Grove Medical Associates, P.C. – Core Return on Investment
Date:
July 30, 2014
Name of Application Organization:
Grove Medical Associates, P.C.
Address:
250 Hampton Street
Auburn, MA 01501
Submitter Name:
Submitter Title:
Submitter’s email address:
Gail Cetto, R.N.
Office Manager
gcetto@aol.com
Additional Contact’s Name:
Additional Contact’s Title:
Additional Contact email address:
Sharon Magner
Data Manager
rmagner1936@charter.net
Core or Menu Item:
Return on Investment
Executive Summary
The primary goal of Grove Medical Associates, P.C. (GMA) has always been to improve the
safety and quality of patient care delivery, as well as manage the high volume of patients and
their medical needs. GMA developed a set of clinical and business objectives to establish a
framework for electing EHR/PM product to help accomplish these objectives. This EHR
decision would allow GMA to facilitate the timely and comprehensive delivery of healthcare
services to its patients, resulting in improved clinical outcomes.
We were interested in an EHR decision providing a closed loop system for tracking outside
testing/labs ordered, allow follow-up for GMA staff and GMA providers to ensure patient
compliance, and reconcile the results with the patient’s chart for review and action by GMA staff
and GMA providers.
Additional business objectives which were identified and influenced the selection criteria were:





Increased efficiency of providers and office staff through improved workflow
Reduced malpractice risk through improved patient documentation and follow-through
Improved financial performance of the practice in the following areas:
o Ability to capture detailed, legible information to allow for increased coding
levels
o Ability to meet Pay for Performance criteria for insurance payers
o Ability to identify ancillary services that could be provided by our practice
Increased job satisfaction of providers and staff
Increased patient satisfaction based on efficient care delivery, improved communication
and outcomes
1
Grove Medical Associates, P.C. – Core Return on Investment
Since the adoption of the EHR, GMA was able to successfully attest for Meaningful Use and
achieved Patient Centered Medical Home Level III certification. We feel strongly without the
EHR the above achievements would have been close to impossible.
1. Background Knowledge
Grove Medical Associates, P.C., (GMA), is an internal medicine practice serving Worcester
County in Massachusetts and is affiliated with the Central Massachusetts Independent Physicians
Association (CMIPA). GMA employs four Board Certified Internal Medicine physicians, a
Physician’s Assistant, a Certified Nutritionist (once a week) who is working towards her CDE
certification, registered nurses, medical assistants and administrative support staff.
With a diverse patient population of over 6,500 in an urban setting, our office is busy. Our focus
has always been on the patient – what is best for the patient – and we knew we needed an
electronic medical health record to track continuous quality improvement. We have been fully
operational since 2005, adding a Patient Portal in 2007, both of which have greatly enhanced our
communication with patients, helped them become more engaged in their care, opening a
channel for outreach.
2. Local problem being addressed and Intended Improvement
Prior to the implementation of the EHR, GMA struggled with paper charts. Locating paper
charts, reading illegible hand writing, incomplete progress notes and improper filing of paper
charts was always a challenge. One other challenging area prior to the implementation was the
proper coding of an office visit. Our PCPs routinely perform extensive patient interviews and
exams, however, they were not always sure they captured enough information and tended to code
a 99213 (evaluation of management Level 3) instead of a 99214 (evaluation of management
Level 4). There is approximately a $35 increase in payment for a 99214 versus a 99213. In 2002
we brought in Coding Specialists to sit with the Physician Providers to educate in proper coding
technique. Still, they did not feel comfortable with the increased office visit code until the
adoption of the EHR. The EHR has a built in billing coder guiding to select the proper code. This
feature allowed the physicians to feel confident when utilizing the higher coding level.
Prior to the implementation of the EHR, GMA struggled with the tracking of all preventative
measures. On paper, we had to place sticky notes on a patient chart as a reminder to the staff and
physician to schedule any preventative exam needed. As you can imagine, the sticky notes were
frequently lost and/or ignored. We were not able to maximize our incentive money due to being
unable to track and report on the completed preventative measures. The only resolution would be
to adopt an EHR.
After the adoption of EHR and the Patient Centered Medical Home Initiative, GMA realized we
were not actively capturing the transition of care for patients coming from a different setting. The
Massachusetts PCMHI educated our office on what transition of care meant and how to apply it
to our office. We also were able to put into place a procedure to track all transition of care
patients and allow for the proper billing of Transition of Care visits.
