the electronic medical record: is it the holy grail? · 2012-01-17 · confidential1 dos cme course...

DOS CME Course 20111 Oxtober 20101Confidential

The Electronic Medical Record: Is it the Holy Grail?

Jonathan L. Schaffer, MD MBAManaging Director

eClevelandClinic, Information Technology DivisionProgram Director

Advanced Operative Technology GroupOrthopaedic and Rheumatologic Research CenterBiomedical Engineering, Lerner Research Institute

Staff Surgeon, Center for Joint ReconstructionDepartment of Orthopaedic Surgery, Orthopaedic and Rhuematologic Institute

Cleveland Clinic

Ermie Herring, MSN, PMPChief, Medical Informatics

The Office of Medical ServicesThe Department of State

© Cleveland Clinic 2011DOS CME Course 2011

DOS CME Course 20112

The last time you needed cash, did you………..

Wait in line at the bank? Stop at an ATM?


The last time you needed information, did you…

Use the card catalogue at the library?

Google it?

• Many daily tasks are easier and more convenient

• We save time

• We save money

• We can’t remember what life was like before

• We rely on many of these services

• When applied to medical care– Increased patient safety and service– Increased physician productivity– Decreased transcription costs– Improved billing cycles– On demand information access

Information Technology Benefits


DOS CME Course 2011

Today’s patient is demanding a similar level of service from their health care providers.

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• Clinical, workflow, administrative, and revenue enhancement benefits of the EMR– Outweigh barriers and challenges– Only if healthcare organizations redesign work processes– Train and motivate users to navigate EMR systems– Develop a common structured language

• Clinicians who use EMR– Electronic access to clinical information– Saves time– Provides a thorough and efficient way to manage patients

• ORGANIZED CLINICIANS ARE ORGANIZED !– And they will find the Holy Grail– Eventually– Maybe

Analyzing EMRs



Computerized Physician Order Entry• Streamlines entry of routine orders

– Eliminates re-entry of data collected elsewhere – Monitors ‘completeness’ and accuracy of orders

• Facilitates ordering decisions– Drug interaction checking (drugs, food, allergies, labs)– Alerts physician to other contra-indications– Offers physicians a review of “Best Practice” guidelines– Checks for duplicate orders

• Facilitates clinical follow-up– Offers overview of full patient list ‘at a glance’– Reports order status– Highlights overdue results and abnormal results– Offers ‘best practice’ guidelines re: next steps


HiTech Act

Every Life Deserves World Class Care


EMR Political Landscape• February 17, 2009 President Obama signed the $787 billion

American Recovery and Reinvestment Act of 2009 (ARRA)

• Create jobs, restore economic growth and strengthen America's middle class through measures that– Modernize the nation's infrastructure – Enhance America's energy independence – Preserve and improve affordable health care (28%)– Expand educational opportunities – Provide tax relief– Protect those in greatest need

DOS CME Course 2011

EMR Political Landscape• $140 billion for “comprehensive healthcare reform”

– $19.5 billion to promote HIT adoption and implementation– Concern that system has flaws

– Over-treatment– Highly fragmented– Uncoordinated care

• Physicians and hospitals are eligible to receive portions of these funds based on– Having an integrated EMR system in place by January 1, 2011– Demonstrating EMR “meaningful use” as defined by a National

Coordinator for Health Information Technology committee

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DOS CME Course 2011

Orientation to ARRA Structure• Divided into two divisions

– Healthcare and HIT are addressed throughout

• Division A: Appropriations Provisions– Title VII Dept. Labor, HHS, and Education– Title XIII Health Information Technology for Economic and

Clinical Health (HITECH) Act

• Division B: Tax, Unemployment, Health, State Fiscal Relief, and Other Provisions– Title IV Medicare and Medicaid HIT (incentives

–A: Promotion of HIT (ONC)–B: Testing of HIT–C: Grants and Loans Funding–D: Privacy

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Orientation to ARRA StructureDIVISION A: TITLE XIII—HEALTH INFORMATION TECHNOLOGY• Subtitle A—Promotion of Health Information Technology

– PART 1—IMPROVING HEALTH CARE QUALITY, SAFETY, AND EFFICIENCY– 13101 ONCHIT; Standards Development and Adoption.– 13102 Technical Amendment.

