Fall 2016  
Optimizing the EHR to Enhance Physician Efficiency and Satisfaction
By Dr. Nancy Gagliano
The September 6th, 2016 Annals of Internal Medicine Article “Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties” by Dr. Christine Sinsky, et al. confirms the perception that EHRs add time to documentation and administrative tasks currently facing physicians. According to the article, physicians appear to spend half of their time doing administrative work, much of it on the EHR. This certainly is an important contributing factor to rising physician dissatisfaction and burnout.
The deployment of EHRs across the system was supposed to be the panacea to cure the health system woes. Electronic codified data supports high quality care, while integration of clinical records eliminates duplication of tests. Care protocols support ordering necessary tests and the implementation of the best treatment plan. Everything based on the latest science. However, the burden of data entry was not fully considered as a factor that might impede efficiency and impact physician satisfaction. And, with each new idea on how to improve care or new regulation, think ICD -10, the weight of the EHR documentation burden continues to grow.
Although every EHR vendor is actively working on usability concerns, the complexity of healthcare limits the speed at which vendors can solve these issues. EHR vendors must meet the numerous demands of meaningful use, HiTECH certification, and other ONC expectations. In addition, EHR’s need to meet the needs of academic medical centers, private practices, inpatient and outpatient settings, the nuances of individual specialty practices, and the complexity of specialized areas such as oncology suites and emergency departments. Layered on top is managing the health of entire populations over the course of time while managing costs of episodes of care. In addition, there is the revenue cycle with institutional billing, professional billing, CMS, Medicaid, private payors plus PQRS reporting, other value based care models, and now MACRA. All constituents clamor for functionality and usability. Healthcare IT is clearly an evolving field and, while usability is a high priority for vendors, the list of demands for each release is exhausting.
What can be done now?
Focusing resources on training, workflow re-design, determination of the least expensive approach to
documentation can significantly reduce the to the burden on physicians. Although clinical documentation is crucial to quality care and meeting health system performance goals, it makes little business and financial sense to have the revenue generating physicians spend 50% of their time, as the article highlights, on non-revenue generating tasks. There are numerous opportunities for health systems and practices to enhance their documentation approach and improve physician efficiency and satisfaction.
Training Because the majority of physician’s income is based on productivity, physician time dedicated to EHR training is typically suboptimum. And often “once and done”. Therefore, many physicians have only the basic knowledge of how to document in the EHR and never learn the tools and tricks to be more efficient. Even if some of that was covered in their training, providing refresher training focused on efficiency can be extremely valuable.
Templates, Macros, Flow sheets, Favorites All EHRS have tools to support documentation, particularly of common clinical events. Have these tools been adequately utilized? Are there support resources to develop the templates and macros? Is there a clinical team with the right governance structure to agree upon clinical templates and protocols so that each physician does not need to develop their own individually? Does someone in the organization own the responsibility to help the providers be as efficient as possible? Does someone have the responsibility to keep up-to-date with vendor usability enhancements with releases and have a process to deploy the enhancements to the physicians?
Documentation Look at all aspects of patient documentation related to clinical care. What components can be done by others? Is there the right balance between required documentation and data collection time? What is the ROI of adding new data requirements? Are there opportunities for using dictation or voice recognition? How many additional patient visits would be required to pay for the additional support in the practice to reduce the physician documentation burden?
Clinical Office Work Flow How is the office set up? Where are the printers, the keyboards and the monitors? Is the flow of patients, information, and equipment all designed to maximize the efficiency of the caregivers? Because the physician is the most expensive resource in the practice, it is important to look at all the components of the physician workflow and determine what tasks can be done only by the clinician and how to make that work as efficient as possible as well as determining what tasks can be done by others. Dr. Sinsky’s article highlights that about half the physician time is spent on administrative tasks. Practices should look for cost effective resources to share that work.
In 1990, I had my first brief-case sized cell phone to use while “on-call”. Although very cumbersome, it was liberating, I could now leave the house without a pocket full of quarters and knowledge of the location of every payphone on my path. Now over twenty years later we have smart phones. Exponential technologic advancement such as this gives me tremendous hope for the future of the EHR. Let’s help clinicians make it till then.
