Larry Garber, Medical Director for Informatics at Reliant Medical Group, presented on how the organization has used health information technology to improve quality, efficiency, and safety. Key points include: - Reliant implemented an electronic health record system in 2007 that is now used by all physicians and staff. - The EHR integrates with other technologies like patient portals, health information exchange, clinical decision support, and analytics tools. - These technologies help improve care processes like diabetes and hypertension management, follow-up of abnormal test results, and medication management. - The investments have helped lower Reliant's average annual costs per patient compared to other organizations in Massachusetts.

1. Reliant
Medical Group
Atrius Health
iHT2 Health IT Summit, Boston MA
May 14th, 2014
Larry Garber, M.D.
Medical Director for Informatics
Reliant Medical Group/SAFEHealth

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 Building the foundation for
transformation
 Efficiency improvements
 Quality improvements
 Safety improvements
 Return on investment

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 Medical Director for
Informatics x 16 years
 Principle Investigator
for $3.5M AHRQ and
ONC grants for SAFE
Health and IMPACT HIEs
in Massachusetts
 Chair, MAeHC
 Member ONC HIT Policy
Committee’s HIE
Workgroup and Privacy
& Security Tiger Team,
and MA HIT Council
 Internist at Reliant
(AKA Fallon Clinic) x 28 yrs

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•300+ provider multi-specialty group practice
•30 specialties, including Occ Med & Behav Med
•23 sites in central Massachusetts
•200,000 patients with over 1 Million visits/year
•Not affiliated with any hospitals
•Not-for-profit, member of Atrius Health & ACO
•At financial risk for 80% of our patients
•Winner of HIMSS Davies Award for implementing
HIMSS Stage 7 EHR
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 Electronic Health Record
 Patient Engagement Tools (Personal
Health Record, Home monitoring, etc…)
 Health Information Exchange
 Clinical Decision Support
 Healthcare Analytics and Reporting Tools

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 Completed rollout in 2007
 100% utilization by all physicians and staff
 Includes the MyChart Personal Health Record for
patient engagement

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 Prescriptions – 22 years
 Lab Results – 16 years
 Transcribed Visit and Imaging Notes–15 yrs
 Immunizations, Health Maintenance,
Disease Management – 15 years
 EKGs (MUSE) – 15 years
 Allergies – 10 years
 Future Lab and Visit appointments – 1 year
Over 100 Million Records Preloaded into EHR

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 Patients plug home health monitoring
devices (e.g. BP, weight, sugar, O2, etc…)
into home computer
 Automatically loads into Epic EHR via
Microsoft HealthVault
 Batches readings, but sends critical ones
© 2014 Epic Systems Corporation

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Mckesson &
Patient References
5 Hospitals
and 8 SNFs
CareEverywhere to
Other Sites
Reliant’s EHR &
Data Warehouse
Home Health
Agency
Patients
Ancillaries
(Surescripts,
QS1, Quest Lab,
MUSE EKG,
Infinitt PACs +
Powerscribe)
4 Payers
Health Coach
Disease Management
Registry
Vignette Document
Imaging
to
Community MDs
MA DPH
Immunization Registry
Transcription
and
Dragon
Clinician
References,
Intranet
CCDs
Appt Reminder IVR
Clark
Mailing
Service

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St. Vincent
Hospital
Reliant Medical
Group’s Epic EHR
Outside
Record Icon
in MedHost
Bedboard
blinks
CCD with
SVH MRN
ADT for
Reliant
Patients
CCD with
SVH MRN
30 seconds after ED registration, Reliant’s
CCD is automatically loaded into ED’s EHR

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FCHP
Hospitals
Ref
Lab
PBM
Imaging
Centers
Solo
MD’s
Reliant
Medical
Group

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 FCHP Claims  medication list and fill hx
 FCHP and Fallon Clinic claims/billing:
◦ Immunizations
◦ Health Maintenance Dates (e.g. Mammo,
Colonoscopy, CPE, etc…)
◦ Disease Management Dates (e.g. HA1c, Retinal
Exam, Smoking status, etc…)
◦ Past Medical Hx (filtered for chronic & signif. dxs)
◦ Past Surgical Hx (filtered for significant procedures)
◦ Visit Hx (OV, CPE, Consults, ER, Hospital, SNF, LTC)

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Factor Criteria Points
DxCG Likelihood of Hospitalization Score
(Model 71)
Individual Patient Score >= 0.25
(90th Percentile)
3
Hospital Admissions or ED Visits Three or More in past 12m 3
Behavioral Health (Psychiatric, Substance
Abuse, Dementia)
Active Diagnosis (Enc or Prob List) 2
CHF or COPD or CKD Active Diagnosis (Enc or Prob List) 1
Poly-pharmacy (Exclude topical &
supplies)
14+ active medications on current EPIC
medication list
1
Maximum Score 10
Risk Level Flag Score % Total
Low 0 58%
Medium 1 - 2 26%
High 3 – 7 13%
Very High 8 - 10 2%

