Optimizing Electronic Health Record Software in a Primary Care Practice

Optimizing Electronic Health Record Software in a Primary Care Practice Ricardo A. Pascual PSM Candidate, Biomedical and Health Informatics Carolina Health Informatics Program Wednesday, July 19, 2017 1

Agenda About Me Biomedical Informatics Clinical Informaticians Motivations Value-Based Care Internship Report Conclusion 2

About Me: Incoming medical student with training in Biomedical & Health Informatics. University of Puerto Rico, School of Medicine Doctor of Medicine (Expected: 2021) University of North Carolina at Chapel Hill Professional Science Master s Candidate (Expected: August 2017) Biomedical and Health Informatics Emory University Bachelor of Science (2016) Anthropology and Human Biology 3

Biomedical informatics is the scientific field that deals with biomedical information, data, and knowledge their storage, retrieval, and optimal use for problem solving and decision making. Source: Shortliffe and Cimino (2006) 4

AMIA defines clinical informaticians as those who: transform health care by analyzing, designing, implementing, and evaluating information and communication systems With three goals: 1. Enhance individual and population health outcomes 2. Improve patient care 3. Strengthen the clinician-patient relationship Source: (AMIA, 2016) 6

Fee-for service has been the predominant payment model in the U.S. Patient Gets Sick Patient Sees Doctor Doctor Treats Patient Doctor Gets Paid 7

Fee-for service has been the predominant payment model in the U.S. Patient Gets Sick Patient Sees Doctor Doctor Treats Patient Doctor Gets Paid M.D. Traditional Medical Education 8

Value-Based care presents complex challenges to primary care providers. Patient Gets Sick Patient Sees Doctor Doctor Treats Patient Doctor Gets Paid 9

Fee-for service has been the predominant payment model in the U.S. Patient Gets Sick Patient Sees Doctor Doctor Treats Patient Doctor Gets Paid 10

Fee-for Transition service to Value-Based model has Care been the predominant payment model in the U.S. Volume to Value Pay for Performance Patient Gets Sick Patient Sees Doctor Doctor Treats Patient Doctor Gets Paid 11

Fee-for Transition service to Value-Based model has Care been the predominant payment model in the U.S. Volume to Value Pay for Performance Table 1: Laws that Support Transition to VBC Patient Gets Sick Patient Sees Doctor Doctor Treats Patient Doctor Gets Paid care costs (Source: CMS, 2015) 12

Insurance companies may ding physicians if patient s health is not optimal. 13

Insurance companies may ding physicians if their patient s health is not optimal. PATIENT SUMMARY 2017 (DATA THROUGH 06/29/2017) Summary of all measures PaAent Provider InformaAon PCP_Name Name DOB Phone BMI BCS COAF COAM COAP COLO DRE A1c NEPH CBP OSTEO DMARD 14

Optimizing ecw in a Primary Care Practice in Humble, TX An internship report

Northeast Medical Associates, P.A., is a primary care practice of internal medicine physicians. Internal Medicine Small practice Admitting privileges Services EKG, bone densitometry, lab station Location: Humble, TX 16

NEMA Office Layout MD Office Room 7 Room 6 Room 5 Room 4 Room 3 Bone Density Room 8 Nurse/MA Station Closet MD Office MD Station Room 2 Room 1 Kitchen Office Manager Waiting Area MD Office Closet Closet MD Office Empty space (old file room) Check in/out Referral 17