– PART 2—Application and use of adopted health information technology standards; Reports – 13111 Coordination of federal activities with adopted standards and implementation specifications.– 13112 Application to private entities.– 13113 Study and reports.

• Subtitle B—Testing of Health Information Technology – 13201 National Institute for Standards and Technology Testing. – 13202 Research and development programs.

• Subtitle C—Grants and Loans Funding – 13301 Grant, loan, and demonstration programs.

• Subtitle D—Privacy – 13400 Definitions

– Breach Business Associate Covered Entity Disclose Electronic Health Record Health Care Operations Health Care Provider Health Plan National Coordinator Payment Personal Health Record Protected Health Information Secretary Security State Treatment Use Vendor of Personal Health Records

– PART 1—IMPROVED PRIVACY PROVISIONS AND SECURITY PROVISIONS – 13401 Application of security provisions and penalties to business associates of covered entities; annual guidance on security provisions.– 13402 Notification in the case of breach.– 13403 Education on health information privacy.– 13404 Application of privacy provisions and penalties to business associates of covered entities.– 13405 Restrictions on certain disclosures and sales of health information; accounting of certain protected health information disclosures; access to certain information in electronic

format.– 13406 Conditions on certain contacts as part of health care operations.– 13407 Temporary breach notification requirement for vendors of personal health records and other non-HIPAA covered entities.– 13408 Business associate contracts required for certain entities.– 13409 Clarification of application of wrongful disclosures criminal penalties.– 13410 Improved enforcement.– 13411 Audits.

– PART 2—RELATIONSHIP TO OTHER LAWS; REGULATORY REFERENCES; EFFECTIVE DATE; REPORTS – 13421 Relationship to other laws.– 13422 Regulatory references.– 13423 Effective date.– 13424 Studies, reports, guidance.

DIVISION B: TITLE IV—MEDICARE AND MEDICAID HEALTH INFORMATION TECHNOLOGY; MISCELLANEOUS MEDICARE PROVISIONS – 4001 Table of contents of title.

• Subtitle A—Medicare Incentives – 4101 Incentives for eligible professionals.– 4102 Incentives for hospitals.– 4103 Treatment of payments and savings; implementation funding.– 4104 Studies and reports on health information technology.

• Subtitle B—Medicaid Incentives – 4201 Medicaid provider HIT adoption and operation payments; implementation funding.

• Subtitle C—Miscellaneous Medicare Provisions – 4301 Moratoria on certain Medicare regulations.– 4302 Long-term care hospital technical corrections.

www.hipaasurvivalguide.com/hitech-act-text.php

DOS CME Course 2011

Health Information Technology for Economic and Clinical Health Act (HITECH) Act

• Focus on funding for HIT– Promotion of HIT– Incentives for EHR use

• Specific topics – EHR Terminology– Immediate Funding for HIT Infrastructure and Implementation

Assistance– State Grants and Loan Programs– HIT Education– Medicare Incentives for Meaningful Use of EHR Technology

–Eligible Professionals–Eligible Hospitals

– Impact of Payment Incentives– Medicaid Incentives

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HITECH Focus • Enhancements that enable a nationwide health

information network– Nationwide health information network – Nationwide HIT infrastructure– Health information exchanges (HIEs) – Health information exchange organization (HIO)– Regional health information organization (RHIO)– E-prescribing gateway (e-Rx)

DOS CME Course 2011

HITECH Focus• Net opportunity of 19.5B investment in HIT systems

– Improve quality, safety, efficiency, care coordination, population and public health and value– Reduce health disparities– Engaging patients and families– Ensuring privacy and security– Authorizes CMS to provide financial incentives for eligible docs who meaningfully use EMR

• Use a certified EHR in a meaningful manner– Purchase certified EMR (www.cchit.org)– Demonstrate meaningful use of certified EMR (healthit.hhs.gov)

– 28 specific functions with EMR – Submit 29 quality measures to CMS to qualify for payment #1

– Bar raised in 2013 and 2015– Improved clinical performance on key health outcomes

– Payments up to $44,000 per physician over five years– Treat Medicare patients (Medicaid has different schedule)

