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ACHIEVING PHYSICIAN BUY- IN FOR EFFECTIVE IT ADOPTION AND ENGAGEMENT SEPTEMBER 2009 Michael Wagner, MD FACP

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Page 1: Engaging Physicians In Information Technology

ACHIEVING PHYSICIAN BUY-IN FOR EFFECTIVE IT ADOPTION AND ENGAGEMENTSEPTEMBER 2009

Michael Wagner, MD FACP

Page 2: Engaging Physicians In Information Technology

Biographical sketch Mi h l W MDMichael Wagner, MD

Dr. Michael Wagner is currently the Chief of General Internal Medicine at Tufts Medical Center in Boston Mass. He has been practicing internal medicine for 19 years as a primary care internist and hospitalist. He p g y p y preceived his undergraduate degree from Connecticut College and medical degree from Georgetown University School of Medicine. He completed his residency at Dartmouth-Hitchcock Medical Center in New Hampshire. He is board certified in internal medicine and is a fellow of the American College of Physicians. Dr. Wagner has held numerous appointments, including his current role as the Chief of General Internal Medicine at Tufts Medical Center, CEO of EmCare Inpatient Services in Dallas Texas, Regional Medical Director for Cove Healthcare in La Jolla Ca. and Residency Program Director in Internal Medicine at St. Mary’s Hospital/University of Rochester in Rochester NY. Dr Wagner has focused his career on building and managing effective physician practices in community and academic settings. His has been involved in many IT projects from naval underwater warfare simulation to electronic medical records and large database analysis.Dr. Wagner currently manages the clinical division of General Internal Medicine which provides primary care to 33,000 patients in downtown Boston. The division also has an inpatient/hospitalist program, consultative service and concierge practice. Dr. Wagner is actively involved in teaching medical students and residents. He serves on many hospital committees and task forces including the Institutional Review Board.In addition to his academic work, Dr. Wagner has extensive experience with community based physician practices and hospitals. As the CEO of a national physician practice management company, he built and managed over 60 hospitalist programs in 16 states employing 385 physicians.Today Dr. Wagner will be sharing his experience and insights on achieving physician buy-in for effective IT adoption and engagement.

Michael Wagner, 2009

Page 3: Engaging Physicians In Information Technology

Goals of Session

Review the context of primary care practice Review the context of primary care practice environementOutline the framework for an IT implementationOutline the framework for an IT implementationLessons learned from an EMR implementation Questions and discussionQuestions and discussion

Michael Wagner, 2009

Page 4: Engaging Physicians In Information Technology

A little more detail…

Disclosures4

Chief, General Internal Medicine Tufts Medical CenterFounding Member, Phoenix Group

BiasesBiasesClinical – Internal Medicine/HospitalistOrganizational – Academic and community based physician

ipracticesGeography – Northeast, but with national view

GoalLeave you with a few insights and methodsOutline the transformative nature of IT adoption

September 2009 M Wagner MD

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Biases - National experiencep

5 Jan 2009 M Wagner MD

Review and/or design hospitalist programWork as hospitalistReview and/or design primary care practice

Page 6: Engaging Physicians In Information Technology

CURRENT STATE OF CURRENT STATE OF PRIMARY CAREAchieving Physician IT Adoption

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Status report – Primary care physiciansp y p y

Physicians’ Perspective studyPhysicians Perspective studyTrends on where trainees are goingBurdens on primary careBurdens on primary care

Michael Wagner, 2009

Page 8: Engaging Physicians In Information Technology

Physician – Archetypes y yp

Page 9: Engaging Physicians In Information Technology

The Physicians’ Perspective: Medical Practice in 2008Practice in 2008

Study outlineSurvey on physician perspectives mailed to:

>270,000 primary care physicians 50,000 randomly selected specialty physicians

Survey completed and reported in 2008

Sponsored by “The Physician’s Foundation” a non-profit p y y pcompany promoting physician practices and competed by Merritt Hawkins and Associates

