Improving Healthcare Quality for the Underserved: A Davies Story Angela Duncan Diop, ND Unity Health Care, Inc. Washington, DC DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure Angela Duncan Diop, ND Has no real or apparent conflicts of interests to report. 2013 HIMSS 2
Learning Objectives Learn what steps Unity Health Care (Unity) took to overcome problems with governance and change management that threatened to derail an implementation. Learn how Unity uses EHR to improve access to care for its medically underserved patient population. Learn how the EHR was used to shorten the claims payment cycle. Learn how the EHR is used to better utilize medical assistants in order to improve screening for tobacco use. 3
Overview About Unity Health Care Discussions of 4 Case Studies Overcoming Problems in EHR Governance and with Change Management Workflow Analysis and Improvement Creates Efficiencies in Claims Payment Improving Clinical Processes Using EHR EHR as a Tool to Improve Access to Care Lessons Learned Financial Considerations 4
Unity s Davies Team Members Ardell Butler, VP of Finance Angela Diop, VP of Information Systems Tracy Harrison, VP of Clinical Services Angelica Journagin, Director of Policy & Planning Diana Lapp, Deputy Chief Medical Officer Laura Zorrilla, Medical Service Revenue Cycle Manager 5
Unity Health Care, Inc. Federally Qualified Health Center 101,594 patients in Washington, DC 30 sites; health centers, homeless service sites, school based health centers, correctional sites, and a mobile site Mission Promoting healthier communities through compassion and comprehensive health and human services, regardless of ability to pay. 6
Unity s Patients Patient population is racially and ethnically diverse and largely minority. Substantial health disparities and poor health outcomes exist. Great need for accessible and comprehensive primary care services. 7
Health Information Technology Platform Customized version of an integrated practice management (PM) and electronic medical record (EMR) application Implemented EMR March December 2009 in a phased approach (6 phases) All clinical providers and staff use EHR 8
The Importance of EHR Governance and Change Management 9
Fall 2008 - a Failing EHR Implementation Lack of solid plan Ineffective project governance Insufficient resources to work on the implementation IT project Project Status Go-lives postponed twice No real plan to change course Demoralized team Implementation Timeline 2007 Vendor Search 2008 Feb Engaged Vendor 2008 May First Go live Canceled Aug Second Go live Canceled 2008 Fall Self Assessment Hired Consultant 2009 Mar PM Go LIve Jun Dec EMR Go live 10
Design and Implementation 1. Self Assessment Conducted by Executive Management Interviewed staff, industry people and consultant 2. Assessment Results Lacked project management experience Understaffed Clinical and medical staff were not engaged 11
Design and Implementation 3. Identified and Devoted More Resources to the Implementation 4. Secured Project Management Resources 5. Developed a process for issues, concerns and change management FTE of IT and HIT Staff Before During and After Implementation 2008 Before 2009 During EHR/PM Analysts 1 4 6 Data Analysts 1 1 3 Project 0 6* 1 Management IT 7 7 7 Subject Matter 0 0 3 Experts Total 9 17 20 * Includes consultants 2012 Current 12
Design and Implementation 7. Developed a training system 8. Developed support system 9. Developed a Governance Structure 13
Outcomes A solid technology platform. Disciplines are engaged in maintaining and enhancing the EHR. Teams once dysfunctional, now a model for other teams and projects. Profound impact on organizational culture 14
Workflow Analysis and Improvement Creates Efficiencies in Claims Payment 15
Background Prior to implementation, inefficient paper based process for handling claims. Original Process Encounter forms created at the sites. Forms sent using interoffice mail to centralized charge entry. Input into practice management system. Goal Develop a system where EHR is used to resolve outstanding claims efficiently, decreasing the amount of time required to process claims. 16
Design and Implementation 1. Configured the EHR to create claim statuses 2. Created reports to track claims 3. Created a new position Medical claims processors (MCP). 17
Design and Implementation Claims are created at sites 4. Designed workflow Claims review by MCPs before sending to billing If errors a note is sent with the claim to the med. Dir. or provider Provider corrects the claim and returns it to MCP MCP sends claim to billing 18
Design and Implementation 5. Trained staff 6. Roll out and monitor Piloted by Deputy CMO, then rolled out to all providers. Monitored by Deputy CMO and Revenue Manager by reports. Monitored by providers and MCPs through EHR Medical directors work with providers who are not addressing outstanding claims in a timely manner. 19
