Brian T. Rekofke Attorney Witherspoon Kelley

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1 Yuan-Po Tu, MD The Everett Clinic Urgent Care Provider Anticoagulation and Flu Services Medical Director, Brian T. Rekofke Attorney Witherspoon Kelley Largest independent medical group in the Pacific Northwest Located in 9 locations throughout Snohomish County 5th largest private employer in Snohomish County ~ 1,740 employees ~ 500 providers 295,000 patients 1,000,000 annual patient visits More than 40 medical specialties. FORTUNE Top 100 Best Workplace 1

2 To Ask a Question During the Presentation e mail us at TECEHR@gmail.com Disclosures and Conflict of Interests: Pharmaceutical Grants: Pharmaceutical Speaker Fees: Pharmaceutical Boards or Positions: None None None None The Everett Clinic uses EPIC Trade names of other Electronic Medical Record Systems will be used 2

3 Learning Objectives Understand rational and use of guidelines Legal and risk issues with guidelines How guidelines become standard of care Objectives: At End of the Session, Participants will Understand the rational for the development of guidelines Explain and illustrate best practices for the development of guidelines Understand and explain the legal and risk management issues associated with practice guidelines Understand the role of EMR in the use of guidelines and how EMR s can facilitate guideline implementation 3

4 Guidelines vs. Clinical Protocols Guidelines are intended to assist providers in advising patients on the use and best practice for diagnostic and therapeutic interventions. Protocols are intended to support non practitioner staff in applying care guideline clinic wide. Guideline Template 4

5 Guideline Template Preamble Summary Statement Intended Users Inclusions Exclusions Contraindications Supportive Background Management Actions EMR Documentation and EMR Tools/References/Bibliography/Related Links Document Control Indexing and search information Guidelines have existed for years. How have EMR s changed guidelines? 5

6 Major EMR Vendors Cerner HBOC McKesson acquired HBOC in 1999 Eclipsys Allscripts Eclipsys and Allscripts merged in 2010 Epic founded in 1979 as Human Services Computing Siemens IDX GE IDX acquired by GE in % 80% 60% 40% 20% 0% Circ EMR Adoption Small Practices Large Practices Hospital Outpatient Practices Hospital Inpatient And ICU s Complete Partial Paper Only 10% of Large Practices have Completely Integrated EMR s 6

7 More than 50% of the U.S. population will have their medical information stored in an Epic digital record Judy Faulkner Epic Deep Space User Group Meeting September 2013 The Affordable Care Act and Healthcare Economics Driving the change to Electronic Medical Records Meaningful Use 72% of all office based Health Care Providers use some form of Electronic Health Records (EHRs) adoption is anticipated to reach 80% by 2016 National Center for Health Statistics;

8 Cost of EMR Systems $700 M by U. of Pittsburg 2013 EMR s often represent one of the larger investments Health Exchanges ACO Radiology Growth Risk HCC Risk Adjusted Meaningful Use Medicare Operating Income Patient Satisfaction 8

9 EMR expose many system issues Greatest variability Rate limiting step Level Load the work and Standardize each step Standardize each step Lighten the provider s documentation burden Delegate all you can to support staff 9

10 Simplified Workflow BEGINNING MIDDLE END Registration Rooming Provider Assessment End Of Visit Reception Standards Standard Rooming Standard Visit Template Medical Decision Making Standard Protocols Simplified The Visit 1) Beginning Registration and Rooming 2) Middle Medical Decision Making Assessment and Diagnosis 3) End Orders Coding, Patient Instructions and Discharge Subject to Guidelines 10

11 Associated Symptoms: intended to uncover more serious/acute conditions 11

12 Guidelines are most helpful once a diagnosis is reached The more definitive the diagnosis, the more explicit the guidelines. Many medical diagnosis are not definitive but symptom complexes. (i.e. Chest Pain) Guidelines work best for definitive diagnosis. Strep Throat Protocols Well defined. National Guidelines. High Volume event Simple easy to obtain a diagnosis Low cost Rapid Test fast 20 minutes» 80 90% sensitive $35 Overnight Strep Culture No sensitivity testing» Gold Standard $35 Strep is the only common cause of a sore throat that is treated with antibiotics Low Risk Diagnosis and Treatment Cost of diagnosis is low. Cost of Treatment is low 12

13 Strep Throat Test sore throat with Rapid Strep Test No antibiotics if strep test is negative Children have back up cultures Treat with 10 days of antibiotics Penicillin First Choice Cephalexin if PCN Allergic 13

14 How do Guidelines work when you have something more complicated? Easy and Simple High Volume Low Risk Moderate Complexity High Volume Low to Moderate Risk Strep Treatment Urinary Tract Infection Treatment High Complexity Moderate Volume High Risk Chest Pain or DVT Treatment High Complexity Low Volume High Risk Post Exposure Prophylaxis 14