Results ~12 000 respondentsResults ~12,000 respondents

Margin of error of about 1%

The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

Page 10: Engaging Physicians In Information Technology

The Physicians’ Perspective: Medical Practice in 2008Practice in 2008

MoralePhysician rated their colleagues morale

Positive – 6% Poor or Very Low – 42%oo o Ve y ow %

Self rating78% of physicians said medicine is either “no longer 78% of physicians said medicine is either no longer rewarding” or “less rewarding”

Capacity Capacity 76% of physicians said they are either at “full capacity” or “overextended and overworked”

The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

Page 11: Engaging Physicians In Information Technology

The Physicians’ Perspective: Medical Practice in 2008Practice in 2008

Paperworkp

Impact on time spent with patients63% f d d l l k h 63% of doctors said non-clinical paperwork has caused them to spend less time with their patients

Amount of time spent on paperwork94% said time they devote to non-clinical

k i h l h h i dpaperwork in the last three years has increased

The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

Page 12: Engaging Physicians In Information Technology

The Physicians’ Perspective: Medical Practice in 2008Practice in 2008

Government“D li i i b ” hi h d bl d 82% id h i i “Declining reimbursement” highest rated problem and 82% said their practices would become unsustainable if Medicare cuts are made

Reimbursement fails to cover costsMedicaid – 65% of practicesMedicare – 36% of practices

Closed practicesMedicaid – 33% of practicesMedicare – 12% of practices

FinancesHealth and profitable?

17% of physicians rated their practicesWould you retire?

45% f d t ld ti t d if th h d fi i l 45% of doctors would retire today if they had financial means

The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

Page 13: Engaging Physicians In Information Technology

The Physicians’ Perspective: Medical Practice in 2008Practice in 2008

Impact on physician workforceAn overwhelming majority of physicians – 78% – believe there is a shortage of primary care doctors in the United States today

49% of physicians – more than 150,000 doctors nationwide –said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. p y p p g y

11% said they plan to retire13% said they plan to seek a job in a non-clinical healthcare setting20% said they will cut back10% id th ill k t ti10% said they will work part-time

60% of doctors would not recommend medicine as a career to lyoung people

The Physician Foundation: “The Physicians’ Perspective: Medical Practice in 2008.”

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Paperworkp

Consult lettersDrug warningsMedication substitutionsVNA formsOxygen ordersNotifications of PT-1 form reauthorization requirementsPrior authorizationsManaged care patient listsRefill authorizationsLetters from the division chiefMisc letters

Michael Wagner, 2009

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Dissatisfaction with primary carep y

Burden

17

BurdenNon-visit clinical work without support

Administrative paperwork

Technology 70Technology

Compensation

Respect 50

60

70

G l

Role models

Control

Medical school loans20

30

40 GeneralHospitalistSubspecialty

Medical school loans

0

10

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Jan 2009M Wagner MD

Source: Internal Medicine In-Training Examination Survey

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Choices18

Hospitalist Medicine Primary Care Medicine

The graduate

Michael Wagner, 2009

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Choice: Primary Care vs. Hospital MedicinePrimary Care IM Hospital Medicine

Full time work commitment 18.75 days/month 15 shifts/month

Patient encounters per day 20-30 pts per day 15-18 pts per shift

Average compensation $150,000-$180,000/yr $180,000-$220,000/yr

Overhead Office staff equipment Billing and medicalOverhead Office, staff, equipment, supplies, billing, medical malpractice

Billing and medical malpractice

Non-visit clinical work >100 documents/day Minimal

Administrative work Prior authorizationsReferrals, FMLA, PT-1, Disability forms, etc

Inpatient payment denials

Panel size 1,500 to 2,500 0

Schedule Monday - Friday On-off for blocks

Workday Controlled by schedule Controlled by patient need, nursing, DC time

19 Michael Wagner, 2009

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THE FUTURE STATE OF THE FUTURE STATE OF PRIMARY CARE

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Strategic analysis

Strategic Drivers

Aging and chronic illness

Responses

Increasing visit and non-visit burden increase

Shrinking MD workforce

clinical work

Increasing ratio of patients Shrinking MD workforce Increasing ratio of patients per primary care MD

Reduction in health care dollars/patient

Application of evidence based care to make quality and utilization more uniformand utilization more uniform

