Copyright 2012. MGMA-ACMPE. All rights reserved. Using HIT for Practice Improvement Rosemarie Nelson Principal MGMA Healthcare Consulting Group October

Copyright 2012. MGMA-ACMPE. All rights reserved.

Using HIT for Practice Improvement

Rosemarie NelsonPrincipalMGMA Healthcare Consulting Group

October 2013

Derek KosiorekPrincipalMGMA Healthcare Consulting Group


About MGMA-ACMPE

Our mission…

To continually improve the performance of medical group practice

professionals and the organizations they represent• 22,500 members

• Manage and lead 13,200 organizations

• About 280,000 physicians


Abstract

You invest a lot in information technology, but if you're like many practices, you feel like you could be getting more bang for your buck • Take a look at many ways to leverage your existing information technology

infrastructure and help make your practice run more efficiently.

• Wrap-around and bolt-on technology and apps to improve the user experience and deliver operational effectiveness will be highlighted.

• Look at different pitfalls that practices fall into with regard to staffing, training, infrastructure and purchasing to help you avoid the mistakes that medical practices have been making for years.

• Look at innovative ways that practices are using technology to increase revenues, improve quality and make life easier for staff, doctors and even patients.


Objectives

• Analyze ways to gain more efficiency from your practice’s IT systems

• Identify how HIT in medical practices can help increase revenue and improve quality

• Identify how medical practices are using new technologies, such as “the cloud” and mobile apps

• Match the appropriate IT staffing structures to your size practice

• Identify the need for an HIT strategy in your practice


“With the Jan. 1, 2014, deadline for meaningful use (MU)

stage 2 on your doorstep, the conversion to ICD-10 just

down the block, and the demands of value-based

payment, population health management and other payer

initiatives roaming your neighborhood, you might have

decided that your information technology (IT) house isn't

quite in order. You're not alone. Many practices have

taken a long look at their EHRs and practice management

(PM) systems and decided it's time for a change.”


Information Technology is Changing Rapidly

• Virtualization of servers, storage, and workstations

• Remote hosted versus in-house

• Zero tolerance for downtime

• Data network bandwidth and speeds

• Wireless and mobile data and voice

• Explosive demands for medical image storage

• Data security threats and prevention requirements


Leverage existing HIT

• Assumptions:– PM, EHR, patient portal

• Optimize tech > RCM, patient communications

• Wrap around/bolt on > BI reporting, population health management, mobile apps

• Staffing and training

• Infrastructure & purchasing (HW, Cloud, mobile apps) – workstation replacement too

• Innovate to:– Increase revenue– Improve quality– Make life easier for staff, providers, and patients


Study findings

• One IDS claimed to have leveraged PM very well, achieving 95%-97% adjusted collection rate at cost of $.04-$.05 to collect $1.00.– Note: An IDN/IDS may accept 95% adjusted collection from a physician practice within their

organization, but that is below better performer results from private physician-owned practices (an additional 3%-5% in collections can pay for a Medical Assistant in the practice of primary care physician seeing only 25 patients/day).

• Expectations vary significantly: “Great” results with 17 days in AR and 27 days in AR.

• Like many practices, benefits that technology bring via change are difficult to visualize and accept; especially for physicians without data to measure results that are achieved with the application of a technology tool and the associated change.

• Administrators overwhelmed with managing to maintain a flat revenue and various changes (after-effect of 5010, pending ICD-10, electronic prescribing penalties and Meaningful Use incentives, continued HIPAA privacy and security pressures) while implementing technology that they can’t see through the clouds of those changes to anticipate future needs.


More efficiency: Optimize RCM

• Outsource?

• Clearinghouse services

• Charge capture integration with EHR documentation

• Patient portal and/or kiosk

• Real-time claim adjudication


Single Specialty, Primary Care All Owners2012 Report, 2011 Data, Median Per FTE Physician

KPI Paper records/charts EHR

Total supp staff FTE 4.14 4.15

Physician Work RVUs 6,650 6,070

Patients 2,207 1,891

Total procedures 8,285 10,826

Total operating cost $383,528 $428,502

Total med rev after op cost $255,943 $257,621

Months gross FFS charges in A/R

1.06 .95

Reprinted with permission from the Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado. www.mgma.com. Copyright 2012.


