Grove Medical Associates, P.C.: Menu – Innovation
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:
Innovation
Specific NPP Goal addressed:
Ensure
patients
received
wellcoordinated care across all providers,
settings and level of care.
Executive Summary
Grove Medical Associates, P.C. (GMA) implemented the eClinicalWorks (eCW) EHR in August
2005. The new technology allowed us to successfully apply for Meaningful Use and achieve
Level III Patient Centered Medical Home (PCMH) through the National Committee for Quality
Assurance (NCQA) and joined a Medicare Accountable Care Organization (ACO) in January
2014. We are currently negotiating with an insurance company to join their Patient Centered
Primary Care Program (PCPCP), in collaboration with eCW, to utilize their Chronic Care
Management Record (CCMR) module. This module has an algorithm to predict future costs and
improve patient outcomes. The EHR has also allowed GMA to make great progress in quality
improvement measures, such as breast cancer screenings, cervical cancer screenings, colon
cancer screenings, and diabetic retinopathy eye exam screenings. In preparing for the Patient
Centered Medical Home Initiative (PCMHI) we changed our workflow to include a Transition of
Care measure to more closely monitor our high risk patients recently discharged from an outside
health facility. We launched the Patient Portal in 2007, allowing the patients to communicate
more effectively with our office. We utilize the Portal in many ways, including flu vaccine clinic
appointments, weekly glucose readings, normal lab test results, prescriptions refill requests, nonurgent appointment scheduling, referral requests and reaching out to patients. We implemented a
bidirectional lab interface allowing for patients to receive lab results, in most cases within four
hours. We were able to incorporate a diagnostic imaging order interface as well with St. Vincent
Hospital (SVH). This HL7 connectivity allows all radiology results (including high tech
radiology) to be received within hours, including all Emergency Room radiology tests ordered.
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Grove Medical Associates, P.C.: Menu – Innovation
We recently adopted e-messaging, which allows patients to receive reminders, notifications and
communication via voice messages, SMS (text) messages, App notifications, e-mail, and secure
messages to the Patient Portal, based on the patient’s choice of communication method.
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 (one day 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 often busy. Our
focus has always been on the patient – what is best for the patient – and we realized an electronic
medical health record was needed to track continuous quality improvement. We have been fully
operational since 2005, added a Patient Portal in 2007, both of which have greatly enhanced our
communication with patients, helping them become more engaged in their care.
2. Local problem being addressed and Intended Improvement
GMA realized having to rely on claims-based data from insurance companies for our incentive
payments was not the most accurate way to ensure proper payment. In a world which is changing
to Pay for Performance (P4P) we need to have the most accurate data. Therefore, we felt it was
necessary for us to extract our own data routinely to measure against the claims-based data. This
allows us to reach the highest level of payment for quality improvement measures. In 2010,
GMA began generating running a monthly registry report through the EHR, demonstrating the
accurate number of patients who have had quality improvement measures. The reports are
presented at the weekly staff meetings and discussed in great detail where ideas from all staff can
flow and improvements can be made to increase the quality improvement measures. We maintain
an average of 77% compliance for breast cancer screenings, 74% for cervical cancer screenings,
78% for colorectal screenings and 78% for diabetic retinopathy eye exams. This has generated
increased revenue for GMA and helped us to achieve our Level III Patient Centered Medical
Home status.
3. Design and Implementation
Due to national guidelines, and our commitment to excellent patient care, our Physician
Providers have always felt strongly about reviewing with the patient the need for all pertinent
preventative measures at each office visit, not just an Annual Physical Exam. The telephone
triage staff quickly became involved in the process once live with the EHR by reviewing alerts
during a telephone encounter and discussing directly with the patient. Initially in 2005, each
Medical Assistant (M.A.) ran a daily “Patient Recall” report to identify patients who were due, or
overdue, for any preventative measures. The M.A. routinely completed the preventative measure
section located in the progress note with the most up-to-date information, and reviewed directly
with the patient during all office visits. This also allowed the M.A. to place an alert in the chief
complaint section of the progress note if the patient refused or needed additional educational
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Grove Medical Associates, P.C.: Menu – Innovation
support from the Physician Provider. By 2010, we felt we could run a monthly registry report
demonstrating percentages of all preventative measures completed. This information is shared
and discussed monthly to maintain and continue our efforts to improve the quality of patient
care.
GMA’s strategy for achieving and maintaining high levels of performance was a process which
was developed by trial and error. Initially, we allowed patients to book their own appointments,
and believed we would receive the reports from the outside testing facilities. Unfortunately, our
reports proved that was not always the case. In late 2006, we devised a new strategy allowing our
Data Manager to receive preventative measure reports (electronically or by fax), attach the
reports to a diagnostic imaging order and send the order to the Physician Provider for review.