3. Design and Implementation
2
Grove Medical Associates, P.C. – Core Return on Investment
In 2004, at the suggestion of Dr. B. Dale Magee, then President of Central Mass Independent
Physicians Association (CMIPA), Grove Medical Associates, P.C. explored the feasibility of
implementing an EHR/PM (Electronic Health Record/Practice Management) system. With the
assistance of CMIPA, and the Doctor’s Office Quality – Information Technology (DOQ-IT)
program managed by MassPro (FREE organization that assists physician offices in the transition
to an EHR), GMA developed a set of clinical and business objectives to establish a framework
for electing EHR/PM product to help accomplish these objectives.
The key contributors to the selection of the EHR were the three GMA physician owners, the
R.N., Office Manager and the Billing Manager. MassPro and the CMIPA EHR Committee, led
by Dr. Magee, provided the opportunity to participate in EHR vendor presentations. Based on
MassPro’s final list of Top Ten EHR evaluations and careful review of all information from
EHR vendor presentations, GMA was leaning toward eClinicalWorks (eCW) of Westborough,
MA as its vendor of choice.
Based on ease of use, comprehensive medical record, and integrated PM system, we felt that
eCW was a good solution for the issues that we were hoping to address with our EHR/PM
selection.
During the decision process to switch to an EHR, the staff was informed on almost a daily basis.
The majority of who approached the coming challenge with enthusiasm and open minds. Input
from every staff member was considered in the decision. Once we went live, we scheduled
weekly team meetings to provide an opportunity to discuss progress, problems and solutions and
reinforce “we are all in this together” as we worked through issues together to strengthen and
provide moral support for our team.
We utilized MassPro’s advice as often as possible, as they provided comprehensive EHR
information and ‘Go Live’ recommendations and continued post-implementation assistance.
eCW was supportive from the beginning of the relationship and continued to provide ongoing
support to GMA. Regular system upgrades provide new tools and opportunities for improved
patient care. eCW offers free webinars and CMIPA offered monetary support for training.
Trainers met with us to ensure we were utilizing the most recent features; the training sessions
were invaluable. Our practice philosophy remains… “it is all about the training”.
Our goal in the pre-implementation phase was to allow staff and PCP providers to become
familiar with the software screens to maximize the training for the ‘Go Live’ date in August of
2005. We viewed CD tutorials on “How to set up a Telephone Encounter” or “How to set up
your own Template”. Physicians used remote access to test the application from their homes.
This also allowed them to view and become familiar with screens while at home with no office
distractions. MassPro provided lists of anticipated decisions, processes and workflow changes to
occur. We reviewed our paper system to identify the changes that occurred by using test
exercises for the front desk, telephone triage department, and billing. Learning how the workflow
would change helped us understand the transition process before it occurred. Most of the
employees were very receptive.
3
Grove Medical Associates, P.C. – Core Return on Investment
As part of the initial planning process, we scheduled two site visits to practices using eCW in
order to see the product in a real practice setting. This helped us set realistic goals for the
implementation and ‘Go Live’ phase of the project. Our goals were to minimize disruption,
change our schedule for training, and allow physicians to see a full electronic medical record,
and have a relatively stress-free ‘Go Live’.
Our plan for minimal disruption in patient care included:
1. Seven weeks prior to ‘Go Live’, GMA staff began scanning in paper charts and inputting
the following data:
 Most recent CPE exam progress notes
 The last two (2) office visit progress notes
 Most recent EKG, echo, mammogram, CXR, colonoscopy, pap screen, last set of
labs
 Medication list and allergies to medications
 Chronic assessment lists from previous PM system
2. Tutorial CDs were distributed to allow staff to become familiar with eCW screens
3. Staff members spent time in the scanning room to view and become familiar with this
process.
4. First week of July 2005: Two days were blocked off and arrangements were made to shut
down Grove Medical Associates for the first two days of training prior to the ‘Go Live’
date. The remainders of the ‘Go Live’ week were booked at 50%, allowing everyone’s
primary focus training.
5. First week of July 2005: Each provider’s schedule was adjusted to include an extra 15minute block per hour to allow for complete documentation time for one month after ‘Go
Live’. We originally allowed for 2-3 months of extra time in the schedule but the
physicians quickly became proficient on EHR charting after just one month.
6. ‘Go Live’ week: Patients were notified they would be seeing providers who were in
training with a new product and were receptive to being part of the process. They were
shown the electronic Medical Summary, which was created in real-time; they were very
interested and engaged in the project.