– ePrescribing bonus available now– 2% of Medicare payments starting in 2010, decreasing thereafter, then penalties in 2012

– 5% reduction in payment for those who do not use EMR– Hospitals $2M over four years

• Regional Extension Centers– Educational and technical assistance govt funded agencies– Priority are rural, poor urban area, small group, primary care docs

• Care transformation is the goal with improved health system performance

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Meaningful Use


EHR Terminology• Meaningful use of EHR:

– Eligible professional demonstrates use of certified EHR technology

• In a meaningful manner– Definition to be determined but you had better be meaningful– E-prescribing as determined to be appropriate by the Secretary– Exchange of information to improve quality of health care and

promoting care coordination– Reporting of clinical quality measures and other measures

selected by Secretary– Measures may become more stringent– HHS may not require electronic reporting unless there is the

capacity to accept data

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Meaningful Use of the EMR• Hospitals and eligible professionals report that the EMR

has been implemented in a meaningful way such that the quality of health care will be improved

• Five Health care outcomes policy priorities1. Improve quality, safety, efficiency and reduce health disparities2. Engage patients and families3. Improve care coordination4. Improve population and public health5. Ensure adequate privacy and security

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Modern Healthcare March 29, 2010 page 9

DOS CME Course 2011


Meaningful Use “Finalized” Q2 2010

Year Engagement Objectives Engagement Measures2011 Provide clinical summaries for

patients for each encounter, electronic copies, access to patient specific educational sources

Percentage of patients with electronic access to clinical summaries, personal health information and educational resources

2013 Offer secure patient – provider messaging; upload data from home monitoring devices

Percentage of patients with access to secure messaging and implemented ability to incorporate data uploaded from home devices

2015 Access for all patients to PHRs populated in real time with data from EHR and electronic reporting on experience of care

National Priorities Partnership quality measures related to patient and family engagement and percentage of patients with access to real-time PHR

Adapted from Modern Healthcare June 22, 2009 page 6

Orthopaedic surgeons will have great difficulty in meeting the current 25 Meaningful Use standards. Orthopaedics would derive greater benefits from standards promulgated by our medical specialty society rather than a set of

generic requirements that mostly do not apply to musculoskeletal patient care.Thomas C. Barber MD, EMR Task Force team leader, AAOS NOW

Max Incentive Payments to Eligible Physicians


Year 2011 or 2012 2013 20141 $ 18,000 $ 15,000 $ 12,0002 $ 12,000 $ 12,000 $ 8,0003 $ 8,000 $ 8,000 $ 4,0004 $ 4,000 $ 4,000 $ 2,0005 $ 2,000 $ 2,000 $ 0

Total $ 44,000 $ 41,000 $ 26,000

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Reportable Quality Measures Round 1• % Diabetics with A1c under control• % Hypertensives with BP under control• % LDL under control• % Smokers offered cessation counseling• % Patients with recorded BMI• % Colorectal screening for 50+• % Mammogramns for women 50+• % Current pneumovax status• % Annual flu vaccinations• % Aspirin prophylaxis for patient at risk for cardiac event• % Surgical patients receivng VTE prophylaxis• Avoidance of high risk meds for elderly• % Orders entered thru CPOE by physicians

DOS CME Course 2011

DOS CME Course 2011

2011 Objectives• Using CPOE for inpatient and outpatient

• Incorporating lab test into EMR for inpatient and outpatient

• Mining the data for lists of patients by condition for quality improvement and outreach

• Provide patients with PHR

• Provide patients with printed clinical summaries after an encounter

• Exchange data between providers (problems, meds, allergies, all tests

• Provide public health agencies with immunization data

• Comply with HIPPA privacy and security laws

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Cleveland Clinic’s Implementation of EMR



Cleveland Clinic 1921


• Group practice model– 2,700 physicians and researchers – 120 specialties and sub-specialties– 40,000 employees

• Main Campus– 17 Family Health Centers in Ohio

• Cleveland Clinic Health System– 9 Regional Hospitals– Children’s Hospital for Rehabilitation– 1 Affiliate hospital