NEMA ::: Pictures (Slideshow) requires Adobe flash. Consider that mobile phones (Apple products) do not support flash. Design, layout with shadows appears on each tab of the website and may distract some Welcome to Northeast Medical Associates. Here we understand that you want nothing less than the best for your health care. Our entire team at NEMA dedicates themselves to providing our patients with a warm, comfortable experience during their time with us. It is our promise to provide you with kindness, respect, quality care and make your visit a pleasant one. Come visit us for your healthcare needs including routine primary care, physical exams and other chronic medical conditions. New patients are always welcomed. For your convenience you can download our new patient sign in sheet from our download section to bring with you for your scheduled appointment. We accept most major insurances including Medicare. Patient (sign-in?) sheet can be hyperlinked. Possibly confused with registration form. Furthermore, there is NO Download sections, but there is a Forms section. Either way, the sheet in the Forms section is not working. 2017 Northeast Medical Associates Select Drop Down Content: - Office Visit Does not state the practice speciality (i.e., internal medicine). Could describe the type of services and treatment provided, such as: routine primary care (e.g., physical exam); acute & chronic conditions (diabetes, hypertension, thyroid, and cholesterol disorders), well woman exams, etc. Layout: Consider changing background and text color. Blue s tend to blend in and make it hard to read. Website is not mobile-friendly (non-responsiveness), and layout/page does not adjust when page is minimized/maximized, etc. Important to consider for patient portal accessibility. Under Comments/Notes type: Consult and Treat HTML tag attached to all pages. Not needed/ consider removing Consider adding a Services page to describe clinic s EKG, Bone Densitometry, lab station, etc. 18648 McKay Drive, Suite 220, Humble, Texas, 77338 Opens to new tab, may confuse user who is looking for a page describing how to log in, etc. Request for Health Spring Referral Comes in Does NOT open in new Srinivas Kumar Rumalla, M.D Sunita Rumalla, M.D. Santiago Segurola, M.D. There are four physicians in the practice. Have to add Jonathan Guirguis, M.D. Pt. arrives and checks in at front desk. Fax to Specialist http://nemamd.com/index.html Press Submit & Print 1/1Office Is this a new pt.? Change Status code for pt. on Office Visits screen to MD, ecw. Reviews Progress Note & previous visits in ecw. Visit is complete. Change Status code for pt. on Office Visits screen to CHK, ecw. Click Enter Referral Enter patient s: - Member ID# - Date of Birth Click Search -select Patient Enter patient s: - Last PCP Visit - Last Date of Service - ICD Code(s) [Find in pt. Progress Note, ecw] Enters pt. room and greets pt. Notify patient through preferred method of communication found in ecw. Web enable patient, ecw. Did pt. complete yearly update form? Measures vitals, reviews medical history, allergies, medications, ecw. Completes yearly updated form. Completes new pt. registration form. Greets and escorts pt. to room. Orders/ review treatment plan (prescribe meds, lab/di orders, immun., procedure, etc.), ecw. Assign Referral to appropriate staff, ecw. Does pt. need referral? Scans to pt. Documents, ecw. Assigns room; Change Status code for pt. on Office Visits screen to NURS, ecw. In-house follow up needed? Collect co-pay Is pt. web-enabled $$ (Patient portal)? Schedule follow up appointment. Fulfills order (test, EKG, bone density, immunization, etc.) Does pt. need follow up appointment? Hours: 8:30 am 12pm 1:30 4:00 pm 15 minute appointments Change Visit Status code for pt. on Office Visits screen to ARR, ecw. Prints pt. Superbill Complete s pt. Superbill Examines Superbill Enters & completes the billing and follow up information. As an informatician, I help maximize the use of information and communication technologies. Systems Analyst Process Improvement Electronic Health Record (EHR) Training, functionality, capability MD Office Room 7 Room 6 Room 5 Room 4 Room 3 Bone Density Contact Us : 281 548 1210 (Office Hours) Fax : 281 548 3786 24Hrs Answering Service : 281 812 5606 Room 8 Nurse/MA Station Home Doctors Patient Education Forms Patient Portal Contact Us Closet Referral Texas Health Spring Referral MD Office MD Station Room 2 MD Office MD Office Kitchen Closet Office Manager Closet Empty space (old file room) Welcome to Northeast Medical Associates Room 1 Open patient Progress Note, ecw Waiting Area Check in/out Referral Log-in to HealthSpring Connect & click Accept NEMA Patient Visit Our Doctors Summer 2017 Patient Registration Nurse/MA (Front Desk) Yes No No Yes Physician No Yes Yes No Check-out (Front Desk) Yes Summer 2017 No No Yes 18

My internship timeline: Shadowing Crash Course, ecw Process Maps Optimizing ecw Reporting Tools Tutorial/Guides 19

