Going to the InternetExperience of a 50 Person
- Slides: 107
Going to the Internet-Experience of a 50 Person Group John Bachman MD Jan Engberg PHD Kurt Angstman MD Inquiries to bachman. john@mayo. edu
Competition-Primary Care becoming a commodity? • Retail Centers • Recruiting Difficulties • Large clinics are electronic 75% of clinicians in groups over 50 are electronic Small groups are not
2 Basic Principles
4 FACTORS THE INCIRCLE ACCESS FOR PATIENTS INCLUDES SATISFACTION SENSE OF BEING CARED DECREASED COSTS HAPPIER PROVIDERS IMPROVED QUALITY OF CARE
Margin For Our Mission Paid for Thinking Eliminating Waste
This is not a pilot This is disruptive technology Status Quo People gather data People do medicine on the phone or office Disruption Computer gathers data People do medicine online Messaging Standardized Medicine
How to be successful Sustaining technologies Listen to customer Give people what they want Seek higher margins Target larger markets Culture of control, oversight, and planning Disruptive Technologies Separate from the organization Creativity is destructive Find markets not served well and ignored Revise as you move Uncertainty Show rising profit/value
Our Department • Our Online Presence was not coming in a timely way • Two initiatives – Retail Clinics to compete with 3 that had been established in our town – Primary Care Online-Online Services
Selecting a Vendor • MEDFUSION – Approved by AAFP – No interfaces – Instant Medical History was a component – Success stories elsewhere – Planned Parenthood Mysis – Contract 6 months
Registrations 1381 Registrations TRAINING TESTING PAUSE EXPANSION Billing
At end of Year 3500 patients
Online Consultations Cumulative Total 517
Impact on Practice • 126 of VOV would have come in who were employees • 36 Dependents of employees would have come in
Of Course there was learning along the way
Implementation of a Patient Portal in a 56 Physician Group Practice Jan Engberg, Ph. D Systems & Procedures Mayo Clinic 12/2/2020 16
Timeline: Vendor May 15 Contract signed May 31 June 29 July 16 2007 8 week implementation Kick off Set-up done Training Implementation done
Timeline: Actual May 15 Contract signed Nov 1 Dec 3 Feb May June July Sep 4 2008 2007 7 month Implementation Kick off Set-up Training Set-up done Re-done Training done Today “Soft” Start Continuing Implementation
Timeline: Vendor vs. Actual May 15 Contract signed May 31 Nov 1 June Dec 29 Feb 3 July. May 16 June July 2007 8 week implementation 2007 7 month Implementation Kick off Sep 4 Set-up Training Implementation done Training done Set-up Training “Soft” done Re-done Start done Today 2008 Continuing Implementation
Why the Difference? • Vendor template plan unrealistic for large practice – High level tasks were good but lacked detail – Timeline unrealistic for large practice with large support staff – Summer People were gone/organizing teams • Small implementation team at Mayo – Inexperience of analyst led to underestimation of time & effort – Initial planning at Mayo too focused on product & not processes • Standard vendor training did not fit Mayo needs – Vendor screens did not match Mayo screens – Login confusing because not integrated with Mayo logins 12/2/2020 20
What Drove Extended Timeline? • Plan extended to 7 months pre-implementation – – Medfusion needed to be customized for Mayo Product set-up cumbersome & time consuming New analyst assigned in August 2007 Functionality not as robust as first anticipated • Key areas for improvement: – Product needed to be overhauled & updated with Mayo enhancements/fixes in October – Some functions still not acceptable • Prescribing in particular
Support & Resource Issues • Project was approved with minimal resources – No internal IT support for product, users or patients – No interfaces into Mayo’s electronic medical record requires manual transcription – No operational owner other than a very busy physician • Three Year Pilot lacked governance structure 12/2/2020 22
Marketing to our Users • “Soft” start was through providers telling patients about PCOL – Direct contact with provider successful in recruiting patient users • Lack of control over portal entry point causes patient confusion • Wider marketing planned for near future • Patient registration goals have been met 12/2/2020 23
Marketing to Our Providers & Staff • Training done too early – “Soft” start meant patients were not registered & using when training occurred • Lack of initial buy-in led to misperceptions about PCOL adding to daily work load • Training not effective until significant numbers of patients sent Online Office Visit requests to their providers – This was best marketing of all! 12/2/2020 24
Key Lessons 12/2/2020 25
