Achieving Operating Efficiencies with an EMR - a CIO's ...
Achieving Operational Excellence with an EHR a CIOs Perspective Phyllis Schuck, SPHR CIO of Pinehurst Surgical HIT Session 6.02 Thursday, March 29, 2007 Pinehurst Surgical Organization Overview
Founded in 1947 Physician Owned 8 Surgical Specialties & 1 Non-Surgical 36 Physicians & 18.5 Mid-Levels Support staff of 221 One primary location 6 satellite clinics
Approximately 110,000 active charts Goal of Implementing EHR Goal is NOT Chartless or paperless Goal IS Control Expense of Visit Related Processes Increase Provider Productivity Outcome IS
Operational Excellence Measuring EHR Goal Success Achieving Operational Excellence Relies on Improved Processes Bill Gates, CEO of Microsoft, says A rule of thumb is that a lousy process will consume ten times as many hours as the work itself requires. A good process will eliminate the wasted time and technology will speed up the remaining real work.
Implementing EHR created a unique opportunity to redesign workflow processes to achieve operational excellence! Source: 1999, Business @ The S peed of Thought Workflow Runs your Practice Not Software EHR involves redesign of Information Workflows for Collection
Opportunity for largest and immediate gains in process improvement & staffing efficiencies Management Opportunity for maintaining current gains and achieving new gains Information Collection Digital Technology Improves availability of information Eliminates mini-charts & filing lag time
Eliminates issue of chart availability at point of care Permits operational efficiencies with building block approach Eliminates document prep & scan FTE costs Saves costs on chart supplies, paper & toner Information Collection Electronic Workflows Transitional Workflow Conversion of paper & chart centric
processes to electronic New Workflow Interfaces Digital Faxing Secure File Transfer Protocol Direct entry into EMR Scanned entry of loose reports Transition Information Collection Chart Conversion Reduce your charts to lowest level possible
retention statutes; current with purges & shredding Analyze chart activity to decide what to convert Future scheduled appointments, Activity in past 1- 3 years, Minors with no activity Consider storage for retention period of inactive charts unless revenue opportunities in storage space Indexing High Labor Costs Analyze labor costs of various historical indexing strategies and present to physicians -20% vs 100%
Transition Information Collection Chart Conversion Internal or Outsourced Scanning Cost of scanning equipment needed to scan documents & non-standard chart items Time frame for conversion process usually driven by EMR implementation strategy Volume of charts and activity of charts Work space adequate for document prep, scanning, indexing staff
Additional staff needed to handle in house conversion while still supporting old process Transition Information Collection Chart Conversion - Staffing Transition Information Collection Chart Conversion Outsourced Chart Conversion Compare in house costs to vendor quotes. Add costs of: partial indexing, boxes, pickup, shredding and stat
requests Add internal costs of completing indexing, developing chart management reports and importing of converted electronic files Contract should cover image quality, turn around time, % of records QA, sample tracking reports and successful test of electronic file delivery Transition Information Collection Chart Conversion Begin scanning charts with appointment activity
90+ days in advance of users on EMR Require users to view scanned documents on echart as soon as possible for operational gains Turn on Document & Lab Interfaces, Digital Faxing and FTP STOP creating new charts or pulling scanned charts STOP filing loose paper in charts Rededicate filing & chart pull/refile FTEs to new processes Transition Information Collection
Chart Conversion Set up a QA process so you can shred charts within 30 days of scanning If providers require paper, print it from the echart Add just enough temporary staff to continue current chart pulls. Have temps work late & early hours Track productivity to insure your reach your conversion targets monthly
New Information Collection Interfaces Eliminate duplicate entry into multiple information systems registration, scheduling, providers, ICD9 & CPT4 codes Provide discrete data Lab Information System Link processes across information systems LIS order & results, PACS orders & results, charges Cost effectiveness of interface Data synchronization and timeliness of data
delivery more important consideration than cost New Information Collection Digital Faxing efax phone numbers deliver documents directly to each providers sub folder in the Fax Check folder Documents are reviewed online and
moved to Fax File for efiling or to Fax Sign for efiling and tasking to provider Information Collection New Secure FTP New Information Collection Direct Entry
Electronic Forms Benefits Pre-Cert & Coumadin Tracking New Information Collection Direct Entry - Nursing Convert nursing processes to new workflows well in advance of provider Problem & medication entry with appropriate status of active, D/C, resolved, history of Order entry of diagnostic tests Build enotes that become a central portal for all EMR
data & functions problems, meds, vital signs, lab results, orders Print enote for provider but also task to review electronically New Information Collection Direct Entry - Nursing NURSES must EXCEL in EMR Nursing is the key to EMR productivity for the provider Nursing collects the building block data
for provider documentation problems, medications, vital signs Redesign your nursing processes for triage and office visits New Information Collection Direct Entry - Nursing Triage Encounters Tasked to Provider New Information Collection Direct Entry - Nursing
Records Problems during Office Visit Building Block New Information Collection Direct Entry - Nursing Records Medications during Office Visit Building Block New Information Collection
Direct Entry - Nursing Record Vital Signs during Office Visit Building Block New Information Collection Direct Entry - Nursing Cite information to Note and add Reason for Visit & Carbon Copy 60-80% of Office Visit Documentation is complete
New Information Collection Direct Entry - Provider Make sure all nursing building block processes are working smoothly Combine nursing documentation into a note with provider documentation Nurse captures 60-80% of the documentation for the office visit Provider portion of new process should require about the same time as dictation
New Information Collection Direct Entry - Provider Completes Physical Exam New Information Collection Direct Entry - Provider Assesses Diagnosis Code