21 Michael Wagner, 2009

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Transition analysis

Strategic Drivers1. Aging and chronic illness burden increase2. Shrinking MD workforce3. Reduction in health care dollars/patientanalysis

22

Accelerants1 Investment

3. Reduction in health care dollars/patient

1.Investment2.MD workforce3.Hospital medicine

Current state Future state

ConcernsGeneral InternistVi it f

The New InternistL d f tConcerns

1.MD-Patient relationship

Wildcards

•Visit focus•Space and staff volume focused

•Solo

•Leader of team•Population focus•Employed in larger organizationWildcards

1.Retailization2.Health Care reform3.Information technology4 R t it i

g

Michael Wagner 20094.Remote monitoring5.Non-physician providers6.Organizational acceptance

Michael Wagner, 2009

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The patient – physician relationshipp p y p

Minimal23

RadiologyAnesthesia

Episodic What is the value of a continuous EpisodicConsultantsHospitalistUrgent care

relationship between a patient and physician?

gED

ContinuousInternistInternistPediatricsFamily MedicineSome specialty carep y

Jan 2009Michael Wagner, 2009

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Levels of Patient Engagementg g

Highly engagedHighly engaged

EngagedEngaged

Engaged with normal promptsEngaged with normal prompts

Fragmented engagementg g g

Disengaged g g

Michael Wagner, 2009

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Deconstructing Primary Careg y25

1.Visit and non-visit work2.Disease/condition care 1.Visit based work

management3.Multidisciplinary teams

2.Access is essential3.Physical space designed

for urgent care4.Triage and collaboration

with ED and hospital for

Urgent Care

Chronic Care

with ED and hospital for transfers

Health Screening

1.Non-visit work is substantial2.Screening based on accepted

guidelines3 Requires coordination with3.Requires coordination with

specific screening services (Mammo, Endo)

Michael Wagner, 2009

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The New Internist - Role

Expert in the care of the medically complex patient p y p pManages patients with complex medical conditions across the spectrum of healthcare services and over titime

Team player Works in collaboration with a multidisciplinary and Works in collaboration with a multidisciplinary and integrated team

NursingSocial workHome based servicesNutrition

Michael Wagner, 2009

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The New Primary Care Physician – practice structure

Physician is part of the multidisciplinary team and is the medical leaderDirect patient careSupervision of non-physician providersClinical guidelines, protocol developmentCase reviewCase review

Practice is structured to support visit and non-visit clinical workInformation technology

Integrated EHR, e-prescribing, patient portalStaff

For visit work focused on efficient patient flowFor non-visit work – phone/electronic staff, case management

SSpace

Practice supports lifestyle needs of providersContinuous professional development programT f f l ti hi ith i li t /h it l th t id hi h l l Transfer of care relationships with specialists/hospitals that provide a higher level of care (applicable to rural and community facilities)

Michael Wagner, 2009

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An Organizational Approach to P i CPrimary CareAlign patients with your healthcare organization through effective primary care practices

Create a platform for physician recruitment and retention by offering a stable employment structure. Align compensation program with value based health care

Implement an electronic health record that is integrated with other information systems in order to p g yavoid duplication of data entry and facilitate access and transparency

Quality integrated into clinical operations with appropriate staffing and support

Reorganize staff to manage populations of patients in addition to managing visit based clinical work. Augment with multidisciplinary team members for niche issues such as home bound patients, hospice, etc.

Reconfigure space to handle visit and non-visit clinical workReconfigure space to handle visit and non visit clinical work

Reorganize physician work schedule to account for non-visit work and team participation

Negotiate payer contracts to assume greater control over medical budget with appropriate Negotiate payer contracts to assume greater control over medical budget with appropriate risk/reward

Michael Wagner, 2009

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Review

Primary care is on the cusp of a major changeCurrent workloads and burdens are making the current practice structure non-sustainableIn order to create sustainable models for primary care In order to create sustainable models for primary care, organizations or physician groups must rebuild the infrastructure supporting physiciansIT can be transformative in this process

H d h i i t b IT How do you engage physicians to embrace an IT implementation in the face of such a negative work environment?

