are triggered by electronic health record (EHR) data. TTC staff will have the
ability to make decisions on what information is displayed as a matter of course and what should
be available through direct provider-patient interactions.
TINY TOWN CLINIC CASE ANALYSIS 6
E- prescribing. According to Centers for Medicare & Medicaid Services (CMS) (2014), e-
prescribing gives providers the ability to electronically send accurate, error-free and legible
prescriptions directly to a pharmacy from the point-of-care. Pennell (2009) notes that e-
prescribing has been described as the solution to improve patient safety and reduce sky-rocketing
medication costs. It is estimated that approximately 7,000 deaths occur each year in the United
States due to medication errors. Pennell (2009) states that these errors are predominately due to
handwriting illegibility, inaccurate dosing, and overlooked drug-drug or drug-allergy reactions.
There are approximately 3 billion prescriptions written annually, which constitutes one of the
largest paper-based processes in the U.S. (Pennell, 2009). This targets e-prescribing as a vital
element in improving the quality of patient care. CMS reports that adopting the standards to
facilitate e-prescribing is one of the key action items in the government’s plan to expedite the
adoption of the EHR and build a national electronic health information infrastructure in the
United States.
It is essential for TTC to integrate e-prescriptions in their EHR to improve patient safety
and overall quality of care. Since the mesosystem of TTC is a hospital 45 miles away, the
management of TTC should coordinate with the leaders of the hospital to provide resources such
as installation of high-speed internet connection, computers, and an EHR system, which includes
e-prescribing. One networking company that Pennell (2009) has recommended is SureScripts.
TTC may use SureScripts as it is the nation’s largest electronic prescribing network that provides
a true, seamless electronic connection between physician offices and pharmacies. This network
provides secure and reliable two-way transmissions between physician offices and pharmacies
(Pennell, 2009). TTC will realize several benefits if e-prescriptions are integrated in the EMR.
First, TTC will notice an improvement in patient safety and overall quality of care. The
TINY TOWN CLINIC CASE ANALYSIS 7
illegibility from hand-written prescriptions provided by TTC providers will be eliminated,
decreasing the risk of medication errors and liability. The e-prescription system can also provide
an overall medication management process through drug utilization review (DUR) programs.
DUR programs perform checks against the patient’s current medications for drug-drug
interactions, drug allergy interactions, diagnoses, body weight, age, drug appropriateness, correct
dosing, contraindications, adverse reactions, and duplicate therapy alert (Punnell, 2009). Second,
TTC will notice a reduction or elimination of phone calls and call-backs to pharmacies clarifying
orders. Punnell (2009) reports that physician offices receive over 150 million call-backs from
pharmacies with questions, clarification and refill requests. These call-backs interrupt office flow
and reduce productivity related to chart-pulls and refilling, follow-up calls, and faxing
prescriptions. Third, e-prescribing will streamline the refill requests and authorization processes.
Punnell (2009) explains that refill authorizations from the pharmacies can be a completely
automated process and refills can usually be generated in one click of the mouse. The pharmacist
generates a refill request/authorization that is delivered through the network to the provider’s
system. The provider then reviews the request, approves or denies the refill, and the pharmacy
system is immediately updated. Fourth, the compliance rate of TTC will increase. Punnell
(2009) noted that 20% of paper-based prescription orders remain unfilled by the patient. E-
prescribing systems expedite the filling of prescriptions at the pharmacy, and drug literature can
be printed and given to patients. E-prescribing will also increase the convenience for patients in
Tiny Town by reducing patient trips to the pharmacy as well as reducing wait time. Fifth, e-
scribing will improve Tiny Town’s formulary adherence. By checking with healthcare
formularies at point-of-care, generic substitutions and generic first line therapy choices are
encouraged, thus reducing patient cost (Punnell, 2009). Sixth, TTC providers will have full
TINY TOWN CLINIC CASE ANALYSIS 8
mobility of prescribing anytime and anywhere. Seventh, the reporting ability of TTC will be an
improved query reporting system. This function will be helpful in identifying those patients who
are being treated with a medication that is has been recalled or discontinued (Punnell, 2009).
Office management software. Increasingly, providers are seeking software solutions,
such as integrated EMRs/Practice Management (PM) systems that accurately measure and reflect
clinical, financial, and quality improvements. This allows physicians and office administrators to
set performance goals appropriately across the practice. Integrated EMR/PM systems offer the
most comprehensive reporting of hard data and metrics to help manage issues such as population
health conditions, track provider performance, and identify first-time claims rejections. In
addition, less tangible analyses can be performed, such as staff scoring and patient satisfaction
(Hicks & Lieberthal, 2013).
Practice Fusion is a viable, affordable EMR software option for TTC. Practice Fusion is
the largest and fastest-growing healthcare platform, with a mission of connecting doctors, patients
and data to drive better health care practices and save lives (PR Newswire, 2014). Medical
professionals can sign-up for Practice Fusion online anytime and be live with their new EHR
system in just five minutes at no cost. PR Newswire (2014) noted that unlimited meaningful use
support and integration with local labs and imaging centers are included in Practice Fusion’s free
service. PR Newswire (2014) states that Practice Fusion’s free EHR is compliant and has been
certified as a Complete EHR by Drummond Group, approved by the Office of the National
Coordinator’s Authorized Testing and Certification Body (ONC-ATCB) to certify any complete
or modular EHR both ambulatory and inpatient, in accordance with the applicable certification
criteria adopted by the Secretary of Health and Human Services (HHS). PR Newswire (2014)
reports that in a 2014 survey, 83% of Practice Fusion users reported the company’s meaningful
TINY TOWN CLINIC CASE ANALYSIS 9
use dashboard is excellent or above average, and only 29% reported that it is difficult to navigate.
The World Economic Forum recognized Practice Fusion as a technology pioneer for the year
2013. Practice Fusion has partnered as well with free clinics, nonprofits and community health
organizations throughout the country, including the National Association of Free and Charitable
Clinics (NAFC). This free software is an ideal implementation choice for TTC as it complies
with meaningful use requirements for reimbursement from Medicaid and Medicare.
Clinical decision support. Clinical decision support systems (CDS) are designed to
assist the clinician in making decisions about a specific patient. There are several tools including
computerized alerts and reminders to providers, clinical guidelines, condition-specific order sets,
focused patient data reports and summaries, documentation templates, and diagnostic support, to
name a few (HealthIT.gov). The intention is to increase quality of care, avoid errors and adverse
events while improving efficiency. The bottom line is cost effectiveness coupled with quality
patient care. One important consideration is determining the approach in which the system will
work with patients who have co-morbidities, confounding conditions, or other circumstances that
might affect a medically complicated patient (Hyman, 2012). Based on the population seen in
TTC, a beneficial function of CDS would allow communications that will alert the clinicians
about unusual data specific to a particular patient regarding encounters with other providers,
current medications, and tests that have been ordered at other facilities within the health care
system. One example of a clinical decision support tool that was developed by the Veterans
Health Administration (VHA) is called “Tool to Enhance Management of Symptoms (TEMS).
The CDS tool can be used in the EHR to adapt clinical strategies to the preferences, symptoms,
behaviors, and clinical histories of individual patients (Nader et al. 2009). In the VHA, TEMS
collects information on a portable electronic tablet (Panasonic model CF-08) that enables
TINY TOWN CLINIC CASE ANALYSIS 10
respondents to answer questions by using a hand-held stylus similar to a pen, or alternatively by
touching the screen with a finger. After a patient has had vital signs measured, the medical
assistant registers the patient in the tablet-based survey application and remains with the patient in
order to help with any technical difficulties. The tablet queries patients about their symptoms by
using symptom questionnaires. The TEMS elicits symptom information at the time of check-in,
filters, and organizes that information into a concise and clinically relevant EHR note available at
the point of care, and facilitates clinical responses to that information (Nader et al., 2009). TTC
can also create a CDS tool to encompass a wide spectrum of information management necessary
for clinical care. These tools should synchronize with the workflow of a typical visit at TTC.
