1. Practice Transformation in a Physician Organization Mary Barton Durfee, M.D. September 17, 2009

2. The Transformation Story IHA – Who Are We? Building Infrastructure –Access –EMR –LEAN –Care Management –PCMH

3. Physician Owned; Founded in 1994 160 Physicians 37 APN/PA 30 Sites 260,000 Active Patients 22,000 New Patients in 2008 488,000 Patient Visits in 2008 2,652 Deliveries 700 Employees SJMH/UM Linked IHA – Who Are We?

4.  5 divisions including Internal Medicine, Family Medicine, Pediatrics, OB/GYN, and Surgery  After Hours  Ancillary Services – CT, General Ultrasound, General Radiology  Specialty Services – Maternal and Fetal Medicine, Pediatric and Adult Neurology, Dermatologic Surgery, General Surgery  Hospitalist Services at SJMH Ann Arbor and Livingston, Saline, and Chelsea for adult patients IHA – What Are We?

5. IHA – Where Are We?

6. Leadership Structure and Committees

7. Access  90 days to Advancing Access o Patient Satisfaction – “Getting through to the Office by Phone”  Call Center After Hours  ED utilization Building the Infrastructure: Access

8. “Getting through to the Office” Patient Satisfaction at IHA

9. Access: What Did We Measure? Evening hours after 5pm Morning hours before 8am Weekend hours Walk-in hours Third available Phones answered live Answered the phones during lunch

10. Advanced Access Percent of offices answering the phones during lunch June 2007August 2009 38% 100% Percent of offices that a live person answering phones June 2007August 2009 31% 45% Percent of offices that have addressed advanced access June 2007August 2009 45% 90%

11. “Getting through to the Office” Patient Satisfaction at IHA

12. Week hours Evenin g hours Mornin g hours Week end hours Nurse triage service Tracking supply and demand Walk- in hours 3rd availabl e Access mainte nance Live phone answer Phone answer during lunch Phone Access Hours Total June 20073.722.071.411.793.662.002.592.552.522.552.72 27.59 July 3.762.071.481.833.692.282.592.692.55 3.00 28.48 August3.722.141.481.833.792.282.662.832.722.693.21 29.34 September 3.722.171.521.793.762.452.622.86 2.663.10 29.52 October4.002.071.622.003.932.762.793.103.002.863.21 31.45 November3.862.101.591.973.902.862.663.102.902.863.2831.07 December4.102.001.591.973.902.932.723.102.862.933.2431.34 January 20084.002.101.551.934.033.002.723.142.792.973.3831.62 February3.972.101.661.934.313.243.073.283.142.833.7633.28 March3.972.171.571.934.333.333.073.403.302.834.1734.07 April3.902.201.572.074.303.803.103.573.633.174.2735.57 May4.072.271.602.104.433.933.133.573.773.374.4036.63 June4.102.321.552.064.194.003.103.483.843.004.392.7738.81 July4.302.371.632.074.233.903.103.304.032.834.402.8038.97 August4.272.331.571.904.303.933.173.433.972.904.332.8038.90 September4.332.271.601.934.204.073.203.603.932.904.302.8039.13 October4.202.331.601.904.204.033.133.473.802.804.272.6738.40 November4.332.301.631.904.234.203.303.604.002.934.402.7039.53 December4.352.321.711.944.264.233.263.683.972.904.422.7739.81 Januray 20094.352.391.742.004.234.193.263.584.002.844.392.7739.74 Febraury4.322.421.812.034.16 3.263.523.942.944.352.7739.68 March4.322.451.842.033.974.133.323.523.972.944.352.7739.61 April4.322.451.812.063.974.163.353.613.972.974.352.7739.81 Difference between June 07 June 07Jan. 09Feb. 09 March 09April 09 and April 09 Percent of offices answering phones during lunch38%97% 59% Percent of offices that have a live person answer phones31%42%45% 14% Percent of offices that have started Advanced Access45%94%90% 45% Percent of offices only have 3 days or less for 3PE28%52% 55%27%