What Went Right • Patients like the product & want to use it • Committee approvals validated pilot • Weekly meetings keep issues in front of vendor • Ongoing meetings of implementation team helps to deal with issues as they arise 12/2/2020 26
What Went Right • Small team of “local” support dedicated to success of pilot – Site generator expert – Transcriptionist for transfer to Mayo EMR – Physician proponent – Systems analyst • Department leadership support critical to success of implementation • Cross department implementation team worked extremely well together 12/2/2020 27
What Was an Issue • Reliance on vendor timeline unrealistic – Vendor experience mainly with smaller groups – Larger groups did not do Virtual Office Visits – Vendor training did not meet Mayo needs • Vendor Quality Control needs to be strengthened • Disruptive technology caused problems to established projects 12/2/2020 28
Recommendations • Have strong support from Department Chair & Institution Leaders – Helps when dealing with resistance – Keeps the message & direction clear • Details with vendors are important – You cannot talk to them enough about issues & needed enhancements – Ask for rigorous, detailed testing of “your” screens & customizations 12/2/2020 29
Recommendations • Expect Resistance – It is normal & OK – Have change management plan in place • It will take longer then you think & it will be harder – Set realistic timelines up front – Carefully manage & prioritize scope changes – Identify adequate resources for development, testing, implementation & support
Basics of the Project
We have Instant Medical History
Patient was also scheduled for a mammogram-20% of the time
Hypertension
Protocols-90 since Nov 1
Results of symptom assessment algorithms
Results of patient symptom assessment
Prescription Refills • Issue that was not expected
Errors
Abbreviations
Theory
Where we are going • • Complaint list Spanish version Mayoize it DIAMOND PROJECT
Hooking Your Office Up to the Internet—The Experiences of a 56 FM Group Kurt B Angstman, MD Consultant- Department of Family Medicine Assistant Professor of Family Medicine Medical Director- Mayo Family Clinics Mayo Clinic Rochester
Patient Advisory Group • Patient Portal – Resounding- YES!! • (except Charlie!) – “If airlines and my bank can do this- why can’t my doctor? ? ”
Patient Portals • Patients are excited to use this for: – Prescription refills • Especially “in-house” • Encouraged by the faxing electronically) capability – Virtual visits – Scheduling appointments • After-hours contact • Increased flexibility (sending
Patient Portals • If there is new technology that will improve the provider/patient relationship • Patients will embrace it; BUT…. – Needs to be as good or better than existing policies or systems – Can not detract from the provider/patient relationship- it needs to improve this – Will need duplicate systems as we work with patients in both ehealth and conventional methods
New Processes • In designing the processes, we often fall back into old routines of development. • With Internet-based patient connectivity, as we design new systems and treatment plans-we should investigate new processes for management of these.
DIAMOND • Depression Improvement Across Minnesota, Offering a New Direction • Collaboration of ICSI, multiple clinical sites and several payors in Minnesota
DIAMOND • Based on IMPACT study – The use of a care manager role to help the PCP and psychiatrist manage these patients – Improved quality of care – Improved patient outcomes – Lowered total cost of care • Not all that surprising- as care managers have been shown to be helpful for other chronic diseases
Cost savings using IMPACT model over time Unutzer et al. Long-term Cost Effects of Collaborative Care for Late. Life Depression, Am J Managed Care Vol 14(2) p 95 -100 Feb 2008.
Care Manager • Involved with patients who have a specific diagnosis – Depression or dysthymia – PHQ-9 score > 10 – Contact with the patient (phone, electronic, face to face) – Weekly chart review with psychiatrist • Patients triaged into Red/Yellow/Green
Practice details • • Weekly or more often contact by the nurse. Repetitive completion of all multiple forms. All psychometric scales are “self-reported”. Current nursing flow involves either face-to-face visits or phone conversation. – the diamond nurses are finding it difficult to contact the patient’s by phone during routine working hours.
Patient portal • To utilize this in the Diamond project – Created web-based copies of the forms – Create a scheduling system for the RN to contact patient – Enable the patient to complete the required testing at the time of their convenience. – Schedule either a virtual visit for the nurse to evaluate the information with the patient or to schedule a time for phone conversation.
