1 Electronic Health Record (EHR) Optimization: 5 tips to Optimize Use of Your EHR and Get Your Time Back February 22nd 2017 This presentation is provided free-of-charge and is supported by Grant Number 1L1CMS from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided in this webinar are solely the responsibility of the presenters and do not necessarily represent the official views of HHS or any of its agencies.

2 Barbara Banks-Wiggins, MSAHealthcare Consultant 25 years experience leading multi- specialty healthcare delivery systems Population health Care coordination Workflow redesign Community engagement Health information technology adoption Electronic medical record implementation and optimization

3 Webinar Objectives You will learn how to optimize use of your Electronic Health Record (EHR) You will learn how to leverage your EHR You will learn strategies to improve clinical workflows You will learn strategies to increase productivity You will learn how to save time and improve patient outcomes Speaker Notes: For today’s meeting: We will explore the growing importance of Electronic Health Record (EHR) Optimization. We will teach you how to leverage your EHR to improve clinical workflows, increase productivity, save time and improve patient outcomes. If time allows, we will take the opportunity to address your questions.

4 5 Tips to Optimize Use of your EHR and Get Your Time BackTeam based approach Establish protocols Visit preparation Encounter documentation Creating patient registries and reports Speaker Notes: This webinar will provide 5 tips to get your time back. We will discuss how a team-based approach to establish protocols will help you improve clinical workflow and productivity, effectively prepare for visits, effectively document encounters into your EHR, create reports and registries to track patient outcomes, and how to use effective data capture to meet MACRA reporting requirements.

5 What is EHR OptimizationRefining how you use your EHR Serve your needs Promote clinical productivity Shift to value based reimbursement Uncover common problems Implement best practices Speaker Notes: What is EHR Optimization? Simply put, EHR optimization is the process of refining how you use your EHR to serve your own needs, serve the needs of your practice's and to focus on clinical productivity and efficiency. Most recently, the push for value-based care and reimbursement has heightened the need for EHR optimization among physicians. EHR Optimization is a quality improvement activity that can help you uncover any common sets of problems that if addressed could do wonders for improving your EHR satisfaction. By researching best practices and identifying the workflows that support those practices you will be better positioned for the future.

6 Why optimize? CMS-Medicare shift from paying fee-for service to paying for high value care Need to meet the performance category Advancing Care Information (ACI) under (MIPS) replaces MU Improve quality, safety and efficiency Improve technology use Move from EHR fragmentation to Optimization Receive financial incentives Risk financial disincentives for failing to optimize As MACRA replaces Medicare reimbursement with its value based payment programs, physicians should prepare for the shift from fee-for service reimbursements to getting paid for high value care. Optimization activities can help practices prepare to meet the new performance categories in Advancing Care Information or ACI. ACI replaces MU and has an emphasis on patient engagement, interoperability and security. Accountability begins now, whether you’re ready or not. EHR optimization not only helps you prepare for ACI, but it helps you to improve the quality of care you deliver, promote patient safety and gain practice efficiencies. EHR optimization efforts focus on improving how you use your technology to address current inefficiencies and better manage your patients. Moving from fragmented use to optimization will help practices provide information on the quality of care being delivered. You can receive financial incentives for Clinical Practice Improvement Activities, which EHR Optimization fits into. Lastly, you can protect your practice from the risk of financial disincentives if you fail to optimize.

7 Common Challenges Common Outcomes Technical competencyResistance to the “new way of doing things” Inertia—not wanting to make changes & improvements EHR Nuances Competing demands Finite Resources Changing Roles Inefficiencies Duplicate Work Inconsistent use among staff Frustration Some common challenges that practices currently face include: Technical competency: staff unable to effectively navigate the EHR Resistance to the “new way of doing things”, that is using and documenting in the EHR Inertia—not wanting to make changes & improvements post-implementation of their EHR Nuances and limitations within your EHR Competing demands that keep the practice from focusing on optimization Finite or limited resources to focus on optimization and address practice improvements Changing Roles to adapt to more efficient workflows These challenges can result in practice inefficiencies, duplicate or rework, inconsistent use of the eHR among staff and providers, with some even opting out and choosing to not use the HER at all, which can lead to frustration.

