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1 DAVIES AMBULATORY AWARD APPLICATION Date: July 31, 2012 Name of Application Organization: Coastal Medical, Inc. Organization Address: 10 Davol Square, Suite 400, Providence, RI Submitter Name: Kimberly McHale Submitter Title: Director, Marketing & Communications Submitter Core or Menu Item: Infrastructure Innovation Coastal Medical, Inc. Infrastructure Innovation

2 EXECUTIVE SUMMARY Coastal Medical s organization is a case study in the building of a progressive medical organization from the ground up with a clear definition of our goals and objectives for the IT investment. Coastal s unique infrastructure as it relates to the development of health information technology was designed with the understanding that we were striving to achieve measurable clinical quality improvements, rather than simply streamlining processes with an IT solution. As we selected and implemented our EMR, we learned how to leverage a new kind of infrastructure in which our core focus was the innovative deployment and management of personnel and team building across the entire organization. This unique structure and emphasis on team building set us apart at the beginning of our journey to process improvement and continues as we expand on and maximize our EMR use. Our success with the implementation of our healthcare information technology is due to Coastal s two-pronged approach to infrastructure: 1) Invest in the right IT solution and importantly, 2) invest in the staffing needed to lead the initiative. 1 BACKGROUND KNOWLEDGE Coastal Medical is a physician-owned and governed ACO founded in 1995, in Providence, Rhode Island. Our group came together via the merger of seven small private medical practices. Coastal is led by a COO and CEO, a physician Board of Directors, and a Director-level staff of nine. Coastal now employs 91 providers in 19 offices across the state, delivering mostly primary care to 110,000 patients that account for 10% of Rhode Island s population. Our patient mix is predominantly commercially insured, with an 18% Medicare population,.01% self-pay, and 3.17% underserved. Our mission, in part, is to engage with each patient to improve health and promote wellness We take responsibility for ensuring that sustainable, patient-centered, costefficient, high quality health care is provided at all times to our population of patients. In 2005, we were hard pressed to prove our care was different or of higher quality than other community providers. We understood that if we hoped to be an organization that continually improved quality as part of our mission we needed to establish measurable objectives for patient outcomes. Further, we needed to be able to document the clinical data in a system that could report on the care provided vis-à-vis our established objectives. Electronic medical record technology was emerging and showed great promise in the areas around securing patient information, reducing medication errors, streamlining office workflows, and providing the ability to mine data that would allow us to measure the quality of care being delivered and make improvements as needed. Coastal Medical, Inc. Infrastructure Innovation 2

3 2 LOCAL PROBLEM AND INTENDED IMPROVEMENT Since Coastal s inception in 2005, we have been known for providing quality care in a progressive and visionary atmosphere. Our group began to see very clearly that to truly evaluate and continuously improve the quality of care we were providing, and move toward a model of more proactive care giving, we needed to embrace new technology. Better clinical quality would mean more secure patient information, improved medication management, a system to more simply evaluate patient tests, and the ability to use data to provide more proactive care to our patient population. As a group, our physicians voted to purchase and implement the eclinicalworks EMR/PM system. While this was an exciting decision, it was expensive and had associated risks. Even more concerning, we knew that the implementation of a health record across 17 practices, with 85 physicians of various technological interests and abilities would be a challenge. Along with the enormous task of getting provider and staff buy-in and standardizing the internal processes of 17 somewhat disparate offices, financial concerns for the project were also very real. Our physician practices are all a product of practice mergers. When a new practice joins Coastal, they understand the benefits of centralized office infrastructure and look forward to the support that will be provided to their office. At the same time, each group has its own culture and way of working. The idea of an EMR that would standardize their processes made some offices uneasy and staff and physicians expressed concern. Stories of costly failed EMR implementations were not uncommon at that time and the technology was not fully embraced by all of our physicians and staff at the time we began the transition to the eclinicalworks EMR/PM system. 3 DESIGN AND IMPLEMENTATION The infrastructure for the EMR selection and implementation developed differently at Coastal than it has in many other practices across the country. Because we at Coastal viewed the EMR as a clinical tool, we focused on developing a Clinical Quality Team (CQT) to lead us through the complex changes we knew lay ahead. This team was comprised of various levels of office staff, physicians, and corporate leadership. Building a team with clinical level leadership was a costly but strategic decision. We also understood that as the team expanded we would need to invest significantly in quality data staff while at the same time building our IT infrastructure. We hired two key individuals to provide our organization with a new level of IT experience and expertise, another enormous financial investment. We believed that this investment would pay dividends with a smoother implementation, improvements in clinical quality, patient care, and satisfaction, and provider and staff buy-in to the project. The first new formal roles that were established in support of the EMR implementation were the Director of Clinical Quality and an EMR trainer. The Director was a practicing clinical pharmacist and at the time, Director of Coastal s Clinical Pharmacy Program. Coastal Medical, Inc. Infrastructure Innovation 3