7. One week after ‘Go Live’ week: weekly meetings were held to allow for all eCW users to
be in a room to learn from each other for 30 minutes. These 30 minutes meetings were
very important and provided the quickest way to move forward with all employees
helping each other. These weekly meetings continue to this day.
4. How was Health IT Utilized?
Since the adoption of EHR in 2005, GMA has attempted to utilize all the functions of the EHR to
the best of our ability. There are several reporting methods utilizing the Registry function within
the EHR and the eBO server for financial and some clinical reporting. Both of which allowed us
to achieve Patient Centered Medical Home Level III certification and Meaningful Use
attestation. We did use the PCMH module located in eCW eBO for the majority of the reporting.
We use the MAQ (Meaningful Use Adoption Quality) Dashboard, created by eCW, to easily aid
in the attestation process for Meaningful Use. We also utilize the registry function on a monthly
4
Grove Medical Associates, P.C. – Core Return on Investment
basis which allows us to continue to receive increased incentive money from the insurance
companies and our IPA.
The Physician Providers utilize several tools of the EHR to aid in accurate documentation of
their progress notes. They utilize Voice Recognition software, which allows for the accurate
description and legible notes for each visit. The EM (Evaluation and Management) coder located
within the progress note of the EHR guides the providers in accurately coding each office visit.
In 2011, we added the IMO (Intelligent Medical Objects) assessment tool which allows the
Physician Provider and staff to easily search for the proper and complete ICD9 code. This aids in
coding properly and achieving higher RAF (Risk Adjustment Factor) scores.
The Physician Providers all use wireless tablets and the Medical Assistants use wireless laptops.
Midmark products such as EKG, spirometry and Holter Monitors are integrated into the EHR.
The Physician Providers use their eMobile phones when they are out of the office to stay
connected. They also receive “doc alerts” on their mobile phones to notify a patient is being
discharged from St. Vincent Hospital. This is very helpful information in contacting the patient
within 48 hours of discharge and ensuring a follow up appointment is scheduled.
GMA has a bidirectional lab interface which allows for lab results to be received directly into the
proper patient chart and for the Physician Provider to review them much quicker than if we had
to rely on results being faxed to us. We also receive some diagnostic imaging results,
admit/discharge notes, op notes and ER visits via an HL7 interface with St. Vincent Hospital.
These results are received by the Physician Provider within 3-4 hours.
GMA added eprescribing (eRX) in 2007. We eprescribe all prescriptions routinely. Medi-Span
Drug Reference Database (Surescript) checks for drug interactions in real-time.
GMA added Patient Portal, the secure web-based communication program located in eCW. This
allows 24/7 access for our patients to send non-urgent messages. We were able to launch
emessaging which allows for voice and text messaging, to patients who prefer this method of
communication.
GMA has set up several automated tasks to allow for a more efficient workflow. All patient
insurance eligibility is checked automatically by our EHR system the night prior to the scheduled
appointment. All patient prescription formulary rules are run automatically by our EHR system
the night before to allow for accurate prescription selection. The EHR is set up to send voice and
text messages to each patient as an appointment reminder the day before their appointment. The
Patient Portal is set up to automatically send appointment reminders to their email seven (7) days
and again two (2) days prior to their scheduled appointment.
Emdeon and Navicure are two electronic clearing houses that are utilized for electronic referral
submission and electronic claims submission. This has streamlined the referral and billing
processes and increased claims collections. We utilized eStatements which downloads a file and
eCW mails a paper bill to the patient’s home address. This saves time and money for staff. We
also use the Collection module which uploads patients to Transworld Collection Agency and
they contact the patient and send a series of five (5) letters.
5
Grove Medical Associates, P.C. – Core Return on Investment
5. Value Derived/Outcomes
With the adoption of the EHR, GMA was able to increase the level of service billing due to
proper E&M coding. Overall our Physician Providers were coding only 20% of their office visits
as a 99214 in 2004. After the implementation of the EHR in 2005, our Physician Providers are
properly coding 80% of the office visits as a 99214 (versus a 99213). The difference in
additional revenue is approximately $35.00 per office visit.
GMA did experience an increase in insurance collections with the adoption of the EHR. The
providers were able to increase the number of office visits per day. The average number of office
visits per day in 2004 was 17, and is now 20-22. Annually, this translates to approximately
3,000 additional office visits. Average insurance collections doubled since 2004 with the
adoption of the EHR.
GMA was able to maximize, in most cases, the amount of incentive money offered by the
insurance carriers and CMIPA. We were also able to participate in two incentive programs;
MCMP (Medicare Care Management Program) and BTE (Bridges to Excellence) when offered.