The Physician Provider then sends the diagnostic imaging order to their designated M.A. to
contact the patient with the results. The M.A. then sends the diagnostic imaging order back to
our Data Manager who then verifies that the proper alert is in place in the EHR and creates a new
diagnostic imaging order for the future exam to be scheduled. There is a medical records staff
member who maintains the future diagnostic imaging orders, ensures all exams are scheduled
annually and the patient is notified of the appointments. This new procedure is easily maintained
and has increased the percentage of compliance, which results in better quality care for the
patient and increased P4P revenue for the practice.
In 2006, we participated in a Medicare Care Measure Performance (MCMP) program. Our 2006
statistics revealed our colon cancer screenings were 31%. In interviewing both Physician
Providers and staff, it was noted all staff needed additional education on the proper technique for
Fecal Occult Blood Test (FOBT) cards, how to discuss with patients the preparation for a
colonoscopy and obstacles for the patient. GMA approached New England Gastroenterology
Associates, Drs. Peter Krims, Kyung Kim, and Kelly O’Callahan and Dee Guido, Office
Manager, to meet with our entire staff for an educational and instructional session. Dr. Peter
Krims was able to answer many questions, which resulted in new strategies both by GMA and
N.E. Gastroenterology Associates to increase our compliance record, as indicated in Appendix I.
In 2009, after the MCMP program, our colon cancer screenings had increased to 58%. Today,
our colon cancer screenings are 78% and continue to improve.
4. How was Health IT utilized?
Grove Medical Associates, P.C. has used the following eClinicalWorks EHR features:
a. Meaningful Use Adoption Quality Dashboards (MAQ Dashboard); a tracking program
created by eCW, providing reports with all necessary data required for Meaningful Use.
b. Patient Portal; a secure web based communication system within the EHR, allowing our
patients to communicate with their physicians, report weekly glucose readings, receive
normal lab test results, request prescription refills, schedule non-urgent appointments and
request referrals online.
c. Mandatory Practice Defaults; to collect demographic data on every patient (race,
ethnicity, language). The electronic system prompts the Front Desk to collect the specific
demographic information needed and will not move on until the data is input into the
EHR fields.
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Grove Medical Associates, P.C.: Menu – Innovation
d. Electronic Business Objects (eBO) PCMH Module; for reporting requirements. GMA
was the only practice in the Massachusetts PCMH Initiative (48 practices) who utilized
the PCMH module for electronically reporting metrics rather than the paper workbook.
e. eBO Financial Reports; GMA utilizes several monthly financial reports via eBO. These
reports are shared monthly with Physician Owners and are very helpful.
f. eClinicalWorks ScanShell Dual Sided Scanner; scans patient’s photo ID cards and
insurance cards. This scans directly into the patient chart and aids us in proper patient
identification.
g. Scheduled Tasks; run on a daily basis and include: insurance eligibility, update
prescription formulary, prescription insurance eligibility for all scheduled patients, and
appointment reminder emessaging.
h. Registry Reporting; we use registry reporting for several areas of clinical data:
preventative measure compliance rates, PCMH structured data, chronic care
management, immunization tracking, demographic measuring, etc.
i. Emdeon and Navicure; two electronic clearing houses that are utilized for electronic
referral submission and electronic claims submission.
j. Survey Monkey; for online patient satisfaction survey.
k. ePrescribing; GMA utilizes eRX to the best of our ability to allow for Meaningful Use,
Medicare incentives and other insurance P4P revenue.
l. Medi-Span Drug Reference Database (Surescript); checks for drug interactions in realtime.
m. Lab Interfaces; allowing for bidirectional receipt of lab test results.
n. Diagnostic Imaging interface with SVH (an HL7 interface); This allows for rapid test
results to be sent within four hours of radiologist reporting.
o. Midmark Products; Clinical device interface to include EKG, spirometry and Holter
Monitor. We are presently testing the interfaced Vital Sign unit for Midmark.
p. Smart Forms; these are structured data reports for smoking cessation and depression
screening utilized for Meaningful Use reporting.
q. eStatements; downloads a file so eCW can mail a paper bill to the patient’s home address.
r. Collection module; upload patient information to Transworld Collection Agency and they
contact the patient and send a series of five (5) letters.
s. eMobile; The Physician Providers utilize eMobile when they are performing their rounds
in the hospitals and offsite facilities.
t. Dragon; Three of the Physician Providers use Dragon, voice recognition software, for
parts of their narrative progress notes.
u. eMessaging; Each patient is given a choice of receiving messages via text (SMS) or voice
messaging upon check in for their appointment.