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Risk Score Calculated with 2011CY data
Outcome Window = 1st 6 months 2012

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 Have the right person do the work
 Use the right tools
 Re-use data whenever possible

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In order of preference:
1. The computer (last note, history, results,
keyboard macros)
2. The patient (patient portal or forms)
3. The nurse triaging problem on phone
4. The medical assistant that rooms patient
5. The doctor assisted by speech recognition
6. The doctor assisted by transcriptionist
7. The doctor typing
8. A scribe typing

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 Chief Complaint(s)
 Allergies/Medications (including OTC)
 Preferred Pharmacy
 Pends medications that need renewals
 Full Social and Family History
 Vital signs
 Rooming note
 Loads MD’s note template & pastes last CPE
 Review of Systems and Health Risk

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© 2014 Epic Systems Corporation
Decision Support built into documentation:
Payer/visit/patient-specific template

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Where do you start?
© 2014 Epic Systems Corporation

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Automatically
Populates

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10 – 12% of Radiology orders at
Reliant were ordered incorrectly
and required changing

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 The total economic burden of diabetes
in the United States is estimated at
$245 billion, a 41% increase from 20071
 Reliant’s Diabetes HbA1c Screening
Rate and Control Rate did not change
significantly with EHR implementation
1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care.
2014;36(4):1033–1046.

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No Clinical
Decision
Support
No change
with the
EHR!

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 EHR guidelines automatically suggest testing
based on age, gender, diagnoses, meds,
smoking history, and existing orders/results
 Staff draft orders & physician signs if they agree
© 2014 Epic Systems Corporation

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Last date Next order
But doesn’t ask for an order if it’s not due or
already ordered
© 2014 Epic Systems Corporation

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Barometer of
Actionable
Deficiencies

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 Hypertension Control was 69%,
significantly below 90th Percentile of
73% for nation

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 Graph of BP readings revealed peaks
every 10 mmHg
 Staff were rounding up to the next higher
multiple of 10
 Abnormal readings were not rechecked

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 Digital Cuffs
 Real-time alerts for abnormal readings
 Monitoring compliance with repeating
abnormals
 Nurse Blood Pressure Clinics
 Pharmacist review of patients with poor
BP control and diabetics not on ACE/ARB
 Report cards showing site-specific
performance

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Reliant had two patients where lung
nodules were incidentally found on
abdominal CT scans at other
institutions for diverticulitis and
appendicitis, and were not followed-
up until metastatic cancer was
diagnosed 1-2 years later

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 More than 1200 patients currently
tracked in Pulmonary Nodule Registry
 Certified reminder letters for overdue
patients, those that refuse testing,
and patients who leave our network
 No patients with follow-up failures in
4 years

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• 90,000 preventable life-threatening
or fatal ADEs in the elderly yearly
nationwide
• Warfarin is the most common cause
of preventable life-threatening or
fatal ADEs
• 1.4% of Reliant’s levels overly thin
(Gurwitz JH, Garber LD, Bates DW, et al. Incidence and preventability of adverse drug
events among older persons in the ambulatory setting. JAMA 289:1107-1116. 2003.)

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 3 Days after hospital discharge,
medication claims data are reviewed
along with past and future labs
 Alerts sent to PCP’s InBasket suggesting
dose checking, monitoring or
discontinuation

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 Automatically generated
 Automatically sent to Anticoag Clinic
InBasket
 Anticoag clinic makes sure follow-up INR
ordered
© 2014 Epic Systems Corporation

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 IVR calls to remind patients of upcoming
lab tests just prior to “expected date”
 Alerts when patient calls or is seen that
they have overdue labs that have been
ordered already
 Letters to patients who no-show labs
◦ If 25% overdue (e.g. 1 month late on a 4 month
f/u or 3 months late on a 1 year f/u)
◦ Letter automatically sent to patient from EHR

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Avg. Massachusetts FFS: $13,000+
Avg. Massachusetts ACO: $12,000+
Atrius Health ACO: $10,700
Annual Cost Per Patient (Age 65+)
(12 months ending March 2014)
© 2014 Atrius Health, Inc. All rights reserved.

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With thoughtful use of the
EHR, HIEs, clinical
decision support, and
analytics, you can
improve the quality,
outcomes, safety, and
efficiency of healthcare
delivery

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Lawrence.Garber@ReliantMedicalGroup.org