We were also able to offer Bone Density (DXA), ultrasound and echocardiogram services at our
office due to the adoption of the EHR. We utilized the registry reporting tool to receive an
accurate picture of the number of tests ordered annually by our Physician Providers at other
facilities. Thus, we were able to accurately predict the level of income adding these office-based
procedures would provide. This increased the procedure charges in our office from zero to
$1,215,200.00. Along with the financial gain, the patients are more compliant and are pleased to
only have to visit one central location.
Our most recent change to the quality of patient care is Transition of Care, which involves
coordinating and communicating with patients recently discharged from hospitals, or sub-acute
rehabilitation centers. This did contribute new revenue for GMA, promoting better care for our
patients across all settings. The patient satisfaction remarks when we call these patients to follow
up on their recent hospitalization or discharge from sub-acute centers are innumerable.
The largest expense for GMA was the rent we were paying monthly. In 2010, we were able to
purchase a building located in a suburb of Worcester which easily accommodated all exam
rooms, procedures rooms (ultrasound, echo and DXA), physician and staff offices. The new
building is in a safer neighborhood, easy to get to, has a private parking lot and is located 10
(ten) minutes from our previous office. We were able to negotiate contracts with Quest
Laboratory, St. Vincent Hospital Radiology, St. Vincent Hospital Mammography and St. Vincent
Physical Therapy. These ancillary providers are the most commonly utilized services for our
patients. This allows us to easily coordinate care on the same day and promotes patient
compliance. As a result our quality measures continue to improve and patient satisfaction has
increased.
6
Grove Medical Associates, P.C. – Core Return on Investment
6. Lessons Learned
GMA would have ensured we reviewed the date training would occur, how many trainers would
be present at GMA and what the itinerary would be, prior to the ‘Go Live’ date. This would have
required us to have a list of employees and job titles available prior to negotiating the contract.
In hindsight, training for one week was possible. If GMA had it to do over again, we would have
made arrangements for one eCW trainer to stay onsite one week after the training. This would
have allowed for employees to continue the learning and also have a good resource for questions
and this opportunity would have allowed for reinforcement of what was learned the previous
week.
Additionally, GMA would have considered bringing in the Practice Management billing system
three months prior to the EHR. Although we have no regrets, we could have used the additional
time to familiarize with EHR screens, continue training when available and continue scanning
paper charts during the PM set-up and training. If they were available, this would have been a
good time to view webinars and other forms of EHR training to be ready for ‘Go Live’ week
with trainers on-site. This would have allowed us to be even more familiar and ready for hands
on training.
Furthermore, we learned not to underestimate the volume of incoming and outgoing faxes. The
amount of faxes changed dramatically within days of ‘Go Live’. This did initially create a
problem, which resolved quickly by applying separate servers for incoming and outgoing faxes.
GMA should have accomplished the setup of separate servers prior to ‘Go Live’ date.
Utilizing the MassPro tool to anticipate the changes from paper to EHR was a valuable tool. It
ensured every department and procedure was considered prior to implementation. Actively
thinking about each department and each task helped us anticipate changes.
In all of the reporting projects, the biggest lesson learned was we needed to know where the data
was being pulled from in the electronic record. Educating staff members to understand the source
of the data helped to understand the concept was instrumental in obtaining the proper reports.
This has forced GMA to change some workflow but we have greatly improved our ability to
report on our measures.
Continuing education is critical. Learning how to allow the EHR to work for your facility is a
never-ending part of the EHR experience. To continuously recognize and utilize any and all
training is very important. The ongoing education after the ‘Go Live’ date allows for staff to
become stronger and more efficient when using the EHR. In addition, we take advantage of
opportunities for all staff members to learn from webinars and onsite training routinely. Do not
assume once you are six months into the EHR, the learning is over. Learning and teaching are
constantly necessary and all staff members will benefit from each other’s EHR knowledge.
Having a billing supervisor who could oversee and counsel Physician Providers is still necessary
and critical. Although the EHR provides recommendations for CPT coding, the billing supervisor
oversees and provides ongoing education to providers and staff. One improvement GMA made
7
Grove Medical Associates, P.C. – Core Return on Investment
was to bring in our own Medical Records auditor once or twice per year, to address a sample of
progress notes and identify the needs for proper charting. This auditor also reviews EHR billing
‘pitfalls’ directly with Physician Providers. This allows GMA Physician Providers to stay in
compliance with coding regulations and fully understand the coding process.