Health education documents for patients. Practice Fusion is a superior choice for EHR
as it is designed to fit any system. Practice Fusion (2014) notes that this system makes patient
education materials, discharge instructions, and drug information sheets easily accessible within
the provider’s workflow. Practice Fusion also ensures that the educational contents are
evidenced-based, easy-to-understand, and consistent with current medical practices and
guidelines. The content of Practice Fusion is peer-reviewed and updated four times a year by
medical professionals in common specialties. Practice Fusion (2014) reports that the educational
content is written at a 5th to 8th grade reading level to address the needs of the large percentage of
patients with low health literacy. Some of the educational materials are written at or below 4th
grade reading level and are marked as “easy-to-read”. The standards for easy-to-read materials
include creative use of color, subheadings, bullets, and illustrations to increase comprehension.
Practice Fusion also has video options that can engage patients at varying health literacy levels
using digital and animated graphics.
TINY TOWN CLINIC CASE ANALYSIS 11
Provider order entry. Provider order entry in the EHR is a feature that allows providers
to efficiently enter orders into the record after developing the patient plan of care. As one might
expect, some writers refer to this feature as Computerized Physician Order Entry (CPOE).
Numerous articles have been written about CPOE as if it were merely electronic prescribing. As
stated by Hoyt, Yoshihashi and Bailey, (2012), CPOE is the actual feature that orders
medications, lab tests, x-rays, consults and other diagnostic tests (p. 67). Based on the fact that
the TTC has limited resources related to staff and clinical support, an EHR must be selected that
includes a provider order entry feature that is well-designed and comprehensive in scope. Errors
are one of the more serious concerns that plague both the inpatient and outpatient treatment
environments. With the appropriate software installation, TTC can utilize a CPOE system that
rapidly notifies the ordering provider of drug-drug interactions as well as medication dosage
errors. VHA has been using some form of CPOE for the last ten to fifteen years. With the
introduction of CPOE for medication ordering, illegible orders, non-existent hand-written drug
names, imaginary routes and nonsensical schedules were eliminated. A CPOE system that is
integrated with diet and diagnoses can alert providers of incongruent ordering scenarios such as
ordering insulin for a fasting (NPO) patient or a teratogenic drug for a pregnant patient (Dumitru,
2008).
A CPOE for TTC should also include a system of alerts. Alerts can be programmed to
assist the provider in numerous ways. Upon opening the EHR, providers can be alerted to
allergies as well as preventive health reminders and serious psychiatric issues. In the event a TTC
provider chooses to prescribe a medication on the patient’s allergy list, an alert would
immediately appear on the screen. This is an extremely helpful feature, as patients with low
TINY TOWN CLINIC CASE ANALYSIS 12
health literacy often do not know the names or classes of the medications previously prescribed
that may have caused an allergic reaction.
In evaluating any EHR system, one concern to address is how different health care
systems effectively and efficiently shares patients’ medical information. For the patient who has
been referred to the hospital emergency department after presenting to TTC with an acute illness,
prompt access to the patient’s medical records at the hospital emergency department is crucial.
Hopefully, a CPOE may be designed that will allow the provider to place an order that will result
in an immediate transfer of records to other health care providers or systems. While some may
consider the topic of EHR prosaic, it should be abundantly clear that their ultimate adoption and
full interoperability will prove fundamental to the future of medicine (Topol, 2012).
Interoperability with other entities. Interoperability, the exchange in health data
involving more than one medical facility, was cited more often as a barrier than as a facilitator to
EHR implementation in one study done in 2011 (McGinn et al.). Generally, inadequate
interfacing with other information technology systems (IT) was perceived as a barrier by users
and in some cases led to negative outcomes. For example, Ferris et al. (2009) found that when
there was no communication between medical offices and laboratories regarding test results, both
EMR and paper-based systems were required to manage test results. This issue can often lead to
increased time and man-hours required to manage test results that often includes scanning and
shredding documents.
An EMR will be beneficial to TTC only if the clinic system is well interconnected to
the hospital system. It is imperative that interoperability of the systems be such that health data is
available from outlying clinics, diagnostic facilities, and labs that all feed important information
into the system. To provide high quality care there needs to be sharing of data across the care
TINY TOWN CLINIC CASE ANALYSIS 13
continuum and the multiple health care entities that are part of the mesosystem. EHRs can enable
a better quality of care if patients have essential health data accessible to their various providers.
Dr. Enriquez has indicated that her patient population has a large number of patients who have
chronic health issues being managed by other providers (Tiny Town, Texas, 2014). Efficient and
comprehensive care for TTC patients can be accomplished only when TTC providers have access
to outside records, diagnostic and lab results. This access would assist in preventing duplicate
services and create a more efficient healthcare system. A possible barrier to the provision of
efficient care is related to the interoperability with other EMR systems. Other healthcare entities
may be utilizing systems that do not effectively communicate with one installed in TTC. An
interesting perception noted when working with a high school population or one with low
education status reveals that patients often think that because their medical record is part of a
computerized system at one clinical setting, their health information is therefore available at other
facilities where a computerized EMR system is used. While that would be the ideal, it is not
currently reality.
Security. Yang, Lin, Chang, & Jian (2006) note that the protection of patient’s health
information is a very important concern in the information age. American Health Insurance
Portability and Accountability Act of 1996 (HIPAA) is a well-known model in the area protecting
patient information. HIPAA was enacted on August 21, 1996 with the goals of improving the
portability and continuity of health insurance coverage (Yang, Lin, Chang, & Jian, 2006). Yang,
Lin, Chang, & Jian (2006) presented two globally recognized principles in addressing health
information on privacy and security. During implementation of an EMR, TTC must facilitate
processes that assure that both privacy and security issues are addressed. First, the principle of
non-disclosure which states that covered entities may not use or disclose protected health
TINY TOWN CLINIC CASE ANALYSIS 14
information (PHI), except as permitted or required by law. Secondly, when using, disclosing, or
requesting PHI, a covered entity must make reasonable efforts to limit protected health
information to the minimum necessary to accomplish the intended purpose of the use, disclosure,
or request. Yang, Lin, Chang, & Jian (2006) explain as well that with the privacy rule,
individuals have a right to access and amend the PHI. Each individual has the right of access to
inspect and obtain a copy of PHI about the individual in a designated record set; and the right to
have a covered entity amend the PHI or a record about the individual in a designated record set.
The covered entities can deny the individual request, and some PHI are exempted from the
individual’s access, such as psychotherapy notes; information compiled in reasonable anticipation
of, or for use in, a civil, criminal, or administrative action or proceeding; and health information
subject to the protection of the Clinical Laboratory Improvements Amendments of 1998 (Yang,
Lin, Chang, & Jian, 2006).