Restructuring Physician Compensation in a Value-Based World
By Brad Boyd
Spotlight Article
The concept of value-based care can be traced back to the days of capitation during the 1990s. Under capitated agreements, healthcare providers were provided a fixed, prospective payment for the management and delivery of care for an assigned panel of patients.
In a capitated environment, the primary care provider served as the gate-keeper responsible for directing care based on their professional judgment and clinical practices. Clinical outcomes and cost containment (i.e. value) were major components of the formula which determined an individual PCP’s capitation payment levels.
In many markets, pure managed care arrangements became obsolete due to the challenge or inability to manage and coordinate medical services throughout the continuum of care. Several macro-level changes have occurred since this time. Clinical integration strategies have organized care networks inclusive of primary and specialty care, as well as inpatient services. Payer contracting is occurring more frequently at the health system level, often extending to networks of affiliated physicians. Electronic health records have drastically improved the ability to capture and exchange patient information. Each of these factors have played an important role in developing a new foundation for value-based reimbursement programs.
As value-based care takes hold, revenues and financial performance will be dependent on a practices ability to embrace care coordination, enhance patient access, achieve quality outcomes, manage costs, and improve patient satisfaction. Yet during the transition to value-based care over the next few years, the reality is that fee-for-service, volume based reimbursement will remain the essential component of physician practice and health system revenues.
A major challenge facing healthcare executives is how and when to shift physician compensation to ensure alignment with the future tenets of value-based reimbursement. The shift from volume to value will not happen overnight. Both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) requires practice executives to establish practice short and long term goals and strategies, as well as physician compensation structures. 2017 performance, which starts in less than three months, will impact reimbursement in 2019. Commercial payers are implementing these changes in different timeframes compared to CMS, but the reimbursement mechanisms are aligned with the same objectives. As a result, physician compensation programs will need to change over time.
During this transition, physician productivity and volume-based reimbursement are essential for practice viability. Yet practices today need to prepare for inevitable reality of value-based care. To ease this transition, practices should start incentivizing those behaviors which will be necessary for success in the near future. Incentivizing the tenets value-based care tenets today (panel size, access metrics, patient satisfaction), while transitioning the overall compensation structure concurrently with your payers’ transition to value-based reimbursement programs mitigates the operational, cultural, and financial risks of the shift from volume to value. Over the short term, practices will need to accommodate prevailing productivity measures while gradually adding quality-based incentives to the mix.
Keep in mind, of course, that overall practice compensation will not necessarily go up or down under value-based care models; it will simply shift toward high performers and away from lower performers. It will incentivize collaborative and preventive care typically seen in the primary care setting. Primary care compensation should reflect the increased time spent on care coordination, provide the appropriates results are achieved in terms of quality.
The objective for practices now is to redesign physician compensation in a way that adjusts the practice culture to incentivize collaboration, coordination, patient engagement, and other components of value-based care. Compensation will shift towards a base salary, plus a range of incentives for achieving target metrics for factors such as panel size, patient access and care quality.
Specialty appropriate quality measures, such as those found in the 2016 PQRS measure lists, can be used to measure and reward care quality, and tools built into the EHR can help providers access clinical “best practices” to guide appropriate orders, documentation and treatment plans. Likewise, physicians should be encouraged to maintain patient panels of a size that allows both optimal care coordination and improved patient access.
After all, value-based care forces some providers to alter the way they have cared for patients for decades. Physician communication and engagement, therefore, are critical to how well value-based compensation plans take root in any practice. Even the best goals and most carefully aligned compensation will still fall flat without these two drivers of cultural change. They are every bit as important—if not more—as setting target percentages and dollar amounts.
One small—but crucial—early step that group practices must take is to ensure that their compensation plans encourage physicians to embrace the new value-based ideals. Most physicians applaud the concept of collaborative, proactive care; they just need the tools and reimbursement mechanisms to support it.
Focus your Optimization Initiatives: Reporting Staffing, Structure and Governance
By Jaffer Traish
Change continues to be a constant in 2016: From STAR to Cogito to Caboodle, from MACRA to MIPS and more, we’re all feeling like taking a break from the reporting rollercoaster that seems to be speeding faster and faster.
