Transcript Financial Survival: Optimizing Revenues in Primary Care

EMR Applications in Primary Care
SWVTC Medical Technology Summit
Nick Ulmer, MD CPC
Principal Consultant, ProTime, LLC
Director, Quality and Compliance, Preserve Health, PA
Physician, Doctors Care Urgent/Family Care Centers
Lead
Objectives
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Understand office efficiencies gained by
implementation of an electronic health record
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operational flow
coding and documentation.
Understand how with this “tool”
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patient satisfaction was enhanced
clinical delivery of healthcare improved
Realize the most common pitfall in EMR use
Where is SC?
South Carolina
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Palmetto Tree and Crescent Moon
Carolina Wren
Myrtle Beach, Hilton Head, and Charleston
Governor Mark Sanford and Argentina……
House of Rep Joe Wilson--- “You lie!!”
Fox News Sept 19: “14 WF bags 14’ gator”
Where is Laurens/Clinton?
The Family Healthcare Center, PA
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1991, 6.5 FTE providers, full-scope Family
Medicine practice, ~18K patients, privately owned
Decision to make a change after 10 years
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“Lost” charts and chart chasing
Paper costs (charts, transcription paper, etc.)
“Sticky note” toxicity
“Can’t keep up”……hire more staff?
Second storage building full
The “tool” to address our needs
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System efficiencies
Staffing ratios
Data mining
Billing, coding and documentation
Patient satisfaction/healthcare delivery
System efficiencies
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Messaging
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Eliminated paper inefficiencies & costs
• No more lost charts
• No more ‘can’t read’ inquiries from pharmacy
• Cut supply costs by more than $10,000 in one
year
• eRx efficiency was huge
• Sticky pads piled up
• The “busyness” of office faded
System efficiencies
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Scheduling
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Emails after hours/during day via web portal
• 7 AM and 1 PM each day
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Non urgent appointment needs
Refill requests
• Phone congestion plummeted
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Information dissemination
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Output functions to perform multiple tasks at once
Faxing and attaching directly into EMR system
from subspecialists/hospitals
Staffing concerns
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Staffing full time equivalents/provider
• FHC vs. MGMA (all family practice types)*
• 3.23 vs. 3.57
(6.5 FTE)
• Prior to EMR we were above MGMA
• 2 FTE left, 1 FTE position eliminated
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• Able to keep up with work load
Data mining
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Birthday cards….?
Clinical Trials participation
Patient recruitment - targeted
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Drug recalls (Bextra and Vioxx)
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• Gardacil, Menactra
• IPPE (Welcome to Medicare)
Billing, coding and documentation
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Higher levels for providers
Better overall documentation
Ease of reading notes
Templates allow better care by setting up
exams to meet quality standards of care
• Team involved in patient care after EMR
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Physician billing/order entry
Patient satisfaction/healthcare delivery
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eRx efficiencies: time saver, “wow” factor
Lab information exchange
Templates set up to augment quality of care
Patient educational material: user/system defined
After hours phone dialogue
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Chart access
Satellites (much lower cost for expansion)
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Second clinical office started and access at 3 NH
Student health clinic
Return on Investment - FHC
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Transcription cost
• 2000
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• 2002
• 2003
• 2004
• 2005
• 2006
$65,848
$62,145 (EMR in 10-2001)
$26,691
$15,553
$ 6,636
$ 2,923
$ 0 (any needed done in house)
Return on Investment - FHC
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Staffing
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Coding and Documentation
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Research
• Below MGMA by 1.6 FTE
Return on Investment - FHC
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Corporate market
• Quality wellness emphasis (reminders)
• Data tracking and reporting
• Executive physicals
Return on Investment - FHC
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Family time
• Convenience of doing charts at home
• I used to do them pre-EMR nightly, cut back to once a
week to catch up (2-3h on Sunday afternoon)
• Less work after hours
• HUGE learning curve
Preserve Health, PA at The Cliffs
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Background
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Primary care medical practice, north of Greenville, SC
Rural location
Service to
• The Cliffs Community residents
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(4000, many part-time)
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(800+ employees)
• The Cliffs Community, Inc. employees/dependants
