How to Stop Losing Money Using Your EMR

John Bachman MD

Saunders Professor of Primary Care

Mayo Foundation

Bachman.john@mayo.edu

You are at the office

• A partner’s patient who has hypertension comes to see you because in the last ten days she has noted that her blood pressure is elevated from its baseline.

• Meds Lisinopril 20 mg daily

• BP 152/93

It collects for appraisal a large and comprehensive body of information

about the patient’s medical history at no expenditure of the physician’s time;

it facilitates interview by making available

to the physician a preliminary survey of the patient’s total medical problems; its data being systematically arranged,

are easier to review than those of conventional medical histories,

and, by calling attention to the patient’s symptoms

and significant items of past history,

it assures that their investigation will not be overlooked because

the physician lacked time to elicit them

1949-1980 “An era of Questionnaires”

• Answer questions in form of paper and physician got paper back

• Lahey Clinic Duke Medical Center Kaiser

• Clinicians would write on output

• Patients complete at their own pace

• Patients can do things at home

• Patients are prompts to remember things

• The forms are inexpensive

• More data is retrieved

• Provides an outline

Advantages

Disadvantages

• Patients do not complete forms

• Forms are hard to change

• Forms do not clarify symptoms

• Prime MD-3 minutes too long

• Mayo 1971 study

• Forms not personalized

• Too many forms that you need

General

• Mayo Clinic-PPI 13 page form 216 questions, 25 spaces

• ACOG on line 90 questions

• How many are enough?

Review of AFP in just one year

• 44 questionnaires (2 an issue)

• 4-37 questions

• CAGE-alcoholism

• Check list to Assessment areas for Maintaining Healthy Geriatric Patients

• Depression scales

• Smoking Scales

• Lead

Patient Computer Dialogue

• Mayo Proceedings in January 2003

• Solves input problem into computers

• Powerful Tool for Quality

• Pilot: You want passengers to use electronic tickets

Recognizing Depression

0

1

2

3

4

5

6

7

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

26,671 Patient visits

%

Implementation of Screening

8

20.1

2

0

1

2

3

4

5

6

7

8

Min

ute

s

Traditional

S

O

A

P

E

Time of a Routine Office Visit

Subj. Obj.

Plan

Pat Ed

3 2 0.13

20

1

2

3

4

5

6

7

8

Min

ute

s

Software

S

O

A

P

E

Future Time of a Routine Office Visit

Subj. Plan

Pt. Ed Obj.

Complete Physical Exam 35

7

0.1

5

8 7

0.1

1517

0

5

10

15

20

25

30

35

Minutes

OLD NEW

S

O

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P

E

Subj

Obj Plan

Subj

Obj

Plan

Extra Time

Going to the Web 2005-2012

• Primetime “Instant Medical History” went to the web beside computers

• Published study of over 2500 online visits at Mayo in 2010 at Mayo Proceedings

• Integration of patient to the EMR (Sage)

How many of you have a computer do a history before seeing the

patient?

2 Competitors

Doctors Good At

• Get them the information they can put it together

Companies

• Primetime Practice “Instant Medical History”

• Engine for almost all EMRs

• Competitors just do not last

• EMRs

• Incentives are to sell product

• Not necessarily add ons

How does it work?

OUTPUT IS GIVEN TO YOU

• Given to you on paper

• Given to you in electronic form like into Word

• Directly into an EMR

ADVANTAGES

Collects more data then a clinician and organizes it into a readable form

Patient is better organized Patients can do this

Patient collects information that the clinician misses

• 40% of time provided useful information not typically elicited

• Essential Questions missed

• Pilot’s Checklist

How dangerous is health care?

Number of encounters per death

De

ath

s p

er

ye

ar

REGULATED DANGEROUS (>1/1000)

ULTRA-SAFE (<1/100K)

Mountain Climbing

Bungee Jumping

Driving

Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Note: both dimensions are logarithmic scales

10 10,000 100,000 1,000,000 10,000,000

10

100

1,000

10,000

Health Care

Socially Sensitive

Highly Adaptable

SARS

Others

• Patient controls interview-length of time

• Doctor only deals with positives

• Research

• Multimedia

• High patient acceptance

• Scales

Scales

• Zung Depression

• Rahe Stress Scale

• Urology Scales

• Wast

• Conners

• Anxiety

• Pain impairment

• Patient Education Needs

Tough Diagnosis

Jane Doe

Chief Complaint Sore throat

VS stable

Sore throat 3 days duration

Lets look at history

80/20 Rule

20% of your questions get you 80% of the content

Negatives are time intensive

Analogy Mining for Diamonds!

Mining-Topsoil sand it is easy Open ended questions

Listening 2 minutes

What are the results of

All this labor

It is like Mining Yes/No questioning-tailings

You can use a machine to

Do the hard time consuming

Work

You are in control

You will trust the work done

Check out a few things

Benefits of Patient-Delivered Medical History Data

• See more patients each day

• Reduce dictation and data entry time

• Cut transcription costs in half

• Populate EHR data fields automatically

• Support appropriate billing levels

• Enhance patient communication and satisfaction

• If over Web, option to enable triage: assess urgency, lab/X-ray in advance of encounter, schedule for appropriate amount of time, recommend self-care, etc.

• Patients are most incented and cheapest resource

Several Studies

• Acceptance has been documented in ethnic18 diverse groups, rural practices19, in prenatal visits20, patients seeking a urologist help21, adolescents22, sports examinations23, and well child visits24. Reliability has been assessed between personal interviews for gynecologic patients25, preoperative patients26, and general practice27-29.

