Going to the InternetExperience of a 50 Person

  • Slides: 107
Download presentation
Going to the Internet-Experience of a 50 Person Group John Bachman MD Jan Engberg

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

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

2 Basic Principles

4 FACTORS THE INCIRCLE ACCESS FOR PATIENTS INCLUDES SATISFACTION SENSE OF BEING CARED DECREASED

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

Margin For Our Mission Paid for Thinking Eliminating Waste

This is not a pilot This is disruptive technology Status Quo People gather data

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

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 •

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

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

Registrations 1381 Registrations TRAINING TESTING PAUSE EXPANSION Billing

At end of Year 3500 patients

At end of Year 3500 patients

Online Consultations Cumulative Total 517

Online Consultations Cumulative Total 517

Impact on Practice • 126 of VOV would have come in who were employees

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

Of Course there was learning along the way

Implementation of a Patient Portal in a 56 Physician Group Practice Jan Engberg, Ph.

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

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

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

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

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

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

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

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

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

Key Lessons 12/2/2020 25

What Went Right • Patients like the product & want to use it •

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

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

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

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

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

Basics of the Project

We have Instant Medical History

We have Instant Medical History

Patient was also scheduled for a mammogram-20% of the time

Patient was also scheduled for a mammogram-20% of the time

Hypertension

Hypertension

Protocols-90 since Nov 1

Protocols-90 since Nov 1

Results of symptom assessment algorithms

Results of symptom assessment algorithms

Results of patient symptom assessment

Results of patient symptom assessment

Prescription Refills • Issue that was not expected

Prescription Refills • Issue that was not expected

Errors

Errors

Abbreviations

Abbreviations

Theory

Theory

Where we are going • • Complaint list Spanish version Mayoize it DIAMOND PROJECT

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

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

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 •

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

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

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,

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

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

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

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

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

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

FORMS for DIAMOND • Patient demographics • PHQ-9

Output

Output

FORMS for DIAMOND • • • Patient demographics PHQ-9 Audit- 10 questions (alcohol use

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 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

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

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? ?

Questions? ?

Messaging • We sent out one message – Patients did great! • • How

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

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

People do online consults for Rx

Prescription Refills • Important to recognize history before refilling is exciting area • We

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

Treatment Plans • Safe!!! • Quick • Oversight group to help

Security • One member of a family-(they go online as the other person) •

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

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 •

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

Communication • Issue is brought up time measured to response is fast • Issues we do not know or are repeated after solved?

DATA

DATA

Mechanical Swiss Watch

Mechanical Swiss Watch

Who do you want sitting on the chair entering information?

Who do you want sitting on the chair entering information?

Leadership of Disruptive Technology-INFPs • INFPs focus deeply on their values, and they devote

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

DOOR TO EXCELLENCE • TWO SENTINELS-Courage Faith • KEYS-Risk Learning

CASES

CASES

Case Heartburn/Depression

Case Heartburn/Depression

Diamond Project-This is where Kurt comes in with your slides • • Project for

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

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

Output

How PCOL does it now

How PCOL does it now

Diamond Project-Possibilities 1. Phq+scales 5 2. Message patients (Depression Pit Stop) 1. Stop phone

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