Practice Transformation in a

Physician OrganizationMary Barton Durfee,

M.D.

September 17, 2009

The Transformation Story

• IHA – Who Are We?

• Building Infrastructure– Access– EMR– LEAN– Care Management– PCMH

• Physician Owned; Founded in 1994

• 160 Physicians

• 37 APN/PA

• 30 Sites

• 260,000 Active Patients

• 22,000 New Patients in 2008

• 488,000 Patient Visits in 2008

• 2,652 Deliveries

• 700 Employees

• SJMH/UM Linked

IHA – Who Are We?

5 divisions including Internal Medicine, Family Medicine, Pediatrics, OB/GYN, and Surgery

After Hours Ancillary Services – CT, General Ultrasound, General

Radiology Specialty Services – Maternal and Fetal Medicine, Pediatric

and Adult Neurology, Dermatologic Surgery, General Surgery Hospitalist Services at SJMH Ann Arbor and Livingston,

Saline, and Chelsea for adult patients

IHA – What Are We?

IHA – Where AreWe?

Leadership Structure and Committees

IHA

endeavors through its evolved and participatory structure to bring all its resources to meet the

needs of our patients and the community.

Inspired by our Mission Integrated Health Associates (IHA) exists to meet community needs

through the provision of personalized, high quality health and medical services

to our patients in a manner which results in high levels of patient satisfaction with clinical quality, services, accessibility and value.

Driven by our Values Commitment

Advocacy Respect

Efficiency Service

PATIENTS AND COMMUNITY

FAMILY MEDICINE OFFICES Ann Arbor Family Practice

Brighton Family Care Specialists IHA Family Practice

Milan Family Medicine Okey Family Practice Pinckney Family Care

INTERNAL MEDICINE OFFICES Chelsea Internal Medicine

AIIM-Cherry Hill AIIM-Commonwealth

Huron Valley Neurology IHA Plymouth Internal Medicine

IHA Hospitalists AIIM-Pauline

OB/GYN OFFICES Ann Arbor OB/GYN Associates –

Ypsilanti/Milan/Plymouth Associates in Gynecology &

Obstetrics – Brighton/Ypsilanti/Chelsea

Canton Obstetrics and Gynecology IHA Maternal-Fetal Medicine

IHA Menon, Miller & Midwives IHA WestArbor OB/Gyn

Walker Gyn. of IHA

PEDIATRIC OFFICES Chelsea Pediatrics

Child Health Associates-Ann Arbor Child Health Associates-Plymouth

Huron Valley Neurology IHA Livingston Pediatrics

Pediatric Healthcare Associates-Canton

Pediatric Healthcare Associates-Ypsilanti

Primary Pediatrics

SURGICAL OFFICES Canton Obstetrics & Gynecology?

Chelsea Surgical Associates IHA Dermatologic Surgery

Associates

FAMILY MEDICINE OPERATING TEAM

Bob Breakey, MD - Chair Michael Bruderly, MD

Karen Edwards Cindy Elliott

Zoë Foster, MD Janet Hubert, MD Mike Jasbeck, MD

Marty Murray Monty Okey, MD

Melissa Sokol-Keith, MD Mark Zawisa, MD

INTERNAL MEDICINE OPERATING TEAM

Karl Brenner, MD Peter Dews, MD Mary Durfee, MD

Cindy Elliott Michael Friedlander, MD

Joyce Leon, MD Mark Lindley, MD - Chair

Evan Padgitt, CNP Art Tai, MD

Dave Winston, MD Steve Yarows, MD

OB/GYN OPERATING TEAM Cheryl Bachman, CNM

Wes Beemer, MD – Chair David Bryant, MD

Cindy Elliott Jody Jones, MD Kris Miller, MD

Bryan Popp, MD Joanne Vicari, MD Karen Walker, MD

PEDIATRIC OPERATING TEAM Nancy Anastasi, MD

Ginny Bareham, CNP Susan Bass

Karen Brenner, MD Cindy Elliott

John Gardner, MD Beth Hall, MD

Kim Meisenhelder, MD Marty Murray

Lisa Profera, MD Nancy Spangler, MD - Chair

Elizabeth Stone, MD Howard Weinblatt, MD

Mary Westhoff, MD

SURGICAL OPERATION TEAM (part of OB/Gyn Ops Team)

