Davies Ambulatory Award Community Health Organization

Transcription

1 Davies Ambulatory Award Community Health Organization Name of Applicant Organization: HealthNet, Inc. Organization s Address: 0 E. Raymond St. Indianapolis, IN 60 Submitter s Name: Richard Reifenberg, MD Submitter s Title: Associate Medical Director Primary Contact: Sheila Allen, sallen6@iuhealth.org, (7) Secondary Contact: Richard Reifenberg, rreifenb@iuhealth.org, (7) Menu Case Study: Integrated Specialty Areas Executive Summary Patients seen at large multi-specialty medical groups like HealthNet typically fare no better than those seen at completely separate, individual practices due to lack of consistent and coordinated care and communication between specialties at these organizations. Patient care quality and as well cost inefficiencies are major factors that can raise the cost and worsen outcomes for our patients. The implementation of an integrated and coordinated care system through a single Electronic Medical Record (EMR) can mitigate these problems and allow organizations like ours to provide the highest quality and most cost-efficient care available for our patient population.

2 Background Knowledge HealthNet, Inc. is a Federally Qualified Health Center (FQHC) and since 968, the organization has improved the health status of Indianapolis inner-city neighborhoods by delivering quality health services. Through 50 licensed providers, HealthNet annually provides affordable health care to more than 59,86 individuals, 65% of whom are Medicaid recipients. In addition, 77% of patients served are under the age of 5 (5% ages 0-7 years, % ages 8- years). HealthNet has a network of 8 primary care health centers, OB/GYN care center, pediatric and adolescent care center, maternal fetal medicine center, 6 dental clinics, 97 school-based clinics, a homeless program with 8 shelter clinics, and additional support services. HealthNet s mission is to improve lives with compassionate health care and support services, regardless of ability to pay. The organization has also been accredited by Joint Commission as an Ambulatory Practice since 980, and is the only FQHC in Indiana with this distinction. HealthNet achieved Patient Centered Medical Home (PCMH) designation from the Joint Commission in October 0 and has successfully attested 98% of its eligible providers for Medicaid Meaningful Use. Some of HealthNet s goals of EMR implementation were to improve clinical care and performance on standardized measure sets, as well as reduce costs by creating a coordinated and integrated care model that would link all our health centers and practitioners in one EMR. Prior to 009, HealthNet utilized only paper charts and every Health Center and service line had their own medical records department. As a result, the only sharing of information was if one provider called another or there was a fax or physical transfer of records. As such, patients seen at different Health Centers or in different service lines were basically cared for in a vacuum, without the benefit of knowing other testing or treatment that had been provided to this individual patient. Opportunity for Improvement The Centers for Medicare and Medicaid Services (CMS) has long sought ways to reduce medical care costs (especially medical waste) while at the same time improving quality of care. In fact, many of the primary outcome objectives of the CMS EMR Meaningful Use Program designed to accelerate the adoption of EMRs nationwide were meant to specifically target these problem areas. Medical waste can occur due to duplication of services or testing due to a lack of access to complete medical records. Studies estimate that, at a minimum, 0% of all medical testing is a duplication of labs and x-rays recently done and thus medically unnecessary (Wang SJ, Middleton B, Prosser LA, et al. A cost-benefit Analysis of Electronic Medical Records in Primary Care. Am J Med 00;:97 0). Other studies have shown that when medical

