Presentation to Pharm EHR Summit, Philadelphia PA, 4/6/2011

1. Day in the Life of a Primary Care Physician Presented by Dr. David Voran, M.D. April 6, 2011 Heartland Clinic

2. 2 Heartland Health

3. 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 CONFIDENTIAL 3

4. 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? 4

5. 5 Single EMR Ambulatory Schedule Inpatient Patient List

6. One Place for all Visits 6

7. Integrated HIE 7

8. 8 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

9. 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

10. 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 10

11. 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 11 Templates provide structure and consistency distribute work to even the patients

12. 12 Message Center All communication in one location Incoming Paper converted to digital documents at the door Reduced workflow variability Can now manage incoming information

13. 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? CONFIDENTIAL 13 25 - 50 decisions each visit 625 - 2,500 a day

14. 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 14

15. Real Decision Support 15

16. 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 16

17. 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 17

18. 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” 18

19. At the end of the day CONFIDENTIAL