Yang, Lin, Chang, & Jian (2006) noted that HIPAA requires that all covered entities
that maintain or transmit health information electronically establish and maintain reasonable and
appropriate administrative, technical and physical safeguards to ensure integrity, confidentiality
and availability of the information. TTC will need to adopt security standards that are reasonable
and appropriate to maintain security such as: technical capabilities of record systems used to
maintain health information; costs of security measures; need for training persons who have
access to health information; value of audit trails in computerized record systems; and needs and
capabilities of small health care providers and rural health care providers (Yang, Lin, Chang, &
Jian, 2006)
TINY TOWN CLINIC CASE ANALYSIS 15
Disaster back-up. Fahrenholz et al. (2009) identified two kinds of system downtime as
unscheduled and scheduled downtime. Unscheduled downtime is the time in which a functional
machine or system is not functioning properly or is otherwise unavailable to users. Scheduled
downtime is planned in advance for reasons including scheduled maintenance, system updates
and patches, and system upgrades. Unscheduled downtime is due to system or environmental
failures such as power outages; semi-planned downtime includes software or hardware upgrades
that the practice does not schedule itself but is scheduled by vendors to patch quickly to avoid
security vulnerability.
Planned and unplanned system downtime require policies and procedures that address
the same considerations: how the downtime and alternate processes are communicated; how
providers and staff document patient care; how charges are captured; how systems are brought
back up; and how downtime documentation is transferred to the EHR once the system is live
again (Fahrenholz et al., 2009). It is vital for TTC management to include a “System Back-up
Plan” when preparing to install EHR. Staff should be familiar with the policies affecting their
area to facilitate patient care and maintain clinic flow. EHR system training, which includes
downtime back up, should be mandated for all staff to with the goal of preventing patient flow
interruptions at TTC.
Plan for incorporation of legacy records. One of the advantages of EHR over paper
charting is the tremendous amount of space that is available when the paper charts are removed
from the clinic setting. One office that converted to an EHR eliminated four storage rooms on
site that were used to store paper charts (Harney, 2009). TTC is a small clinic and any space that
can be gained with elimination of paper chart storage will improve clinic flow and efficiency as
well as allow for maximizing use of available space. Space change recommendations with
TINY TOWN CLINIC CASE ANALYSIS 16
implementation of an EHR will eliminate the current area of paper chart files. Eliminating the
chart files will open up space in the reception area that can be used for additional workspace. An
EHR will allow for provision of better patient care in today's milieu of meaningful use, shifting
government regulations, and changes in reimbursement.
Equipment. Didonato (2013) identified the following important considerations when
integrating medical devices in the office: how the new solution will affect workflow; how it will
affect the facility’s physical requirements; and how it can adapt to future infrastructure changes
and updates. TTC should consider the workflow and the physical structure before installing EHR
equipment. Rooms need to be carefully planned, with special consideration to placement of
equipment. Didonato (2013) suggests that patient exam rooms require several wall outlets and
network jacks to ensure that medical devices are always connected to the network and that data
are being transferred. Cable management is also important since some medical devices need to be
hardwired into the network (Didonato (2013). A facility such as TTC needs action plans that
include periods for network downtime. When considering the implementation of an EHR, a
focused analysis must be performed to determine what equipment is required for TTC. Any staff
member who accesses patient health information will need the ability to access EHR through
some type of platform such as laptop, desktop, or tablet personal computer (PC). Careful
consideration must be made in selecting a scanner that will allow TTC staff to integrate the paper
charts into the EHR. The clinic will require a large volume scanner capable of handling the
workload (Jimenez, n.d.). In addition to those costs, others that must be considered include
purchase of hardware and software licenses. Maintenance costs for software licenses, hosting and
technical support must also be considered (Fleming, Culler, McCorkle, Becker, & Ballard, 2011).
TTC will need a server in the event it implements the EHR as a stand-alone clinic rather than part
TINY TOWN CLINIC CASE ANALYSIS 17
of a hospital system. When considering initiation of EHR, it is also important to remember that
Dr. Enriquez states that internet speeds are slow and sometimes unreliable (personal
communication, January 28, 2014). This may create challenging issues with reviewing patient
charts, writing notes, creating an encounter, and billing.
The installation of an EHR will have a definite affect on the environmental footprint. As offices,
clinics, and hospital systems convert to EHR, it will be intriguing to see how the conversion
affects the environment. A study done at Kaiser Permanente found decreased paper consumption
and reduced gas consumption from ambulatory visits that were handled with secure email
communications with patients. It was also found that there was decreased plastic waste, toxic
waste and water use by digitizing and archiving x-rays rather than printing them (Turley et al.,
2011).
When considering the expense of equipment needed to set up an EHR system, the cost
for each provider license must also be considered. One study indicated that maintenance costs,
which began at implementation, was approximately $17,100 per physician/provider per year for
software licensing, hosting and technical support, and networking (Fleming et al., 2011).
Space. It is imperative that available space be used effectively. The first suggestion
includes dividing the current receptionist/chart space into two areas 10 X 6 with the addition of a
wall. These changes include moving the copy/fax machine to the wall where the charts are
currently housed. The plan would call for moving the area labeled “Nurses Office” on the Fire
Evacuation Plan to the area that is newly created from the division of the reception/chart area.
The area labeled “Nurses Office” would provide office space for an additional nurse practitioner.
Routers and other equipment needed to convert to an EHR will be placed in the storage area at the
TINY TOWN CLINIC CASE ANALYSIS 18
back of the clinic if an area can be divided and secured. If that change is not feasible, a portion of
the reception area may require reconfiguration to serve that purpose.
TTC is part of a mesosystem in which other clinics/hospitals may be operating with an
established EHR in place. If that is the case, the computer system chosen and installed will be
Thin Client or Citrix, which are systems that are used remotely. They systems include
specifically designed software and hardware topology that provide performance of applications
over remote locations. There is one file server, which connects through digital modems to the
computers in other locations (MedFlow, n.d.). In this case, space concerns when implementing
the HER should not present any significant challenges. The following will be needed in the
conversion of paper to EHR: First, computer and monitors on the reception desk, in the lab, in the
triage area, and in both NP offices. The monitor screens will need screen covers to protect patient
information. The screen covers will not require any additional space. Second, printer in the
reception area and both of the NP offices for printing hard copies of prescriptions to be faxed or
given to patient and printing patient education materials if they are available on the EHR system
(Smith, 2003). Third, shredding bins in the reception area, triage area, and both NP offices.
Fourth, ergonomically appropriate keyboard height, mouse position, and monitor-viewing height
for any computers not at designated seated areas (Smith, 2003). This will affect the
monitor/computer in the lab area. Fifth, consider mounting the monitor in the lab area on a
movable arm attached to the wall so needed space is not taken from the lab counter. Sixth,
additional electrical and network wiring/cables will be needed (Smith, 2003). Seventh, a scanner
will be needed for scanning outside documentation into a patient’s record. The scanner may be
located in the reception area. Consideration needs to be given to placement of monitors if they
are hardwired in the exam rooms so that the provider is able to face the patient during an
TINY TOWN CLINIC CASE ANALYSIS 19
encounter.
The advantages of EHR implementation include the elimination of clutter in numerous
areas of TTC including the reception desk, the reception area, the medical assistant’s office and
NP’s office. It will result in an reduction of lost paperwork/lab results/chart notes that may often
become separated from paper charts and get filed incorrectly. The implementation of the
electronic record system will lead to a more efficient use of limited space in a small clinic as the
hard chart filing system is removed and the work space is more effectively utilized. Conversion
to EHR in TTC will increase the amount of usable space in the clinic and will increase
productivity and work flow. A decrease in the amount of time spent searching, retrieving and
filing records will be realized.
Telehealth
Chronic disease management. Stephenson (1998) notes that healthcare professionals
who use telehealth improve delivery of medical care to medically underserved or isolated
Americans. The delivery of health related services and information via telecommunications
technology, that is called TeleHealth, can facilitate treatment in the remote rural regions such as
the TTC. Patients living in Tiny Town can benefit from specialized services in a timely fashion.