Family Practice, All Owners2012 Report based on 2011 Data, Median Per FTE Physician

KPI Paper records/charts EHR Hybrid

Total supp staff FTE 4.73 4.25 4.24

Total Physician Work RVUs

6,601 5,915 5,416

Patients 2,960 2,062 -

Total operating cost (% of med rev)

62.29% 63.04% 56.95%


1.01 1.00 1.71

Total Medical Revenue after Operating Cost

$232,608 $238,787 $295,141



Multi-specialty with primary and specialty care, Hospital-owned 2012 Report, 2011 Data, Median Per FTE Physician

KPI Paper records/charts EHR

Total supp staff FTE 5.06 3.98

Physician Work RVUs 6,148 6,293

Total operating cost $408,988 $411,875

Total med rev after op cost

$324,440 $260,981


1.31 1.30



KPI 1 year or less 2 to 4 years 5 or more years

Total support staff FTE 4.99 4.71 4.87

Total RVUs 13,184 12,714 14,515

Patients 1,381 1,536 1,676

Total operating and NPP costs (% of medical revenue)

68.04% 65.86% 63.59%

Total medical revenue after operating and NPP costs (% of medical revenue

31.96% 34.17% 36.41%

Days gross FFS charges in A/R 39.74 36.66 39.08

Multispecialty Groups by Years of the EHR in Practice Median per FTE Physician (2009 Data published in 2010)



Assess EHR utilization

• Patient communications– Integrated portal services

• Information flow during the patient encounter– Physician-nurse communications and encounter documentation

• Charge capture at time of service

• Information flow after patient encounter– Interfaced results tied to interfaced orders delivered to patient portal


Market forces driving physicians

Self-service impact Reduce operational and labor costs Improve efficiency in communications Improve patient satisfaction with self-service capabilities Add new revenue sources

Consumer driven healthcare Patients routinely search for information about their condition

Patients are more involved and educated about their care options Health savings accounts (HSAs) modify patient behavior driving self-service demands

Online Personal Health Record (PHR) use expands Third party payers support online physician-patient communication

HITECH incentives Millions of patients communicate with their physician online


Consumer Demand

Patients want improved communication

79+% of patients have internet access

% of patients wanting the following services: Ask questions where no visit is necessary 77% Fix appointments 71% Get new prescriptions for medications they take 71% Receive the results of medical tests 70% None of the above 6% Don’t know 4%

55% indicated the ability to communicate with their doctors in the above manner would influence their choice of health plans.

-Harris Interactive™


Increase EHR Utilization

• Are only 10% of patients using the portal?–What functionality have you added?

• Are you using a kiosk in the reception area?

• What have you done to increase remote access?–Time patients spend in the reception area

completing forms or even using the kiosk impact the productivity of front staff

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• Refresher Training – EHR compares to any other technology owned; never quite sure

if we are using all the features. – During initial training and the first few weeks of use, users

focused on using the new technology as opposed applying the technology

– Once accustomed to using the technology in the way that feels most comfortable, it is difficult to change behavior

– Beneficial for sub optimal users of the system

• New Users– Assign to super user

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• Software updates– Practices do not fully evaluate new features in updates to

determine which ones will be beneficial and can be incorporated into their workflows

– Train employees on update functionality– Missed opportunity to get more out of your investment

• Updates increase the value of investment

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• “Leaner” Workflows – Re-evaluate people and process – Practices often evaluate process without even knowing that they

are doing so• Can be a formal process - in some cases it comes after a few

days of usage by the staff that suggestions are made “on the fly”• For example, in some practices staff noted that the location of

the printer isn’t optimal. They’ve either repositioned the printer or added another printer to optimize workflow.

