Electronic Physician Documentation: Increased …...2017/07/26 · Medical Speech Recognition (SR) – Quantitative: retrospective longitudinal observational study of a period of

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Electronic Physician Documentation: Increased SatisfactionCHIME CollegeLIVE WebinarJuly 26, 2017

© 2017 Nuance Communications, Inc. All rights reserved. 2© 2017 Nuance Communications, Inc. All rights reserved. 2

Kshitij Saxena, MD, MHSAChief Medical Information OfficerHealth Quest Systems, Inc.

Speaker Introduction

Robert (Bob) DiamondChief Information OfficerHealth Quest Systems, Inc.

Reid Conant, MD, FACEPChief Medical Information OfficerNuance Communications


– EMR Clinical Documentation Reid Conant

– Introduction of Health Quest Systems, Inc Bob Diamond

– Health Quest Baseline Bob Diamond

– Goals and Strategy: Electronic Physician Documentation Bob Diamond

– Implementing the Physician Documentation Strategy Bob Diamond

– Dragon Medical Impact Study Tij Saxena

– Quantitative, Qualitative Findings Tij Saxena

– Speech Recognition EMR Best Practices Reid Conant

– Q& A

Agenda


– EMRs rolled out at nearly all health systems across the country, adoption increasing

– However, providers reporting dissatisfaction with documentation workflow

– Transcription delays, structured notes, and time spent documenting contribute to burnout

– EMR Optimization

– Taking EMRs from adoption to increased provider satisfaction with documentation

– Speech recognition

– Providers speak patient notes directly into EMR

– Clinical narrative captured more naturally, with intuitive workflow

– Eliminates transcription and increases provider satisfaction with clinical documentation

EMR Clinical Documentation – Current State


EMR Clinical Documentation Optimization

Customer Challenges Desired Outcomes Success Factors Measured By

Clinician dissatisfaction, frustration, burnout, and attrition

Less time spent documenting & more time on self or patient

Hours saved documenting w/ Dragon MedicalProductivity using Dragon Medical vs. other capture methods

High cost of documentation / Unleveraged Front End Technology

Clinical Documentation Cost Reduction / Clinician Front End Speech Recognition Adoption

Cost reduction from baseline / Increased adoption of Front End Speech Recognition

$$$ SavedAdoption %

Improvement in Clinician Experience and Satisfaction

Clinicians unhappy with documentation tools

Increased Clinician Satisfaction Voice of the Customer Surveys

Reduced Clinician Burnout


Health Quest Systems, Inc.– Acute Care – 4 Acute Care Facilities– Non-Acute – Nursing Homes /

Adult Care– Community – Home Care– 400 Employed Physicians / 250 Community Physicians– $1.2 Billion Annual Revenue– 6000+ Employees– Financial Margin: 8%– HIMSS Level 6 – Starting HIMSS 7 Collection Period

(Early 2017)– EHR(s)

– Acute – Cerner– Ambulatory – eClinicalWorks / Allscripts – In process

of converting to Cerner Ambulatory

Health Quest


Health Quest

Northern Dutchess Hospital, Rhinebeck, NY– 69 Acute Beds– Community-Based Physicians– Major Services:

– OB– Orthopedics – Ambulatory Surgery– Physical Rehab– Bariatric Surgery– Outpatient Diagnostics– Nursing Home


Health Quest

Putnam Hospital Center, Carmel, NY– 169 Acute Beds– Community-Based Physicians– Major Services:

– Orthopedics – Ambulatory Surgery– Cancer– Mental Health– Bariatric Surgery– Outpatient Diagnostics


Health Quest

Vassar Brothers Medical Center, Poughkeepsie, NY

– 385 Acute Beds– Community-Based Physicians– Major Services:

– Trauma Center– Orthopedics – Ambulatory Surgery– Neurosurgery / Stroke Center– Open Heart Surgery– Cancer– OB– Intervention Neurology


Health Quest

Sharon HospitalSharon, CT

– 79 Beds– Community-Based Physicians– Major Services:

– Orthopedic – Ambulatory Surgery– Cardiology– OB– Mental Health


Health Quest

– Hudson Valley Heart Center – 40 Physicians– Health Quest Medical Practice – 400+

Physicians– Health Quest Urgent Care (4 locations) – 18

Physicians

Health Quest Medical Practices: NY


Baseline (Before Electronic Physician Documentation)History: Acute Care Facilities (Prior to Speech Recognition / Electronic Documentation)Status of Electronic Health Record (EHR):– Certified HIMSS Level 6– Vast majority of clinical processes within EHR– High level of CPOE Utilization (95%+)– High level of nursing clinical staff documentation in EHR– Remainder of workflow primarily paperless– Comprehensive integration with devices throughout organizationPhysician Status (Satisfaction / Documentation) – Acute Care:– Physicians using paper documentation / transcription (issues with legibility and timely access to data)– Estimated annual transcription costs - $1.5+ Million– Physician Satisfaction Score (PRC National Survey – Excellent rating) – 25th Percentile– Continued frustration (Physicians) being half in EHR (Orders – In / Documentation – Out)


Physician Status (Satisfaction / Documentation) Acute Care – Continued:– Significant legibility concerns– Delays in discharge – Significant delinquency issues– Documentation issues (Present on Admission, completeness, etc.)

