American Medical American Medical AssociationAssociation

Advancing The Quality AgendaAdvancing The Quality AgendaPhysician Performance Physician Performance MeasuresMeasuresChicago, IllinoisChicago, IllinoisJune 16, 2003June 16, 2003

Improving Physician PerformanceImproving Physician Performance

by by

James L. Holly, MD James L. Holly, MD Managing PartnerManaging Partner

Southeast Texas Medical Associates, LLPSoutheast Texas Medical Associates, LLPBeaumont, TexasBeaumont, Texaswww.setma.comwww.setma.com

YesterdayYesterday

Southeast Texas Medical Associates, LLP Southeast Texas Medical Associates, LLP (SETMA) was formed in 1995 by the (SETMA) was formed in 1995 by the merging of Four independent, solo merging of Four independent, solo practices of Family Physicians and practices of Family Physicians and InternistsInternists

– Two practices transcribed medical records and two had Two practices transcribed medical records and two had hand-written medical recordshand-written medical records

– Three practices organized records alphabetically and Three practices organized records alphabetically and one numericallyone numerically

– One practice used an antiquated computer One practice used an antiquated computer management system; the other three used peg boardmanagement system; the other three used peg board

ProblemProblem

After two years, it was apparent that theAfter two years, it was apparent that the

complexities of a multiple specialtycomplexities of a multiple specialty

practice were beyond a paper-basedpractice were beyond a paper-based

system and the practice managementsystem and the practice management

computer system we had inherited fromcomputer system we had inherited from

one of our partners.  one of our partners. 

AdditionalAdditional ComplicationsComplications

1.1. Four providers had grown to eight Four providers had grown to eight (currently 34)(currently 34)

2.2. Additional services had been added:Additional services had been added:a.a. A level-two, moderately-complex reference A level-two, moderately-complex reference

laboratory had been added to the practicelaboratory had been added to the practiceb.b. Physical therapy had been addedPhysical therapy had been addedc.c. A Medicare + Choice home health agency A Medicare + Choice home health agency

had been addedhad been addedd.d. A Hospice had been addedA Hospice had been added

ComplicationsComplications Cont’dCont’d

3.3. A large hospital practice added A large hospital practice added complexity to continuity of care and complexity to continuity of care and to data-base access simultaneously to data-base access simultaneously at multiple locationsat multiple locations

4.4. A large long-term residential-care A large long-term residential-care practice added new challenges for practice added new challenges for transition of care between out-transition of care between out-patient, in-patient, nursing home, patient, in-patient, nursing home, etcetc

Complications Complications continuedcontinued5.5. The nature of our practice made The nature of our practice made

management of medications, management of medications, telephone access and provider-to-telephone access and provider-to-provider communications criticalprovider communications critical

6.6. Involvement with emerging Involvement with emerging managed care both from a provider managed care both from a provider standpoint and as Medical Director standpoint and as Medical Director of a 450 physician IPA demanded of a 450 physician IPA demanded electronic management of dataelectronic management of data

The Straw and the The Straw and the CamelCamel 7.7. SETMA began to manage the SETMA began to manage the

majority of emergency care in a majority of emergency care in a community of 130,000.community of 130,000.

The desire and need to improve The desire and need to improve quality of care in a measurable quality of care in a measurable way, which could be proved, way, which could be proved, dictated change.dictated change.

SolutionSolution

In March of 1998, SETMA, In March of 1998, SETMA, purchasedpurchased

a robust electronic medical record a robust electronic medical record andand

enterprise practice management enterprise practice management

applications from a national applications from a national vendor.vendor.

TodayToday

SETMA is a growing multi-specialty clinic with 34SETMA is a growing multi-specialty clinic with 34providers including:providers including:

– Nurse PractitionersNurse Practitioners– Internal MedicineInternal Medicine– Family PracticeFamily Practice– PediatricsPediatrics– PulmonologyPulmonology– Critical CareCritical Care– General SurgeryGeneral Surgery– UrologyUrology– RheumatologyRheumatology– Ophthalmology Ophthalmology – Sports MedicineSports Medicine

CriticismCriticism

Being the first users of electronic Being the first users of electronic patient records in our region, many patient records in our region, many criticized the financial investment and criticized the financial investment and the energy expenditure required to the energy expenditure required to transition from a conventional paper-transition from a conventional paper-based record to an electronic medical based record to an electronic medical record.  record. 