29Michael Wagner, 2009

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FRAMEWORK FOR FRAMEWORK FOR ENGAGEMENT

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Components of an IT Implementationp p

Providers/ Users

Project Plan

TechnologyOperations

Michael Wagner, 2009

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Technology - IT system invasivenessgy y

Highly Invasive

• Electronic Medical Records• CPOE• Patient portal

Highly Invasive

The more invasive the IT system is in termsof daily workflow, the more MD engagement will be needed to successfully implement the system

• Billing / Charge entry

Invasive

y p y

g / g y• Managed care registries• Clinical information systems

Minimally Invasive

• Backend dictation systems• Patient scheduling systems• Order entry systems (non-CPOE)

Minimally Invasive

Michael Wagner, 2009

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Organizational factorsg

What are the drivers for the IT system?What are the drivers for the IT system?Who is driving the program?Have those who will be effected be engaged?Have those who will be effected be engaged?Have the goals of the project been clearly outline, including:including:

What the system is designed to do?What the system is not designed to do or fix?What the system is not designed to do or fix?

Have resources been appropriately allocated?

Michael Wagner, 2009

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Organizational - Recheckg

What are the intended and unintended What are the intended and unintended consequences of the IT system?Let’s recheck – do we have the right people and Let s recheck do we have the right people and resources?

Michael Wagner, 2009

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Engagement is a state of mind…g g

RespectRespectCommunicationInterests

The engagement and attitude of the leaders/drivers of the IT implementationInterests

ConcernsI lli

leaders/drivers of the IT implementation will set the tone for the project.  A challenge for the executive team driving this project will be to use these qualities listed to the left when 

h h d d ff hIntelligenceData

interacting with the providers and staff using the new IT system.

Michael Wagner, 2009

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The Core Implementation Team p

MD

NursingOperations

VendorIT

Michael Wagner, 2009

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Project plan(ner)j p ( )

Experience and organizational skills matter. Experience and organizational skills matter. Frequent organized meetings with project manager to hold participants feet to the fire.to hold participants feet to the fire.Action plans and minutes.Experience with successful implementation of same Experience with successful implementation of same program in similar size organization.Good sense of humorGood sense of humor.

Michael Wagner, 2009

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Where to find Physician Leadership?y p

Michael Wagner, 2009

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Physician factorsy

Role of physician leadershipNurturing future physician leadersScoping out your doctorsA dAvoid

Nattering nabobs of negativismTechnocratiDisorganization

Go for the silent, and usually appreciative, middleT i h i d l f d iTrain the trainer model of educationBehind the scenes lobbying, education and occasional deals

Michael Wagner, 2009

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Physician Typesy yp

Michael Wagner, 2009

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Levers for transition

What is broken? What will be fixed?What is broken? What will be fixed?What is in it for me?How will this help the practice?How will this help the practice?How will this help patients?

Michael Wagner, 2009

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Strategies for Successg

Have clear objectives that penetrate clinical work flowsRespect existing clinical work flows, but seize on opportunity to re-work and fix what is recognized as brokenbrokenListen carefully to physician concerns and incorporate suggestions when feasible – be graciousFocus on the silent majority and build a system that will work for themProvide options and choices. Developing 3-4 well p p gworked out clinical work flows is better than forcing one solution on everyone or keeping the 20 different ways it is done todayy

Michael Wagner, 2009

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Essential componentsp

Engagementg gPlanning that involves all partiesTraining gAdjusting clinical volumes during implementationPre-loading datagTrain the trainer model and super usersPhasinggHigh touch and presence during GO-LIVEHave Fun!