Renee Bayer Wes Beemer, MD – Chair

Cindy Elliott Jody Jones, MD

Jennifer Kulick, MD Mel Larson Bruce Maki

Karen Walker, MD

COMMITTEES AND SUBCOMMITTEES

CLINICAL QUALITY IMPROVEMENT COMMITTEE

Wes Beemer, MD Robert Breakey, MD

Amy Cooke, MD Mary Durfee, MD –Chair

Cindy Elliott Nancy Griffith

Olav Jaren, MD, PhD Lynn Klima

Jennifer Kulick, MD Lynn Lewis, CNP Mark Lindley, MD

Lee McDonagh, RD, CDE Pary Reza, MD

Nancy Spangler, MD Sandy Talbott, CNP

Steve Thiry, MD

CLINICAL RESEARCH COMMITTEE

Will Chamness, MD Jeff Dimaya Cindy Elliott

Olav Jaren, MD, PhD Mark Lindley, MD

Gayle Moyer, MD – Chair Sharon O’Leary, MD

Melissa Sokol-Keith, MD Lowell Sprague

Steve Yarows, MD

COMPENSATION COMMITTEE Wes Beemer, MD Bob Breakey, MD Karl Brenner, MD

Bill Fileti Dawn Johnson

Mike Kucera, MD – Chair Ted Merkel, MD Lowell Sprague

Art Tai, MD

APN/PA COMPENSATION SUB-COMMITTEE

Wes Beemer, MD Craig Brockman, CNP

Cindy Elliott Bill Fileti

Dawn Johnson Mike Kucera, MD

Jodi Lambert, CNP Linda MacEllven

Pat Reckling, CNP Nancy Sebby, CNP

Diane Weid, CNP – Chair

COMPLIANCE ADVISORY COMMITTEE Cindy Elliott

Jackie Gandol Chris Holda

Brad Judge, MD Linda MacEllven

Marty Murray Lena Payne

Joanne Vicari Block, MD Carol Ways, MD – Chair

David Winston, MD

FINANCE COMMITTEE Bob Adams, MD

Raj Deenadayalu, MD Bill Fileti

Mike Friedlander, MD Jim Marley, MD – Chair

Marty Murray Melissa Sokol-Keith, MD

Lowell Sprague Neal Weinberg, MD

Francie Youssef, MD

HEALTH PROMOTION Mira Agrawal, MD Lynn Klima, CNP

Ginny Johnson, MD Jay Lodwick, PA-C

Amy Middleton Pary Reza, MD

Nancy Sebby, CNP Steve Thiry, MD – Chair

Marti Walsh, MD Melissa Zarow, DO

Vicki Zilke, CNP

HUMAN RESOURCES COMMITTEE

Renee Armstead, MD Yuvelle Eaton-McFarland, MD

Cindy Elliott Bill Fileti

John Gardner, MD Joyce Leon, MD Linda MacEllven Gayle Moyer, MD Alberto Nacif, MD

Karen Walker, MD – Chair

LEADERSHIP DEVELOPMENT COMMITTEE

Wes Beemer, MD Bob Breakey, MD – Chair

Mary Durfee, MD Bill Fileti

Michael Kucera, MD Mark Lindley, MD

Nancy Spangler, MD

IHA GOVERNING BOARD (IGB)

Wes Beemer, MD Bob Breakey, MD – Chair

Mary Durfee, MD Bill Fileti

Julie Gargan Kozma, CNP Mike Kucera, MD Mark Lindley, MD Jim Marley, MD

Gayle Moyer, MD Melissa Sokol-Keith, MD

Nancy Spangler, MD Steve Thiry, MD

Neal Weinberg, MD

MARKETING COMMITTEE Sue Archer, MD

Nancy Anastasi, MD Cheryl Bachman, CNM

Mike Bruderly, MD Cindy Elliott

Bill Fileti Julie Gargan Kozma, CNP

Bridget Long, MD Kristin McFadden, DO

Amy Middleton Lisa Profera, MD – Chair

MEDICAL INFORMATICS

COMMITTEE Matthew Bressie, MD

Chris Holda Janet Hubert, MD Chris Kottke, MD Joyce Leon, MD

Marty Murray Mike O’Donnell

Evan Padgitt, CNP Sandy Talbott, CNP Neal Weinberg, MD

Mark Zawisa, MD - Chair

MULTI-SPECIALTY EXPANSION Robert Breakey, MD

Mary Durfee, MD Cindy Elliott

Bill Fileti Mike Friedlander, MD - Chair

Maria Heck, DO Jennifer Kulick, MD

Rajiv Deenadayalu, MD Peter Meyers, DO

Lowell Sprague Brian Woodruff, MD

NOMINATING COMMITTEE

Rossana DeGrood, MD - Chair Mary Durfee, MD

Bill Fileti Madelyn McMurtrie, CNP

Monty Okey, MD Steven Popper, MD

PATIENT SERVICE COMMITTEE

Roger Chen, MD Pam Davies, MD – Chair

Joanne Dommer-Kind, CNP Mary Durfee, MD Kathy Kise, CNP Linda MacEllven

Kimberly Meisenhelder, MD Darcey Owings, CNP

Pat Reckling, CNP Brian Woodruff, MD

PUBLIC POLICY COMMITTEE Cindy Elliott

Delores Garcia, MD Maria Heck, DO

Chris Holda Jody Jones, MD – Chair Madelyn McMurtrie, CNP

Pary Reza, MD Karen Selle

RETIREMENT PLANNING

COMMITTEE Jim Alford, MD

Virginia Bareham, CNP Osamah El-Aroud, MD

Bill Fileti John Gardner, MD Jay Lodwick, PA-C Linda MacEllven Ted Merkel, MD

Kelly O’Connor, MD Monty Okey, MD

Jim Sansone, MD – Chair Lisa Sprague, MD

Lowell Sprague Liz Stone, MD

David Winston, MD

RISK MANAGEMENT COMMITTEE

Wes Beemer, MD - Chair Cindy Elliott

Bill Fileti Ginny Johnson, MD

Julie Gargan Kozma, CNP Allison Kreske, MD Mark Lindley, MD Ken Owings, MD Carol Ways, MD