FORMS for DIAMOND • Patient demographics • PHQ-9
Output
FORMS for DIAMOND • • • Patient demographics PHQ-9 Audit- 10 questions (alcohol use disorders) Gad-7 (anxiety) WAST- 8 questions (abuse) MDQ- 15 questions (bipoloar screen)
DIAMOND Opt out • One of the frequent patient reasons for opting out of DIAMOND / PSYCH Care Managers – Even though we tell them that this is costeffective improvement in their care • TOO Time consuming
PROCESS CHANGE • WORK TOWARD – Interactive history – Patient supplied documentation – Web based connectivity • Flexibility • Improved connectivity • Follow up based on patient need- Not just the schedule
Comparison of EHR Data-Entry Workflows • Physician 1 2 6 • Nurse 1 2 12 • Patient 12 10 12 1 2 3 12 4 4 1 = $42 1 = $37 1 = $29 • Patient at Home 2 = $9 Patients are a fast and free way to gather data.
Questions? ?
Messaging • We sent out one message – Patients did great! • • How to inform patients of information Standards Sub groups Birthdays
Prescription • An area of significant deficiency • Worked with our team from pharmacy • The process of doing it online requires you to be on the ball • Pharmacy and Therapeutics Committee met • Upgrade in Feb did not help us at all • Move Prescriptions to do an online consultation
People do online consults for Rx
Prescription Refills • Important to recognize history before refilling is exciting area • We stopped having users do prescriptions in Medfusion-Black Berry – NE was not up to snuff – Enterprise Orders? – Medfusion solution or solutions? – Fax number
Treatment Plans • Safe!!! • Quick • Oversight group to help
Security • One member of a family-(they go online as the other person) • Directed by people – New patient – Phone
Patient Access Problems • 90% of problems are related to being on the wrong site 2 -3/week • Patients stop too early in online consultation • Amazing how well we are doing
Expansion • Psychiatry • Internal Medicine • Jacksonville Scottsdale FP • Not ready • Beyond the pilot • Site generator is poor
Communication • Issue is brought up time measured to response is fast • Issues we do not know or are repeated after solved?
DATA
Mechanical Swiss Watch
Who do you want sitting on the chair entering information?
Leadership of Disruptive Technology-INFPs • INFPs focus deeply on their values, and they devote their lives to pursuing the ideal. They often draw people together around a common purpose and work to find a place for each person within the group. They are creative, and they seek new ideas and possibilities. They quietly push for what is important to them, and they rarely give up. While they have a gentleness about them and a delightful sense of humor, they may be somewhat difficult to get to know and may be overlooked by others. They are at their best making their world more in line with their internal vision of perfection.
DOOR TO EXCELLENCE • TWO SENTINELS-Courage Faith • KEYS-Risk Learning
CASES
Case Heartburn/Depression
Diamond Project-This is where Kurt comes in with your slides • • Project for Depression PHQ-9 to monitor depression Record information Hired people to be case managers
Interesting Information 1. Most of cost in depression is recognizing 2. Unaware that screening tests used to monitor have been successful 3. Labor intensive 4. Joe Furst asked me if PHQ-9 can be done online
Output
How PCOL does it now
Diamond Project-Possibilities 1. Phq+scales 5 2. Message patients (Depression Pit Stop) 1. Stop phone call tag 2. Stop dealing with people who are ok 3. 4. 5. 6. Screen all vovs Present to their group How to get it into our chart What happens in three years-Cerner
- Tic tac toe going high going low going criss cross lollipop
- Reflexive pronouns
- 2 person singular
- Speaking in 1st person
- Person person = new person()
- If you are going through hell, keep going
- When a person is logrolled the person is
- Person a and person b
- Person-job fit and person-organization fit
- Language features of a biography
- A person swings on a swing when the person sits still
- Conflict in fahrenheit 451
- A person's trash is another person's treasure
- First person vs second person
- Hi hi what are you doing
- Private string
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- When moving a person in segments what do you move first
- First person vs third person writing
- Thế nào là sự mỏi cơ
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- Hát kết hợp bộ gõ cơ thể
- Dot
- Corinna's going a-maying
- "momentum wall system"
- Mrs wild going wild
- We aren't/we're not going to miss the train
- James is going through puberty quite early
- Team spirit becomes team infatuation
- Will structure
- A struggle between a character and an outside force
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- Hughie erskine was a very good looking
- Going for goals
- Which car is going faster a or b
- Going into hiding gif
- General zaroff first comes to the island after
- Going to 6
- Interogative form
- Worksheet on direct and indirect speech for class 8
- If you are going to write
- Accounting language of business
- Will going to quiz
- Going concern assumption
- Going beyond the information given
- Hemp industry rizal
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- Wherever you lead i will follow
- From the rising of the sun till it's going down
- Tenses be
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- The going concern assumption assumes that the business
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- Going into business for yourself
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- Planlı gelecek zaman
- 7 accounting principles