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• Shifting Resources– Optimization can be compromised because employees

remain in traditional roles– Employee tasks should be assigned to optimize the

goals for the practice• Enhance the ability to move towards a paperless

system• Evaluate care management opportunities• Build care templates to be used by the nurses and

providers 21


Bottom line

• Delegate all duties that don’t require a physician’s license

• Use patient reminder tools

• Use web/email for patient communications

• How many telephone transactions can you transfer to your web site

• Revamp patient registration – web and EMR and introduce it on the phone scheduling the appointment

• Anticipate needs for visit


BIG Data

• Query/reporting in real time for business intelligence

• Population health management reporting– Integrated to patient communications tools

• Staff analytical skills


Pay for Performance/Quality Reporting: Rationale

• Currently– Healthcare costs an issue for both public and private sector– U.S. spends 15 -18% of GDP on health services (about 12¢

per dollar)– Medicare beneficiaries and private sector face continued

rise in premium payments, doubled from 1998 to 2006, projected to triple from 1998 to 2015

– Dartmouth atlas shows wide variation in Medicare spending per beneficiary among different areas in U.S.

– No correlation in cost variation with quality or outcome


Identify and Manage Patient Populations

• Patient information

• Clinical data

• Comprehensive health assessment

• Use data for population management


Study findings

• Patient population management carries different meanings to many and is not understood to require additional resources.– Believe the EMR vendor solutions are inclusive of patient population care management

functionality. – Very few practices regardless of ownership have ventured this deep into their IT

solutions to identify gaps.


Business Intelligence Reporting

• Add-on tools for reporting from practice management system– www.trellishc.com

• The Diver Solution, Dimensional Insight• www.dimins.com/decisionsupport

– www.bridgeitsolutions.com– www.dashboardMD.com

• Service – runs nightly • Web based – hosted/on your server (data warehouse)• Turn-key enterprise-wide• Custom KPIs

– MGMA DataDive www.mgma.com/datadive


One Health Plan’s Approachto Preventive Measures

Breast Cancer Screening

Colorectal CA Screening

Osteoporosis Screening

Hypertension Screening

Depression Screening

Pneumococcal Vaccine

Influenza Vaccine

Hypertension Control

Smoking Cessation Education


And, Disease Management Measures

Chronic Obstructive Pulmonary Disease (COPD) • Spirometry• Sao2 Measurement• Beta-agonists/Anti-Cholinergic Prescribed

Coronary Artery Disease (CAD)• LDL Screening• LDL Control• Beta Blocker Prescribed (history of MI)• Antiplatelet Therapy Prescribed• Statin Prescribed

Congestive Heart Failure (CHF)• LVF Assessment Completed• ACE or ARB Prescribed • Beta Blocker Prescribed

Diabetes Management

• HbA1c Screening

• HbA1c Control

• LDL Screening

• LDL Control

• Microalbuminuria Testing

• Creatinine Testing

• Eye Exam Screening

• Foot Exam

• Statin Prescribed

• Hypertension Screening

• Hypertension Control


Quality Outcomes

Increased Mammograms

80%

Osteoporosis Screening

37%

Diabetic Foot Exams

360% - X5

Diabetic Retinal Exams

27%

Pneumonia Vaccine

88%Influenza Vaccine

246%

Depression Screening

71%


Improved Efficiency of Care

• Decreased acute care costs

• Decreased outpatient diagnostic testing

• Decreased emergency room costs

• Increased payments to physicians!!

Pilot of 17 Medical Groups

Net: Decreased total expenses


Query and Contact: First 30 Days Results

621 additional appointments

– $65,080 inMonthly Revenue

– $780,960 inAnnualized Revenue

– 15X ROI

Case Study: East Texas Medical Center (First Physicians):Multi-specialty practice employed by Integrated DeliveryHealth System with 200 providers across 12 different specialties.

Compliance Booking Rate

QualityImpact

Financial Impact

Average days since last chronic visit was 235 with a

max of 380 days


Tools support staff

• Online or on the phone?

