PHYSICIAN PRACTICE 2.0 TOOLS FOR SUCCESS IN HOSPITAL-OWNED PRACTICES Rosemarie Nelson MGMA Healthcare Consulting Group April 10, 2013

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AGENDA Technology deployment impact on day-to-day

operations The right benchmarks establish practice

performance standards Quality reporting The physician champion Managing up

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EFFECT OF IT EXPENDITURES ON PROFITABILITY

Total medical revenue after operating cost per FTE physician.

MGMA Cost Survey Data April 2010

Total IT expense/FTE physician

<$10,000 $10,001-$20,000

$20,001-$30,000

>$30,001

Multispecialty $230,968 $313,900 $320,854 $358,991 Cardiology $574,732 $483,426 $587,402 $648,955 Ob/Gyn $324,286 $407,244 $417,891 * Orthopedic Surgery $584,433 $600,135 $598,869 $675,938

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HOW FAST CAN YOU TYPE? (ACCURATELY!)

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www.pcshorthand.com Not just for your providers Never type your name again! Better than auto text – it branches How about the nursing staff? ~ $30 for one year subscription

Try it for $5.95! Multi-users: $139.95/year for 5 users

ONLINE SCHEDULING Eppointments (www.eppointments.com)

Online patient services: forms, email messages, confirm appts

Internal patient tracking www.needmydoctor.com – web-based communication

channel Employee scheduling

www.abs-usa.com $20/month - $33/month

25-50 employees www.asgardsystems.com

$500 - $800 30-50 employees

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KIOSK CHECK-IN AND MORE

www.otechgroupllc.com www.ncr.com www.clearwaveinc.com www.seepoint.com www.phreesia.com

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KIOSK CHECK-IN COST-BENEFIT Range of costs: free to …

$2,000-$5,000 per tablet/kiosk $3,000-$5,000 installation, training, setup $2,000-$10,000 integration services $250-$400 monthly fee (updates insurance info)

Benefits beyond reduced paper: Reduced denials Better performers: 3% of claims denied on first submission

(others 5%) $11,520 costs recovered annually

30 claims/day, 4 days/wk, 48 wks/year, $40/claim to rework

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FREE ELECTRONIC FORMS

www.memag.com www.physicianspractice.com www.toolkit.cch.com

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TELE – SERVICES: NO MORE LETTERS/CARDS MedVoice PhoneTree TeleVox

43.79% of Better Performing Practices use automated telephone reminder call system to limit no-shows and last-minute appointment cancellations v. 28.33% of other practices*

*Performance and Practices of Successful Medical Groups 2011

Report Based on 2010 Data. 9

LAB RESULT INTERPRETATION DELIVERY

Patient goes to retrieve the message • Over the Internet • Over the telephone

Patient sees or hears

Physician assigns lab result to patient utilizing the phone or Internet

Patient is given a card with: • Your web site address • A toll free number • A date to retrieve the interpretation

Patient visits physician

Patient has specimen taken

The Physician’s Interpretation of the Lab Result

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GET WILD AND CRAZY

Informed consent Webcast for patients v. surgeon’s time

Online scheduling – pick date/time Flu shot clinic

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QR - - QUICK RESPONSE CODES Scan the QR (like bar codes) using smartphone

camera to access data that links to web page Add QR code to patient statements that link to

your payment page online Free QR code generation:

Qrstuff.com Zxing.appspot.com/generator Quikqr.com Create the code, print it, and it’s ready!

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Deliver content Get nurses off the phones with FAQs www.selfcarenet.com Physician-authored, peer-reviewed content for

patients Description of symptom, injury or condition Guidance on when to call doctor (right away, within 24

hours, during office hours) Advice for self-care or care at home

PATIENT PORTAL: BUSINESS OF MEDICINE IS COMMUNICATIONS

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FREE PATIENT HELP/EDUCATION LINKS • Insert library in frame or have banner w/ link

– www.patienteducationcenter.org – www.vivacare.com

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MEDICAL FORMS - MANY LANGUAGES

www.healthinfotranslations.com

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AUTOMATE CHARGE CAPTURE Scan encounter forms 30 percent to 70 percent time savings

Use the Internet Reduce cycle time for hospital-based services

www.whiteplume.com www.medaptus.com www.patientkeeper.com Best practices for charge posting lag time 24 hours for office service charges 48 hours for hospital service charges

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SMART PHONE CHARGE CAPTURE

Outside the office - nursing facilities, hospitals, surgi centers, etc.