This year, we’ve seen many organizations reflect on their reporting strategy – taking a breath after finishing rollouts and Connect installs to evaluate strategic initiatives, performance improvement plans and clinical behavior change driven by data.
Many organizations remain on custom data warehouses – where developers, extract staff and database administrators dig deep building queries, tables and connections to service niche applications, one-off databases and hunt for the meaning of ‘readmission’. Very quickly, these teams can grow to the size of a small army – but good troops need great direction.
Some key decision points many organizations are evaluating this year include the following:
  • Cost / benefit to transition to Epic’s data warehouse and Healthy Planet for population health
  • Evaluating all custom databases for transition to Epic universes
  • Assigning/funding a chief analytics or chief data officer to be the accountable point person for marrying enterprise initiatives to work efforts
  • Establishing a metadata council to manage data definitions and data integrity
  • Re-aligning analyst teams into cost accounting analysts, intelligence analysts, and back-end developer teams
From an optimization point of view, there are many initiatives many of us are working on that benefit from this maturing, including copay collections after analyzing front end workflows, cash collections with tablets and MyChart, workqueue scoring and overall staffing productivity measurement. Clinically, mature teams are able to better review utilization of content, and provider productivity reports (including time spent in each Epic activity).
With many organizations planning on selecting where they will take financial risk in the next 1-3 years, it has become a must-do urgent task to regroup, restructure and focus reporting across the enterprise.
Epic’s UGM has an executive track this year focused on analytics as well as a population health forum on Wednesday of the conference. We’re excited to attend and continue collaborating with many Epic organizations to further analytics initiatives!
Nurse Triage Raises the Bar for Centralized Patient Access Centers
By Lisa E Monteleone, RN-BC, BSN, MHA
Centralized patient access centers are an important investment for medical groups and health systems as they provide an access point for current and prospective patients. Used as a means to attract and retain patients, a centralized access center that focuses solely on revenue cycle functions (scheduling, registration, insurance verification and payment collection) may not meet the needs of your patient population and may result in missed opportunities to fully improve patient access and appropriately drive care and service delivery. A patient access center that includes telephone nurse practice functionality provides the key components for population health management: providers and systems alike deliver enhanced health outcomes while reducing overall cost of care and improve patient retention.
Why Do Anything?
Despite the implementation of centralized patient access centers, patients continue to have difficulty obtaining access to urgent or acute care services with their providers. Often times this is due to the non-clinical office personnel’s inability to clinically assess the acuity of the patient complaint or concern. Same day appointments intended to be filled by the more urgent or acutely ill patient are instead filled with patients whose care needs should have been met in an alternate, more appropriate environment. Add in call demand from patients recently discharged from the hospital or outpatient surgery, those with a newly prescribed medication or care regimen, and of course the chronic consumers of health care services to the office call demand and staff have the potential to be overwhelmed and resulting in the patient being underserved. These patient access issues have a secondary effect on the centralized patient access center in the form of higher call volumes and prolonged wait or callback times, making it difficult for patients to obtain an available appointment with their providers. As a result there is an overutilization of emergency departments for urgent care and primary care concerns. The inability to provide a fully rounded patient access experience, not meeting all the needs of the patient population being serviced, has a negative impact on patient satisfaction. Medical groups and hospital systems increase their risk of losing patients to competing practices and systems.
What’s The Answer?
Balance the revenue cycle centric patient access center with Nurse Triage and other telephone nurse practice (TNP) services. A centralized nurse triage service line is staffed by registered nurses with multiple areas of expertise: emergency department, critical care, surgical, pediatric, obstetrics, and complex care management. Telephone nurse practice or triage nurses are able to provide clinical advice encompassing the treatment of fevers, wound care, and emergent conditions such as chest pain. The nurses are trained to triage conditions to the appropriate level of care at home, with a same day physician appointment, at an urgent care center, or at an emergency department.
The care and services provided by the TNP nurses are guided using nationally standardized triage for both pediatric and adult patient populations. The protocols allow for timely and accurate assessment of the patient and recommendations for care. In addition, the practice of the TNP nurse can be guided using protocols that are customized to specific practice guidelines used by individual providers to address the needs of their patient populations. TNP nurses provide safe and clinically appropriate care advice and service referrals founded on sound nursing practice and principles.