Operational Impact (Partial Electronic Chart):– Patient information was not being fully utilized due to hybrid chart– Both nursing and physician frustration– Physician documentation was not actionable due to significant use of

handwritten notes

History: Acute / Ambulatory Care Facilities (Prior to Speech Recognition / Electronic Documentation)

Baseline (Before Electronic Physician Documentation)


Financial Issues:– $1.5+ Million in annual transcription costs (Acute Care)– Coding Issues – Inability to read handwritten notes– Chart Delinquencies – Increased “Discharged / Not Final Billed” status impacting cash flow– Increased physician satisfaction drives volumes

Physician Status (Satisfaction / Documentation) – Office Practices:– Comprehensive use of EHR in ambulatory setting – HIMMS Level 6– Physicians / staff enter discrete PHI information during visit– Handwritten notes not allowed– Coding Issues – Physicians not expanding on documentation beyond discrete data entry;

Not wanting to type to expand on information

History: Acute / Ambulatory Care Facilities (Prior to Speech Recognition / Electronic Documentation)

Baseline (Before Electronic Physician Documentation)


– Complete migration of chart to fully electronic

– Increase adoption of electronic documentation

– Support ease of use and provider efficiency (physicians / physician extenders)

– Support documentation compliance, quality and completeness

– Reduce documentation deficiency and improve timely access to provider documents

– Improve provider satisfaction with EHR Use

– Ease of use

– Legibility of documentation

– Timely access to data for patient care

– Reduce costs associated with transcription services and scanning

– Eliminate paper in charts (scanning is costly and painful)

– Develop Metrics and Comprehensive Reporting

– Develop reporting system – Measure provider utilization of electronic documentation

– Monitor for performance improvement opportunities

– Measure satisfaction / experience

– Set groundwork for Natural Language Processing (NLP)

– Leverage Speech Recognition and electronic documentation to take advantage of NLP and Computer-Assisted Solutions to further support documentation efficiency and improvement initiatives

Goals: Electronic Physician Documentation


– Implement efficient documentation templates and Speech Recognition to support provider use of EHR and improve satisfaction

– Ensure Speech Recognition integrates seamlessly within EHR and documentation templates

– Set groundwork for Natural Language Processing

– Rationale: Decrease work effort related to provider documentation while improving the quality and completeness of the final documents

– Collaborate with physician leadership to promote cultural change and gain buy-in

– Identify, engage, and leverage provider champions

– Support provider use of Dynamic Electronic Documentation and Speech Recognition

– Provide extensive mandatory physician / physician extender provider training

– Provide ongoing provider support on the units

– Monitor utilization metrics and address opportunities for improvement

– Secure Medical Executive Committee approvals to ban handwritten notes

Strategy: Electronic Physician Documentation


Completed migration of chart to fully electronic – Implemented advanced provider documentation across all specialties – Acute Care

– Implemented Electronic Dynamic Documentation (Cerner)– Created a dynamic template-driven system integrating EHR information into provider documents– Provides an efficient approach to creating documentation– Allows providers to tag other information in the chart that is pertinent to the patient encounter– Integrated fully with Speech Recognition best practice templates (Nuance)

– Implemented industry-leading Speech Recognition across all provider documentation devices / including content templates

– Deployed Speech Recognition (SR) to work seamlessly with the EHR– Provided best practice templates to support efficiency, greater specificity and context, while allowing

providers to customize their SR experience– Provided PowerMics and SR access at all provider workstations / all facilities– Monitored performance, metrics, and provider feedback

Implementing the Physician Documentation Strategy


Supported provider use of Dynamic Electronic Documentation and Speech Recognition– Leveraged collaboration and partnership with physician leadership and provider champions to ensure success– Provided extensive mandatory physician / physician extender training

– Health Quest IT training team developed comprehensive classroom and web-based training– Classroom training took 4+ hours per provider– After class, providers were brought to the units to document electronically in the chart– Trainers provided elbow-to-elbow support to providers until they were comfortable