One example of telehealth that TTC can utilize is called the Turkcell TeleHealth System.
Ayyildiz et al. (2012) noted that the Turkcell TeleHealth System is designed to remotely track a
patient’s vital signs including weight, blood sugar/pressure, heart rate, and oxygen. Lee and
Harada, (2012) state that
The U. S. Department of Veterans Affairs (VA), in 2001, was one of the first health care
systems in the United States to implement home telehealth services, and by 2012 the VA
aimed to have 92,000 patients using telehealth services. The VA states that the “value
TINY TOWN CLINIC CASE ANALYSIS 20
derived from telehealth is not in implementing telehealth technologies alone, but how the
VA uses health informatics, disease management and telehealth technologies to target
care and case management, thereby facilitating access to care and improving the health of
its patients” (p. 463).
This data of vital signs can then be securely transferred to the clinician who analyses the
information. Ayyildiz et al. (2012) state that chronic diseases such as diabetes, heart disease, and
chronic respiratory diseases are the leading cause of mortality in the world (p. 463). As TTC
integrates the concepts of telehealth, the remote patient monitoring will be an efficient and cost-
effective solution to monitor and treat chronic disease.
Clinic based physical therapy. The telehealth system being planned for TTC is one that
will allow a professional physical therapist to direct therapy sessions directly from the main PT
clinic at the hospital. It will allow TTC patients to participate in group or individual therapy
sessions. Outcomes of one study revealed that those patients who received PT through a
telehealth program achieved outcomes comparable to those of the conventional rehabilitation
group with regard to flexion and extension range of motion, muscle strength, limb girth, pain,
Timed “Up & Go” Test scores, quality of life, and clinical gait scores (Lee & Harada, 2012).
Interoperability with the planned Electronic Health Record
Didonato (2013) notes that the 2009 Health Information technology for Economic and
Clinical Health (HITECH) Act calls for hospitals to adopt meaningful use of their EHRs through
a set of objectives that a health care facility must meet to qualify for CMS incentive payments.
Medical devices can rarely be connected directly to the EHR to allow a free flowing exchange of
information. Didonato (2013) states that this is due to the differences in types of information
being transferred and the format in which this information is displayed. A medical device data
TINY TOWN CLINIC CASE ANALYSIS 21
system (MDDS) has the ability to transfer, store or display medical device data. MDDS can
convert data into specific formats within preset specifications. MDDS is considered a Class 1
medical device, which the Federal Drug Agency (FDA) classifies as having the lowest risk for
patients and does not require clearance before marketing. Tiny Town management should be
aware that if the decision is made to create connectivity solutions, the facility should verify the
regulatory classification of any connectivity solution or service under consideration to avoid any
repercussions (Didonato, 2013). Connectivity solutions are available from a variety of vendors.
However, different vendors achieve integration in different ways. Some vendor solutions may
include both hardware and software components, while other vendors may provide only a
software solution. Solutions are based on characterizing the medical devices as either an episodic
or a continuous device (Didonato, 2013). Episodic devices obtain a single set of measurements
from a patient at a specific time. One such device is the vital-sign device. Continuous stand-alone
devices, such as ventilators, are used to monitor or treat a single patient over an extended period
of time, but are not networked to any vendor-supplied central server (Didonato, 2013). These
devices are similar to episodic devices and require a point of care (POC) component that is
stationed either in the patient’s room or attached to the medical device (Didonato, 2013).
Finances
As millions of people become newly insured in 2014, primary healthcare centers are
encouraged to implement EHR, including telehealth services, to remain viable sources of care.
For primary care providers, the move from paper to EHR and integration of telehealth services is
a challenging prospect-requiring investment of money, time, and expertise (Gebretatios, 2014).
Gebretatios states that cost continues to be a significant barrier to successfully implementing an
EHR system. The Medicare and Medicaid EHR Incentive Program provides incentive payments
TINY TOWN CLINIC CASE ANALYSIS 22
to encourage eligible professionals to adopt, implement, upgrade or demonstrate meaningful use
of certified EHR Incentive Programs (Centers for Medicare & Medicaid Services, 2014).
Current Revenue and Sources
The budgeted total patient revenue of TTC in year 2013 was $373,247; the actual
expenses in 2013 were $387,443, showing a budget variance of $14,208. TTC has mixed payers
that include Medicare, Medicaid, private insurance, and self-pay. In the month of March 2013,
141 clients were seen with private insurance, 74 Medicare, 58 Medicaid, and 36 self-pay.
Potential Funding Sources
The Economic Stimulus Act of 2009 includes $19 billion in grants and loans for
infrastructure and incentive payments under Medicare and Medicaid for physicians who adopt a
certified EHR system (Mevis, 2014). Mevis also reports that grants and loans totaling $17 billion
are slated for incentives, with $2 billion allotted to jump-start HIT adoption. The Economic
Stimulus Act provides funding for physician practices to receive incentive payments totaling
$44,000 per physician over a five-year span. TTC, located in an underserved rural region, can
receive additional funding as well (Mevis, 2014). Lynn (2009) reports that 18 grants tallying
more than $22.6 million will support EHR implementation. Grants totaling more than $2.6
million will help implement a variety of HIT installations; whereas, five grants totaling over $2.5
million will fund health centers devising plans to use EHRs to improve patient outcomes (U.S.
Department of Health, 2014).
TINY TOWN CLINIC CASE ANALYSIS 23
Table 1
Tiny Town Clinic - Revenue 2013
Total operating revenue 2013
(actual expenses)
$387,455
Total operating revenue 2013 (budgeted) $373,247
Total operating revenue variance 2013 $ 14,208
Table 2
Tiny Town Clinic - Proposed Budget
Proposed Expenses 2014
Telehealth 25,098.81
EHR 77,435.00
Total 102,533.81
The grant that fits the needs of TTC is the State Government Electronic Records that is
listed in grant.gov (grant number 201412, with an estimated amount of $600,000). Submission of
the grant application by TTC management should be done before the deadline of December 2014.
This grant money is estimated to be sufficient to cover the expenses of EHR and telehealth
implementation at TTC.
TINY TOWN CLINIC CASE ANALYSIS 24
Current Workflow
Measurable Outcomes for Quality of Care Assessment
President George W. Bush formally initiated Health information technology (HIT) and
EHR in 2004 in his State of the Union Address. President Obama passed legislation that put into
effect an incentive-penalty system when he signed the American Recovery and Reinvestment Act
of 2009 (ARRA), commonly known as the stimulus bill. Part of this legislation contains the
Health Information Technology for Economic and Clinical Health Act (HITECH) that has the
goal of improving health care delivery through investment in health information technology. The
TINY TOWN CLINIC CASE ANALYSIS 25
HITECH act provides the U. S. Department of Health and Human Services with the authority to
establish programs to improve health care quality, safety, and efficiency through the promotion
and adoption of EHRs, advanced information technologies, and private and secure electronic
health information exchange. Through these incentive programs, hospitals and providers can
qualify for reimbursement through Medicare and Medicaid services when they initiate EHR and
follow the guidelines for use (Reilly & Polifroni, 2012).