3 providers have full access to all recent medical records, on a national level, we could potentially save billions of dollars annually by avoiding duplicate testing (Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The Value of Health Care Information Exchange and Interoperability. Health Aff (Millwood). 005;:W5-0 8). Other areas that affect both cost and safety is medication prescribing. Again, lack of access to a complete prescribing history for the patient can lead providers to add duplicate medications (including interacting or contraindicated) for a patient. Our focus in implementing an EMR at HealthNet was to allow the various Health Centers and specialty service lines to utilize and share the same medical information for every patient and during each patient encounter. Our goals were to improve continuity and integration of care, reduce medical waste (duplicate testing and prescribing) and increase collaboration between providers of different specialties all caring for the same patient. We also hoped to decrease or limit administrative burdens, such as manually storing paper charts, transporting charts to other Health Centers when patients moved, or the need to fax thousands of charts per year to hospital-based providers when our patients where admitted for inpatient care, such as planned obstetrical deliveries. Design and, Implementation, and Health IT Utilization Our overall long-term goal was to create a seamless, integrated care model that allows a provider from any HealthNet specialty to access the patient s entire electronic medical record. The plan was to, over a several year period, implement a single EMR capable of connecting our Primary Care providers, our many specialty services, and our 5 clinical practice sites. We wanted the ability to schedule patients, document medical care and test results, as well as perform accurate and complete billing for all our patient encounters. After a lengthy and multi-disciplinary search process for an EMR, HealthNet chose eclinicalworks and began a stepwise implementation starting in the fall of 009. Our design involved installing the Practice Management system (used for patient scheduling and billing) at all our clinical locations on day one of the EMR implementation Go Live. Our plan also included initially limiting the Medical Record component Go Live itself to just one Health Center (Southwest Health Center, our largest and highest volume Health Center). This gave us the ability to minimize the system-wide financial and other impact on our clinical services as we learned a brand new system and processes. We then waited months to go-live with the next two Health Centers because we realized there were many internal patient care processes that we needed to update (e.g. best way to refill medications, log patient calls, order and track labs, etc.). It also

4 became clear that our IT infrastructure was not robust enough to support so many EMR users concurrently. Therefore we purposely delayed the rollout for an additional 5 months before moving on to the next Health Center in the late spring of 0. We used this time to update and refine processes, improve IT infrastructure (higher speed computers and communications lines) and to improve our internal training for our staff and providers to learn the EMR. Value Derived While it required a year process from 009 to 0 to accomplish, at HealthNet we have now achieved 00% integration of our clinical patient care. This currently includes all our Primary Care providers as well as all of our many Specialty Services. This includes OB/GYN, Dental, Behavioral Health (BH), Social Work, Optometry, Podiatry, Dietary, and Tobacco Cessation. Our EMR system is available in all our Health Centers, including the various off-site locations we operate including our School-based clinics, clinics at 8 homeless shelters, and at Methodist Hospital where our pregnant patients are sent for obstetrical services and deliveries. It is also accessible wherever our providers have Internet access. Examples of benefits realized from our integrated EMR have included: Sharing of clinical data with all HealthNet providers allowing reduction in duplicate testing and improving patient safety by having complete access to medication allergies Improving legibility of records Eliminating the need to fax and transfer records when patients are seen at different practice site locations. One area in particular to highlight is HealthNet s integration of Primary Care and Behavioral Health (which includes both Behavioral Health Therapy and Psychiatry). At the national level there have been strong recommendations to improve patient care quality and safety. In turn, there is the need to have Primary Care and Behavioral Health services both co-located in the same facility as well as, tightly coordinating the patient care itself. This is done by ensuring both groups of providers have the ability to share the same patient care data. At HealthNet this has now been fully accomplished. We have both Primary Care and Behavioral Health/Psychiatry co-located in our Health Centers and our entire provider group can readily share information though our one unified EMR. Over the last years medication prescribing practices for our patients has greatly improved (e.g., no duplication of care for psychiatric medications or laboratory testing between Behavioral Health and Primary Care providers) as well as enhanced ability for providers of different specialties to collaborate directly with one another. The

5 final outcome from this is higher quality and more integrated care for our patients. We have realized this very same benefit as we added other specialties to our EMR over the years. Regardless of specialty, all of our providers can now meaningfully contribute to the patients medical record as well as utilize the combined information to optimize the medical care provided. The following graph and table on the following page represent the timeline for EMR implementation and integration at HealthNet between 009 and 0: 5