MDEverywhere MDAnywhere PocketBilling, ProcLog and more:

www.pdamd.com

•Register online •Small hardware device plugs into iPhone and reads credit cards Download cost: Free

Squareup.com

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NURSING EFFICIENCIES - HANDHELDS Skyscape Taber’s Medical Dictiona Davis’ Drug Guide for Nurses RN FastFacts ABCs of Interpretive Laboratory Data

FEWER MANUALS: WWW.STATCODER.COM

E&M Coder ICD9 Coder CPT Coder Growth – BP GRACE –ACS Risk Cardiac Clearance and more…

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NURSE MOBILITY AND PRODUCTIVITY Wireless headsets PhonePad

www.cybercom-software.com NotifyMD.com

DEPOSIT AND CREDIT/DEBIT CARD PROCESSING Rates ~ 2% plus transaction fees ( 20¢)

Online debit less than half that www.bankofamerica.com

Remote deposits: www.iStreamImaging.com Stop driving to the bank!

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PASSWORDS MADE EASY RoboForm www.roboform.com Saves user name and PW Heavy encryption Master password – reboot, sleep mode,

inactive time Creates passwords – random character

generator Inserts a toolbar into your browser $29.95 (free version for up to 10

passwords)

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LAPTOP SECURITY

nTracker (www.synet.biz) – ISP change TheftGuard (www.softex.com) – remote recover and

destroy data Computrace LoJack software – monitoring center and

recovery team can remotely delete PHI when stolen computer logs on Internet

Caveo Anti-Theft PC Card – issues audible signals if PC moved beyond distance specified when on or off

SprintSecure Laptop Guardian – mobile broadband connection card as ignition key (must insert to use)

Encrypt entire hard drive with SafeGuard Easy (preboot authentication)

Biometric identifiers 24

“ALL OR NOTHING” IS A LOSING PROPOSITION

Accept the incremental benefits. Waiting for the “next upgrade” or the “next

release” delays all benefits realizations. Use of PDF forms on the web is a precursor

to interactive forms – get ready to go interactive!

Transferring 30% of incoming phone calls to web communications is better than 0%.

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MGMA COST SURVEY 2012 REPORT BASED ON 2011 DATA – MULTISPECIALTY GROUPS

Per FTE Physician 25th %tile Median 75th %tile

Months gross FFS charges in AR

1.00 1.23 1.51

% of AR > 120 days 9.32% 14.66% 22.86% Support Staff FTE 3.25 4.41 5.68 Total RVUs 10,806 14,003 17,687 Patients 1,155 1,640 2,837 Medical Revenue after Operating Cost

$131,258 $270,348 $386,350

Operating Cost as a % of Medical Revenue

70.84% 63.94% 61.86% 26

QUALITY…WHERE’S THE CONFUSION? E-prescribing PQRS Meaningful Use And…PCMH, ACO…

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MEDICARE ERX INCENTIVE*

Effective Jan. 1, 2012 Part D prescriptions can no

longer be sent to pharmacies by computer generated fax Print, hand to patient or manually fax

*MIPPA: Medicare Improvements for Patients and Providers Act of 2008 28

ESTIMATED E-RX PENALTIES USING MGMA COST SURVEY 2010 REPORT FOR UROLOGY

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Median Net FFS Revenue per FTE

Physician

Median Medicare FFS of Total Medical

Revenue

Median Net Medicare FFS Revenue per FTE Physician

1% Penalty

1.5% Penalty

$930,434 32.00% $297,738.88 $2,977.39 $4,466.08

PQRS – PHYSICIAN QUALITY REPORTING SYSTEM Voluntary

Payment reduction of 1.5% if not participating in 2013 (taken in 2015)

% of total allowed charge from Medicare Part B Physician Fee schedule (during reporting period)