Outcomes Decline in the Days of Revenue in AR In 2008, number of days of revenue in AR was 67.6 days. By December 31, 2011, it declined to 49 days, a 28% decrease. Days 70 65 60 55 50 45 40 Days of Revenue in AR 67.6 63.4 52.7 49 2008 2009 2010 2011 Results $1.3 million of cash, or 1.6% of our operating budget, is available for operations that would not be available without this improvement. 20
Outcomes Increase in Net Revenue Per Visit 120 115 110 Net Revenue per Visit 110.61 116.56 Net revenue per visit increased from $93.08 in 2008 to $116.56 in 2011. Dollars 105 100 95 90 93.08 102.11 Due to a number of factors that include this intervention and changes in payor mix. 85 2008 2009 2010 2011 21
Outcomes Decrease in Bad Debt as a % of Uninsured Revenue % 60 50 40 30 Bad Debt as a % of Uninsured Revenue 49.1 41.8 33.3 Bad debt as a % of uninsured revenue has decreased from 41.8% to 33.3%. 20 20.2 10 0 2008 2009 2010 2011 22
Outcomes 8 of the 15 staff are certified coders or enrolled in training Revenue Manager s Staff Table 1 Year 2008 2012 Staff 12 15 Coder (Certified or training) 0 8 Result: MCPs have greater opportunity for career growth then they did in their previous role and their job satisfaction has improved. 23
Improving Clinical Processes Using EHR 24
Background DC is 10 th in the nation for tobacco use - 16.2% of the adult population smokes. This case study discusses how medical assistants are a part of the team with their provider in screening for tobacco use in our patient population. 25
Design and Implementation 1. Developed and generated tobacco use documentation reports 2. Reviewed workflows 3. Revised workflows 4. Reconfigured the EHR 5. Trained clinic staff 6. Roll Out and monitor. 26
Outcomes MAs document tobacco use on 79% of patients. Tobacco Documentation 2011 2012 98% Providers assess, counsel and providing treatment options. 63% 79% 60% Providers assess 98% of tobacco users and provide interventions for nearly 60% of these patients. 0 0 Tobacco Use Tobacco Assessment Tobacco Intervention 27
Outcomes More accurate recording of all patients smoking status. Positive change in organizational culture - in alignment with the PCMH model and coordinated care Increased provider and MA job satisfaction. Documented over 783 patients who claim to have discontinued tobacco use. Nearly 600 of these patients had been counseled to quit by the health center. 28
EHR as a Tool to Improve Access to Care 29
Background Before EHR, patient scheduling was done at each site No practical way to communicate enterprise wide schedules Often missing one of the three essentials to patient care o patient o provider o information (the medical chart). Goal Leverage EHR to improve patient scheduling 30
Design and Implementation Phase 1 Installed a new phone system Piloted centralized scheduling Implemented EHR and practice management Phase 2 Created in-house scheduling center Developed scheduling experts 31
Design and Implementation Phase 3 Implemented a patient reminder system Improved scheduling rules 32
Outcomes 1.3 1.2 % Increase in Kept Visits/Provider/Month 1.1 21% increase in provider productivity 1 Realized 12.1% additional revenue since 2009 0.9 0.8 2009 2010 2011 2012 $12.2 million through 2012 from increased revenues due to increase provider productivity. Millions $ 8 7 6 5 4 3 2 1 0 Revenue from Increased Provider Productivity 2009 2010 2010 2011 2012 33
Outcomes Significantly decreased no show rates 2008 no show near 36% No Shows 2010 no shows at 32%* 2012 (through Jun) no show rates at 28%. * (before implementing reminders) % 36 34 32 30 28 26 24 22 20 Jan Feb Mar Apr May Jun 2010 2012 2011 34
Outcomes Decrease in abandoned call rate. 40 30 Abandoned Call Rate 40 20 2009, abandoned call rate nearly 40% 2012 abandoned call rate is about 20% % 20 10 0 2009 2012 Result: Greater patient satisfaction! In a 2011 survey, 85.5% of patients agreed with the statement it was easy for me to make an appointment. 35
Outcomes Decrease in average call wait times Call Wait Times 4.21 May of 2009 call wait times 4.21 min. 5 Minutes 4 3 2 2.4 May 2009 June 2012 June 2012 call wait times 2.4 min. 1 0 Result: Again greater patient satisfaction! 36
Financial Considerations Our initial investment to implement the EHR was $5.5 million We received $1.98 million in grants from HRSA for our implementation 150 Eligible Providers for Meaningful Use Will receive $4.4 million from the incentive program between now and June of 2013 37
Lessons Learned It is critical to have an implementation plan and adequate resources to implement. Returning claims to the originator for correction is a great learning tool. EHR has made it necessary to create new positions giving us the opportunity to upgrade skills sets of staff. We can have a major impact on provider productivity and revenue by focusing on the efficiency of other staff. 38
Thank You Angela Duncan Diop, ND Unity Health Care, Inc., Washington, DC adiop@unityhealthcare.org