Meaningful Use is the Medicare and Medicaid incentive program that is in place to
encourage providers to use electronic health records to improve quality of patient care. There is a
set of criteria that must be met to quality for reimbursement funds. It has been implemented in a
phased approach over a series of three stages. Stage one is adoption of EHR and data gathering
with stage two emphasizing care coordination and exchange of patient information. Stage three
involves improvement of healthcare outcomes. Providers qualify for Meaningful Use when their
patient population includes Medicare or Medicaid patients. TTC qualifies based on their patient
cohort and their status as a Federally Qualified Health Center (FQHC) FQHCs may participate if
they are a rural health clinic and have a 30% needy individual patient volume (CMS.gov, n.d.).
Implementation of stage one requires reporting on all of the following core measures and
five menu measures. The core measures required are: Computerized physician order entry
(CPOE) which requires entering at least one prescription order for more than 30% of all patients
seen; drug interaction checks; maintenance of problem list which requires at least one diagnosis
for more than 80% of all patients seen; e-Prescribing which requires sending more than 40% of
prescriptions electronically (TTC may qualify for exclusion if the one pharmacy in the
community does not accept e-prescriptions); an active medication list with at least one medication
listed for more than 80% of all patients seen; medication allergy list with at least one allergy
TINY TOWN CLINIC CASE ANALYSIS 26
entered for more than 90% of all patients seen; demographics of date of birth, sex, race, ethnicity,
preferred language recorded for more than 50% of all patients seen; blood pressure (BP) for
patients over age 3 (TTC sees patients beginning at age 2) and height and weight for all patients;
smoking status for more than 50% of all patients age 13 and older; one clinical decision support
rule; patient electronic access to health information for more than 50% of patients; provision of a
clinical summary to more than 50% of patients within three business days; and protection of
electronic health information with security risk analysis and implementation of security updates
as needed.
Five menu measures must also be reported, one of which is a public health measure. The
menu items include drug formulary check, clinical lab test results, patient lists (lists of patients
with specific diagnosis), patient reminders, patient-specific education resources, medication
reconciliation, transition of care summary (pertains to patients referred or transitioned from the
practice), immunization registries data submission (public health measure), and syndromic
surveillance data submission (public health measure).
Implementation of EHR at TTC requires Meaningful Use to begin by July 1, 2014, to
avoid Medicare penalties in 2015. The clinic will have two years to implement stage 1 before
transitioning to stage 2. During the first year the criteria is to be fulfilled over a 90-day reporting
period. After that, they will have a full calendar year. Starting in 2015, providers who are
eligible for Medicare Meaningful Use program but don’t demonstrate it will be penalized. As a
provider starting in 2014, TTC will avoid a 2015 penalty if they begin their reporting period by
July 1, 2014 and attest by October 1, 2014. Maximum payout for TTC beginning stage 1 will be
$12,000. If they wait until 2015, they will be penalized 1% (Practice Fusion, 2014).
TINY TOWN CLINIC CASE ANALYSIS 27
Physical Therapy services are reported differently than medical services. The system for
therapy is reported with G-Codes. These are functional reporting codes required by Medicare
starting July 1, 2013. They are reported at the outset of therapy on the initial date of services and
at least every ten-treatment days (or 30 days). They are also reported anytime an evaluation or re-
evaluation procedure is submitted. Discharge reporting is required, except for those cases where
therapy services are discontinued by the patient prior to the planned discharge. G-Codes are
categorized by mobility, self-care, and other functional limitations. These codes are included in
the medical record and are accompanied by rationale on determining severity. Currently
Medicare requires this coding and third party payers are adopting the same policies and putting
into their contracts that they are following Medicare policies. If the functional reporting is not
done monies may be taken back from the therapy provider. Software in the TTC EHR system
will need to have a program that allows the therapist to chart plan, progress, and goals in the
existing chart for patients participating in the physical therapy component of services offered at
the clinic.
Outcomes of EHR. The outcome in EHR to be measured in the first stage of meaningful
use will be that of data capturing for TTC. This will be measured by running the data on the
number of patients entered into the system with the onset of the Go-Live date. Patients will be
entered into the new system at check in and demographics will be recorded. Email addresses will
be noted if the patient has an active email account. Eighty percent of the patients seen will need
to be entered into the system and the data will be run at the end of the first quarter period in which
the EHR is in place as mandated by the government. The reporting period must be started on July
1, 2014 and the first attestation deadline is October 1, 2014 (CMS.gov, n.d.).
TINY TOWN CLINIC CASE ANALYSIS 28
Outcomes of physical therapy. The physical therapy (PT) component will be initiated to
focus on the community health risk factors of weight loss, increasing functional strength and
improving cardiovascular fitness. Outcomes may be monitored by measuring glycosylated
hemoglobin (HgbA1C) levels that will be drawn at the outset of physical therapy interventions.
After three months of therapy, diet changes, and instruction by the physical therapy providers
both in the clinic and through the telehealth program, Hgb A1C will be drawn and levels will be
compared with the initial values. These values will be entered in the EHR system and the
national database will provide a summary of results. This will alert the therapist to any trends that
have occurred during the course of the therapy. Noting trends will provide feedback that can be
analyzed and used to determine changes that may need to be made in individual treatment plans.
Utilizing this data in EHR allows patient specific plans to be formulated that will improve quality
of patient care and the delivery of services.
Outcomes for telehealth. Telehealth will be utilized in this setting to review previously
taught diet changes, recommended activities for strength training and improving cardiovascular
health. Telehealth will be instrumental in maintaining continuity of care in this rural population
with limited financial and transportation resources. Patients will be individually instructed during
their initial evaluation face-to-face in the clinic with the therapist and will be given a plan tailored
to their specific health needs and goals. The telehealth sessions will be utilized to review teaching
points as well as to evaluate progress in strength training and increased activity goals. Telehealth
outcomes will be monitored by the ongoing evaluation of individual patient goals and the
comparison of weight changes as well as the above-mentioned HgbA1C results. This information
will be entered into the patient’s record and tracked.
TINY TOWN CLINIC CASE ANALYSIS 29
Request for Proposal
Gebretatios (2014) reported that purchasing and implementing an EHR system is a
complex process that requires an organized approach. TTC will adapt Indiana Family Health
Council (IFHC) as a model in purchasing and customizing EHR. The first step is to establish a
project team. The team should include a representation from a clinical and an administrative
staff. The second step is to arrange a meeting between the TTC EHR team and the Indiana Health
Information Technology Extension Center (I-HITEC) to deliberate “meaningful use” of the EHR
and telehealth program. The meeting will also include discussion of strategies on negotiating
discounts with vendors and creating a project timeline (Gebretatios, 2014). The third step is to
select a vendor. Gebretatios (2014) said that I-HITEC would manage the task of researching EHR
system and compile recommendations that would be good fit for the IFHC network. The
following questions should be considered when evaluating the software vendors according to
Gebretatios: Is the EHR system designed specifically for primary health care clinic; can data
fields be customized and what are the functionalities; what training and support is offered; what
types of reports can the system generates; what acquisitions, implementation, maintenance cost;
and any recurring and non-recurring cost?
Recommended Products and Rationale for Selection
TTC will use Practice Fusion software for their EHR. Practice Fusion is the largest and
fastest-growing healthcare platform, with a mission of connecting doctors, patients and data to
drive better health care practices and save lives (PR Newswire, 2014). Medical professionals can
sign-up for Practice Fusion online anytime and be live with their new EHR system in just five
minutes at no cost. PR Newswire (2014) noted that unlimited meaningful use support and
integration with local labs and imaging centers are included in Practice Fusion’s free offer. PR
TINY TOWN CLINIC CASE ANALYSIS 30
Newswire (2014) reports that Practice Fusion’s free EHR is compliant and has been certified as a
Complete EHR by Drummond Group, an ONC-ATCB approved to certify any complete or
modular EHR both ambulatory and inpatient. This is in accordance with the applicable
certification criteria adopted by the Secretary of Health and Human Services. PR Newswire
(2014) reports that in a 2014 survey, 83% of Practice Fusion users reported the company’s
meaningful use dashboard as excellent or above average, and only 29% reported that it was
difficult to navigate. The World Economic Forum recognized Practice Fusion as a Technology
Pioneer for 2013. Practice Fusion has partnered with free clinics, nonprofits, and community
health organizations throughout the country, including the National Association of Free and
Charitable Clinics (NAFC). This software is ideal for TTC because of the free cost and
meaningful use application.