WEB SITE COMMITTEE

Cindy Elliott Pat Gordon, MD

Chris Holda Vaishali Katial, MD Lynn Klima, CNP Amy Middleton Lisa Morris, MD

Theresa Poppe, MD Brian Woodruff, MD - Chair

Steven Yarows, MD Carla Zahuranec, MD

Mark Zawisa, MD

IHA MANAGEMENT TEAM

Jackie Gandol Chris Holda Lynn Klima Amy Middleton Director of Business Director of Technology & Director of Clinical Director of Marketing Services Information Services Improvement Marty Murray Linda MacEllven Vice President - Director of Human Administrative Services Resources & Customer Service Cindy Elliott Lowell Sprague Chief Operating Officer (COO) CFO

Bill Fileti President & CEO

• Access 90 days to Advancing Access

o Patient Satisfaction – “Getting through to the Office by Phone”

Call Center

• After Hours ED utilization

Building the Infrastructure:Access

“Getting through to the Office”

Patient Satisfaction at IHA

Survey Period IHA Overall AMGA Norm (Excellent) (Excellent) Spring 2005 33% 39% Spring 2006 38% 42% Spring 2007 38% 45% Fall 2007 41% 45% Spring 2008 44% 44% Fall 2008 45% 44% Spring 2009 47% 44%

Access: What Did We Measure?

• Evening hours after 5pm• Morning hours before 8am• Weekend hours• Walk-in hours• Third available• Phones answered live• Answered the phones during lunch

Advanced Access

Percent of offices answering the phones during lunch

June 2007 August 2009

38% 100%

Percent of offices that a live person answering phones

June 2007 August 2009

31% 45%

Percent of offices that have addressed advanced access

June 2007 August 2009

45% 90%

“Getting through to the Office”

Patient Satisfaction at IHA

Survey Period IHA Overall AMGA Norm (Excellent) (Excellent) Spring 2005 33% 39% Spring 2006 38% 42% Spring 2007 38% 45% Fall 2007 41% 45% Spring 2008 44% 44% Fall 2008 45% 44% Spring 2009 47% 44%

Average IHA ER Rates

Combined IHA ER Rates

Building the Infrastructure:EMR

• EMR– 2003 - Commitment to implement EMR – right

thing to do to ensure quality and safety for our patients despite cost

– 7/06 – 1 Internal Medicine and 1 OB/GYN office go live on EMR – major challenges

Time to Revisit our Options

• Re-organize process– Designate EMR training team– Hire director of EMR training – CNP with clinical

experience– Develop roll-out schedule for offices– Fine tune process– All IHA offices now live on EMR or in implementation

EMR Implementation

EMR OUTCOMES

• Improved consistency of work flow around Preventive and Chronic Disease Care

• Allowed direct upload of quality data/ HEDIS indicators to payers

• Enhanced patient safety• Developed disease-specific registries• Cost

– Overall total Capital Investment > $8,000,000– Ongoing Costs - about $1,400,000/year

• Registry Function• Test Tracking• Development of Internal Coaches• Roles and Responsibilities• Care Coordination

Learning Collaborative with HVPA and U of M

Building the Infrastructure: LEAN

Make the Right Thing the Easy Thing

Same WayEvery Time

No Double Work

Increase Efficiencies and Decrease Errors

• Planned Care

• Self Management

• Prevention

• Patient Portal

• Back Pain

• Care Coordination Hospitalist Pilot

Building the Infrastructure:Care Management

Hospitalist Pilot Program: Continuity of CareHospitalist enters info into the Admit/ Discharge template.

Hospitalist tasks the Nurse Triage group of the PCP’s location

Nurse Triage accepts task

Nurse Triage (or their designee)

•Opens PCIS•Prints discharge summary •Scans summary into ICS•Notifies appropriate person per office workflow

To provide continuity of care, Nurse Triage

•Reads discharge summary and contacts patient •Assures patient that the IHA Hospitalist has been in touch with his/her PCP.•Does med reconciliation over phone (if possible)•Sets up follow-up appointment•Answers any immediate questions or gives any appropriate cautions (eg: if SOB go to the ER)•Activates a recall (or task appropriate person for this)•Task PCP per office protocol (eg: at completion of above tasks).

IHA Patient Satisfaction Results – Fall 2008

• Complete implementation of EMR with development of new templates to support clinical quality

• Patient Centered Medical Home designation for every IHA practice

• Full implementation of the Patient Portal• Continue to integrate with other community groups

to provide coordinated care• Multi-specialty Growth

Next Steps

Next Steps

• Continuous improvement on Quality and HEDIS metrics

• Improve Access and continued reduction in ED utilization

• Work with hospitalist group to reduce re-admission rates through improved coordination of care work flow

It’s kind of fun to do the impossible!

Walt Disney

Questions?

Thank you.

For more information:

www.ihacares.com