My internship timeline: Shadowing Crash Course, ecw Process Maps Optimizing ecw Reporting Tools Tutorial/Guides 20

Shadowing at NEMA: Room 8 MD Office Room 7 Room 6 Nurse/MA Station Room 5 Room 4 Room 3 Bone Density Closet Shadowing locations MD Office MD Station Room 2 MD Office Kitchen Closet Office Manager Closet Room 1 Waiting Area 21 eclinicalworks stations MD Office Empty space (old file room) Check in/out Referral 21

After shadowing, I suggested updating the clinic's website. NEMA ::: Consider adding a Services page to describe clinic s EKG, Bone Densitometry, lab station, etc. Contact Us : 281 548 1210 (Office Hours) Fax : 281 548 3786 24Hrs Answering Service : 281 812 5606 18648 McKay Drive, Suite 220, Humble, Texas, 77338 For example: Layout Mobile-friendly Services provided Registration forms Patient education Home Doctors Patient Education Forms Patient Portal Contact Us Opens to new tab, may confuse user who is looking for a page describing how to log in, etc. Pictures (Slideshow) requires Adobe flash. Consider that mobile phones (Apple products) Does NOT open in new do not support flash. Design, layout with shadows appears on each tab of the website and may distract some Welcome to Northeast Medical Associates Welcome to Northeast Medical Associates. Here we understand that you want nothing less than the best for your health care. Our entire team at NEMA dedicates themselves to providing our patients with a warm, comfortable experience during their time with us. It is our promise to provide you with kindness, Our Doctors respect, quality care and make your visit a pleasant one. Come visit us for your healthcare needs including routine primary care, physical exams and other chronic Srinivas Kumar Rumalla, M.D medical conditions. New patients are always welcomed. For your convenience you can download our new Sunita Rumalla, M.D. patient sign in sheet from our download section to bring with you for your scheduled appointment. Santiago Segurola, M.D. We accept most major insurances including Medicare. Patient (sign-in?) sheet can be hyperlinked. Possibly confused with registration form. Furthermore, there is NO Download sections, but there is a Forms section. Either way, the sheet in the Forms section is not working. There are four physicians in the practice. Have to 2017 Northeast Medical Associates add Jonathan Guirguis, M.D. Content: Does not state the practice speciality (i.e., internal medicine). Could describe the type of services and treatment provided, such as: routine primary care (e.g., physical exam); acute & chronic conditions (diabetes, hypertension, thyroid, and cholesterol disorders), well woman exams, etc. Layout: Consider changing background and text color. Blue s tend to blend in and make it hard to read. Website is not mobile-friendly (non-responsiveness), and layout/page does not adjust when page is minimized/maximized, etc. Important to consider for patient portal accessibility. HTML tag attached to all pages. Not needed/ consider removing http://nemamd.com/index.html 1/1 Artifact Model 22

My internship timeline: Shadowing Crash Course, ecw Process Map Optimizing ecw Reporting Tools Tutorial/Guides 23

eclinicalworks (ecw) is the EHR of choice for NEMA. Clinical Documentation Clinical Data Patient Portal Care4 Interface CPOE Lab Interface Prescriptions 24