15 Uncomplicated Female UTI Treatment Moderate Complexity High Volume event More complexity to diagnosis Urinalysis fast 20 minutes» 80 90% sensitive $35 Culture and Sensitivity» Gold Standard $35 Multiple organisms diagnosis is more complex. Usually a Low Risk Diagnosis. Multiple Treatments Cost of Diagnosis is moderate, cost of Treatment is inexpensive Treatment of Deep Vein Thrombosis Diagnosis is usually definitive Venous Duplex Doppler is positive or negative Lots of different treatment options IV Heparin + Coumadin Low Molecular Weight Heparin + Coumadin Inpatient vs. Outpatient Newer TSOAC Rivaroxaban, Dabigatrin, etc. High Risk Medication 15

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18 Why Guidelines? Mounting financial pressures Rapid spread of technology Need data to show improvement of care and performance Active management of Quality Improvement Continuous Quality Improvement 18

19 Guidelines Decrease Unexplained Variation Expert/evidence based guidelines Review critical checklists Enoxaparin Prescribing Review Acute DVT/PE n=51 Bridging Peri Op n=78 Thromboembolic Event 0/51 (0%) Thromboembolic Event 0/78 (0%) Minor Bleeding Event 12/51 (24%) Minor Bleeding Event 12/78 (15%) Correct Weight Dose 51/51 (100%) Correct Weight Dose 78/78 (100%) Correct Renal Dosing 51/51 (100%) Correct Renal Dosing 78/78 (100%) After switching from dalteparin to enoxaparin in April 2013, we conducted a review of all patient from April-July 2013 receiving a prescription of enoxaparin for treatment. 19

20 30% 25% 20% 15% 10% Anticoagulation Clinic Results 11.80% Usual medical care (no ACC clinic process) External ACC (benchmark) TEC ACC % 0% 3.90% 1.60% 1.95% 2.51% 2.50% 3.30% 0.60% 0.88% 0.85% TEC ACC 2011 Major bleeding Thromboembolism EMR allow organizations to crunch data EMR Analytics can allow for spotting trends Decision Support Diagnostic Guidelines Treatment Guidelines 20

21 Point of use Decision Support Helps uses pick the correct test. Are you looking to prove immunity? Or diagnose an infection? Laboratory Cost Analysis Cost per Test Name Cost # Tests # Positive % Positive Pos Test C. Difficile Toxins & GDH Antigen $ $ if positive, reflex to C. Diff PCR to PacLab $ Ova & Parasite Screen: $ $9, Entamoeba coli % Endolimax nana % Cryptosporidium species oocytes % Entamoeba hartmanii % Giardia lamblia % Giardia Ag $ $3, Stool Cultures $ $4, H. Pylori, Stool $ $6,

22 Point of Use Decision Support TEC background rate of positive O & P is approximately 1%. O and P is seldom positive unless the patient has had recent foreign travel or is severely immunosuppressed. If Giardia diarrhea is a concern, order Giardia Antigen (GIARD). If C. difficile diarrhea is a concern, order C. difficile (CTGD2). Scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. It takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice. 22

23 Only 15 20% of Medical Practice has Grade A Evidence Based Medicine Dr. David Eddy 80% is the Art of Medicine Internal Data and Guidelines 23

24 Internal Laboratory Monitoring Detects Outbreak Intervention Acremonium An internal audit identified a cluster of positive fungal cultures The fungus was identified as Acremonium and was found in some of the atomizers used to provide anesthetic and preparation for patients undergoing nasal endoscopy procedures patients were potentially exposed. 34 had positive cultures. The remainder had negative culture or were not cultured. 24

25 Only patients who had endoscopy in a single department between March 1, 2012 and November 21, 2012 were potentially exposed. Patients who did not have endoscopy were not exposed. The standard cleaning processes in place were strengthened and no further positive cultures were obtained. The decision was subsequently made to transition to disposable devices. State and County Health officials were involved and support the steps taken. Acremonium Smart Set Using the Acremonium Smart Set 1) Will give you the correct CC 2) Will give you a progress note template 3) Will give you options to choose if you need to perform Endoscopy or cultures 4) Will allow you to easily enter a consult 5) Will give you the correct Dx so the patient will not be charged 6) Gives the correct Level of Service so the patient is not charged 7) Gives options for patient instructions 25

26 This link will bring in the past five fungal cultures This is where the idea for the new EHR starts getting a little complicated 26

27 Standard of Care A healthcare provider has a duty to exercise the degree of skill, care, and learning expected of a reasonably prudent healthcare provider in the State of Washington acting in the same or similar circumstances at the time of the care or treatment in question. The degree of care actually practiced by members of the medical profession is evidence of what is reasonably prudent. EMR Data & Standard of Care Utilizing internal data and trends to alter guidelines may impact standard of care from a state wide standard to facility specific standard 27

28 Risk Management Challenges Patient populations, resources, and infrastructure may impact individual hospital statistical outcomes. Exposes hospital to potential criticism regarding data production and analysis. Accuracy of data analysis and conclusions tested as with Peer Reviewed Literature. Questions to Consider How much scientific data and analysis is required to change the standard of care? Who decides? Who scrutinizes the information and course of treatment in the facility setting (peer review)? How is all this documented 28

29 Questions? The Everett Clinic Yuan-Po Tu, MD Brian T. Rekofke Attorney Witherspoon Kelley 29