Three applicable measures, 80% of patients How to submit quality data codes (QDC):

On Medicare Part B Claims To a qualified Physician Quality Reporting registry To CMS via a qualified EHR product To a qualified Physician Quality Reporting data

submission vendor 30

GPRO (GROUP PRACTICE REPORTING OPTION)

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Required to report 29 quality measures http://www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html

Required to report through web-based interface Single TIN with 25 or more individual EPs

(identified by NPIs) Must self-nominate

MEANINGFUL USE STAGE 2 - GOOD NEWS

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Extra time! Stage 2 is 2014 Special 3-month reporting period for providers

attesting to Stage 2 in 2014 Ability to use a batch reporting process for MU –

submit attestation info for all EPs in one file Hospital-based specialties can apply for incentive

if can demonstrate that they fund acquisition, implementation, and maintenance of CEHRT (including supporting hardware and interfaces needed for MU) without reimbursement from an eligible hospital and use such CEHRT at hospital in lieu of using hospital’s CEHRT

STAGE OF MU CRITERIA BY PAYMENT YEAR

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First Payment Year

2011 2012 2013 2014 2015 2016 2017

2011 Stage 1 Stage 1 Stage 1

Stage 2 Stage 2 Stage 3 Stage 3

2012 Stage 1 Stage 1

Stage 2 Stage 2 Stage 3 Stage 3

2013 Stage 1

Stage 1 Stage 2 Stage 2 Stage 3

2014 Stage 1 Stage 1 Stage 2 Stage 2 2015 Stage 1 Stage 1 Stage 2 2016 Stage 1 Stage 1 2017 Stage 1 For 2014 only, providers that are beyond the first year of demonstrating meaningful use will have a 3-month quarter reporting period to allow an additional up to 9 months to upgrade certified EHR technology to the 2014 edition.

FAILURE TO BECOME MEANINGFUL USER

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Medicare EPs that demonstrate MU in 2013 will avoid a payment adjustment in 2015.

Medicare provider first attesting in 2014 will avoid the adjustment if attestation is before Oct. 1, 2014.

PCMH Intent

Coordinated/integrated care across all types providers and locations

Care planning process with use of evidence-based medicine Informed by patient’s participation in decisions Enhanced through processes assure access and use of

technology Elements (NCQA Recognition)

Access during office hours Use of data for population management Care management Support for self-care processes Referral tracking and follow-up Implementation of continuous quality improvement steps 35

ENHANCE ACCESS AND CONTINUITY Access during office hours

Same-day appointments (sample policy, procedure, control) Clinical advice by phone Clinical advice by electronic messaging

After-hours access After-hours care After-hours availability of medical record After-hours clinical advice by phone After-hours clinical advice by electronic messaging

Electronic access Continuity Medical home responsibilities Culturally and linguistically appropriate services The practice team (sample job description and Team

Huddles) 36

IDENTIFY AND MANAGE PATIENT POPULATIONS Patient information Clinical data Comprehensive health assessment Use data for population management

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PLAN AND MANAGE CARE Implement evidence-based guidelines Identify high-risk patients Care management Medication management Use electronic prescribing

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PROVIDE SELF-CARE SUPPORT AND COMMUNITY RESOURCES Support self-care process Provide referrals to community resources

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TRACK AND COORDINATE CARE Test tracking and follow-up Referral tracking and follow-up Coordinate with facilities and manage care

transitions

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MEASURE AND IMPROVE PERFORMANCE Measure performance

Preventive care, chronic care, acute care measures Utilization measures affecting healthcare costs Vulnerable populations (disparities of care)

Measure patient/family experience Implement continuous quality improvement Demonstrate continuous quality improvement Report performance Report data externally

Medicare’s eRx, PQRS, EHR incentive programs Use certified EHR technology 41

STATUS QUO If we keep doing what we’ve always done, we’ll keep getting what we always got.