Documentation. Pursuant to this Agreement, Customer may receive copies of or access to certain written technical support or explanatory documents regarding eclinicalworks s software; eclinicalworks s services; and/or eclinicalworks s internal policies and procedures (collectively, Documentation ). Customer acknowledges and agrees that all such Documentation is and will remain the sole property of eclinicalworks and that eclinicalworks shall retain all intellectual property rights in all Documentation, including but not limited to patents, copyrights, or trademarks. Customer agrees that it will treat Documentation as highly confidential information and that Customer will not share Documentation with any third party, post any Documentation on the internet, or otherwise externally publish any Documentation. Customer may disclose Documentation to its employees or independent contractors for the purposes of utilizing eclinicalworks s software or services, provided that Customer (i) obtains reasonable assurances prior to making any such disclosure that Documentation will not be used in violation of this Agreement and (ii) such disclosure will not result in Documentation becoming generally accessible to the public at large. Notwithstanding any other provision in this Agreement to the contrary, Customer agrees that it will never negligently, willfully, or knowingly allow any person or entity that competes with eclinicalworks to access Documentation. Customer agrees to promptly inform eclinicalworks in writing of any violation of this provision by Customer or one of Customer s employees or agents of which it becomes aware. Upon termination of this Agreement, Customer agrees to return all Documentation and all copies of Documentation to eclinicalworks and, if such return is not feasible, to destroy all Documentation and all copies of Documentation. Documentation. Pursuant to this Agreement, Customer may receive copies of or access to certain written technical support or explanatory documents regarding eclinicalworks s software; eclinicalworks s services; and/or eclinicalworks s internal policies and procedures (collectively, Documentation ). Customer acknowledges and agrees that all such Documentation is and will remain the sole property of eclinicalworks and that eclinicalworks shall retain all intellectual property rights in all Documentation, including but not limited to patents, copyrights, or trademarks. Customer agrees that it will treat Documentation as highly confidential information and that Customer will not share Documentation with any third party, post any Documentation on the internet, or otherwise externally publish any Documentation. Customer may disclose Documentation to its employees or independent contractors for the purposes of utilizing eclinicalworks s software or services, provided that Customer (i) obtains reasonable assurances prior to making any such disclosure that Documentation will not be used in violation of this Agreement and (ii) such disclosure will not result in Documentation becoming generally accessible to the public at large. Notwithstanding any other provision in this Agreement to the contrary, Customer agrees that it will never negligently, willfully, or knowingly allow any person or entity that competes with eclinicalworks to access Documentation. Customer agrees to promptly inform eclinicalworks in writing of any violation of this provision by Customer or one of Customer s employees or agents of which it becomes aware. Upon termination of this Agreement, Customer agrees to return all Documentation and all copies of Documentation to eclinicalworks and, if such return is not feasible, to destroy all Documentation and all copies of Documentation. Customer agrees that its obligations under this provision will survive termination of this Agreement. Customer agrees to certify its compliance with this provision in writing How to crash-course the eclinicalworks EHR (1/2): Page 1 of 28 Training guides: eclinicalworks eclinicalworks Page 1 of 22 END USER WORKBOOK EMR I Kentucky Department for Public Health April 2017 END USER WORKBOOK RECOMMENDED WORKFLOWS Hanover Hospital Kentucky Department for Public Health April 2017 Kentucky Department of Public Health January 2016 Training Workbook EMR I EMR Training Workbook Training Workbook EMR II February 2016 EMR II Training Workbook eclinicalworks, 2017. All rights reserved. eclinicalworks, 2017. All rights reserved. User forum: Independent ecw user forum 26

How to crash-course the eclinicalworks EHR (2/2): ecw -> File -> Settings -> My Local Settings 27

My internship timeline: Shadowing Crash Course, ecw Process Map Optimizing ecw Reporting Tools Tutorial/Guides 28

NEMA Patient Visit Hours: 8:30 am 12pm 1:30 4:00 pm 15 minute appointments Summer 2017 Patient Pt. arrives and checks in at front desk. Yes Completes yearly updated form. Completes new pt. registration form. No Registration (Front Desk) Is this a new pt.? No Did pt. complete yearly update form? Scans to pt. Documents, ecw. Yes Change Visit Status code for pt. on Office Visits screen to ARR, ecw. Nurse/MA Change Status code for pt. on Office Visits screen to MD, ecw. Measures vitals, reviews medical history, allergies, medications, ecw. Greets and escorts pt. to room. Assigns room; Change Status code for pt. on Office Visits screen to NURS, ecw. Fulfills order (test, EKG, bone density, immunization, etc.) Prints pt. Superbill Physician Reviews Progress Note & previous visits in ecw. Enters pt. room and greets pt. Orders/ review treatment plan (prescribe meds, lab/di orders, immun., procedure, etc.), ecw. In-house follow up needed? Yes No Complete s pt. Superbill No Yes Check-out (Front Desk) Visit is complete. Change Status code for pt. on Office Visits screen to CHK, ecw. Web enable patient, ecw. Assign Referral to appropriate staff, ecw. Does pt. need referral? Collect co-pay Is pt. web-enabled No $$ (Patient portal)? Schedule follow up appointment. Yes No Does pt. need follow up appointment? Yes Examines Superbill Enters & completes the billing and follow up information.