• Nevada – Lou Ruvo Center for Brain Health, Las Vegas

• Florida– Weston Clinic and hospital

• Canada– Toronto Health and Wellness Centre

• Cleveland Clinic Abu Dhabi

• Patients visit from 50 states and more than 80+ countries worldwide

Cleveland Clinic 2010

DOS CME Course 201128 AAOS Practice Management Course l September 2009 l 28

FHCFHCElyria FamilyHealth Center

Westlake FamilyHealth Center

FHCFHC

Lorain Family HealthAnd Surgery Center

FHCFHCLakewood

Family HealthCenter

FHCFHC

Strongsville Family Health and Surgery Center

FHCFHC

Brunswick FamilyHealth Center

FHCFHCWooster FamilyHealth Center

FHCFHC

Independence FamilyHealth Center

FHCFHCSolon FamilyHealth Center

FHCFHC

Chagrin Falls FamilyHealth Center

FHCFHC

Beachwood FamilyHealth and Surgery Center

FHCFHC

Willoughby HillsFamily Health Center

FHCFHC

HHFairview Hospital

Lakewood Hospital

HH

Lutheran Hospital

HH

Ashtabula County Medical Center

HH

Euclid Hospital

HH

Huron Hospital

HH

Hillcrest Hospital

HH

South PointeHospital

HH

Marymount Hospital

HH

ClevelandClinic


Strategic Application of Information Technology

Infrastructure

Administrative Ops

Clinical Ops

Practice Transformation

Value


• From a paper model

• To a digital model

Moving the Practice of Medicine


VirtualVisit:Patient/Physician

Interaction Globally



eResearch:Research

Standardization: Real Data; Real Results

eResearch:Research


DrConnect:Improved

Communication; Improved Care

DrConnect:Improved


PatientsPatients ProvidersProviders

MyConsult:Your First Choice for

a Second Opinion


a Second Opinion

MyChart:Your Personal

Health Connection


Health Connection

MyMonitoring:Ongoing Condition

Reporting from Home


Reporting from Home

MyPractice:Electronic Medical

Record System


Record System

eHealth ServiceseHealth Services

MyPractice CommunityMyPractice Community


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Patients in MyPractice: 6.2 Million(Electronic Medical Record System)

ClevelandClinic

HHFairview Hospital

HHLakewood

Hospital

HHLutheran Hospital

HHMarymount

Hospital

HHSouth Pointe

Hospital

HHHillcrest Hospital

HHEuclid

Hospital HHHuron

Hospital

HHAshtabula County

Medical Center

HHMedina Hospital

FHCFHC

Elyria FamilyHealth Center

FHCFHC

Westlake FamilyHealth Center FHCFHC

Lakewood FamilyHealth Center

FHCFHC

Strongsville FamilyHealth Center FHCFHC

Brunswick FamilyHealth Center

FHCFHC


FHCFHC

Wooster FamilyHealth Center

FHCFHC

Solon FamilyHealth Center

FHCFHC

Beachwood FamilyHealth Center

FHCFHC

Willoughby Hills Family Health Center

FHCFHC

Avon Lake FamilyHealth Center

FHCFHC

Avon FamilyHealth CenterFHCFHC

Lorain FamilyHealth Center

FHCFHC

Twinsburg Medical Office

FHCFHC

Chagrin FallsFamily Health

Center

FHCFHC

BainbridgeUrgent Care

FHCFHC

Broadview Heights Family Health Center

Lou Ruvo Center forBrain Health, Las Vegas Cleveland Clinic

Florida

Cleveland Clinic Canada

Cleveland Clinic Abu Dhabi (2012)

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Current Processes, Work Flows• Practice Workflow

– Identify each step in process of care– Without complete understanding, transition to automation will fail

• Scheduling an appointment for the service– Registering a patient and obtaining payer-specific information– Verifying insurance coverage and eligibility for benefits – Requesting authorization from a payer for treatments or referrals

• Patient arrival, confirmation, visit– Interaction with clinical support staff– Interaction with provider– Formulation of impression and plan– Documentation of the services provided– Ordering treatment or diagnostic testing

– Reviewing formulary limits of a payer or pharmacy benefits manager

– Implementation of the plan– Receiving test results and conveying them to patients

– Requesting follow-up care, such as return visits or referrals• Billing and submitting claims to third-party payers