13. Average IHA ER Rates

14. Combined IHA ER Rates

15. Building the Infrastructure: EMR EMR –2003 - Commitment to implement EMR – right thing to do to ensure quality and safety for our patients despite cost –7/06 – 1 Internal Medicine and 1 OB/GYN office go live on EMR – major challenges

16. Time to Revisit our Options

17. Re-organize process –Designate EMR training team –Hire director of EMR training – CNP with clinical experience –Develop roll-out schedule for offices –Fine tune process –All IHA offices now live on EMR or in implementation EMR Implementation

18. EMR OUTCOMES Improved consistency of work flow around Preventive and Chronic Disease Care Allowed direct upload of quality data/ HEDIS indicators to payers Enhanced patient safety Developed disease-specific registries Cost –Overall total Capital Investment > $8,000,000 –Ongoing Costs - about $1,400,000/year

19. EMR Costs YEAR TOTAL Capital Investment Software MaintenanceStaff CostsNextGen EMR specific IT StaffData Circuits 2003$141,460.00$0.00 2004$119,600.00$9,000.00$235,000.00 1 Trainer, 1.5 programmers/template builders, 1 IT Support Staff$25,000.00 2005$945,500.00$54,000.00$327,000.00 2 Trainers, 1.5 programmers/template builders, 1.5 IT Support Staff$75,000.00 2006$822,400.00$71,600.00$512,000.00 3 Trainers, 4 programmers/template builders, 2 IT Support Staff$100,000.00 2007$1,461,400.00$96,000.00$750,000.00 10 Trainers, 4 programmers/template builders, 3.5 IT Support Staff$150,000.00 2008$435,000.00$162,000.00$700,000.00 10 Trainers, 4 programmers/template builders, 3.5 IT Support Staff$200,000.00 2009 (through June)$250,000.00$81,000$300,000 10 Trainers, 4 programmers/template builders, 3.5 IT Support Staff$100,000.00 TOTAL$4,175,360.00$473,600.00$2,824,000.00$650,000.00 TOTAL EMR COSTS$8,122,960.00 Capital Investment Software MaintenanceStaff CostsNextGen EMR specific IT StaffData Circuits Ongoing Costs$400,000.00$162,000.00$600,000.00 3 Trainers, 6 support/programmers/template builders, 5 IT Support Staff$200,000.00 TOTAL ONGOING COSTS$1.362,000.00

20. Registry Function Test Tracking Development of Internal Coaches Roles and Responsibilities Care Coordination  Learning Collaborative with HVPA and U of M Building the Infrastructure: LEAN

21. Make the Right Thing the Easy Thing Same Way Every Time No Double Work Increase Efficiencies and Decrease Errors

22. Planned Care Self Management Prevention Patient Portal Back Pain Care Coordination  Hospitalist Pilot Building the Infrastructure: Care Management

23. Hospitalist Pilot Program: Continuity of Care Hospitalist enters info into the Admit/ Discharge template. Hospitalist tasks the Nurse Triage group of the PCP’s location Nurse Triage accepts task Nurse Triage (or their designee) Opens PCIS Prints discharge summary Scans summary into ICS Notifies appropriate person per office workflow To provide continuity of care, Nurse Triage Reads discharge summary and contacts patient Assures patient that the IHA Hospitalist has been in touch with his/her PCP. Does med reconciliation over phone (if possible) Sets up follow-up appointment Answers any immediate questions or gives any appropriate cautions (eg: if SOB go to the ER) Activates a recall (or task appropriate person for this) Task PCP per office protocol (eg: at completion of above tasks).

24. IHA Patient Satisfaction Results – Fall 2008

25. Complete implementation of EMR with development of new templates to support clinical quality Patient Centered Medical Home designation for every IHA practice Full implementation of the Patient Portal Continue to integrate with other community groups to provide coordinated care Multi-specialty Growth Next Steps

26. Continuous improvement on Quality and HEDIS metrics Improve Access and continued reduction in ED utilization Work with hospitalist group to reduce re- admission rates through improved coordination of care work flow

27. It’s kind of fun to do the impossible! Walt Disney

28. Questions? Thank you. For more information: www.ihacares.com