More Than More Than A Transcription ServiceA Transcription Service

To be “worth it,” EMR had to be To be “worth it,” EMR had to be more than a transcription service, more than a transcription service, -- the EMR had to provide more -- the EMR had to provide more value and benefit than simply value and benefit than simply documenting a patient encounter documenting a patient encounter electronically.electronically.

Electronic Patient Electronic Patient ManagementManagement

This realization grew into a vision This realization grew into a vision of the electronic patient records of the electronic patient records becoming a tool for electronic becoming a tool for electronic patient management. patient management. 

Hospital ConnectivityHospital Connectivity

Development of connectivity with Development of connectivity with hospitals in our community. Admission hospitals in our community. Admission H&Ps and Discharge Summaries H&Ps and Discharge Summaries are documented in the EMR on over are documented in the EMR on over 250 admissions per month.  250 admissions per month. 

This allows for a seamless continuum This allows for a seamless continuum of care whether the patient is at home, of care whether the patient is at home, in the office, on the phone, in the in the office, on the phone, in the nursing home, hospital, hospice, home nursing home, hospital, hospice, home health, physical therapy, or sending an health, physical therapy, or sending an e-mail.e-mail.

Phone CallsPhone Calls

The documentation for the past threeThe documentation for the past three

years of years of EVERYEVERY telephone call which telephone call which

has come into our practice, twenty-fourhas come into our practice, twenty-four

hours a day, seven days a week, with ahours a day, seven days a week, with a

computer generated time and datecomputer generated time and date

stamp and documentation of who stamp and documentation of who calledcalled

and why.  and why. 

Quality of Care/Quality of Quality of Care/Quality of LifeLife

The employment of two CFNPs who work from The employment of two CFNPs who work from 10:00 PM to 9:00 AM seven days a week:10:00 PM to 9:00 AM seven days a week:

1.1. Seeing our patients in the hospital and ERSeeing our patients in the hospital and ER2.2. Working up admissions, documenting H&Ps in Working up admissions, documenting H&Ps in

the EMRthe EMR3.3. Responding to telephone callsResponding to telephone calls

This has improved:This has improved:

1.1. The quality of care for our patients and The quality of care for our patients and 2.2. The quality of life for our providers. The quality of life for our providers. 

Hospital ManagementHospital Management

Completing the hospital dischargeCompleting the hospital dischargesummary in the EMR which makessummary in the EMR which makesthat data instantly available to:that data instantly available to:

1.1. ProvidersProviders2.2. The clinicThe clinic3.3. The nursing homeThe nursing home4.4. The IPAThe IPA5.5. The home health agencyThe home health agency6.6. Other members of the healthcare teamOther members of the healthcare team

Tickler FileTickler File

Utilizing the interface with Microsoft Utilizing the interface with Microsoft Outlook provided by the EMR, we remind Outlook provided by the EMR, we remind ourselves of needed medical or ourselves of needed medical or diagnostic issues in the future.  diagnostic issues in the future. 

This has been particularly helpful in This has been particularly helpful in behavior modification, as it has allowed behavior modification, as it has allowed us to be reminded to call our patients and us to be reminded to call our patients and to make sure they have quit smoking, to make sure they have quit smoking, etc.etc.

Chronic-Conditions Chronic-Conditions ManagementManagement The identification of patients who need The identification of patients who need

extra management allows us to call extra management allows us to call them on Thursday to make sure they are them on Thursday to make sure they are taking their medications and are doing taking their medications and are doing well for the weekend.  If they are not, well for the weekend.  If they are not, they are given an appointment for they are given an appointment for Friday.  Friday. 

They are also called on Monday to see They are also called on Monday to see how they did over the weekend.  If they how they did over the weekend.  If they are not doing well, they are given an are not doing well, they are given an appointment immediately.appointment immediately.

Integrated Delivery: Integrated Delivery: IPA and Private IPA and Private PracticePractice

As a partner in an IPA and in a PSO, As a partner in an IPA and in a PSO, SETMA shares a CMS fiduciary SETMA shares a CMS fiduciary responsibility to complete a Health and responsibility to complete a Health and Wellness Questionnaire on every patient Wellness Questionnaire on every patient who joins one of the health plans offered who joins one of the health plans offered by our PSO.  by our PSO. 

From this questionnaire a "Health Risk From this questionnaire a "Health Risk Assessment" is generated which allows us Assessment" is generated which allows us to predict which patients need immediate to predict which patients need immediate attention.  attention. 

Integrated Delivery: Integrated Delivery: IPA and Private Practice IPA and Private Practice Cont.Cont. Through electronic patient management, Through electronic patient management,

SETMA has been able to allow our IPA to SETMA has been able to allow our IPA to make appointments for patients who are make appointments for patients who are at risk.  at risk. 