EHR
Health information technology has the potential to improve health care quality, prevent
medical errors, and increase the efficiency of care provision (Lynn, 2009). The health care
providers of TTC must demonstrate “meaningful use” of electronic health records to be awarded
Medicare and Medicaid incentives under the Obama administration’s stimulus package and the
Affordable Health Care Act (Horowitz, 2010).
TINY TOWN CLINIC CASE ANALYSIS 31
Table 3
EHR System Purchase Order
IT Contractor
1-HITEC $3,750
Hardware-Health Dynamix
Desktops, Laptops $10,950
Tables, rolling tables, docking stations $ 20,813
Routers $1,690
Firewall $10,950
Scanners $5,739
Printers $4,141
Hardware installation $ 8,402
Software – Practice Fusion Free
Customization, training $11,000
Total $77,435
PT Equipment
Initially, PT services will be offered to patients diagnosed with some strength and balance
problems. Ambulation and gait training will also be offered. As the clinic’s PT practice becomes
larger and the demand for services increases, additional equipment may be purchased if the clinic
budget can accommodate the cost. A listing of proposed PT equipment to be purchased may be
found on Addendum D. Most of the items listed there are crucial for evaluating and treating
patients with physical challenges related to muscle strength, ambulation and balance.
TINY TOWN CLINIC CASE ANALYSIS 32
Telehealth Equipment for Physical Therapy Treatment Sessions
The Cisco telehealth monitor EX 9 has been selected to televise and monitor PT therapy
sessions remotely from the main hospital. This equipment has been chosen due to its
comprehensive design and integration of speakers and a microphone. This Cisco product requires
that users receive minimal training in order that they may use it effectively.
Project Management Plan
This project is projected to take approximately 18-24 months from initiating the process of
adding EHR to successfully completing the addition of the telehealth physical therapy component
in TTC.
The first step of the project is implementing the EHR system. The first question to be
addressed is whether TTC is part of a larger system that has an EHR in place. If that is the case,
budget can be established based on the projected cost to add TTC to the larger system. This will
be more cost effective than instituting a system that is isolated to the clinic because there will
already be templates and an IT vendor in place. This will also eliminate bidding for contracts and
the time involved in searching for products and services. Time will have to be built in to allow
for training of staff. This initial training will slow down the clinic flow and will necessitate a
lighter patient load until staff is comfortable working with the new system.
Current hard charts will need to be secured and transported to an off-site storage facility
that is secure and HIPAA compliant. This will take place as pertinent portions of chart records
are scanned into the new EHR system. If TTC is part of a larger hospital system, this transition
will be smoother as there will be a system in place for the charts to be archived. If TTC is
responsible for storing the hard charts, a secure location will need to be acquired and the
TINY TOWN CLINIC CASE ANALYSIS 33
appropriate guidelines followed for transporting and storing the charts. Storage facility costs will
need to be built into the budget.
After the EHR system is determined, the next step is fitting the system into the existing
clinic. This entails rearranging the clinic to make maximum use of available space. Space
recommendations have been addressed in an earlier section of this proposal. (See page 16).
When the EHR system is in place, the next step is implementing the hybrid telehealth
physical therapy component of the project. This part of the project will entail acquiring the media
equipment needed to provide the telehealth portion of the therapy as well as the PT equipment
needed for the actual therapy sessions. In reality, this is two projects. See appropriate sections
outlining equipment needed. Staff will need additional training to oversee the therapy/exercise
and record the appropriate notations within the chart.
Timeline for initiation of EHR:
Nine to 12 months before Go-Live for EHR
Investigate if possible to connect with larger hospital system
If Tiny Town is independent, review proposals and select vendor
Determine go-live dates
Schedule vendors (if needed), trainers, consultant
Six to nine months before Go-Live
Determine workflow for check-in, encounter documentation, lab results,
medications, etc.
Review database
Conduct site assessment
TINY TOWN CLINIC CASE ANALYSIS 34
Identify top 20 medical visit codes and most frequent assessments done in the
clinic
Identify hardware needs
Three to six months before Go-Live
Install hardware
Customize to clinic
Evaluate readiness of staff and schedule staff training
Make decisions about scanning documents needed for continuity of care
Verify installation timeline with vendor
Begin to educate patients about new system and explain benefits of EHR
One to three months before GO-Live
Build interfaces with lab, e-scribe/eFax (if available), imaging, hospital (if part of
the larger system)
Test go-live: begin building patient records
Adjust patient schedules-allow more time for visits and charting
Go-Live to one month out
Customize templates
Keep patient load reduced
Assess, recheck
Monitor staff and reward
30 days out to 120 days out
Continue to customize templates
Add charting phrases to expedite charting
TINY TOWN CLINIC CASE ANALYSIS 35
Call vendor with any problems
Timeline for Initiation of Telehealth/Clinic Physical Therapy
Four to Six months prior to GO-Live
Consult with PT providers to determine needed space and equipment for therapy
Determine software needs to add PT to clinic
Determine go-live dates
Determine space allocations for conducting the PT in the clinic and begin planning
for in-clinic PT sessions as well as telehealth sessions
Reorganize current space as able to accommodate clinic PT sessions as well as
telehealth sessions
Contact vendors for pricing of physical therapy equipment.
Two to Four months prior to Go-Live
Purchase additional laptop and rolling stand for PT to utilize while in clinic
Purchase physical therapy equipment
Purchase media equipment needed for telehealth sessions
Determine what space will be utilized for physical therapy sessions held in clinic
Determine what space will be utilized for physical therapy sessions conducted by
telehealth in real-time/synchronous
One to two months prior to Go-Live
Determine clinic schedule for in-clinic PT sessions
Plan patient scheduling for PT sessions in clinic with therapist
Plan patient scheduling template for in-clinic PT sessions with therapist
Determine billing for services and reimbursement of therapist
TINY TOWN CLINIC CASE ANALYSIS 36
Determine schedule for in-clinic telehealth PT sessions
Plan patient scheduling template for telehealth sessions
Educate patients about both in-clinic with therapist and in-clinic with telehealth
options
Educate staff that will be conducting telehealth sessions
Go-Live to one month out
Evaluate both PT sessions and telehealth sessions
Keep patient scheduling light
Evaluate patient response and participation
Assess and recheck
Summary Document of Recommendations
The Tiny Town project includes initiation of EHR and meaningful use followed by the
addition of physical therapy services through a hybrid program of on-site and telehealth delivery.
This project will start with assessment of current space and best utilization of space that will
become available when the hard charts are removed from the premises and a significant amount
of usable square footage will become available for alternate use. Reorganization of the reception
area will allow for movement of staff and reassignment of current space utilized for the licensed
vocational nurse (LVN) and the medical assistant (MA). It is recommended that EHR be
researched and implemented before July 1, 2014 to allow for Stage One of Meaningful Us to be
instituted so the clinic is not penalized by CMS for noncompliance with the federal mandate.
