Day in the Life of a Primary Care Physician

Presented by Dr. David Voran, M.D.

April 6, 2011Heartland Clinic

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Heartland Health

CONFIDENTIAL3

Heartland Clinic of

Platte City• Free standing clinic• 30 miles away from hospital• Located in suburb of Kansas

City• 3.5 physician FTE• 1,000-1,200 visits/moth• Specialists visit periodically

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Typical Day• 20-24 patient visits

– Mini meetings

• 1-3 procedures– Exam room operative or

diagnostic

• 1 meeting– Staffing, billing, marketing or

professional

• 20-40 asynchronous messages– Nurses, patients colleagues

• 10-15 interruptions– Pharmacies, phone calls, detail

reps

• So how does technology help?

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Single EMR

AmbulatorySchedule

InpatientPatient List

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One Place for all Visits

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Integrated HIE

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Ditched Paper … What’s

Changed?• Paper chart pulls– Eliminated 6-8 hours of work/week/nurse

• Paper chart creation– Chopped 8 hours of clerical work– Saved $32 in material cost per patient

• Point-of-care documentation– Instant access instead of 24-48 hour delay– Saving $20-$30K per physician per year

• Electronic patient access– Eliminated 1-2 hours of phone

conversations per day– Quick access to results

(36 hours)

OVER A DAY A WEEK IN

LABOR SAVED

Point-of-care documentation• Use flexible templates

– Over 500 that can be combined in unlimited ways

• Most work done with patient at provider’s side– Increased transparency– Increased accuracy

• Nurses and Physicians contribute equally– Information carries forward– Eliminates redundant

documentation– Improves quantity and quality of

clinical information– Simplifies work flow and training

• Significantly streamlined workflow

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POC Technology• Push as much

technology to the point of care as possible

• Device is as much for the patient as the provider

• Used as a “window to the world”

• Evolution– notebook > tablet >

standard workstations > expanded large screen workstations > multi-touch wide-screen devices

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Clinic Visit Interview

Standardized “SOAP” • Subjective

– What the patient says

• Objective– What we see and

measure

• Assessment– Diagnosis

• Plan– Prescriptions, orders,

education and follow up

Templates provide structure and

consistency distribute work to even the

patients

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Message Center

• All communication in one location

• Incoming Paper converted to digital documents at the door

• Reduced workflow variability

• Can now manage incoming information

CONFIDENTIAL13

Decisions, Decisions, Decisions

• What to ask?• What to examine?• What to include?

– What to exclude?

• Diagnosis– ~40% uncertainty

• What tests to order?

• What to prescribe?

25 - 50 decisions each visit

625 - 2,500 a day

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Prescribing• ePrescribe – Uses CPOE interface• Part of the documentation process

– Launched from the template– Actions rendered as text in the note

• Usually done at the point of care• Can get outside information

before decisions are made• Can tell which meds are on

formulary before ordering– List of various medications available with

generic components– Shows alternatives

• Dramatically reduces interruptions and increases productive time in the exam room

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Real Decision Support

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Have more to do ….

• Pharmacy selection should be smarter– Many pharmacies identified by number– Lack of maps– Entering zip codes don’t help as nearby zip

codes not listed

• Product status– Dither out products that are no longer available– Indicate relative prices

• Diagnostic orders• Medications

• “Gotcha” discern support– Alert fires AFTER selection– Should act like formulary notification

• Indicator to AVOID selection

• Lack of condition-based prescription recommendations– Make a diagnosis > produce a list of orders and

medications indicated for this diagnosis

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InterruptionsThe biggest bane

• Not easy to recover from many of them• Interruptions are more than lack of timely

decision support• Technology has eliminated more than half

– Patient portal– Electronic messaging

• Many pharmacies still resorting to telephones and faxes– Electronic communications preferred

• Good news is that the industry is slowly catching on

• Long way to go

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About that trip…• Meaningful Use

– Feds missed the boat– Should be building highways instead of buying cars

• Very little benefit from the incentives – Much larger costs are interfacing EMRs to the all of the other systems

involved in the care of a person– However, every little bit helps

• Need to have similar mandates for 3rd party payers• Too much emphasis on documentation

– Concerned about the leaves instead of the trees– Should do more to help us manage the forest

• Conflicting mandates between different regulatory branches– ePrescribe EXCEPT for scheduled medications (What the #I@*?)

• Everyone will still follow the money– Ride the RVU and fee-for-service wave until it crashes– Need some reward for those of us that are voluntarily “falling on our swords”

At the end of the day

CONFIDENTIAL