Be open minded, be committed to learning and have a sense of humor is some advice we would
share with anyone who is implementing an EHR.
7. Financial Considerations
The funding for the implementation of the EHR software and hardware was in the form of a loan
given to us by one of the Senior Partners at GMA. We were also given a $15,000 grant from
CMIPA which was applied towards the initial loan, which we were able to pay back quickly.
There was no reduction of income for any of the Physician Providers or staff. We maintained our
staff salaries and profit sharing. There was a significant increase in both insurance collections
and incentive money. We now have the capability to be organized and maintain EHR alerts. We
have the ability to predict anticipated income through the addition of ancillary testing such as
Bone Density (DXA), Ultrasounds and Echocardiograms. These ancillary tests generate
additional income for GMA.
Grove Medical Associates, P.C. attributes their success to the staff who actively and diligently
participated in the EHR from start to finish. Each staff member performs valuable and essential
tasks to obtain the common goals of providing good patient care and ensuring preventative
measures are met. Each staff member provides new ideas on how to accomplish these tasks and
should be consulted often. Recognizing each individual’s strengths will ensure growth for the
practice, allow for easier implementation of procedures, and allow for the evaluation of the
practice’s workflow to best facilitate improvements. This also creates a team atmosphere where
no single individual is solely responsible for any given task. The team approach provides staff
with support, and allows them as a whole to have input on major decisions. Once a new idea is
proposed, consulting the staff opens a dialogue regarding the pros and cons of the proposed
implementation. This saves time and effort on possible restructuring of a new idea, and creates
team spirit. Nothing can be accomplished without a great staff.
8
Grove Medical Associates, P.C. – Core Return on Investment
Appendix I – Return on Investment Analysis
INVESTMENT
I.
EHR SOFTWARE (2005 – 2013)
a. EHR Software (licenses for providers, users
and enterprise)
b. EHR – related software (Midmark)
c. EHR software billed yearly (e-RX, Emdeon,
Patient Portal, Express Bill Option
d. Interfaces (labs, PM system, devices, hospitals,
etc.)
e. Yearly EHR and EHR-related software
maintenance/support EHR
f. IMO (CPT search engine)
II.
$13,400.00
$44,825.00
N/A
$92,400.00
$1,600.00
HARDWARE (2005 – 2013)
a. IT EHR Equipment
b. Technical Support
III.
$47,500.00
$151,302.00
ADDITIONAL COSTS (2005 – 2013)
a. Training costs for EHR and EHR-related
software *
b. Ancillary costs related to training (travel,
yearly eCW Conference)
c. Server software (SQL, Windows, backup
software, faxing software, etc)
d. Ancillary costs for DXA, Ultrasound, Echo
TOTAL EXPENSES
$6,600.00
$3,850.00
Included in eCW EHR
$970,940.00
$1,332,417.00
RETURNS
I.
PAPER CHART COST SAVINGS (2005 – 2013)
a. Reduction in transcription costs.
No reduction in transcription costs as GMA
has never used transcription services.
b. Malpractice Reductions
GMA malpractice insurance does not offer any
discounted amounts for having EHR.
c. Reduction in paper chart supplies
GMA has not had to purchase paper charts,
therefore, saved on that expense.
d. Reduced need for paper chart space and $118,800.00. GMA was able to eliminate the
storage.
medical record room of paper charts when we
relocated in April 2011, adding extra exam
rooms in lieu of medical record storage space.
9
Grove Medical Associates, P.C. – Core Return on Investment
II.
STAFFING SAVINGS (2005-2013)
a. Reduction in overtime hours paid.
GMA policy has always been to stay within 40
hours per week.
GMA noticed that when an employee would
leave, workflow was easily adjusted and no
need to fill the position. Work was distributed.
GMA has always utilized their in-house billing
staff.
GMA was able to become more efficient in
billing department. It is still critical to have
biller oversee billing, however, Accounts
Receivable (AR) improved with the ability to
be more efficient.
b. Reduction in staff to provider ratio.
c. Reduction in billing costs.
III.
a.
b.
c.
d.
INCREASE COLLECTIONS (2005-2013)
Increase collections for providers
Increase procedure charges
PQRI incentives, grants, or other P4P monies
Change in level of service billing before and
after
TOTAL RETURNS
TOTAL RETURN ON INVESTMENT
$1,310,661.00
$1,215,200.00
$1,555,472.00
60% improvement (revenue is included in a.
increase collections for providers)
$4,200,133.00
315%
10