Grove Medical Associates, P.C.: Core Clinical Value

Date: July 30, 2014

Name of Application Organization: Grove Medical Associates, P.C.

Address: 250 Hampton Street Auburn, MA 01501

Submitter Name: Gail Cetto, R.N. Submitter Title: Office Manager Submitter’s email address: [email protected]

Additional Contact’s Name: Sharon Magner Additional Contact’s Title: Data Manager Additional Contact email address: [email protected]

Core or Menu Item: Clinical Value

Executive Summary

In 2004, with the assistance of GMA’s Independent Physician Group (IPA) group, Central Mass Independent Physician Association (CMIPA) and the Doctor’s Office Quality – Information Technology (DOQ-IT) program managed by MassPro, Grove Medical Associates, P.C. (GMA) developed a set of clinical and business objectives to establish a framework for selecting an Electronic Health Record/Practice management (EHR/PM). The primary goal of GMA has always been to improve the safety and quality of patient care delivery, as well as manage the high volume of patients and their medical needs. This EHR decision allowed GMA to facilitate the timely and comprehensive delivery of healthcare services to its patients, resulting in improved clinical outcomes. The practice was interested in an EHR with the ability to provide a closed loop system for tracking outside testing/labs ordered, allow for increased patient engagement, allow follow up for GMA staff and providers to ensure patient compliance, and reconcile the results with the patient’s chart for review and action by GMA staff and providers. Based on ease of use, comprehensive medical record, and integrated PM system, the staff felt eClinicalWorks (eCW) was a good solution to address without an EHR/PM.

Due to the implementation of the EHR, GMA was able to successfully apply to Meaningful Use and achieve Level III Patient Centered Medical Home certification. Amazingly, the practice now consistently maintains the highest level of individual PCP Quality Performance scores through CMIPA which consists of 250 physicians.

1. Background Knowledge

Grove Medical Associates, P.C., (GMA), is an internal medicine practice serving Worcester County in Massachusetts and is affiliated with the Central Massachusetts Independent Physicians Association (CMIPA). GMA employs four Board Certified Internal Medicine physicians, a

1 Grove Medical Associates, P.C.: Core Clinical Value

Physician’s Assistant, a Certified Nutritionist (one day a week) who is working towards her CDE certification, registered nurses, medical assistants and administrative support staff.

With a diverse patient population of over 6,500 in an urban setting, its office is often quite busy. Its focus has always been on the patient – what is best for the patient – and it was realized an electronic medical health record was needed to track continuous quality improvement. Fully operational since 2005, adding the Patient Portal in 2007, both of which have greatly enhanced communication with patients, helped them become more engaged in their care, and opened a channel for outreach.

2. Local problem being addressed and Intended Improvement

Prior to implementing the EHR GMA did its best to follow up and ensure all diagnostic testing appointments were scheduled and attended. The practice quickly realized more work still had to be done even after implementing. Although all appointments were scheduled in a timely manner, staff did not always realize when a patient was a no show or when results were not received. Keeping track of the paper charts and results was always a challenge that presenting unforeseen obstacles. These obstacles included delays in filing the results in paper charts, receiving the results in the mail, lacking notification of patients who did not attend these appointments. A huge liability was created presenting concerns that some information would be missing from the patients’ charts. With the EHR implementation, GMA added a closed loop system for tracking outside testing for patients. Now the practice can easily track follow up testing to ensure patient compliance and reconcile outside testing results.

Managing telephone calls was also very challenging. Prior to implementing, the telephone triage staff would take a hand written message on a message sheet, ask the medical records department to pull the paper chart and then the Physician Provider would visit the triage department twice a day to answer all messages. This delay resulted in the patient calling the office several times seeking an answer to the same problem, overburdening the telephone lines. Adopting an EHR allowed the practice to improve communication drastically with the patient and providers.

3. Design and Implementation

The key contributors to the selection of the EHR were the three GMA physician owners, the R.N., Office Manager and the Billing Manager. MassPro and the CMIPA EHR Committee, led by Dr. Magee, provided the opportunity to participate in EHR vendor presentations. Based on MassPro’s final list of Top Ten EHR evaluations and careful review of all information from EHR vendor presentations, GMA was leaning toward eClinicalWorks (eCW) of Westborough, MA as its vendor of choice.