• 24x7 patient convenience

• Outreach efficiency– Patient management


Apps to help educate patients

• DrawMD (free in Apple app store) – physicians can sketch, stamp or type on detailed anatomic images and then save to EHRs and/or share images with patients

• NumeraNET (free in Apple app store) – patients can share info such as weight, blood pressure, pedometer results with physicians,who can send the info to an EHR

• Survey on the Spot (free in Apple app store) – Gather instant feedback on your practice with custom surveys– See compiled survey results in your account– Get software alerts when a patient rates service as poor

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Train and support

• Vendor app training

• Practice training on how to apply the tool to the operations

• Dedicated role and/or shared position

• Technical support– Dedicated staff and/or outsource firm


Staff training via online courses

• www.Bridgefront.com – Revenue cycle– Compliance and HIPAA– Medical terminology– Nursing continuing ed

• www.learnthat.com – General computer and Windows basics– Microsoft tools (Excel, Word, Powerpoint, Access)

• www.mgma.com/online – Billing courses

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http://www.bridgefront.com/

http://www.learnthat.com/

http://www.mgma.com/online


Effect of IT expenditures on profitability

Total medical revenue after operating cost per FTE physician.

MGMA Cost Survey 2013 Report Based on 2012 Data

Total IT expense/FTE physician <$10,000 $10,001-$20,000

$20,001-$30,000

>$30,001

Multispecialty $249,824 $326,924 $362,485 $395,228

Cardiology $473,201 $497,465 $570,023 $592,741

Ob/Gyn $357,061 $380,586 $493,046 *

Orthopedic Surgery $578,934 $685,839 $718,461 $783,487



Infrastructure



Information Technology


Client Server


Cloud


Cloud


Cloud

• Remote hosting• SaaS


Cloud Backup




Which is the tablet?


Information Security


• Increased connectivity

• Hard to detect loss

• Easy to steal MASSIVE amounts of information

• Increased use of portable devices

• Increasing complexity of systems

Why Worry About Info Security?


• May occur continuously and indefinitely

• Motives of attackers more varied

• Doesn't require physical access to facility

• Low risk of getting caught

Why Worry About Info Security?


Risk =Threat x Vulnerability x Impact


Reducing Vulnerability - Controls

• Technical– Software and hardware tools or products

• Physical– Protecting physical access to information

• Administrative– Policies & procedures, management


Technical Control

• Computer– Username/password

• Server & Local Area Network– Roll based access

• Wide Area Network– Firewalls, Data Encryption

• PDA, Blackberry, Jump drives

– Username/password, Biometric

• Remote Access– VPN (data encryption)

• Wireless– Encryption, Device Filtering


Physical Controls

• Physical access control– Keys, prox cards

• Surveillance and monitoring– Closed circuit TV (CCTV)– Guards or staff watching

• Alarms– Door alarms, motion detectors

• Cable locks on equipment

• Signage


Physical Controls

Environmental Controls

• Power protection– UPS– Backup generators

• Environmental monitoring/detection– Heating, ventilation & air conditioning (HVAC)– Humidity controls– Water detection and alarms

• Fire detection and suppression


Physical Controls

Device and Media Controls

• HIPAA requires proper handling, storage and disposal of media containing PHI

• Includes computers, servers, laptops, USB memory devices, PDAs

• Disposal could include– Overwriting– Demagnetize– Rendering unusable


Administrative Controls

Policies

Effective policies:• Are Enforceable

– If not, it probably won’t be followed

• Are Measurable– Some methodology to know to what extent they are being complied

with

• Are Accessible– communicated, including changes

• Include Sanctions– Consequences for non-compliance that are consistently applied


Administrative Controls

Policies

• Should not be suggestions or guidelines

• Policies, perception, practice need to be in alignment– Gap analysis


Threats to Information

• Insiders making innocent mistakes• Insiders abusing access privileges• Insiders knowingly accessing for spite or profit• Unauthorized physical intruder• Vengeful employees and outsiders who mount attacks to

access information, damage systems and disrupt operations


Staffing


Fundamental Staffing Assumptions

• IT has become essential (IT does matter)• IT has become financially significant• Healthcare IT is different than IT


Why have IT Staff?