Improving Quality of Care to Underserved Communities Through EHR Jeremy L Bradley, MD PSC 40
Conflict of Interest Disclosure Jeremy L Bradley, MD PSC Has no real or apparent conflicts of interest to report. 41
Learning Objectives 1. How HIT increases access to care to underserved communities 2. How HIT improves quality of care utilizing evidence-based guidelines and population management functionalities 3. How HIT improves patient satisfaction and compliance 42
Jeremy Bradley, MD Family Practice Owensboro, Kentucky 43
Health In Kentucky Heart Disease and Stroke Risk Factors Among Adults - Kentucky Compared to the United States Kentucky Nationwide (States and D.C.) Diabetes Cigarette smoking High blood pressure High total blood cholesterol No moderate or vigorous physical activity Overweight or obese Eat fruits and vegetables less than 5 times/day 9.9 8 28.2 19.8 30 27.8 38.5 37.6 55.8 50.5 69.1 62.9 81.6 75.6 0 10 20 30 40 50 60 70 80 90 United States Center for Disease Control and Prevention: 2007 Behavioral Risk Factor Surveillance System 44
Meaningful Use Core Measures Provide clinical summaries to patients 50 100 Dr. Bradley Provide electronic copy of patient's health information 50 80 MU Threshhold Record smoking status Record vitals/bmi/growth charts Record special patient demographics 50 50 50 100 100 100 Maintain active allergy list Maintain active medication list 80 80 100 100 Generate and transmit electronic prescriptions 40 86 Up-to-date problem list 80 100 0 10 20 30 40 50 60 70 80 90 100 45
Meaningful Use Core Measures Enable the functionality of drug-drug and drug-allergy interactions Report ambulatory clinical quality measures to CMS Implement one clinical decision support rule relevant to specialty Perform at least one test of EHR capacity to electronically exchange information Review a security risk analysis and implement security updates as part of risk management process Demonstrate EHR ability to submit electronic data to immunization registry Incorporate external drug formulary Incorporate more than 40% of all clinical lab data results into EHR Generate report listing patients with a specific condition Provide disease-specific education to more than 10% of patients 46
BTE Quality Measure Data 100 Hypertensive Patients Aged 18-75 Pre-EHR 2007 and Post-EHR August 2012 Services Provided to Hypertensive Patients pre-ehr post-ehr 2012 Diet and exercise counseling Smoking status and cessation advice 70 70 100 100 Annual diabetes screening test (blood glucose) Annual serum creatinine test Annual complete lipid panel 84 84 84 100 100 100 Annual urine protein test 80 97 0 20 40 60 80 100 47
BTE Quality Measure Data 100 Hypertensive Patients Aged 18-75 Pre-EHR 2007 and Post-EHR August 2012 Indicator pre-ehr 2007 post-ehr 2012 % decrease Average systolic blood pressure (mmhg) 136 132.3 2.7% Average diastolic blood pressure (mmhg) 82 70.6 13.9% Avg. LDL value (mg/dl) 140 101.1 27.8% Avg. HDL value (mg/dl) 32 43.6-36.3% Avg. total cholesterol (mg/dl) 196 177.2 9.6% Avg. Triglyceride level (mg/dl) 168 151.2 10.0% 48
Clinical Practice Advisories This Clinical Practice Advisory is set to trigger whenever the doctor sees a patient between the ages of 18 and 75 with an ICD9 diagnosis of diabetes. 49
Query Building and Data Mining Queries built with basic SQL. Reports can be exported in a variety of formats. DataMiner automatically reports denominators, numerators, and exclusions, and calculates resulting percentages for Meaningful Use. 50
Stage 2 Meaningful Use Criteria Indicator % compliance NQF 13 Blood pressure management in hypertensive patients 100% NQF 28 Tobacco use assessment and smoking cessation counseling 100% NQF 31 Mammogram screening in females age 40-69 100% NQF 34 Colorectal screening in patients age 50-75 100% NQF 36 Use of appropriate medication in asthma patients age 5-40 100% NQF 41 Influenza immunization in patients age 50 and older 100% NQF 43 Pneumovax immunization in patients age 65 and older 100% NQF 55 Documentation of diabetic eye exam in patients with Type I or II diabetes 96% NQF 56 Documentation of diabetic foot exam 100% NQF 421 Adult weight screening and follow-up plan in patients age 18 and older 96% 51
Patient Satisfaction Pre- and Post- EHR Implementation Percent Respondents "Very Satisfied" with: Pre-EMR Post-EMR Obtaining a copy of my office lab work 87 97 Obtaining a copy of my office visit note 72 95 The timeliness of having phone messages returned Having routine prevantative care testing done The timeliness of having prescription refill requests completed The timeliness of getting referred for specialty consults The timeliness of getting referrals for procedures Receving disease-specific material 82 85 81 85 83 80 99 99 95 96 96 96 The amount of quality time spent with Dr Bradley during my appointment 90 98 Scheduling office visits/same day appointments 85 95 0 20 40 60 80 100 52
Questions? Dr. Jeremy Bradley Booth 140 Praxis EMR 10:30 12:00 pm 53