Some of the features in the patient portal: Medical Records Messaging: Providers & Refills Appointments 32

Process Map: Web-enabled patients have access to the patient portal. My Account Questionnaire 8-page registration form 33

Process Map: Patient Registration Form Import 34

Process Map: Lab, Medication, and Diagnostic Imaging Orders 35

Process Map: Lab, Medication, and Diagnostic Imaging Orders 36

Process Map: Printing Medication, Lab, Diagnostic Imaging Orders

My internship timeline: Shadowing Crash Course, ecw Process Map Optimizing ecw Reporting Tools Tutorial/Guides 38

ecw offers two reporting tools for extracting data: Registry Simple Reports ecw Query Studio ebo Report Studio 39

ecw offers two reporting tools for extracting data: Registry Simple Reports ecw Query Studio ebo Report Studio 40

Registry 41

Registry challenges and workaround 42

Registry challenges and workaround 43

Registry reports can help the practice target patients for quality improvement initiatives. Encounters No-shows, future Demographics Web-enabled Insurance ICD codes Example Report: Patients who are currently uncontrolled and have not had an HbA1c test in greater than 3 months 44

ecw offers two reporting tools for extracting data: Registry Simple Reports ecw Query Studio ebo Report Studio 45

ebo Enterprise Business Optimizer, features: Email reports Frequency Burst reports Specific individuals based off of data Unlocked Progress Note No show report Control access 46

ebo Query Studio Query Studio Create Enhance Manage Drag and Drop Less restrictive than Registry 47

ebo Report Studio did not open 48

ebo Report Studio did not open 49

ebo Report Studio did not open 50

ebo Report Studio did not open 51

ebo Report Studio opened! 52

My internship timeline: Shadowing Crash Course, ecw Process Map Optimizing ecw Reporting tools Tutorial/Guides 53

Tutorials Referral Texas Health Spring Referral Request for Health Spring Referral Comes in Open patient Progress Note, ecw Referrals Log-in to HealthSpring Connect & click Accept Click Enter Referral Enter patient s: - Member ID# - Date of Birth Click Search -select Patient Select Drop Down - Office Visit Enter patient s: - Last PCP Visit - Last Date of Service - ICD Code(s) [Find in pt. Progress Note, ecw] Under Comments/Notes type: Consult and Treat Press Submit & Print Fax to Specialist Office Notify patient through preferred method of communication found in ecw. Summer 2017 54

Some lessons learned and challenges: Stakeholder engagement You know what would be really cool? If Under-promise, over-deliver Internet Cloud-based 55

Conclusion: This summer I gained some great hands-on experience in health IT! Value-Based care is changing how care is provided Improved workflow efficiency and processes at NEMA Informaticians do a little bit of everything Thanks! Q/A linkedin.com/in/ricardo-a-pascual ricardo.a.pascual@gmail.com 56

ADDENDUM

Value based Care MACRA: Medicare Access and Chip Reauthorization Act (2015) MIPS: Merit Based Incentive Payment Systems APM: Alternative Payment Model MACRA MIPS APM 58

CPOE Computerized physician order entry (CPOE) permits clinical providers to electronically order laboratory, pharmacy, and radiology services. CPOE systems offer a range of functionality, from pharmacy ordering capabilities alone to more sophisticated systems such as complete ancillary service ordering, alerting, customized order sets, and result reporting 59

Clinical Documentation Physician, nurse, and other clinician notes Flow sheets (vital signs, input and output, problem lists, MARs) Discharge summaries Transcription document management Medical records abstracts Advance directives or living wills Durable powers of attorney for healthcare decisions Consents (procedural) Releases of information (including authorizations) 60

ecw Market Share: 61

ecw Settlement: 62