4 She became an EMR super user. Our trainer, a hospital-based nurse care manager, became our second EMR super user. A data analyst and an additional EMR trainer were eventually added to round out the Clinical Quality Team. A second Pharm.D became actively involved in later clinical quality initiatives, NCQA, Meaningful Use measurement, and reporting work. Because we chose to host our instance of eclinicalworks, this involved not only an investment in hardware, but in the staff to support the complex hardware infrastructure. We have expanded to five full-time IT positions, and recruited a new IT leader who has a strong customer service orientation toward the physician practices and brings a creative approach to the challenges of IT support to our increasingly complex organization. Physician leadership was critical to the success of EMR adoption. Our physician CEO and one of our cardiologists were first to Go Live with the clinical use of the EMR. They worked out the bugs, learned how to learn, and helped our team refine the training processes for the physicians that were in the queue for the phased roll-out of the EMR. The confidence and enthusiasm of these early adopters set the tone for all those that followed. Because our clinical quality team was comprised of many different levels of users, their input became an invaluable resource as we developed and expanded the use of the EMR. As we began the Patient-Centered Medical Home (PCMH) transformation work in earnest, a Clinical Practice Team was created to oversee and guide that work, cochaired by the Director of Clinical Quality and physician CEO, with membership including our COO, two Office Managers, a Nurse Practitioner, a Nurse Care Manager Supervisor, and other members of the Clinical Quality Team. The work of successfully attesting to Meaningful Use and the PCMH practice transformation initiative entailed changes in office workflow, new roles for front desk staff and medical assistants, and integration of Nurse Care Managers (NCM s) into the process of care. Due to the high level of physician leadership and the strong support in place at Coastal, in early 2011, every Coastal primary care provider achieved NCQA Level 3 status and almost all of Coast s 91 providers have successfully attested to MU. 4 UTILIZATION OF HEALTH IT The many challenges surrounding the deployment of large-scale health IT forced us to look closely at our infrastructure. Coastal s innovation in infrastructure was clearly our immense and sustained financial and emotional investment in clinical personnel. Rather than taking the short-sighted view of infrastructure as it relates only to hardware, software, and facilities, Coastal focused on hiring and training personnel to use the technology appropriately to support our long-term goals. Quality Team: The implementation of the EMR led us to create several levels of Clinical Quality Teams staffed by engaged leaders. It was this early decision that has been the Coastal Medical, Inc. Infrastructure Innovation 4