• Number of connected sites

• Computers & servers– Quantity & type– Age– Operating systems

• Servers– Quantity & Type– Age

• Age of network

• Applications

• Security

• Staff development

• Tech purchasing

• Other

Factors that impact technology staffing


What is normal?

Multispecialty Staffing per FTE Physician

Median: .11 IT Staff

90th Percentile: .24 IT Staff

Source: 2011 MGMA Cost Survey


What is normal?

Multispecialty IT Operating Cost per FTE Physician

Staff

Median: $5,970

90th Percentile: $13,317

Operating Cost

Median: $10,495

90th Percentile: $29,258

Source: 2011 MGMA Cost Survey


Factors That Impact Technology Staffing

Facilities

– # of facilities– Geographic area - distance between facilities– Age of the facilities – access for cabling and wireless coverage– Electrical Stability



Computers & Servers

– Quantity/type – Desktop, laptop, tablet, PDA – Age – 5 or more years old – Number of manufacturers

• Eg. Apple, HP, Gateway, Dell, ……….– Number of operating systems/versions

• Eg. OS 9.nn, OS 10.nn, Windows 2003, Windows XP , Linux



• Age of network– Quality of the installation– Building network electronics – over 4 years old– Inter-building electronics– Access to Internet



• Quantity and type applications– Mission Critical– Server level databases

• Security– Wireless– Portable memory devices– Portable wireless devices



• Operational processes/documentation– Key processes undocumented– No disaster recovery or IT security plan– No process for deleting staff or students server access rights when they leave

• Staff development– Little or no training of technology staff– No access to peers in other districts



• Other technologies– Copiers/printers– Projectors– Monitors– Security systems


What do they do all day?

• End user support – “Helpdesk”

• Equipment procurement & replacement

• Server management & monitoring

• Network & data connections

• Remote management

• Software upgrades– Desktop software– EHR, PM

• Information Security

• Other equipment (phones, copiers/scanners, printers)


Buy or rent staff?

• In-house staff benefits– Sense of vision– Immediate response– Skin in the game– Institutional knowledge

• Outsourced IT staff benefits– Reduced cost– More all around knowledge– Better ability to keep up with trends


Vendor support of technology

• Tablet rage– Providers and patients

• Mobile apps– Providers and patients

• Integrated reporting tools

• Integrated patient portal and communication– Kiosk functionality

• Cloud support


Where do you find these wonderful people?

• Classifieds are dead

• Job websites– Monster.com, careerbuilder.com, simplyhired.com, indeed.com, dice.com

• Recruiters

• Word of mouth

• LinkedIn

• HIMSS JobMine– Healthcare Information and Management Systems Society– http://jobmine.himss.org


What do they do all day?

When something works well, there is a perception that it is easy to change without risk of losing what is working well.


Technology Support

Proactive

Vs.

Reactive


Reduce Reactive Support

• Keys to reducing technology support– Implement recommended replacement cycles– Negotiate warrantees to replacement cycle– Limit number computer manufacturers– Implement remote computer support– Implement automated software imaging– Implement server centralization/consolidation– Increase technology staff training– Outsource applications


Tech Staff Development

• Technology support staff development

– Training– Opportunities to network with peers

• User group meetings• Conferences


Tech Staff Development

Credentials

• A+– Hardware technicians– Offered through ComTIA

• MCSE– Microsoft Certified Systems Engineer

• Healthcare IT – CPEHR/CPHIT (http://www.healthitcertification.com)

• Certified Professional Electronic Health Records• Certified Professional Healthcare Information Technology

– CPHIMS/CAHIMS (http://www.himss.org/health-it-certification)• Certified Professional in Healthcare Information & Systems• Certified Associate in Healthcare Information & Management Systems


Metrics

• Support tickets– How many closed?