– Provided ongoing provider support on units– Physicians Liaison - Health Quest IT provides on-unit provider staff to support the provider’s use of the EHR,

electronic documentation, and Speech RecognitionSecured Medical Executive Committee approvals to ban handwritten documentation– Medical Executive Committee approved to ban handwritten notes once 80% utilization for 3 consecutive months achieved– Realized utilization goal within 9 months of go-live



Utilization Metrics (Provider utilization of electronic documentation)



Utilization Metrics (Provider utilization of electronic documentation)



Rollout Approach– Leveraged employed hospitalists as the pilot group (controlled group / creates excitement)

– Initially elected to work with the providers to modify documentation templates to support their preferred preferences and workflow

– Providers found this approach to be challenging as they did not have a frame of reference to recommend changes to the templates (were not yet using the templates and Speech Recognition)

– Elected to go live with standard templates, based on documentation best practices, across all hospitals using a specialty-by-specialty approach

– Maintained close collaboration and partnership with physician leadership and provider champions

Implementation Rollout / Support Approach


Provider Support– Provided extensive mandatory physician / physician extender provider training

– Health Quest IT training team delivered comprehensive classroom and web-based training (classroom training took 4+ hours per provider)

– Accompanied providers to the unit after class to document electronically in the chart– Trainers provided elbow-to-elbow support to providers until they were comfortable

– Provided ongoing provider support on units (still in place today)– Utilized dashboards to understand where specific providers need more assistance– Engaged with providers to seek feedback and offer support if needed– Focused on any immediate workstation / technology issue resolution– Collaborated with providers regarding customizations of best practice templates

Implementation Rollout / Support Approach


– Conducted at 385-Bed flagship hospital, VBMC, during the final phase of Dragon Medical (with Cerner Dynamic Documentation) deployment for the system in April 2015

– Goal: Measure adoption, satisfaction, quality, efficiency, and cost savings using Speech Recognition (SR)– Methodology: A two-pronged study consisting of qualitative and quantitative analyses

– Qualitative: surveys to measure providers’ expectations & experiences pre- and post-deployment of Dragon Medical Speech Recognition (SR)

– Quantitative: retrospective longitudinal observational study of a period of 2 years & 7 months, starting in January 2014 through July 2016 (pilot was June 2014 and final deployment at VBMC was April/May 2015) –collected analytics data from the involved HIT systems to measure the following:

– How documentation and modality mixes changed after full deployment of SR and Cerner Dynamic Documentation

– Adoption of Dragon– Cost savings attributed to the shift from Medical Transcription to Dragon

– First industry study to interlink EMR reports and SR sessions through leveraging HIT systems and a custom algorithm

– Key Findings: Improved Satisfaction, Documentation Quality, Efficiency, and Cost Savings

Dragon Medical Impact Study



Quantitative Results


Note Volume Per Input Modality Evolution


Adoption



Qualitative Results


Dragon Medical Impact StudyQualitative Results Overview – Provider


Speech Recognition Post-Deployment…Support elimination of transcription services 77%

Notes from other providers available sooner 92% always/often; 0% rarely/never

Satisfied with Speech Recognition 90%Document more timely after seeing the patient 68%

Dragon Medical Impact StudyAdditional Qualitative Results (Post-Survey Only Questions)


– Accuracy– Don’t have to write or type– No need to complete medical records

by signing a document after dictation for transcription

– Timely consult notes appear/How quickly we see notes from other providers/Information readily available/Real-time availability of transcribed notes

– Immediate incorporation into the record– Cuts down on typing errors/Easier to

speak than type/Faster than typing

Dragon Medical Impact Study– Could never function with EMR

without it– Increased efficacy of writing office

notes– Fast and easy to use/more

efficient/time savings– Fast and complete information– Recognizes my accent/Very voice

recognizable– Ability to pull in medical information

(i.e., Labs)– Teaching function

Provider Comments (Summary of Free Text Survey Entries)


Dragon Medical Impact StudyQualitative Results Overview – Case Manager


– Next best thing to an actual conversation

– Treatment plan appears to me more clearly leading to a more thorough discharge plan

– Being able to decipher what providers are planning for the patients helps us to expedite continuing care needs and communicate with provider more easily regarding coordination of plans

– MD notes readily available to be sent to outside agencies who require such information to provide care post-discharge to the patient

Dragon Medical Impact Study– Assists me in completing Patient

Review Instruments in a more timely manner

– Tentative discharge date and clearer patient plan; Notes clearer and easier to read

– All documentation in one place and available more quickly than before; Documentation is in real-time, making discharge planning more efficient