8 Tip #1: Team Based ApproachEngage your team Take time to meet with staff: physician, nurse, clinician, medical assistant, receptionist, lab tech, etc. Map current workflow Define current workflow problems Develop strategies Identify super-users Tip #1: The first tip we will share is Using a team based approach to optimize use of your eHR. A Team based approach is simply involving the people who do the work, and engaging them in workflow decisions. Include every member of the team: physician, nurse, clinician, medical assistant, receptionist, lab tech, etc. Work with them to Understand and map out your current workflow so you can define where the current problems are. Use real scenarios to define problem areas or “pain points.” Develop strategies as a team to address the problem areas that cause long patient wait times, overtime issues, lost productivity or billing rejections. Closely examine your EHR to understand fully the problems you are dealing with, and then create an action plan in order to make your optimization effective. Identify super-users. The technology does amazing things, but it’s just a tool. You have to learn how to use it effectively, and superusers can help with staff training and guidance. ”

9 Questions for Staff What tasks can I do for my providers?What tasks can my providers shift to me? How can I help prepare the patient for the visit? What information does the provider need in advance to see the patient? What additional training do I need? After mapping existing workflows, the staff should ask themselves the following questions: What tasks can I do that my provider is currently doing? What tasks, within my license and training, can the provider shift to me to save time? What else can I do to help prepare the patient for the visit? What information does my provider need in advance to prepare for the patient and treat the patient quickly, efficiently and make a medical decision? What additional training do I need to perform these additional tasks? Answer these questions to plan your future workflow with the EHR

10 Tip #2: Establish Team ProtocolsEstablish protocols on how staff will participate in your patient’s care. Receptionist’s role – practice management, appointment reminders, reason for visit, preferred pharmacy Medical Assistant’s role - patient work up, review histories and current medications, ensure previous test results are available, and capture preventive tests to track care gaps Nurse’s role – verify histories, problem lists, current medications, review and enter test results, process prescription refills, screen and document call-backs/messages Tip #2: Establish Team Protocols You should work with your team to establish protocols on how staff will participate in your patient’s care. Define team roles, such as the receptionist who performs practice management tasks such as entering demographics and insurance, verifying insurance eligibility and benefits so the provider will know what tests, procedures and medications are covered. Your receptionist can help reduce no-shows by conducting patient reminders which also improves your appointment access. Capturing an accurate reason for visit contributes to successfully paid claims, and entering the patient’s preferred pharmacy helps the provider submit prescriptions electronically from the EMR to keep the patients medication list up-to-date and help track patient adherence. The medical assistant’s role is to prepare your patient for the visit by taking vital signs, reviewing and documenting histories, updating current medications, entering preventive tests that have been completed by the patient such as mammograms, colonoscopy, annual physical. And then assist the provider by reminding patients of their care gaps and helping patients schedule preventive screening appointments. Your nurse can assist you by verifying the information entered into the EHR, performing a first-level review of test results and highlighting important information that requires your attention. In addition, your nurse can process prescription refills for your review, and screening your call-backs and messages. The data that your staff collects and enters into the EHR for you, will save you time, and help you manage your patient population.

11 Tip #3: Team Visit PreparationPatient check-in to check-out Engage all members of the team in preparing the patient for the visit Document important information that the provider will need Staff should: Shift work to the right nurse or medical assistant Validate and document primary reason for visit Capture and document detailed histories Update current medications for reconciliation Review preventive test alerts and inform provider for referral Know clinical protocols for patient’s conditions Perform tests, per protocol, before provider arrives, such as finger stick for diabetics, and removing socks and shoes for foot check Automate preventive maintenance reminders Tip #3. Team Visit Preparation Oftentimes in a small practice the doctor does many tasks that should be performed by the staff. An efficient workflow from patient check in to check out, involves all team members who can develop the visit so that the doctor is free to focus on information review, patient interaction and decision making. Visit preparation has the greatest opportunity to save provider time. Every minute a physician isn’t gathering information relevant to making future decisions (that no one else can gather), or actually making those decisions, is a waste of a provider’s most valuable asset, which is his or her time, and directly reduces practice revenue. So far, we have covered the initial workflows of the receptionist, clinical assistant and nurse. Shifting as much work as possible, from the physician to the right nurse or medical assistant, can dramatically increase practice productivity. However, this is only practical if the right workflows are in place to make sure the work is done correctly and according to provider preference. The ultimate goal is for the provider to simply walk into an exam room, review patient information, perform the physical exam, decide what tests need to be done, and develop the treatment plan. Here are best practices for efficient visit preparation to save provider’s time: (Review Slide) Shift work to the right nurse or medical assistant Validate and document primary reason for visit Capture and document detailed histories Update current medications for reconciliation Review preventive test alerts and inform provider for referral Know clinical protocols for patient’s conditions Perform tests, per protocol, before provider arrives, such as finger stick for diabetics, and removing socks and shoes for foot check Automate preventive maintenance reminders Automate preventive maintenance reminders. Train your nurse on how to program patient reminders and alerts in the EMR for more efficient monitoring and tracking of patient adherence to the treatment plan. Send automated messages directly to patients prompting them to set up appointments. This process helps to address care gaps and removes any related tasks from your work queue.  Your team can tackle physician burnout head on by perform additional tasks to help you manage your day.