New Information Collection Direct Entry - Provider Provider or nurse enters orders New Information Collection Direct Entry - Provider Provider uses building blocks of nursing documentation - may add Plan, signs enote Completed
New Information Collection Direct Entry - Provider Provider records or Nurse records prescription request and tasks provider to authorize New Information Collection Direct Entry - Orders Eliminates Misinterpretation of handwritten orders Need for manual tracking
Duplicate entry if interfaced Improves Workflow and timeliness of test resulting Strengthens documentation Automates Charge entry if order set to charge New Information Collection Direct Entry - Charges Eliminates Redundant entry of data
Missed charges, keying errors or legibility issues Non-payment of uncovered services Improves Accuracy of coding Claims denial rate for certain denial types Revenue cycle no lag of charge entry New Information Collection FTE Impact
Impact on Scan & Index FTEs of Strategies to reduce paper documents New Information Collection FTE Impact Medical Records Eliminated 7.5 FTEs in Medical Records 4 FTEs chart pull & re-file eliminated; 1 FTE moved to Index Moved 1 FTE Release of Information to Scan & Index 3.5 FTEs filing loose reports eliminated
Transcription Eliminated all 7 FTEs internal Transcriptionists Any remaining transcription is outsourced Will always have some transcription Outsourced transcription cost reduced 60-95% based on specialty New Information Collection FTE Impact March 2005 November 2006 Eliminated 14.5 FTEs
Added 10.5 new providers Information Management Direct Entry - Building Blocks Recorded once for many uses documentation, medical decision making & data based analysis Problems Findings Medications Vital Signs Lab Results
Information Management Prescribing Eligibility and benefits checking inform provider of formularies and preferred medications Eliminates call backs or non-compliance due to cost Drug interactions Eliminates call backs or acute events Facility specific history of prescribed medications
Tracks patient compliance with filling script Eliminates drug seekers Outcome analysis when linked to problem lists, tests and results Information Management Orders
Feeds interfaces for LIS and PACs Allows results to auto complete orders Tracking of past due diagnostic test results When linked to charge, eliminates rekeying of charge Forces diagnosis assignment at time of order and CPT accuracy Tracking of services ordered and performing location for business analysis Information Management
Orders & Results linked to PACS Information Management Charges Provides a link to diagnosis that is assessed for office visit, diagnostic orders and surgeries Simplifies coding audits Simplifies financial audits Audit trail tracks all changes up to submission of charge
Information Management Charges Pay for Performance & Physician Voluntary Performance Reporting Measures are age, sex, diagnosis and procedure specific Build additional
questions that prompt for Category II codes to report Add print screen of addtiional questions Information Management Hospital & Surgery Hospital Census list received by interface daily Use elists as check and balance for charge entry of IP, OP, Consults, ER Visits
Use elists for discharge follow up calls Use elists to track patients scheduled for surgery with outstanding paper work Pending test results Pending orders Information Management Chart Structure Good structure & views take advantage
of computer speed in retrieving & grouping records Increased Productivity for providers Information Management Release of Information
Eliminate duplicate handling to tab documents and copy Eliminate copier & paper costs with efaxing Eliminate 90% of postage costs with efaxing Documents available same day to release if using enotes or 72 hours if transcribed
Tasking logs the receipt of an authorization request eLetters for prebills to insurance company or attorney Release template provides audit trail of documents released Automatically part of the chart Information Management Tasking Specific tasks allow for routing and follow up of tasks by views Create tasks for key actions in workflows
Use specific task such as Surgery Charging or Precert vs. generic task for Insurance/Billing Create views of tasks that allow staff & providers to manage their tasks Information Management Tasking Task Views - Staff Charges are submitted for every encounter Edited/Adjusted charges are resolved Pending orders are scheduled
Past due orders are followed up Precerts are current with authorizations Triage is current with call backs 1yr-5yr follow ups & preventive health services are current Information Management Tasking Task Views Providers Prescription requests & refills Documentation creation & signoff
Review of test results & verification Review of external documents Task Views Managers All of these and more! Information Management Correspondence
Patient Result Letters Pre-Admit H&Ps Patient DKA letters Patient Discharge letters Referring Provider letters Letters to Insurance Companies
Return to Work notes Information Management Processes Management oriented training in your EHR is a must (i.e. EMR, PACS, PMS) Work one-on-one with clinical managers to observe how they use task views, key reports and tools Set the paradigm that technology is integral to processes they supervise so
literacy is a job requirement Information Management Processes Establish physician agreed upon minimums that all providers, nursing or technical staff must do in EMR
Prescribing with meds linked to problems Enter problems and resolve Assess diagnosis codes eNote for nursing & provider documentation Orders entered & tracked electronically Charges for E&M codes, clinical supplies & services Information Management
Processes Schedule Quality Follow Ups Are standards being met? Document what you find and report it to the organization Information Management Processes
Information Management Processes Information Management Processes Organization must agree what steps to take when a provider refuses to follow electronic standards Require clinical staff to input for provider. May increase his/her staffing level and direct expense
Set paper handling costs at punitive levels for pieces of paper that should have been done electronically Address as a peer review issue as non-compliance affects entire organization Achieving Operational Excellence EHR Goal Met? Ratio of Support Staff to Providers has declined by .35 FTEs since March 2005 Current Ratio of 4.05 Support Staff per Provider is in line with MGMA Median of
4.00 Achieving Operational Excellence EHR Goal Met? MGMA Specialty Practice Median is 4.46 FTEs per 10,000 RVUs Based on Total RVUS, PS has 2.90 FTEs per 10,000 RVUs PS ranks above the 75th Percentile for Productivity
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