5 foundation of our success at Coastal Medical. It was the first step in our infrastructure development and created a solid base for our future success with all of the programs we are currently undertaking. Collaboration and Shared Learning: Because we had clinical staff leading our EMR and data collection efforts, we were able to be informed leaders in our community. Coastal provided and gained useful experience as a founding member of CSI-RI in 2007, our state s all payer PCMH demonstration project and as a Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration participant. Integration with Community Partners and Other Providers: Coastal s Imaging and Laboratory Services Director played a key role in establishing EMR interfaces with Coastal s own lab and imaging center and with other providers of lab and imaging services in the community. Our CQT and IT team worked together to successfully connect us with the state s HIE, as well as the HIE of the state s largest hospital system, Lifespan. Increased Access for Patients: Coastal has been able implement Coastal 365 our newest open access initiative. Because we have a central data source, we have opened one centrally located medical office to provide care for our patient population 365 days per year. Opportunity for Patients to Engage in Their Care: We have been able to engage patients in their own care by providing them with a web-based Patient Portal to monitor their healthcare information. The Patient Portal is live and in use in our Internal Medicine, Family Medicine, and Pediatric practices. As of this writing, 34.6% of our patients are web-enabled for the Patient Portal. 5 VALUE DERIVED /OUTCOMES Quality Measurement Tool/Improved Payer Contacting: As clinical quality measurement and reporting progressed, we worked collaboratively to create a series of increasingly sophisticated contracts with our largest commercial payer, BCBSRI. These contracts provided important financial incentives and support for the quality measure reporting work. As Coastal gained experience with PCMH coordinated care through the CSI initiative, BCBSRI was developing its own PCMH program, and NCQA recognition became incentivized in Coastal/BCBSRI contracts. Other payers are now following suit and are working with us to build contracts that pay for improved quality of care. This revenue helps to fund the ongoing costs of maintaining our infrastructure both in terms of technology and personnel. Success with Quality Initiatives: Measurement and reporting of clinical quality metrics was the next step once the EMR was fully implemented. For Coastal the EMR reporting functionality was where we found the EMR investment had the most potential to justify itself. The creation of the Clinical Quality Team assisted with measurement and Coastal Medical, Inc. Infrastructure Innovation 5

6 reporting and gave clinicians insight about their individual performance so that individual provider and office-level performance could be improved as needed. Coastal s executive leadership ensured that appropriate contractual incentives were in place, and success in achieving Pay-for-Performance quality incentive targets helped bring return on investment for the work of EMR adoption. Better Engaged/More Satisfied Staff: The ability to pursue PCMH practice transformation provided an additional opportunity for return on the EMR investment in unexpected ways. Practice transformation to PCMH entailed changes in office workflow as well as new and responsibilities for staff members. As we invested in our personnel via trainings and provided opportunities for professional development within the practices, we noticed a new level of professionalism developing in our offices. The staff was being asked to do more, but it was the real work of patient care which they found was empowering. Coastal Physician Billing: Accuracy of coding and billing efficiency were both greatly enhanced by adoption of the unified EMR/PM system. Because of the success and ease-of-use of the EMR/PM system, we developed a successful billing service that provides billing services to providers outside of the Coastal organization. We have recently expanded that service to include out-of-state-clients including hospital systems. This service generated a previously unthought-of revenue stream of $700,000 in 2011 and continues to grow. 6 LESSONS LEARNED Innovation in infrastructure at Coastal has come to mean something very different than the way other organizations may view infrastructure. Coastal employees spend time talking with visiting medical groups each year to discuss our implementation and use of the eclinicalworks electronic medical record. We have learned that our values and culture are a strong contributing factor to our successful implementation of the ecw EMR/PM system. Coastal continues to maximize our solid infrastructure and the EMR to realize ongoing ROI via favorable contracts, federal incentives, and our physician billing service. We fully support not only the IT portion of the EMR, but we also remain committed to a real clinical quality infrastructure. The value of a clinical person providing training to staff and physicians and the value of the clinical understanding that goes along with the interaction cannot be underestimated. Our leadership has shown a total commitment to building a clinical quality department at Coastal; the goal is to support the offices with ecw and always look at data to determine how to improve our quality. We cannot imagine any other way of truly evaluating the care we are providing to our patients. The clinical teams understanding of patient care and the in-office workflows made expanding the use of the EMR a more thoughtful process. The outcomes are always patient and physician centered, rather than task focused or designed solely for the purposes of mining data. Coastal Medical, Inc. Infrastructure Innovation 6