Clinician’s Roles• Champions

– Clinical team consisting of physician, PA / RNFA, secretary

• Guide adoption– Timing– Strategies– Education

• Content determination– Define physician workflow – Display design

• Create and approve clinical decision support

DOS CME Course 20113535 DOS CME Course 2011


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DOS CME Course 2011

DRUGS:COUMADIN TABLET 2 MG POZOLOFT 50 MG POSIGNIFICANCE LEVEL. Very High

DRUGS:COUMADIN TABLET 2 MG POZOLOFT 50 MG POSIGNIFICANCE LEVEL. Very High Can override and

accept the interactionCan override and accept the interaction

Drug Interaction Alert

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E-Prescribing

E-Prescribing



Age, Gender, Diagnosis Health Maintenance Alerts

DOS CME Course 2011





eResearch:Research


eResearch:Research


DrConnect:Improved


DrConnect:Improved




a Second Opinion


a Second Opinion


Health Connection


Health Connection


Reporting from Home


Reporting from Home


Record System


Record System



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DOS CME Course 201172 AAOS Practice Management Course l September 2009 l 72

Elyria FamilyHealth Center

Westlake FamilyHealth Center

Lorain Family HealthAnd Surgery Center

LakewoodFamily Health

Center

Strongsville Family Health and Surgery Center Brunswick Family

Health CenterWooster FamilyHealth Center


Solon FamilyHealth Center

Chagrin Falls FamilyHealth Center

Beachwood FamilyHealth and Surgery Center

Willoughby HillsFamily Health Center

MyPractice CommunityTotal Users: 1135Providers: 196Residents / Fellows: 149Midwives: 12

Fairview Hospital

Lakewood Hospital

Lutheran Hospital

Ashtabula County Medical Center

Euclid Hospital

Huron Hospital

Hillcrest Hospital

South PointeHospital

Marymount Hospital

ClevelandClinic

Florida

MPCMPC

MPCMPC

MPCMPC

MPCMPC MPCMPC MPCMPC

MPCMPC

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MPCMPCMPCMPC

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MPCMPC

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MPCMPC

MPCMPC

MPCMPCMPCMPC

MPCMPC MPCMPC MPCMPCMPCMPC

DOS CME Course 2011





eResearch:Research


eResearch:Research


DrConnect:Improved


DrConnect:Improved




a Second Opinion


a Second Opinion


Health Connection


Health Connection


Reporting from Home


Reporting from Home


Record System


Record System



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Locate DrConnect by selecting either option


• Objectives– Enhance communications

– Between Cleveland Clinic specialists and referring physicians– Create a user friendly system

– For non-CCF referring physicians to view patient EMR information securely over the internet

– Provide secure, monitored access to patient care records– Operative reports, discharge summaries, testing results, outpatient

documentation, problem lists

• Overview– Access for referring physicians to the records of their patient that has

been referred to CC– Limited to 185 days from the patient’s last appointment at CC– Have to sign up and enroll in order to participate– Referring physicians can request office staff to act as proxy– Access automatically triggered by encounter closure, admission– Manually triggered by signed ROI form and MyChart authorization

DrConnect

New - Additional Resources for Physicians

Online Signup – Physician

Online Signup – Non Physician

DrConnect Login

DrConnect – What’s New

DrConnect – Patient Lists






eResearch:Research


eResearch:Research


Dr.Connect:Improved


Dr.Connect:Improved




a Second Opinion


a Second Opinion

MyChart:Your secure, interactive

health record

MyChart:Your secure, interactive

health record


Reporting from Home


Reporting from Home


Record System


Record System


MyPracticeCommunity:

EMR for Physicians in Private Practice

MyPracticeCommunity:

EMR for Physicians in Private Practice


an Online Medical Second Opinion


an Online Medical Second Opinion

Cleveland Clinic’s Secure Online Services



• Increases access, quality and value– Formalize second opinion process and triage– Second opinion requires data from primary opinion– Removes the geographic barriers to care

• Improves efficiency for patients, their doctors and consultants– Organizes staff functions for patient encounter– Consistent patient care with proactive nursing follow-up– Empower patients with convenient access to personalized information

• Receive the second opinion– From well-known physician and well known institution– Patient and family satisfaction high– Significant health care cost implications