From the start, eCW was supportive and continued to provide ongoing support to GMA. Regular system upgrades provide new tools and opportunities for improved patient care. eCW offers free webinars and CMIPA offered monetary support for training. Trainers met with staff to ensure the most recent features were being utilized.

GMA’s goal in the pre-implementation phase was to allow staff and PCP providers to become familiar with the software screens to maximize the training on ‘Go Live’ date in August of 2005. Staff reviewed CD tutorials on “How to set up a Telephone Encounter” or “How to set up your own Template”. Physicians used remote access to test the application from their homes. This also allowed the physicians to view and familiarize with screens while at home with no office distractions. MassPro provided lists of anticipated decisions, processes and workflow changes expected to occur. Staff reviewed the paper system to identify the changes occurred by using test exercises for the front desk, telephone triage department, and billing.

GMA’s plan for minimal disruption in patient care included:

1. Seven weeks prior to ‘Go Live’, GMA staff began scanning in paper charts and inputting the following data:  Most recent CPE exam progress notes  The last two (2) office visit progress notes  Most recent EKG, echo, mammogram, CXR, colonoscopy, pap screen, last set of labs  Medication list and allergies to medications  Chronic assessment lists from previous PM system 2. Tutorial CDs were distributed to allow staff to become familiar with eCW screens 3. Staff members spent time in the scanning room to view and become familiar with this process. 4. First week of July 2005: Two days were blocked off and arrangements were made to shut down Grove Medical Associates for the first Two Days of training prior to ‘Go Live’ date. The remainders of the ‘Go Live’ week were booked at 50%. This would allow for everyone to be able to focus on the training. 5. First week of July 2005: Each provider’s schedule was adjusted to include an extra 15- minute block per hour to allow for complete documentation time for one month after ‘Go Live’. We originally allowed for 2-3 months of extra time in the schedule but the physicians quickly became proficient on EHR charting after just one month. 6. ‘Go Live’ week: Patients were notified that they would be seeing providers who were in training with a new product and were receptive to being part of the process. They were shown the electronic Medical Summary created in real-time; they were very interested and engaged in the project. 7. One week after ‘Go Live’ week: weekly meetings were held to allow for all eCW users to be in a room to learn from each other for 30 minutes. These 30 minutes meetings were very important and provided the quickest way to move forward with all employees helping each other. These weekly meetings continue to this day.

GMA took advantage of several training strategies as it approached the ‘Go Live’ date:

 Two months prior to ‘Go Live’, eClinicalWorks provided CDs for user self-study and GMA paid its employees for time spent at home reviewing the training CDs (e.g., how to set up Telephone Encounter)  MassPro provided workflow diagrams to assist with changes that would need to be made on processes such a reporting of lab results, telephone messages, patient registration

along with front desk procedures, billing and claims processing, etc. This allowed GMA to anticipate some of the obstacles and pitfalls to watch for, based on experiences of MassPro Physician Advisors.  Every GMA employee was rotated through the scanning and data entry process to become familiar and develop proficiency.  Physicians were provided remote access to eCW from their homes.

The successes we experienced began to offset the stress of implementation during Week 2:

 Phone calls were easier because the practice could view the Medical Summary while talking to the patient and seeing their medications, medical history and PCP name. This was a big change from the paper chart experience, where staff were required to place the patient on hold, find the medical record and then understand the information about the caller.  Patients calling for test results could be helped quickly from the electronic record and results were usually available within 12 hours of receipt. What a relief! The old system involved finding the paper chart and the test results which were often on the provider’s desk for review. Physician Providers can now send a message about the reviewed results with their recommendation orders.  Staff now have the ability to view previous telephone encounters which include the date, time, reason for the call, and the Physician Provider’s response.  Physician Providers were starting to answer their telephone encounter requests within the hour. This was a big change from having them visit the telephone triage department at noon and late afternoon. This also eliminated having staff walk down to PCP’s office to ask a question for the patient.  Adding the closed loop tracking system for all outside testing was easily achieved with the EHR. All diagnostic imaging orders created for outside testing are reviewed on a monthly basis by a dedicated data manager.