12 Tip #4: Team Encounter DocumentationA shared responsibility among all members of team Use encounter templates vs. narrative free text Use mobile devices Provider walks in the exam room with a well populated note Reviews complete history, allergies, reason for visit, and completed tests/procedures based on clinical protocol Performs physical exam, diagnostic tests and referrals Visit summary, treatment plan and patient instructions Tip #4: Team Encounter Documentation. At this time when patient engagement is paramount, and every practice needs to maximize their EMR to enhance efficiencies—not create operational headaches. Populating the EHR is a shared responsibility among all members of the team and Practices need to learn how to use their EMR to maximize the time they spend with patients without adding hours to the workday. Here are some strategies to save time rather than lose it: Take advantage of templates and shortcuts like smart phrases. “Templates help drive the visit and walk physicians through conditions they don’t see regularly and allow staff and physicians to use standard protocols so that the encounter documentation is complete. Work with your vendor to create a EMR template that fits your practice style and captures the data you need to manage your patients. Train your staff on how to use the template and how to document information they way you want it in the patient’s record. When you enter the exam room you’ll simply verify what the patient has reported. Consider mobile devices such as tablets and laptops which provide the ability to perform data entry anywhere at any time while facing the patient — instead of looking at a monitor on the other side of the room, mobile EHRs provide increased flexibility while maximizing time both with patients and between patient visits. When a Provider walks in the exam room with a well populated note, he/she is able to simply review and verify the medical history, review completed tests and perform the physical exam. The conclusion of the visit is also very important but sometimes time consuming. This is when the doctor summarizes the visit and communicates his treatment plan to the patient. The nurse can assist the doctor by reviewing the Visit Summary with the patient, provide detailed instructions and answer questions.

13 Tip #5: Create Patient Registries and ReportsStructured Data from Templates Data capture for meeting MACRA reporting requirements Identify workflows to capture critical data Create Patient Registries Patient tracking and monitoring Identify and address Care Gaps Snapshot of your entire population of patients or an individual Standardized screens and reports Flags and alerts when out of range Satisfy MACRA reporting requirements Tip #5. Create Patient Registries and Report Structured data from your EHR templates allows you to share patient data electronically, and with patient consent….automatically. Structured data refers to any data that resides in a fixed field within the patient’s medical record. The data is connected to standard databases and codes that allow the exchange of information between EMRs, Health Information Exchanges or to satisfy MACRA Reporting requirements. Electronic health records (EHRs) that use structured data elements are documenting patient information using controlled vocabulary rather than narrative text which supports data capture for meeting MACRA reporting requirements. Identify your data requirements and use Templates to capture structured data for interoperability – sending and receiving patient information from and to Health Information Exchanges. Many clinicians complain that they are expected to collect and record much more data in the EHR than when they were using paper charts and forms. In some cases the lack of data collection can cause problems —more complete documentation in the EHR may take more time but engage staff to participate in the documentation. Identify the workflows to facilitate data entry capture. Identifying workflows and implementing processes that will distribute the workload of collecting demographic data and clinical information (vitals, allergies, problem lists, and medication) among staff throughout the care process is critical to maintaining maximum physician productivity. Doing so streamlines data capture and provides physicians more time to review and sign-off on information and less time addressing documentation accuracy. Work with your EHR vendor to create patient registries. A registry is basically a list of all the patients in your practice who have a particular condition. Registries help you keep track of when your patients were in to see you last, what tests they have had and what needs to be done to ensure they get all of the recommended care. Your team can use the registry to organize the clinical information that you will need during the face-to-face visit with the patient, making it easier for you to know what is going on and what advice to give. They can also use the registry to track when to remind patients of needed care. In the typical family medicine office, the conditions for which registries are most helpful include diabetes, asthma, coronary artery disease, hypertension, depression and possibly chronic obstructive pulmonary disease (COPD). Your EHR can collect and organize the clinical data for patients with a selected condition, present you with a snapshot at the time of the visit and allow your team to identify care gaps to ensure that the population of patients with that condition gets the care they need when they need it according to the best evidence. The typical registry program can provide several useful views of the data it contains, including a snapshot of how the entire population of patients with a given disease is doing, a status screen for an individual patient (center) and a variety of "action lists" that can show just the patients who are out of range on any of a number of clinical measures. Your registry will ensure that, when you are seeing a patient in your office, you will have a standardized computer screens and reports that shows all the pertinent clinical parameters. Some registries will even flag entries that are out of range for the patient's condition (for example, an A1C greater than 7 percent). You will have more time to focus on management issues, educate patients and develop collaborative care plans. You'll be able to set up standing orders so that your staff can make sure that patients have had all needed tests or monitoring performed prior to the visit, eliminating call-backs after the visit. In time, you will know how many patients you are managing with a certain condition and whether you are meeting the management goals you set for your practice. This population management perspective allows you to evaluate and improve your overall care in a way that is not possible when you see information for just one patient at a time. Most registries can also report out quality measures, helping with MACRA reporting requirements..