• New way of requesting and receiving health-related services– Anytime, anywhere

MyConsult Online Medical Second Opinions


Assess Satisfaction

Publish opinionComplete opinion

Request opinion

Login, securelyRegisterBrowse website

Pathology review Deliver materials to Physician

Schedule patient

Triage Complete

Submit requested medical records

Complete clinical intake forms

MyConsult ProcessMyConsult ProcessMyConsult Online Second Medical Opinion Process1 Requestor 2 Patient 3 Diagnosis 4 Payment 5 Intake 6 Materials 7 Approval

Brain Tumor

Select Diagnosisfrom List

Complete patient medical history

Identify the questions you would like your Cleveland Clinic physician specialist

to address


MyConsult Outcomes

• Diagnosis– Correct 75%– With changes 15%– Incorrect 10%

• Treatment recommendations– No changes 36%

– Everything that has been done or will be completed matches our recommendations

– Minor changes 22%– Repeat or additional imaging studies, provocative testing to differentiate spine vs. hip, surgical approach

(open vs. MIS), change in pharmacologic dosing or plan for changing agents

– Moderate changes 25%– Changes in invasive procedures or studies needed before proceeding, additional work-up needed to

confirm best approach, change in pharmacologic agents (or incorrect agent noted), change in treatment modalities

– Major changes 17%– Disagree with current treatment plan. Current treatment path may lead to incorrect treatment often unless

further studies are completed.

• Significant health care cost implications

Additional diagnoses, further study to make best decision about intervention, i.e. spine standing or flexion/extension radiographs, pulmonary provocative testing


Spine, Lumbar• 61yo F with back pain

– Trouble walking due to pain and polyneuropathy– Can’t stand straight– EMG with residual nerve damage from previous surgeries

• Multiple back surgeries since 2000– Fusion and then extension L1 to sacrum– Thoracic giant cell cystectomy– Residual motion at L1-L2

• Local MD recommendation– Extension of the fusion to T10

• Cleveland Clinic MyConsult second opinion– Dx is incorrect, Rx is incorrect– Pedical subtraction osteotomy– Previous surgeries did not place spine in proper lordosis

• Financial impact modeling prediction– Over $155K in unnecessary future expenses


Crohn’s Disease• 55yo M with Crohn’s Disease, smoker

– 10 year history, using prednisone with some success– Failed Humira, MTX, imuran, Remicade, asacol and dapson– Diarrhea, rectal bleeding, mouth ulcers– Multiple colonoscopies and endoscopies (> 5), no granulomas– Limited to the colon– ENT Dx was Behcets disease

• Local MD recommendation– Extension of the fusion to T10

• Cleveland Clinic MyConsult second opinion– Dx is incorrect, Rx is incorrect– CMV evaluation, serum and biopsy, if + antivirals– Eval for mycobacterium, stool cultures– Inflammatory bowel disease likely ulcerative colitis– No gential involvement not Behcets– CRS evaluation for Eval for perianal fistulas Crohns– Appropriate med trials

• Financial impact modeling prediction– Over $75K in unnecessary future expenses


Cardiology, CAD• 52yo F with DM, GERD, hyperlipidemia, CAD

– Palpitations and normal stress test– Cath with severe lesions leading to stents in LAD and RCA, 2005– Re-stented with DES in 2006 after repeat cath– Cath post procedure for recurrent symptoms with exertion– Diagonal pinched by more proximal of the LAD stents

• Local MD recommendation– CT angiography– CABG

• Cleveland Clinic MyConsult second opinion– Dx may be incorrect, Rx is incorrect– Studies in women could be misleading especially EKG findings– Cath needed, trial of NTG when symptoms recur– Further diagnostic eval for homocysteine, elevated LP(a), small vessel dx– DM under control (Hgb A1c under 6)

• Financial impact modeling prediction– Over $135K in unnecessary expenses

DOS CME Course 2011

Travel Cost Comparison

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Cleveland Clinic Is Leading The Efficiency Charge

• The cost of delivering health care needs to decrease

• Cleveland Clinic is pioneering tactics to achieve this goal– Employed physicians– Institute model– EMR adoption– Focus on efficiency– Published outcomes



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the electronic medical record: is it the holy grail? · 2012-01-17 · confidential1 dos cme course...

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