This saves us time and it improves the This saves us time and it improves the quality of care received by our patients.  quality of care received by our patients. 

Reducing the HRA to an electronic Reducing the HRA to an electronic computation through the EMR makes it a computation through the EMR makes it a very useable tool for patient management.very useable tool for patient management.

Electronic Practice Electronic Practice ManagementManagement

With multiple locations, and plans for another With multiple locations, and plans for another major expansion, the creation of a "medical major expansion, the creation of a "medical team" requires communication:team" requires communication:

1.1. For quality improvement For quality improvement 2.2. For patient management For patient management 3.3. For clinic management For clinic management 4.4. For utilization management For utilization management

which are only possible with electronic patient which are only possible with electronic patient management through EMR, e-mail and office management through EMR, e-mail and office intranet.  intranet. 

Creation of a Creation of a Healthcare TeamHealthcare Team

The creation of a "healthcare team" The creation of a "healthcare team" withwith

a common culture, purposes and a common culture, purposes and goals,goals,

when providers do not have dailywhen providers do not have daily

contact, is only possible with contact, is only possible with electronicelectronic

communication and interaction.communication and interaction.

Clinic and PhysicalClinic and PhysicalTherapyTherapy

The creation of templates for physicalThe creation of templates for physical

therapy to utilize the EMR allowstherapy to utilize the EMR allows

providers and therapist to providers and therapist to communicatecommunicate

seamlessly to improve the quality ofseamlessly to improve the quality of

care while controlling excessivecare while controlling excessive

utilization.utilization.

Laboratory Results & Laboratory Results & CMS ComplianceCMS ComplianceThe documentation that laboratoryThe documentation that laboratoryresults have been reviewedresults have been reviewedelectronically and the initiation of follow-electronically and the initiation of follow-up instructions electronically haveup instructions electronically haveimproved quality of care and haveimproved quality of care and haveprovided a valuable tool for SETMAprovided a valuable tool for SETMAproviders to remain in compliance with providers to remain in compliance with

CMSCMSrequirements for documentation of the requirements for documentation of the

review of laboratory and ancillary review of laboratory and ancillary services.services.

Treatment Pathways & Treatment Pathways & National Standards of National Standards of CareCareThe ability to create treatment pathways basedThe ability to create treatment pathways basedon national standards of care, particularly inon national standards of care, particularly inregard to:regard to:

– Diabetes Diabetes – Congestive Heart Failure Congestive Heart Failure – COPDCOPD– Coumadin TherapyCoumadin Therapy– Cholesterol and Triglyceride treatment Cholesterol and Triglyceride treatment

have proved the clinical value of electronic have proved the clinical value of electronic patientpatient

management.management.

Provider EvaluationProvider Evaluation

With a growing multi-specialty, With a growing multi-specialty, multiple-site practice, electronic multiple-site practice, electronic patient management has provided a patient management has provided a vehicle for the evaluation of provider vehicle for the evaluation of provider performance.  performance. 

The establishment of quality The establishment of quality standards and benchmarks of care are standards and benchmarks of care are easy to monitor and to correct easy to monitor and to correct deficient behavior.deficient behavior.

Preventive Health Preventive Health InitiativesInitiatives

The consistent providing of The consistent providing of preventivepreventive

health care, and the review ofhealth care, and the review of

preventive care deficiencies, every preventive care deficiencies, every timetime

the patient is in the clinic is only the patient is in the clinic is only possiblepossible

in an electronic environment.in an electronic environment.

2121stst Century Dynamic: Century Dynamic: ThinkingThinkingAbout Patients Not in the About Patients Not in the ClinicClinic EMR allows for the management of EMR allows for the management of

patients as a class, whether it is with a patients as a class, whether it is with a drug withdrawal or the evaluation of a drug withdrawal or the evaluation of a standards of care initiative.  standards of care initiative. 

The ability to think about the patient The ability to think about the patient as a person, a problem and a as a person, a problem and a preventive health strategy is critical to preventive health strategy is critical to the dynamic of 21st Century medicine.the dynamic of 21st Century medicine.

Empowering the TeamEmpowering the Team

EMR has made it possible for all clinical EMR has made it possible for all clinical personnel to be involved in patient care, personnel to be involved in patient care, whether at entry, evaluation, treatment whether at entry, evaluation, treatment or follow-up.  or follow-up. 

Employee satisfaction has never been at Employee satisfaction has never been at a higher level.  a higher level. 