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THE HUMAN FACTOR: BARRIERS TO CHANGE 43

How it’s always been done Provider attitudes and preferences Organizational culture Facility design Reluctance to change due to fear of the unknown Complacency

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ORGANIZATIONAL GOVERNANCE Executing the organization’s strategic plan Data analysis and planning Partnering with physicians to achieve

accountable results (managing up) Developing the practice’s physician champion Mission and culture – achieve performance

expectations

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“Change is inevitable—except from a vending machine.”

-------Robert C. Gallagher

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LEADING THROUGH CHANGE

Change management considerations Is there a compelling reason(s) for change? Are top administrative, physician, and clinical

leadership committed to change?

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SUCCESSFUL STRATEGIES FOR CHANGE MANAGEMENT

A compelling reason is needed. Redesign (change) must address issues people are

battling. For providers, compelling reasons are: Improving their ability to provide care. Improving the quality of patient care.

All stakeholders need to be at the table.

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ASSESS CURRENT ENVIRONMENT

Can champions be identified and developed? Is the culture committed to data and information

sharing? Do employees have the needed skills and tools to

accomplish redesign? Does the organization have the resources to undertake

the redesign process?

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YOUR ORGANIZATIONAL CULTURE The culture of a group is a pattern of shared basic

assumptions that the group learned as it solved problems … that has worked well enough to be considered valid, and therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.

------------------Edgar H Schein

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CHANGE MANAGEMENT…IDEAS TO REALITY

Change management is a learned skill Common barriers to change include:

Vice-like grip on the status quo No perceived need for change Lack of a shared vision Corrosive effect of cynicism and pessimism

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SIGNS OF RESISTANCE Confusion Immediate Criticism Denial Malicious Compliance Sabotage Easy Agreement Deflection (change the subject) Silence In-Your-Face Criticism

Maurer, Rick, Beyond the Wall of Resistance, 2 51

CHANGING CULTURE “You cannot create a new culture. You can immerse

yourself in studying a culture ... Until you understand it. Then you can propose new values, introduce new ways of doing things, and articulate new governing ideas. Over time, these actions will set the stage for new behavior. If people who adopt the new behavior feel that it helps them ... The organizational culture may embody a different set of assumptions, and a different way of looking at things ...”

Edgar Schein, in Senge, Peter, The Dance of Change

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LEADING THROUGH CHANGE Introduce change effectively Build awareness of the need for change

Why change is needed Current performance level Objectives for this particular change The nature of the change

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MANAGING THROUGH THE TRANSITION Develop individual change action plans for each

individual Manage change with the team

As an assessment As a guide for actions

How do I build desire, knowledge and ability

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REINFORCE AND CELEBRATE SUCCESSES

Collect and analyze employee feedback Conduct audits and measure performance Reinforce change with the team through

Accountability systems Root cause analysis and corrective actions Celebrations, recognition and rewards

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LEADERSHIP FOR CHANGE Change is hard work Leadership begins with values Real changes takes real change Leadership is a team sport Expect to be surprised Today competes with tomorrow Better is better Learning from doing Grow people

Sullivan and Harper, Hope is not a Method 56

SUCCESSFUL STRATEGIES FOR CHANGE MANAGEMENT Communication plan Key message easily understood Expect and communicate failures, holdups, etc. as well as

successes Education and training are essential Sustainability requires transformation Inability to go back to the old way is the best approach to

sustainability

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MANAGING CHANGE…LIKE SEARCHING FOR THE WIZARD OF OZ

Hold On: It’s Going to be a Bumpy Ride It is challenging to communicate and train “enough”.

Don’t Be Afraid to Ask Directions Confer with others that have done it.

Pick Up Some Friends Along the Way Outsource and use consultants where possible: don’t do it alone.

Enjoy the Emerald City Parade and Spa Pampering: It’s About to End Don’t let the sales pitches keep you from seeing reality.

Fireballs and Flying Monkeys Are Part of the Deal Have contingency plans for expected problems and a problem evaluation &

resolution process for the unexpected problems. Don’t Discount “Heart” Over Courage and Intelligence: You Need All Three

The human factor in the change management process trumps the technical aspects.

In the End, You will get Home ! People and processes come together and you work things out.

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TRUST YOURSELF. YOU KNOW MORE THAN YOU THINK.

Dr. Benjamin Spock, 1940’s 59