What Are The Benefits?
  • Already have a centralized patient access center? – the infrastructure is in place just add the clinical components
  • Decreases risk of delayed or inappropriate care advice – eliminate non-clinical office personnel giving clinical advice or that “silent” heart attack patient waiting hours for a callback
  • Improves physician practice efficiency – clinical staff focused on providing face-to-face services
  • Improves after-hour provider utilization - calls to providers require their expertise and level of care
  • Improves appropriate utilization of services – physician same day/next day appointments, urgent care center and emergency room utilization
  • Facilitates care delivery and coordination through interdisciplinary collaboration and exchange of information
  • Improves patient satisfaction – patient needs are met in the moment, no wait for callback or extended emergency department wait times
  • Supports Patient Population Growth and Retention Initiatives
Nurse Triage Comes in Many Shapes and Sizes
When adding Nurse Triage to a centralized patient access center this service line can accommodate more than just symptom based call management. The clinical expertise of a TNP nurse allows for coverage of calls for a variety of reasons:
  • Interventional Care Advice – Accurate, Comprehensive, Evidence Based, Specialty Specific, Protocol Driven
  • Level of Care Management – Appropriate Level of Care at the Appropriate Time
  • Essential Service Coordination
    • Appointment Scheduling & Reminders
    • Complex Care Management – Care Regimen Change Follow-up
    • Readmission Reduction Management - Hospital Discharge & Procedure Follow-up
    • Medical Home Service Support
    • Patient Self-care Monitoring Support
    • Diabetes Management
    • Anticoagulation Management
    • Medication Compliance Support
    • Patient Outreach - Diagnostic Results, Preventive Care & Wellness Reminders
There are two primary call model options when providing nurse triage and TNP services: Nurse Answer and Nurse Callback. Both models meet different patient needs and demands are effective in providing patients with accurate health information, advice and service coordination. Nurse Answer services operate by having a registered nurse answer calls directly: capturing demographics, reason for call, and all other caller details before moving onto the triage and service coordination processes. A registered nurse handles all aspects of the call.
Nurse Callback models are typically front ended with a specially trained patient service representative (PSR) who initially answers the triage call, capturing patient demographics and their presenting problem or reason for calling. Calls that are symptom based are checked against a list of clinical "red flag" criteria to screen for emergencies. Calls identified as potential emergencies are directly routed to a registered nurse. Calls that are less urgent, don’t meet the escalation “red flag” criteria, are placed in a callback queue and receive a call from a nurse based on call prioritization triggers defined by the call center guidelines and provider driven contracting and criteria.
When developing a centralized patient access center that includes nurse triage (TNP) services, additional performance metrics and practice standards need to be added to the typical health care call center metrics and standards used to guide and direct activities of the call center. This is in addition to the national triage guidelines that are available to guide vetted and clinically sound nursing practice. National accreditation organizations such as URAC’s Health Call Center program ensure that nurse triage and other TNP services are delivered in a manner that is timely, confidential, and consists of medically appropriate care and treatment advice.
Nurse Triage can be provided during business hours, 24-hours a day 7 days a week, or somewhere in the middle. Nurse Triage services can be “built” or “bought,” brick and mortar based or deployed remotely, managed 100% within your organization or outsourced to regional or national call centers. Larger medical groups and health systems are likely to use more than one of these approaches to meet the needs of their patient population and providers.
Does Your Centralized Patient Access Center Set The Bar?
Centralized patient access centers that include Nurse Triage allow medical group and hospital based staff to focus on the face-to-face patient interactions. Investing in a service line that ensures that patient care needs are being met at the appropriate level of care by the appropriately licensed professional improve operational efficiencies, decrease risk to the patient and the organization, increase patient satisfaction, and improve patient outcomes. Does your centralized patient access center provide appropriate and safe clinical advice, prevent unnecessary readmissions, empower patients in self-care, ensure appropriate emergency department utilization, and initiate referrals to care providers and services within your organization?
800 West Cummings Park, Suite 6000, Woburn MA 01801 Tel 781.935.1002