4. How was Health IT Utilized?

HOSPITAL INTERFACE GMA has taken full advantage of the available technology and its ability to interface with the EHR. Clinical Device Interfaces in the office include Midmark EKG, spirometry and Holter monitor devices. Lab results are received electronically (approximately 150 per day). Based on GMA’s ability to identify and understand the need for diagnostic imaging, DXA scans were implemented in 2006, ultrasounds in 2007, and echocardiograms in 2008. Without implementing the EHR the capabilities never would have been possible in addition to the ability to anticipate the volume of testing patients would require. This has allowed GMA to benefit from ancillary revenue. Presently the practice is using a new HL7 message stream initiated by St. Vincent Hospital (SVH) to send medical information through a NOVO system interface server to automatically populate the correct patient record, linking the name and DOB to any lab result, diagnostic imaging result, emergency room visit physician note, and any hospital activity including discharge summary. The time savings have been significant for both providers and staff. Fax transmissions are eliminated and there is no longer a need to process SVH reports as a document management task. An example of this efficiency occurred when a patient called a GMA Physician Provider on 04/22/10 at 9:00 AM complaining of

4 Grove Medical Associates, P.C.: Core Clinical Value hemoptysis. An urgent CT scan of the chest with contrast was scheduled at SVH on 04/22/10 at 9:57 AM, lab work was drawn at 1:00 PM, CT scan was performed at 1:30 PM, and the Physician Provider who ordered this CT scan received and reviewed the report with the patient at 3:03 PM.

PATIENT PORTAL 81% of GMA patients are web-enabled – (5,046 of 6,264). The Patient Portal allows patients to communicate with their physicians, report weekly glucose readings, receive normal lab test results, request prescription refills, schedule non-urgent appointments and request referrals online. GMA patients can see the real-time status of their health maintenance requirements. GMA does send health maintenance reminders to patients for screening tests, flu and pneumonia vaccines, and overdue mammograms, pap screenings, etc.

ORDERS: e-PRESCRIBING AND LAB AND DIAGNOSTIC IMAGING – GMA utilizes the electronic prescribing capability to order medications for patients at the point-of-care. Medi- Span Drug Reference Database (Surescripts) checks for drug interactions in real-time. eCW also performs patient RX eligibility automatically for patients who are located in the schedules. This is done automatically the morning of the patient’s office visit. For phone prescriptions, staff will check eligibility prior to sending the request to the Physician Provider. GMA utilizes the lab services of Quest Laboratory and SVH LabCorp, which is interfaced with the EHR system. A staff member is assigned to check lab reconciliation daily for labs not allowed into the system due to no matching patient name or DOB. This is done routinely each day before any other tasks. Outstanding results are rectified immediately.

REGISTRY REPORTING and PATIENT RECALL – GMA routinely uses the Registry reporting for easy access to data on patients with chronic diseases, the immunization status of patients and preventative measures. The registry allows staff to send web blasts to groups of patients regarding pertinent information. A routine and systematic review process was developed through the Patient Recall checking the patient’s record one week prior, allowing the medical assistant and provider to discuss the need for preventative measures. Systematic scheduling is conducted for patients who need CT scans, arterial studies, and MRI’s over the next 6-24 months.

MAQ DASHBOARD The Meaningful Use Adoption Quality (MAQ) Dashboard is a tracking program created by eCW providing reports with all necessary data required for Meaningful Use. This has been an extremely helpful tool, allowing the practice to successfully achieve Meaningful Use. eBO Electronic Business Operation (eBO) assists in analyzing, measuring and streamlining the financial operation and clinical reporting content. The eBO delivers detailed reports on predefined measures in real-time to improve operational efficiency and increase profitability margins. eClinicalMessenger An application which can send voice messages, SMS (text) messages, App notifications, e-mail, and secure messages to the Patient Portal. Patients can choose their preferred method of communication.

5 Grove Medical Associates, P.C.: Core Clinical Value healow, Web-based, patient engagement platform that was created to help practices better engage their patients where they already are – online.

P2P (Peer to Peer) provides integrated and easy-to-use functionality for communication, enhanced workflow, and secure sharing of information among a network of thousands of physicians. GMA actively participated in trying to teach other local offices how to utilize P2P. The P2P feature is not limited to eCW EHR users.

5. Value Derived/Outcomes

The value of the EHR was clearly shown during the application process to the National Committee for Quality Assurance (NCQA) for Patient Centered Medical Home (PCMH). The ease of use of the PCMH Reporting Module located in eCW helped tremendously with achieving PCMH Level III recognition in March 2013. Please see appendix I for GMA’s 2011 NCQA PCMH Report Card.