Michael Wagner, 2009

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AN EXAMPLE

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Tufts Medical Center - GMA

Michael Wagner, 2009

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The daily bagy g

Michael Wagner, 2009

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The ask

Michael Wagner, 2009

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The choice

Michael Wagner, 2009

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Transition analysis

Drivers1. Risk management2. Drug recalls3 R f B P bl H l h Danalysis

49

Accelerants

3. Reports for Boston Public Health Department4. On-call access to patient data

Current state –

Accelerants1. MD leadership2. Investment

Current state –Paper based records

Future state –EHR

Concerns Concerns 1. MD-Patient relationship2. Time3. Productivity Wildcards4. Computer skills

Wildcards1. Vendor support2. IT support3. Administrative bandwidth4. MD revolt5. Patient acceptance6. Budget hawk

Michael Wagner, 2009 Michael Wagner, 2009

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Timeline

1999- Realization - practice must have EHRApril 2000 – Presentation to system RACSummer 2000 - Rejection by system RACFall 2000 Project approved under hospital RAC processFall 2000 – Project approved under hospital RAC processLate 2000 – Vendor selected – Medicologic “Logician” productEarly 2001 – Project planning process begun with weekly and bi-weekly meetingsSummer 2001 – Final testing – training beginsg g gAugust 2001 – GO LIVEJanuary 2002 – Physician order entry initiated

Michael Wagner, 2009

Page 51: Engaging Physicians In Information Technology

Implementation team p

MD

NursingOperations

VendorIT

Michael Wagner, 2009

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Functionalityy

Appointment lookup – passiveNote writing – with optionsOrder entryResults reportingResults reporting

LabRadPath

Medication managementMedsPrescriptions (does not meet e-prescribing standard)

Phone call managementED and hospital notificationsED and hospital notifications

Michael Wagner, 2009

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Creating options – Note generationg p g

Fi l N i

Transcription Free formForm 

ComponentsQuick Text

Final Note inElectronic Medical Record

Michael Wagner, 2009

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Paper recordsp

Paper based records

Destinations

1 Clinic chart1. Clinic chart

2. Medical Record

3. Provider copy

Office visit

Our traditional view of what the output of an office visit has narrowed our concept of a “medical record”. We have tended to focus on the note as

Michael Wagner, 2009

the physical structure that must be reproduced in electronic format.

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EMR – not just a pretty note writer j p y

Data repository DestinationsData repository

• Notes• Labs / Rads

Destinations

• Patients• CHIN/Hub

• Phone notes• Orders / sets• Medications

• Hospital(s) • Registries• Research• P4P reportingP4P reporting

However, an EMR is the foundation of a data repository and practice structure for

Michael Wagner, 2009

p y peffective medical management of individual patients and population of patients.

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Loading the EMRg

Demographic data is il dd d t EMR easily added to EMR

through an interface from scheduling system

Michael Wagner, 2009

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Sample reportsClinical data is added manually and requires constant attention to p p constant attention to ensure work is being

done.

Michael Wagner, 2009

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Flu season 2001

In 2001, for the first time, we could track the actual number of flu shots given and who got the shots in real time

Michael Wagner, 2009

in real time.

Page 59: Engaging Physicians In Information Technology

Flu 2009Flu Surge Data

Administrative and Logician Data

9/23/2009 8:229/14 9/15 9/16 9/17 9/18 9/19 9/20 9/21

Human resources Goal Average Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday

Administrative staff out 0 1 1 1 3 3 3Nursing staff out 0 0 0 0 1 0 0MD t ff t 0 0 0 0 0 0 1MD staff out 0 0 0 0 0 0 1

Practice capacity Urgent care capacity at 8AM 25 18 26 29 32 37 20Appointments scheduled at 8 AM 244 411Appointments completed  381 323 285 355 237 363

Historical daily average*

V lVolumePhone notes  318 313 381 290 303 319 270 16 4 387Office Visit notes 260 282 302 313 275 304 215 287ED visits of patients in Logician 26 28 29 25 29 30 31 25 25 22Hospital admissions of patients in Logic 11 14 22 14 14 15 18 5 9 15

Ordering Chest xrays 10 9 14 7 9 9 4 8Flu shots (highlighted cell is to date) >5000 1213 200 39 19 56 16 105Flu shots (highlighted cell is to date) >5000 1213 200 39 19 56 16 105E&M codes with URI/Flu ICD9 code*Average from 9/10/2008 ‐ 9/11/2009

In 2009, we can use a combination of information sources to prepare for a possible flu surge Most of the data comes from our EMR

Michael Wagner, 2009

possible flu surge. Most of the data comes from our EMR.