Implementation of EHR will take place following the timeline discussed earlier in this
paper and will take approximately nine to twelve months to complete from scheduling vendors to
implementing the conversion to electronic records as the patients are seen in the clinic setting.
TINY TOWN CLINIC CASE ANALYSIS 37
After the electronic record conversion has been completed, plans for a hybrid on-site physical
therapy with a telehealth component will begin. This will involve an estimated time frame of
approximately four to six months beginning with consultation with PT providers to determine
needed space and equipment for therapy culminating with provision of on-site physical therapy
services combined with telehealth follow up in between on-site visits.
Benefits of initiating EHR include monetary reimbursement from CMS for compliance
and timely installation, as well as the ability to track changes in patient health status and data
trends such as compliance with medication and diet changes. Other benefits include enhanced
quality and convenience of patient care as well as increased patient participation in care. It will
also increase accuracy of diagnoses and health outcomes as well as improve care coordination.
Evaluation of EHR will be accomplished by data tracking in the system. Historically there
is an increased use of ICD codes with implementation of HER, which in turn translates into
billable gain (Holt, Warsey, & Wright, 2010). This will be evident when the budget is reviewed
and the numbers are compared to previous fiscal years.
Evaluation of the physical therapy component of the project will be tracked in EHR with
criteria discussed previously concerning HgbA1C levels and evaluation of strength training and
weight gain/loss. An additional element that can be tracked through data mining in EHR is
cholesterol and triglyceride levels if the provider chooses to follow those numbers when
evaluating physical therapy outcomes.
Installing an EHR system in TTC has many positive repercussions in the improvement of
delivery of quality healthcare services. It also has the potential of engaging the patients in their
health care and empowering them to take ownership of their current health issues and strategies to
manage their medications, activity, diet, and ultimate improvement of quality of life.
TINY TOWN CLINIC CASE ANALYSIS 38
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TINY TOWN CLINIC CASE ANALYSIS 44
Appendix A
Physical Therapy Advisement Form
Request for Proposal for Physical Therapy
• Tiny Town Clinic (Community context)
The Tiny Town clinic (TTC) is located in a rural community in Texas that is
underserved. The population in 2011 numbered 2,818. It is the only medical facility
within 45 miles and there are currently two nurse practitioner (NP) providers. The
estimated per capita income in 2009 in Tiny Town was $14,304 and the ethnic makeup is
primarily Hispanic. Over half of the residents speak English as a second language. The
average age of residents in Tiny Town is 33.9. There are approximately 500 residents
over the age of 60. Thirty one percent of the population is illiterate and 34 % of families
live below the poverty level.
The average number of patients seen during a typical day is 20-30 with 4-5 new
patients, mostly due to those who are temporarily in the area working. The age range of
the patients is from 2 years old and up. There is a Border Patrol Station that brings illegals
for medical clearance before they are taken to a holding facility prior to deportation.
Many patients use the clinic as a primary care facility due to the distance to the nearest
hospital and difficulty getting appointments with their doctors.
There is one pharmacy in the town to fill prescriptions. There are limited
medications dispensed from the clinic and there are no narcotics offered on site. There is
a problem with medication compliance for many reasons including cost of clinic visit, cost
of medication, lack of time off to visit the clinic, and lack of transportation. Some of the
patients walk to the clinic.
TINY TOWN CLINIC CASE ANALYSIS 45
Description of types of patients
Given the types of patients, illness, and injuries that TTC sees on a regular basis,
what needs do these patients have that could be addressed with physical therapy in the
assigned delivery model?
The demographics of the population indicate there is a problem with obesity,
diabetes, hypertension, heart disease, and hyperlipidemia. Many teens are seen in the
clinic for these chronic health issues and there is a growing problem of obesity in the
children. Many patients are seen in the clinic with extremely high blood sugar and blood
pressure and are unable to go to the Emergency Room for treatment. They are also unable
to purchase the medications they require to manage their chronic health issues. Ancillary
services such as occupational and physical therapy are often not realistic for this
population because of transportation and funding issues. It is often difficult for many of
the patients to travel several times a week the 45 miles required to obtain these services
• System analysis
TTC is an example of a microsystem as it provides front line health care services to a
significant number of people. Without knowing answers to whether the clinic is part of a larger
health system, it is posited that this is the case based on the notation that the billing office is at
another location and there is no specific area noted on the fire evacuation plan that there is an
office for a business/clinic manager. It is also known that a business/clinic manager is not listed
as a clinic employee for the clinic (Handouts provided on blackboard regarding Tiny Town).
This clinic may also be part of a mesosystem, defined as when two or more clinical or
supporting microsystems are joined (Godfrey & Nelson, 2011). First line health care facilities
need a system for referral for the patients who need additional care or diagnostic services. These
TINY TOWN CLINIC CASE ANALYSIS 46
referral sites and specialty providers then become part of the mesosystem that supports Tiny
Town. The individual departments and service providers that are available for Tiny Town fit into
a larger organization known as a macrosystem, which can be a hospital, a multispecialty group
practice, or integrated health system (Nelson et al., 2008). In the case of Tiny Town, the
macrosystem is likely to be a hospital or an integrated health system.
• Current Work flow
Patients are seen on a walk-in basis and do not make appointments to be seen in
the clinic. They arrive at the clinic, sign in and wait to be seen. A nurse calls them back,
takes vitals, and puts them in a room where they will be seen by the provider. There are
three exam rooms and a small lab area where vitals are taken. When the visit is completed,
the patient goes to the front to pay the bill and check out.
Group two is investigating initiating a hybrid PT program for the patients of TTC.
The delivery model in this plan is one day a week on-site PT with the remainder of
additional PT services done by telehealth. The clinic has limited space. Currently space
appears to be well utilized with the exception of the area in the back that is used for
storage. It might be possible to reorganize the storage area and designate a portion of that
space for PT. If that is not feasible, the only other option may be to allocate an area in the
waiting room as the PT site. This is dependent on the amount of space needed and
specific equipment required for customary treatment plans.
• Infrastructure
The clinic will be transitioning to an electronic health record system that will allow
for some changes to be made with space that is currently used for hard charts. Removing
the chart racks will open up space in the current reception area. It may be possible to
TINY TOWN CLINIC CASE ANALYSIS 47
consolidate the clerical area and use the newly opened space as the nursing office, moving
the additional, newly hired NP to the current nursing office.
Space change recommendations with implementation of EMR
• Eliminate the current area of paper chart files
• Divide the current receptionist/chart space into two areas 10 X 6 with the addition of a
wall
• Move the copy/fax machine to the wall where the charts are currently housed
• Move the area labeled “Nurses Office” on the fire evacuation plan to the area that is
newly created from the division of the reception/chart area.
• Use the area labeled “Nurses Office” for the second nurse practitioner
• Available space for physical therapy
• Preferred and potential spaces available for PT use
It would be ideal to have a permanently designated area for PT. PT could be done
on site in that area as well as through a telehealth program. Telehealth will allow patients
to come to the clinic to participate in therapy if they do not have the transportation to
travel the 45 miles to the nearest PT facility in a hospital setting. The ideal location for
on-site PT might be the current storage area or part of the waiting area. If the storage area
can be reorganized a portion of the room could be designated as the PT space. There will
need to be an area where the physical therapist can chart so space will need to be
configured to allow for a computer on a rolling cart.
• Tentative budget
The budget will need to be determined to allow for an additional laptop for the
therapist to use, software for the PTs to work from and access handouts for the patients,
TINY TOWN CLINIC CASE ANALYSIS 48
and any equipment the therapists need to accomplish the therapy. There will also need to
be chairs for the patients to sit in when they are between therapies or waiting. There will
be a need to establish a method for billing for time and therapy services provided. An
important consideration for the software will be interoperability with the system in use
from the therapists’ home site so that the telehealth system will be feasible.