6 00% 90% 80% 70% 60% 50% 0% 0% 0% 0% 0% 8//009 0% % //009 HealthNet EMR Implementation % //00 5//00 8//00 //00 //0 86% 95% 8% 76% 7% 6% 57% % 8% % 9% 5//0 8//0 //0 //0 5//0 8//0 //0 //0 5//0 00% 8//0 Location Date Integration % Complete Pre-EMR 8//009 0% Practice Management (all locations) 9//009 0% Southwest Health Center 9//009 % Barrington Health Center //00 % Care Center at the Towers //00 % Eastside Health Center 6//0 9% Peoples Health Center 7//0 % Southeast Health Center 9//0 % Martindale-Brightwood Health Center 9//0 % Pediatric Adolescent Care Center //0 8% Dietitian //0 57% Tobacco Cessation //0 57% Behavioral Health 5//0 6% Podiatry 9//0 7% Social Work 9//0 7% School-based Clinics 0//0 76% Homeless Initiative Program //0 8% West Health Center //0 86% Optometry 8//0 95% Northeast Health Center 8//0 95% Dental 9//0 00% 6

7 Prior to EMR implementation, patient satisfaction with their overall visit was around. on a 5.0 scale. Even though those results exceeded our goal of.0, we believed implementing EMR would improve the overall experience for our patients. The graph below demonstrates HealthNet performance from on the overall visit score from patient satisfaction surveys. The question patients are asked to rate is Overall today s visit was excellent. Response options with corresponding scores are: Strongly Disagree ; Disagree ; Neutral ; Agree ; and Strongly Agree 5. HealthNet experienced a dramatic increase in overall patient satisfaction after implementing EMR. Avreage Score HealthNet Patient Satisfaction - Overall Visit Scores Lessons Learned The overall process from initial installation to final complete integration, of services across 5 practice locations, was approximately a year process. The project required more than just installing and learning a new computer system, but also reworking a multitude of outdated internal patient care processes (ordering labs, medication refills, triage, etc.) from the paper era of seeing patients a necessary but time consuming process. It also required multi-disciplinary teamwork from our Clinical Staff, IT, Quality Department, and EMR Team to make this all successfully work as a unified and cohesive system. In the end the process took a lot of hard work to create an EMR system that successfully incorporates and integrates all of HealthNet s clinical and business practices. A best practice we utilized as part of our implementation strategy was to train two Primary Care Nurse Practitioners (NP) to be super-users of the EMR before our first Go Live. These Nurse Practitioners were then scheduled onsite at every health center during go live and for the first few weeks after their EMR implementation. The purpose 7

8 of this was to ensure patients would still have access to care and minimize organizational loss in patient revenue during these transitions. So even though the Center s providers schedules were blocked at 50% of usual volume to allow the providers and staff to learn the new EMR, the health center overall was still able to see about 90-95% of usual patient volume during that time because the NP super users were seeing patients that otherwise wouldn t have been able to get an appointment because of the reduction in available appointment slots. This was very beneficial for our patients who still had access to care, and providers and staff appreciated the extra time to learn the EMR and chart during visits. We believe this time given to them during go lives decreased frustration with learning the new electronic way of charting and allowed them to more quickly remove blocks in their schedule and get close to pre-emr productivity. We also benefitted by pausing early in the EMR implementation process and reworking our internal patient flow processes (including updating our nursing standing orders to mirror these new processes) and improving our training and support services. As a result, the subsequent Health Centers to Go Live had much smoother implementation and faster time to return to at least 90% of pre-emr productivity (average of - months as opposed to almost a year for the first Health Centers after their Go Live). 8

9 Financial Considerations HealthNet received two important grants that significantly funded the initial years of the implementation of our EMR. Funding Source Amount Fairbanks Foundation Grant $,500,000 State of Indiana Grant $,000,000 Total Grants $,500,000 Expenses Associated with Implementation Amount Computers, Printers, Software (Fairbanks) $,00,000 Staff/Personnel Costs (Fairbanks) $ 58,000 Building Upgrades (Fairbanks) $70,000 Train the Trainers (Fairbanks) $5,000 IT Infrastructure Upgrades (Fairbanks) $0,000 Computer Equipment (Indiana) $697,000 Communications Upgrade (Indiana) $56,000 Software Licensing/Training (Indiana) $7,000 Total Expenses $,500,000 9