The sense of team work and collegiality The sense of team work and collegiality permeates the clinic and is attributable permeates the clinic and is attributable to the fact that the EMR gives everyone to the fact that the EMR gives everyone the ability to contribute.the ability to contribute.

Patient Access ExpandedPatient Access Expanded

An interactive website where our patients An interactive website where our patients can:can:– Request Request

appointments    appointments    ReferralsReferrals medication refillsmedication refills

– Interact with their provider via e-mailInteract with their provider via e-mail– Complete questionnaires about healthcare Complete questionnaires about healthcare

concernsconcerns

This has added value for our patients who This has added value for our patients who want more access to their provider than at want more access to their provider than at any time in the history of medicine.any time in the history of medicine.

Le Maladie Du Petite Le Maladie Du Petite PapierPapier

When I started medical school, one neurotic When I started medical school, one neurotic condition was called, condition was called, Le Maladie Du Petite PapierLe Maladie Du Petite Papier, , "the sickness of the small piece of paper."  "the sickness of the small piece of paper." 

Health care has changed.  We now want our Health care has changed.  We now want our patients to write down their symptoms and we patients to write down their symptoms and we want them to communicate those symptoms to us want them to communicate those symptoms to us in "real time."  in "real time." 

E-mail is a great way to do this and the EMR gives E-mail is a great way to do this and the EMR gives us the ability to store those e-mails and our us the ability to store those e-mails and our responses in the patient's chart.  responses in the patient's chart. 

I tell my patients, "I can read faster than you can I tell my patients, "I can read faster than you can talk."talk."

Electronic Patient Electronic Patient Management Via Management Via NextGenNextGen: : A Huge SuccessA Huge SuccessWith the benefit of SETMA's financialWith the benefit of SETMA's financial

results and the improvement in patientresults and the improvement in patient

care via care via NextGen'sNextGen's electronic patient electronic patient

records morphed into electronic patientrecords morphed into electronic patient

management, SETMA's transition from amanagement, SETMA's transition from a

paper-bound medical record to anpaper-bound medical record to an

electronic record has been a huge electronic record has been a huge success.success.

Expectations: PatientsExpectations: Patients

SETMA’s patientsSETMA’s patients now expect to have now expect to have a record, which is complete, accurate a record, which is complete, accurate and accessible. and accessible.

Their expectations are such that quality Their expectations are such that quality care for them begins with the capturing care for them begins with the capturing of precise and accurate data about their of precise and accurate data about their healthcare events whether in the clinic, healthcare events whether in the clinic, on the telephone or in the hospital. on the telephone or in the hospital.

Expectations: ProviderExpectations: Provider

SETMA’s healthcare providersSETMA’s healthcare providers now now

expect to challenge every patient withexpect to challenge every patient with

preventive healthcare issues, many ofpreventive healthcare issues, many of

which are irrelevant to the event whichwhich are irrelevant to the event which

precipitated the current encounter, butprecipitated the current encounter, but

each of which addresses long-termeach of which addresses long-term

health needs of every patient.health needs of every patient.

Expectations: CustomersExpectations: Customers

SETMA’s customersSETMA’s customers, the payers, who, the payers, who

pay our charges, expect the kind ofpay our charges, expect the kind of

documentation which gives them thedocumentation which gives them the

ability to properly access the quality ofability to properly access the quality of

care and appropriateness of care care and appropriateness of care whichwhich

their membership is receiving fromtheir membership is receiving from

SETMA providers.SETMA providers.

Fahrenheit 451 ProjectFahrenheit 451 Project

Everyday, SETMA continues its Everyday, SETMA continues its “Fahrenheit 451 Project”.“Fahrenheit 451 Project”.

While we did not literally burn our ships While we did not literally burn our ships or paper, but we do continue to find or paper, but we do continue to find ways to eliminate the use of paper in ways to eliminate the use of paper in every aspect of our practice. every aspect of our practice.

Each piece of eliminated paper Each piece of eliminated paper represents an increase in efficiency, represents an increase in efficiency, excellence and economy.excellence and economy.

The Future and Its The Future and Its FoundationFoundation

The Future -- Electronic Patient Management The Future -- Electronic Patient Management

The Foundation -- Electronic Patient RecordsThe Foundation -- Electronic Patient Records

We're glad we started. We've never had We're glad we started. We've never had more fun practicing medicine and we've more fun practicing medicine and we've never provided the quality of care which our never provided the quality of care which our patients are experiencing in our clinics patients are experiencing in our clinics today.  EMR has been a great tool and a today.  EMR has been a great tool and a great vehicle for our progress. great vehicle for our progress.