• Total, average per day by month, current vs. prior year– How many open tickets– Average time to resolve

• Goals (aligned with organization’s business strategy) accomplished

• KPIs– Percentage of up-time (system, workstations)

• Staff survey

• Anecdotal


IT Staff Separation

• Make sure you have an up to date list of all administrator passwords. – This includes passwords to all servers, routers and the firewall(s).

• Deactivate the employee’s account(s). – Including her/his main account and any accounts created for testing or training.

• Audit the membership of the Admin Group on each server and workstation– One of the functions of a server is to maintain a list of users and the

corresponding access granted to each. It does this by maintaining groups of users that share the same permissions. One of these groups is the Admin Group. Also audit the Domain Admins Group.


IT Staff Separation

• Make sure all necessary user account passwords are changed.

• List any equipment and files in the employee’s possession that must be returned.

• Audit all accounts and ways to access the network remotely.– Changing the passwords for authorized employees– If vendor has remote access, determine whether IT can duplicate the access

and make appropriate changes


IT Staff Separation

Notify all external organizations of the new staff member authorized to contact them on your behalf.

This includes:– Domain name listings for website and email (Network Solutions)– Telecom vendors– External IT consultants– Backup tape storage– Practice Management and Development software vendors


Cutting Edge


Wearable Computing


Science and technology

• Telemedicine transforming traditional view of medicine

• Mobile technology untethers healthcare and enables the practice of care anywhere

• DTC market for genetic testing will expand

• Activist disease foundations upending the way scientific research is done and the way academics interact with pharmaceutical and biotech companies– Demands accountability and information sharing – almost unheard of in broad

scientific community


Mobile technology

• Reduces need for hospital admissions and physician office visits

• Improves access – Remote patients– Creates schedule availability

• 40% of physicians say could eliminate 11% to 30% of office visits thru use*

• Contrary to payment mechanisms– Why accept technology that hurts incomes?

• Provides access to more accurate data at decision-making point of care

*PWC Health Research Institute, Sept. 2010


Mobile health from multiple stakeholders

Stakeholder Target issue Mobile health solution

Employer Rising healthcare costs of self-insured employers

Competition among locations to promote health lifestyles and incentives for lowering healthcare premiums for employees

Provider Efficiency in coordinating care/workflow

Smartphone app to help physicians access patient records, track vitals, order medication and coordinate with care team

Health insurer - Finding physicians in network- Checking claims

Mobilizing “doc” finder and claims check

Pharma Patient compliance in diabetes monitoring

Digital glucose monitor that integrates with Nintendo game console

Retail pharma Cost info and Rx management cumbersome to maintain

Smartphone app for Rx drug info and member management of Rx refills, history and retail location finder


Mobile health reduces provider revenues

Disease Where What Result

Diabetes PA Post discharge remote monitoring 42% drop in overall cost per patient

Cleveland Cell phone size wireless transmitter transferring vital sign to EHR

71% increase in number of days between office visits

CHF Trans-European Network-Home Care Management System

Remote monitoring of patients who received implantable cardiac defibrillators

35% drop in inpatient LOS10% reduction in office visits65% drop in home health visits

COPD Canada Remote monitoring of patients with severe respiratory illness

Reduced hospital admissions by 50%, acute home exacerbations by 55%, hospital costs by 17%


Web sites –daily/weekly feeds

• HITS (HealthIT Strategist) from www.modernhealthcare.com

• www.healthleaders.com

• www.ihealthbeat.org (one of the better ones)

• www.practisinc.com

• www.chcf.org (although named “California” this is a national organization with good credibility)

• www.physicianspractice.com (weekly Pearls)


The New Newspaper

Zite

• Personalized news and features magazine

• An aggregator that collects news and features from other sources

Flipboard

• Socially generates magazines



Questions?

MGMA.org

Documents

Copyright 2012. MGMA-ACMPE. All rights reserved. Using HIT for Practice Improvement Rosemarie Nelson Principal MGMA Healthcare Consulting Group October