Page 60: Engaging Physicians In Information Technology

Typical questions to answer from the EMR

How many patients do we have in the practice?How many seen in past three years?

How many diabetics?What is average A1C?What is average A1C?How has highest A1C?By PCP

How many diabetics?How many have met process measures?How many are meeting outcome measures?

Of the patients coming in today:Who is diabetic?What interventions need to be completed?What interventions need to be completed?

Michael Wagner, 2009

Page 61: Engaging Physicians In Information Technology

LESSONS LEARNED

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Creating a platform for sustainabilityg p y

Issues

Technology

•Upgrades•Problems•Interfaces

Issues•Note structures•User defined

bl

Issues•Specialized

tables•Patient lists•Problem lists•Medication lists p

training•Providers tables•New feature development

•Training and re-training

Product customization

Clinical work flows

development, testing and integration

Michael Wagner, 2009

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General Internal Medicine O f ti t T ftOne of many practices at Tufts

Tufts MC

Medicine Pediatrics SurgeryMedicine

GMA Cardiology GI Renal …

Pediatrics

Gen Peds Ped GI …

Surgery

GMA has 60,000 visits, but 240,000 visits were

happening in other clinics

Michael Wagner, 2009

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Snapshot of work generated in the EMREMR

Document type

Total number of documents since

January 2008

Average number per day for all of GMA

Ratio compared to office visit volume

Number compared to average volume of 20 patients per dayDocument type January 2008 GMA volume patients per day

Office Visit 63,932 256 1.00 20

Coumandin 9,058 36 0.14 3 Phone Note 75,103 300 1.17 23 Rx Refill 20,861 83 0.33 7 e 0,86 83 0 33

Letter - Results 39,310 157 0.61 12 Medication list 14,845 59 0.23 5 External Correspondence 18,726 75 0.29 6 Internal Correspondence 10,241 41 0.16 3 Other letter 39,543 158 0.62 12

Lab Report 258,036 1,032 4.04 81 Imaging Report 17,115 68 0.27 5 Pathology Report 4,052 16 0.06 1

Hospital Admission* 3,530 14 0.06 1 Emergency Report* 9,002 36 0.14 3

Totals (excluding office visit) 519,422 2,078 8 162 Other notes* 87,631 351 1.37 27

Based on Tufts GMA EMR data from January 15, 2008 to January 15, 2009

Michael Wagner, 2009

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Electronic work generatedg

Michael Wagner, 2009

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Avalanche of data

By the end of the week the physician will have reviewed in physician will have reviewed in excess of 700 electronic documents plus mail, fax and email

Michael Wagner, 2009

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IT overload and lack of integration g

Logician / CentricityS i

Clinic electronic health recordH it l li i l i f tiSoarian

PatientKeeperRelayHealthQuantiaMD

Hospital clinical informationPhysician billing systemPatient portal Physician education website

RCO/EnvisionStanding StoneDr. QualityBed Board/ADT

Patient scheduling systemWarfarin management systemQuality reporting websiteInpatient bed tracking systemBed Board/ADT

NEQCA registry MailEmail

Inpatient bed tracking systemManaged care quality monitoringTradition mode of communicationGeneral communication

FaxPhoneIntranet (phone book, Up to Date)Veriphy

Legacy systemLegacy systemInformation resourcesRadiology critical result reportingp y

SoftMed/ESAgy p g

Electronic signature for dictations

Michael Wagner, 2009

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Lessons earned

Like the field I showed earlier, an EMR needs constant tending. The work flows may be automated, but the field and hardware get old, broken and fail to keep up with the changing landscape. Patient, problem and medication lists

d t b d t d t tlneed to be updated constantly.Decisions must be made up front on who and how the product will be maintained. Some of that maintenance will

d b d b li i l l i di lneed to be done by clinical people, so invest accordingly.Information systems are popping up everywhere and there is little integrative analysis being done when a new system is selected and implemented. The end result is clinicians interacting in a fragmented digital landscape. Which will only worsen physician satisfaction and increase patient risk

Michael Wagner, 2009

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THANK-YOU