5. Value Derived/Outcomes
In 2005, after the implementation of the EHR, GMA realized some areas still needed
improvement; specifically, our quality improvement measures. The registry reporting allowed
the office manager to run specific reports showing individual Physician Provider data regarding
the percentages of quality improvement measures completed. These reports were shown to all
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Grove Medical Associates, P.C.: Menu – Innovation
Physician Providers and staff, which were discussed at our weekly staff meetings. This is where
we learned as a practice the value of inputting the data in the correct fields in the EHR for
reporting purposes. Simply knowing a patient had a mammogram was not the same as being able
to report on it in the EHR. Subsequently the staff provided input on workflow changes directly
impacting the method of patient engagement and collection of data. These new methods resulted
in an increased patient compliance and improved patient report cards through insurance carriers.
This increased our P4P payments significantly.
Below is an example of the colon cancer screenings over the last nine years:
GMA has maintained high percentage levels for quality improvement measures in several areas
by running the monthly registry reports and contacting the patients who are not in compliance.
These reports are posted at our Nurse’s Station and individual copies are given to each dedicated
Medical Assistant. These reports are presented to the Physician Providers as a side by side
comparison to motivate their competitive side. This seems to be very effective and easily
sustainable moving forward.
GMA reports monthly on several chronic care measures, other adult population measures,
preventative measures and highest risk populations. This allows us to identify any need for
intervention.
6. Lessons Learned
GMA uncovered one of the major challenges to increasing the quality improvement measures
was determining the correct way to input the data into the EHR in order to extract it properly
through the registry reporting feature. We learned to ask the question “Where are you pulling this
data from?” This became an extremely important question when we applied to the NCQA for
PMCH certification and needed to understand that the data was being pulled from structured data
fields.
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Grove Medical Associates, P.C.: Menu – Innovation
GMA learned early on after the implementation of the EHR that it was helpful to meet with all
staff on a weekly basis. This allowed for the free exchange of ideas and an opportunity to make
necessary changes in workflow. Utilizing the input of all staff members is the most time efficient
method to facilitate the restructuring of a new idea. This “team approach” brings forth the
different strengths of each member and creates a willingness to administer the best patient care
possible.
GMA has learned reporting on a monthly basis versus quarterly was the best way to monitor any
declines in quality improvement measures. This allowed us to make any changes necessary when
reports were reviewed with staff in a timely fashion. Using visual aids when presenting the data
to the staff and Physician Providers is much more effective than verbally reviewing the numbers.
GMA also learned when taking on a new Physician Provider it is very important to obtain the
past medical records for all patients, in order to input the quality improvement data into the
correct fields of the EHR. We recently hired a new provider, and as demonstrated by the graphs
in Appendix A, the initial percentages are quite low. The Medical Assistant is trained to very
aggressively obtain the necessary quality measure reports or schedule the necessary testing
during the initial office visit. The overall percentages of quality improvement compliance for the
practice initially decreased due to a lack of medical records for the new Physician Provider.
GMA has created a unique atmosphere surrounding quality patient care. Encouraged by
Physician Providers, we utilize all staff members to systematically care for patients, provide
patient education, promote patient engagement and focus on preventative measures as a “team”.
It is not uncommon to hear a physician ask an M.A., or staff member, to assist in the
coordination of patient teaching and preventative measures. We all benefit from the positive
atmosphere. Moving forward, GMA will utilize emerging technologies to deliver the highest
quality of care. As a team, GMA has become much stronger and more efficient with the demands
of primary care. GMA’s reporting has demonstrated patients are actively participating in their
own care and now expect preventative measures will be a part of their routine office visit.
Patients now volunteer information at the start of their office visit by informing the M.A. of any
preventative testing they have scheduled. Often, patients will call the office to inform us of the
date and time of any future preventative testing.
7. Financial Considerations
There was no additional funding needed in order for GMA to increase patient compliance with
quality improvement measures. We simply utilized the existing reporting tools within the EHR to
measure, on a monthly basis, the percentage of compliance for each Physician Provider and take
any necessary action to improve these measures.
We were incentivized through the individual insurance companies based on our quality
improvement measures and since the implementation of the EHR, our incentive payments have
increased.
Through our innovations we were able to successfully obtain Meaningful Use and Medicare Care
Management Program (MCMP) incentive money.
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Grove Medical Associates, P.C.: Menu – Innovation
Appendix I. GMA’s Preventative Measure Monthly Reporting
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