Estimated cost for EHR: $155,235 total cost for first year including IT contractor,
desktop, tablets and docking stations, routers, firewall, scanners, printers, hardware
installation, subscription to software, training and customization.
Physical therapy equipment: Equipment necessary to perform basic therapies
offered in a typical physical therapy program are targeted at therapy related to strength
training, balance training and back pain. The listing of the necessary equipment may be
found in appendix D.
TINY TOWN CLINIC CASE ANALYSIS 49
Appendix B
Consultant Recommendations
Proposal for Provision of Physical Therapy to Tiny Town
Group 2 is to investigate initiating a hybrid PT program for the patients of Tiny
Town. Part of the time PT will be done on site in the clinic and part of the time PT will be
accomplished through telehealth. Can you tell us what we need to be thinking about for
this project?
MH: The number one thing that comes to my mind at this point is cost. What
resources do you have available to you as far as funding goes? Is this a project in
which you have unlimited funding or do you have a budget you need to stay
within?
RD: We haven’t had any exposure to telehealth. I think it might be possible, in a
limited fashion for PT. It’s very “hands on”, but could be modified with telehealth
maybe every other visit.
I am speculating that we need to look at space available in the current clinic to determine
where on-site PT can be done as well as consider what needs to be available for the
telehealth part of the project.
MH: Yes, space is certainly an issue. You will need enough space for some cardio
equipment, high-low tables, and an area for resistance training. This does not
TINY TOWN CLINIC CASE ANALYSIS 50
include space that you will need to hold general equipment and supplies for
modalities.
RD: You could get by with a treadmill, maybe an ergonomic bike, set of hand
weights, TheraBands (easy to store), large wall mirror (3x5 ft). A hi-lo mat would
be helpful, but is also very expensive. I assume you would have a padded table for
medical exams; it most likely would work for PT also. The other equipment could
be added in later, as funds allow.
Have either of you been involved with a rural setting where the patients are compliant about
50% of the time?
MH. In my limited experience with treating patients, I would say that as far as PT
goes, geographic location is not the primary factor affecting compliance, but more
so, it is patient motivation/disease type/pt. personality. This has held true for me at
urban clinics and rural clinics.
RD: As I said, I grew up in a small town, so I understand the mentality! I would
see the #1 obstacle as resistance to change. So many of the PT problems we treat
are directly tied to obesity. I see the evidence in every culture across Texas, but,
having recently moved to Dallas from Corpus Christi, see a HUGE issue in the
Hispanic community. Education is the key, and changed need to be made at every
generational level.
TINY TOWN CLINIC CASE ANALYSIS 51
Have either of you participated in telehealth and, if so, do you have suggestions for what
needs to be done from our prospective?
MH: I do not have any personal experience with telehealth but it would definitely
be beneficial for your patient to have a large screen to view exercises/receive
instruction from. There will also need to be in office equipment for filming the
patient as they perform their therapy. This will allow DPT can offer feedback and
suggestions on their performance. Physical therapy is an extremely “hands on” - I
think that it will be very challenging to utilize telehealth and have the patients still
receive the same quality of care.
RD: I have no exposure to telehealth. I agree that a large screen TV would be
helpful. The initial treatment with PT would have to be done by a PT. Carrying out
the exercises could be monitored by a tech, but exercises are only effective if done
correctly, with no muscle substitutions. Therefore, say, session 2 might be possible
by telehealth, with a PT progressing the program, and a tech instructing. This
would only work with orthopedic patients. Neurology patients have far too many
variables.
Do you typically use EMR for your charting?
MH: You mean electronic medical records, yes? If so, yes, but I find that in more
rural settings, paper charts are still the norm.
TINY TOWN CLINIC CASE ANALYSIS 52
RD: EMR would be easiest for telehealth, not only convenience of practitioners,
but billing and charting.
We will have to consider how that works from the telehealth prospective. I speak for myself
only when I say I have no experience with telehealth.
• Needed equipment (Consider minimal and “it-would-be-nice” scenarios)
What equipment do we need to have in the clinic?
This list includes the basic equipment need to start the physical therapy program.
• 1-2 high low tables could use 1 padded standard exam table
• Treadmill agreed
• Nu-Step
• Arm Bike Ergometer YES!
• Set of free weights yes
• Set of therabands yes
• Total gym
• BOSU balls/balance equipment BOSU and Swiss balance ball
• E-Stim kits (great to have, could be purchased later)
• Therapeutic Ultrasound equipment
• Implications for infrastructure changes (i.e. EHR)
TINY TOWN CLINIC CASE ANALYSIS 53
• What computer access do we need?
MH: If you’re wanting to do telehealth, you’ll need high speed internet. Probably at least one
laptop and one desktop. The desktop should be connected to a large monitor - like what we have
in the breakout rooms here. You’ll obviously need excellent sound equipment. Remember - your
patients will probably be older and may have difficulty with vision and hearing.
RD: Agreed. Also printer for handouts/exercise print-outs.
TINY TOWN CLINIC CASE ANALYSIS 54
Appendix C
Graphics of High Performing Clinical Microsystem
The graphic shown below depicts the integration of the systems as they affect Tiny Town.
TINY TOWN CLINIC CASE ANALYSIS 55
Item Function Model Information
Cost
Plinth Table Multi-treatment table
Hausmann Hi-Lo Power
2,095.59
Ultrasound machine Pain management Intellect Legend US
3,254.55
Electrical Stimulation machine
Muscle strengthening
Richmar Winner ST4
2,729.00
Walker/wheels/folding Improve gait Nova 409DW5
40.00
Walker Standard/Folding
Beginning Weight bearing
Invacare 6291-1
55.00
Walker/Rollator Wheels/Seat
Prevent falls Provide support
Nova 4010
168.00
Cane/Straight Single point
Balance re-education
ConvaQuip 835-700
73.89
Cane/small base 4 point
Balance Re-education
Drive Medical 10312FP-1
38.99
Crutch Forearm
Prevent weight bearing
Carex Adult FGA985C00000
115.99
Crutch Under axilla
Prevent weight bearing
Carex Adult FGA976000000
57.89
Gait belt For spot walking during ambulation
Invacare Gait SPTB054
17.85
Aerobic steps Step training Escalade F1028
53.06
Stationary bike Progressive exercise GX 5.0 599.00 TENS Unit Pain management Ultama 5 29.99
Cisco Telemonitor with camera/speaker/mic
Physical therapy telehealth
EX 9 15,800.00 (2 units)
Treadmill Exercise US Medical 2,199 Theraband set Muscle
strengthening US
Medical
126.73
Appendix D
Recommended Equipment for Physical Therapy Treatment Program
TINY TOWN CLINIC CASE ANALYSIS 56
Appendix E
Patient Flow Chart
Pa#ent'in'the'system?'
!
Tiny%Town%Clinic%
Nurse''Available
?'
! !
!
Take''BP,'pulse,'weight,'urine'
Decision
Pa#ent'needs'to'complete'paperwork'
Wai#ng'Room' Pa#ent'with'NP'
Process'
NP'Available
?'
Need''labs'&'
Referrals'
Need''FollowDup?'Wai#ng'Room' Make'followDup'
appointment'
Process'Referrals'Order'labs'
!
Indicates%placement%of%computer%terminal%
Provide'Med'Reconc'&'Educa#onal'Printouts'