14 Quick Steps to Create Patient RegistriesPopulate your list from diagnosis codes Establish procedures for staff Have the care team enter clinical data when patients are seen. Review patient status sheets for upcoming visits Use the registry to optimize care and identify patients who need services. Here are some quick steps that you can take to create patient registries: First, populate your list. You may want to jump-start your registry initiative by having a staff member print out a list of all patients who have been billed for services involving certain diagnosis codes in the past one or two years, such as patients with diabetes, and add those patients to the registry. Once that's done, you can establish procedures for anyone on the care team to add, modify and remove registry records as appropriate. Next, add data as patients are seen. Have your team enter data as patients come in which makes data collection part of the workflow and not a separate task. Also, have your team print out patient status sheets for patients with upcoming visits and start using them to organize and collect data at the time of the appointment. Make sure you are reminded of the patient’s needed interventions. For instance, when a new patient with diabetes comes in for a visit, the nurse or medical assistant could start a record for him or her before you see the patient and print out a patient status sheet summarizing available information and highlighting areas where data is missing. After each visit, a copy of the updated patient status sheet can then be set aside for entry into the registry at an appropriate time. You and your staff are actually doing most of this work already, so make sure it is part of your workflow. 5. And lastly, use the registry to organize care. Although it takes some work to get the registry up and running, you will be rewarded with an organized presentation of critical clinical information as you are seeing the patient, and your staff will be better able to alert patients to needed care. As time goes on, your registry will fill with data and become more useful. By following these steps, you’ll find that the registry frees you to focus more on physician-level work. In summary, registries are a simple way to organize your patient’s care, engage your staff and achieve better results. The work needed to set up a registry will soon pay off with more efficient and effective care for your patients with chronic illnesses.

15 5 Tips to Get Your Time BackAction Items Work with your team Develop workflows that serve you Shift your tasks appropriately Maximize efforts to learn and use your EHR Capture data that you need Use patient registries and reports Meet MACRA reporting requirements 5 Tips to Get Your Time Back Team based approach Establish protocols Visit preparation Encounter documentation Creating patient registries and reports To recap, you can Save Substantial Time and Effort by implementing these 5 tips to get your time back Work with your team to develop workflows so that you serve your patients while your workflow serves you. Establish protocols and shift your tasks to appropriate members of your team to minimize staff idle time and maximize how they support you. Maximize efforts to learn and use your EHR so that your team participates in the visit preparation and encounter documentation. Capture data that you need to properly treat your patients. Use patient registries and reports to track your patients, monitor outcomes and meet MACRA reporting requirements I hope that you found this webinar useful and that you learned strategies that you can implement to improve efficiencies in your practice and get your time back.

16 Barbara Banks-Wiggins, MSA Strategic Management Alliance, LLC Presenter contact information Barbara Banks-Wiggins, MSA Strategic Management Alliance, LLC Washington, DC 20018