7 Another value of having a clinical quality team working in our offices was their understanding of changes that could be made in our workflows to better accommodate our evolving organizational structure. Having solely an IT team training and working with the expansion of the EMR would have put us at a grave disadvantage as we led our physicians into the uncharted waters of federal quality initiatives, PCMH transformation, and now the various ACO and shared savings programs. If one considers all of the assets at Coastal that have supported the physician offices in their journey since EMR adoption began in 2006, our shared values as an organization and the shared culture among our physician owners, our commitment to clinical quality, and a team that has directed those efforts remain the greatest single benefit of our implementation and use of the EMR. 7 FINANCIAL CONSIDERATIONS As with any major investment, financial considerations weighed heavily with Coastal Medical, Inc. as we began the process of evaluating and finally selecting an electronic medical record vendor. A team was created to explore the many options available. After a comprehensive search, including site visits to existing EMR users, Coastal selected eclinicalworks. Factors that influenced us in our selection included ease of use, flexibility in workflows, reporting capabilities, vendor commitment to a strategic partnership, positive site visit experiences, and affordability. Affordability and sustainability were important factors in our selection of a system and a vendor partner. A streamlined and time-limited implementation process was also a consideration at Coastal. With 17 practices scheduled to Go Live, we wanted to minimize the disruption to our providers and our patients. Coastal has realized a significant return on investment (ROI) on the EMR implementation. The clinical quality reporting capabilities of the EMR have resulted in our ability to measure our performance and take advantage of several substantial Pay for Performance programs (Meaningful Use, PCMH, favorable BCBSRI contract, etc.). The increased coding efficiencies that are possible with the unified EMR/PM system have since supported the higher coding and fee for service payments have increased accordingly. The soft ROI cannot be measured in terms of dollars but is a significant factor in terms of our organizational maturity. While prior to the EMR implementation Coastal was a loosely affiliated group of 17 individual practices, the process of EMR selection, implementation, training, and ongoing management has brought those practices together as a single, cohesive organization with a shared vision and articulated goals for our organization and our patients. Coastal Medical, Inc. Infrastructure Innovation 7

8 APPENDIX 1 TABLE 1. RETURN ON INVESTMENT ANALYSIS COASTAL MEDICAL, INC. EMR IMPLEMENTATION ROI ANALYSIS Expenses Amount Capital Expenses 1,544,590 Operating Expenses 654,019 IT Staffing 1,590,396 IT Operating Costs 779,183 Other Staffing 226,381 ecw Licenses for EMR/PM system 71,773 Training, Travel, Conferences 29,477 T-1 line 138,558 Circuits 181,091 Outside Services - data migration 1,500 Annual Costs (Maintenance and Support) 562,824 Total Expenses $ 5,779,792 Returns Amount Blue Cross Revenue 700,500 Blue Chip Revenue - NCQA 1,004,500 PCMH Revenue 3,439,410 Beacon Revenue 267,101 Meaningful Use 1,059,001 R.I. Quality Institute 107,609 CSI 1,142,928 REC Grants 98,000 Medicare Bonus 174,282 CurrentCare (state HIE) 50,780 United Health Stipend 470,000 External Billing Clients 735,902 Quality Partners 4,650 Tufts Quality Initiative 289,000 Increase in BCBS Payments 4,398,683 Malpractice savings 956,976 Transcription services savings 1,023,724 Transcription salary savings 218,537 Coding efficiencies 368,746 Additional revenue from new practices 1,276,351 Total Returns $17,786,680 RETURN ON INVESTMENT 308% Coastal Medical, Inc. Infrastructure Innovation 8

9 APPENDIX 2 COASTAL ORGANIZATIONAL CHART Coastal Medical, Inc. Infrastructure Innovation 9

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