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• Residents of the rural surrounding area
Opened July 7th, 2008
• “Model without statistics”
Objectives
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Prevention first model of healthcare
• Emphasize
• Dietary compliance
• Exercise adherence
• Stress reduction
• Evidence based medical care
• Patient centered approach
• Goal setting, accountability
• Consider alternative medical therapies where
appropriate
The Team Approach
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Mirrors the “Medical Home” model
• TransforMed initiative
• Endorsed by AAFP, AAP, ACP, AOA
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Integrated team of medical providers
• Dedicated to optimizing one’s ability to
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achieve maximum quality of life
Empowering the patient to make decisions for
sustainable wellness
The Team Approach
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Human touch, but high tech
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Electronic medical record
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Team has full utilization of this product
• Allscripts Professional EMR system
• Data collection
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Benchmark to national, internal standards
• Team approach for competition among communities
Marketing to area to show attention to detail and
determination to be outstanding in this area
• Communication
• Patient management
The Team Approach
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Physician is leader
• Total oversight, but weekly meetings with
clinical team
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Clinical Advocate
• RN who is manager of patient clinical data
• Reporting, follow-up of diagnostic studies
• Facilitate scheduling
• High touch when needed
The Team Approach
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Wellness Advocate (hourly, as needed)
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Wellness Coach
Health Education, 4 year degree
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Works with patient for goal setting, vision casting
Coordinates care with rest of team, directs patient to other
ancillary providers as needed, works closely with Clinical
Advocate (the right hand, left hand theory)
Works in concert with Wellness Counselor as support and
accountability individual
Registered Dietitian (hourly, as needed)
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Dietary visits encouraged (2-3), more so if there is clinical
need (i.e., DM)
The Team Approach
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Cognitive Behavioral Therapist (hourly, as needed)
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Called a “Licensed Wellness Counselor”
Meets to encourage sustainable change in patients lives
Patient needs to see benefit and needs to have the “want
to” to change (Wellness Advocate)
Encourage two sessions
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Positive psychology type of sessions more than disease
management (manage stress, maintain focus in life)
Exercise Science (hourly, as needed)
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Functional medicine and exercise prescriptions
Staff nurses (medical office assistants, LPNs)
The Team Approach
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Part time staffers
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RD, CBT, Wellness Coach
Back office heavy approach
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For 2 providers:
• 2 nurses per provider, 1 shared nurse
• 2 lab/x-ray trained staffers
• 1 front office, 1 billing, 1 manager
(5)
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(3)
All with EMR access
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Make recommendations for provider to advise upon
Tracking for improvement and allows accountability
The “back office heavy” model in action
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One person to “check-in”
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Answers phone
Billing will jump in if busy
Hopefully record updated from home via portal
Nurse assigned a room
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Takes patient back
Updates database
Collects the copay
Begins to collect clinical history
Nurse signals provider to come in
Provider does visit or uses nurse as scribe
The “back office heavy” model in action
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Nurse (cont.)
• Completes visit by scheduling needed tests,
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getting follow-up appointment
Escorts patient out.
Second nurse is doing the same type of
process in adjacent room
Third nurse is floating (shared with
second provider)
The “back office heavy” model
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Perception
• Satisfaction is 99.5% “exceeded expectations”
• Patients are never “alone”
Telemedicine
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Pilot project arrangement with Wake Forest
Consider integration into a Smart Home
project
• USC School of Medicine Senior Smart Program
• Floor sensors, bed alarms, home monitors w/alarms
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Distance healthcare impact
• Follow-up care
• Underserved areas
• Corporate work site wellness models
Plans
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Use EMR to decrease staff strain
• Kiosks for check-in
• On-line bill payment, appointment requests, data
updates
#1 problem………?
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Customization
contact me
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Nick Ulmer, MD CPC
[email protected]
864-684-4248