– Saves time in reviewing documentation– Much easier to follow course of the

patient

Case Manager Comments (Summary of Free Text Survey Entries)


Physician Governance Model

IT / MEDICAL GOVERNANCE– IT Medical Executive Committee (MEC) is a

subcommittee of facility MEC– Design decisions were vetted and approved

via IT MEC for approval by facility MEC– IT MEC worked with IT to create implementation

recommendations (Phasing, Education, Rollout)– IT MEC – Reporting / Utilization

(specialty level) are reviewed (ongoing)– IT MEC – Recommendations made to facility MEC

– IT MEC made recommendations related to banning paper documentation

Facility Medical

Executive Committee

Facility IT-Medical Executive Committee

CardiologyGeneral Medicine Surgery

ED Infectious Disease Etc.

Facility CMOHQIT CIO

HQIT CMIO

Health Quest IT/ IT PMO


Improved Financial Outcomes: $1.3M

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Transcription Cost Experiance - 2013 .vs. 2016

2013 Costs (Normalized to 2016 Volumes) Cost 2016 2013 .vs. 2016 Savings

Additional Economic Benefits:

• Significant reduction in chart deficiencies ( Cash Flow)

• Improved documentation (significant reduction in coding queries) –( Cash Flow / Revenue)

• Better tracking of Present on Admissions

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Saving2013 Costs (Normalized to 2016 Volumes) $122,881 $111,770 $119,809 $123,911 $124,786 $118,240 $115,123 $129,025 $117,359 $125,799 $130,106 $131,025 $1,469,835Cost 2016 $14,325 $13,749 $15,296 $13,947 $14,108 $13,594 $11,880 $11,211 $10,801 $10,628 $10,520 $9,288 $149,3482013 .vs. 2016 Savings $108,555 $98,021 $104,513 $109,964 $110,677 $104,647 $103,243 $117,814 $106,558 $115,171 $119,587 $121,737 $1,320,486

Note 1: 2013 volumes - Normalized to 2016 volumes

Transcription Cost Experience – 2013 vs. 2016


In order to maximize our investment in physician documentation, Health Quest is committed to the following:– Inclusion of same comprehensive physician documentation approach for ambulatory setting

(Completed)– With all of the physicians documentation contained in the EHR, implement a Natural

Language Processing application to drive coding completeness and compliance – Real time– Upgrade our existing Speech Recognition solution with the vendor’s latest offering

(SAAS-based) – In Process– Continue to work with providers to reduce any remaining transcription utilization– Expand Speech Recognition solution to community-based providers and surgeon’s offices

to support electronic documentation from their offices and homes – In Process

Health Quest Next Steps


Speech Recognition EMR Best Practices – Clinician Experience

Source: DMO CSO Analytics Survey ‘16/’17 (1,875 clinician responses)

98% of Clinicians

Would Recommend

Dragon Medical Solutions to

Friend or Colleague

93% Agree that Dragon Makes

it Easier to Capture

Complete patient Story

89% Agree that Dragon Helps

Improve Quality of Clinical

Documentation

92% Agree that Dragon

Enables them to Document in

a Timely Manner

93% Agree that Dragon Makes

it Easier to Document

Patient Care in EHR

92% are Satisfied with Accuracy of

Dragon

92% are Satisfied with

Overall Performance of

Dragon


Improve Quality of Life by Reducing Frustration/

Burnout


Improve Overall

Experience with Patients

98% Agree that Training Received Helped

Improve Efficiency


Speech Recognition EMR Best Practices Integrated client success model

Benefits of Nuance Success Management engagement:

• Primary goal is to drive measurable clinical and business outcomes by way of adoption

• Customer Success Manager (CSM) assigned during the customer lifecycle continuously monitors utilization, adoption, and other outcome KPIs day one and proactively engages with you to drive maximum value

• Provides a channel for continual feedback• Enables you to fully leverage Nuance solutions and allows you

to make decisions based on actual usage and behavioral analytics data

• Quarterly business reviews to ensure you get the most out of your Dragon investments

Success Planning

Adoption Monitoring & Management

ROI Optimization Consulting

Success Management Profile


Q & A

Questions?


Questions & Speakers Contact Information

Robert (Bob) DiamondSr. Vice President / Chief Information OfficerHealth Quest Systems, [email protected]

Kshitij (Tij) Saxena, MD, MHSAChief Medical Information OfficerHealth Quest Systems, [email protected]

mailto:[email protected]

mailto:[email protected]

Documents

Electronic Physician Documentation: Increased …...2017/07/26 · Medical Speech Recognition (SR) – Quantitative: retrospective longitudinal observational study of a period of