E mail consultation

I had surgery on June 11th, things went pretty well as far as the surgery went. I did feel pretty awfull for the first 2 weeks and the day I left the hospital my incision broke open---I had to pack it for 3 weeks then it was restitched and healed well.

I have to admit, the first couple of weeks I was really beginning to wonder if I had done the right thing but my mind is slowly changing. It is interesting to feel myself slowly turn my priorities away from eating. It is consistently amazing to realize how much focus there is on food, in society and in my life specifically. Jim and I always have a ton of company, from friends to family and you know, company centers around food!!

It is an amazing feeling to be full so quickly---I am still not used to that feeling. I do have my fears about not getting enough protein in, I seem to be having a problem eating meats but I am not to regular foods yet and I am still trying to tell myself to slow down, that is such a hard habit to break! I can't really eat sweets, so far anything too sweet just makes me sick. The adjustment of not drinking while eating is difficult too, but getting easier. The milk drinking is getting easier too.

I am so grateful for the year prior to the surgery---I know it was a long time and it was making me spitting mad at the time but................the group sessions were such and asset to me ---I learned so much, I developed actual habits and restrictions in that year. I had pretty much given up sweets and over eating and I think that has been a springboard for me with my diet now. I went to group every week with few exceptions. I learned so much about myself, others, and eating disorders. I gained an insight that so diet could have ever brought to light. I learned to quit beating myself up, to recognize weaknesses and avoid them. I learned and practiced the importance of activity. The importance of "self-talk" was emphasized and I used it as a tool every day---especially on the bad days. I learned that it was never too late and that being over weight was not a sentence, that it was overcomable but that the road to overcoming was a difficult one and that I needed help in changing from the well trodden path to a new one. I am now acutely aware of emotional eating, but I have no choice in the matter, I simply can not indulge---it is so wonderful. I ended up losing 50 pounds in year that I went to group and I am very glad for that little boost. I had a fantastic group leader, I really lucked out! Not for sure how much more I have lost but I know the total is well over 100 pounds. and yes..............I feel so much better. I can walk up the back of St. Marys Hill without even getting out of breath. I am still riding bike and of course riding horse. In fact, Jim and I are going to Wyoming in September for our 20th anniversary---we are taking our horses out to the Big Horns riding for a week---I am so excited--this has been a lifelong dream for me and now my horse has 100+ less pounds to lug. Let me tell you, riding is so much more of a joy for me, it is like starting all over.

Karie is doing well, still in PA with Jason, they were home for 2 weeks this month and we really like him, he is very sweet and seems totally devoted to Karie---while I don't care for his tatoos,(its a mom thing)he really is great. He had a great time in Minnesota---so maybe the might move back here.

Justin graduated and Jim and I are really empty nesting it---Justin is working in the cities and staying with my niece--he plans to attend RCTC winter quarter.

I am still going to school, I completed my Associates Degree last spring and I only have 22 credits left for my Bachelors.

I do so hope all is well with you, I think of you and your family often.

I want to thank you again Michelle for all of your years of care and concern, but most of all for directing me to this surgery and the journey that brought me to it.

please......................if you have any patients or aquaintences that would like to "chat" with me about my experience, feel free to use my name and give them my number or e-mail address, I am more than happy to share.

Omissions

• What Pharmacy?

• What do you want from me?

• What meds are you on

• Are you allergic to anything?

Primary Care Online

Vendor

• AAFP Approved

• Other users: Mysis and Planned Parenthood

• Online Visits

• Structured Histories

Missing Features

• Spanish

• Place for free text

• Place for meds and allergies

• Place for vitals

• Credit Card

Exchange Data You do not need to be seen

In Reality Why it Could Work

EVIDENCE BASED

PROTOCOLS

Results of

patient

symptom

assessment

c

Which would you want?

• Call

• Nursing time for protocol

• Clinician time to say ok

• Appointment desk

• Nurse faxes prescription

• Verbal instructions

• Time in hours

• Clinic loses money

• Go Online

• Clinician uses set protocol

• Clinician checks prevention

• Instructions that are written

• Prescription faxed automatically

• Time in minutes

• MMSI $35 charge - margin better then an exam

Save Time - Go Online

PCOL

Our First Online Consultation

Patient was also scheduled for a mammogram

Billing

• Accountants high margin 35 dollars

• (Credit Cards) We went through billing

• Went very smoothly

Totals 2 years Largest Study Reported

• Total Registrations- 4282

• 7% primary family member

• Linked to 12%

• Online Consultations- 2531

• Total Consults Billed- 1159

What was the most common online complaint ???

293 different conditions were found

Who did the consultation???

What else did we learn?

71% were women

Youngest 4 days, oldest 86

8-12

Prevent Visits to Office

• 40% of the time saved a visit

• 12.8% Come in

• 16% Protocols

• 11% of the time handled by “on call”

Pictures

• 49 pictures were sent in

• 2% of our practice

• Diaper rash

• Bites

• Contact dermatitis

• Prescription refills

What are the steps

• Vendor

• How will you get input?

• In lobby? In office room?

• From the web

• With EMR

• Portal??

• How to get into your system?

It collects for appraisal a large

and comprehensive body of information

about the patient’s medical history

at no expenditure of the physician’s time;

it facilitates interview by making available

to the physician a preliminary survey

of the patient’s total medical problems;

its data being systematically arranged,

are easier to review than those

of conventional medical histories,

and, by calling attention

to the patient’s symptoms

and significant items of past history,

it assures that their investigation

will not be overlooked because

the physician lacked time to elicit them