Since implementing the EHR, GMA has demonstrated an improvement in quality of care in preventative measures, which is demonstrated in the graphs below. These graphs are displayed at each nurse station and are discussed at weekly staff meetings. Discussing this monthly is vital to maintain the desired level of care. The medical assistants are trained to utilize the EHR preventative measure alert and structured data to ensure all testing is captured for each patient at all visits. An example of improved care is an appreciative patient who was very reluctant to have her annual mammogram until a GMA staff member spent considerable time on the telephone easing her fears. Unfortunately her mammogram did show early stage breast cancer (Stage I, Grade I) which would not have been detected if the preventative measure was not persuade aggressively. This patient sent a beautiful card entitled “With Gratitude” thanking the staff member for their persistence. She states, “I so appreciate your pushing for preventative testing”. Please see appendix II for the preventative measure monthly reporting graph.

The following chart is a sample of our reporting to the Massachusetts Patient Centered Medical Home Initiative for May 2014. It displays annual data for the Diabetic Population at GMA. This reporting is maintained on a monthly basis. This allows GMA to discuss and demonstrate tracking results and the areas which may need improvement. The practice’s philosophy is “you cannot improve on something you do not know”. Please see appendix III for the MA-PCMH reporting example for GMA, from May 2014.

6. Lessons Learned

 GMA has learned running reports monthly and displaying the results in a graph format to all staff members has helped identify any areas in need of improvement.  GMA learned early on conducting weekly meetings with the entire staff was crucial in the learning curve. During these meetings, staff taught each other the simplest way to perform a task within the EHR. These weekly meetings were an open collaboration for all staff to have input and to feel heard. By discussing in an open forum many errors were eliminated. It was a team effort to transfer to the EHR successfully and it still is.

 In all of the reporting projects, the biggest lesson learned was staff needed to know where data was being pulled from in the electronic record. Educating staff members to see where the data is pulled from and helping them understand the concept was instrumental in obtaining the proper reports. This has forced GMA to change some workflow but has greatly improved reporting capabilities.  Staff quickly realized the learning is never over when implementing an EHR. Taking advantage of the free educational services offered by the EHR vendor is critical in keeping up to date with the evolving EHR. GMA’s goal is to attend two of these services per month (more are sometimes necessary).  With the Physician Providers, it was helpful to have a “Physician Champion” among them to help lead the pack. Dr. Weinstock was our Champion and “go-to person” during pre-implementation and the early stages of implementation.  GMA realized not to underestimate the volume of incoming and outgoing faxes. The amount of faxes changed dramatically within days of ‘Go Live’. This did initially create a problem which was resolved quickly by applying separate servers for incoming and outgoing faxes. GMA should have accomplished the setup of separate servers prior to ‘Go Live’ date.

7. Financial Considerations

The funding for the implementation of the EHR software and hardware was in the form of a loan provided by one of the Senior Partners at GMA. A $15,000 grant from CMIPA was applied towards the initial loan. There was no reduction of income for any of the Physician Providers or staffs as salaries and profit sharing were maintained. There was a significant increase in both insurance collections and incentive money. Now staff has the capability to be organized and maintain EHR alerts. In addition, GMA will have the ability to predict anticipated income through the addition of ancillary testing such as Bone Density (DXA), Ultrasounds and Echocardiograms. These ancillary tests generate additional income for GMA.

Grove Medical Associates, P.C. attributes its success to the staff who actively and diligently participated in the EHR from start to present. Each staff member performs valuable and essential tasks to obtain the common goals of providing good patient care and ensuring preventative measures are met. Each staff member provides new ideas on how to accomplish these tasks and should be consulted often. Recognizing each individual’s strengths will ensure growth for the practice, allow for easier implementation of procedures, and allow for evaluation of the practice’s workflow to best facilitate improvements. This also creates a team atmosphere where no single individual is solely responsible for any given task. The team approach provides staff with support, and allows the staff as a whole to have input on major decisions. Once a new idea is proposed, consulting the staff opens a dialogue regarding the pros and cons of the proposed implementation. This saves time and effort on possible restructuring of a new idea, and creates team spirit. Nothing can be accomplished without a great staff.

Appendix I:-GMA’s 2011 NCQA PCMH Report Card

Appendix II: Preventative Measure Monthly Reporting

Appendix III: MA-PCMH Reporting for GMA, May 2014