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Evidence-Based Ordering in an IPA Setting

June 20, 2011
by Mark Hagland
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How one Rhode Island physician organization has charted its own course

As the concept of evidence-based medicine spreads across healthcare, more physician group organizations are joining hospitals in implementing evidence-based physician order sets. One physician organization that is doing so is the Rhode Island Primary Care Physicians Corporation (RIPCPC), a 160-doctor independent practice association (IPA) based in Cranston, R.I. Albert J. Puerini, M.D., president and CEO of RIPCPC, has been so focused on embedding clinical decision support into the electronic medical record (EMR), that he led his colleagues in creating self-developing their own EMR solution, called EpiChart; the IT arm of RIPCPC, which Puerini also heads, is called Polaris Medical Management. The physician practice itself is known publicly as Family Health and Sports Medicine of Cranston.

Puerini spoke recently with HCI Editor-in-Chief Mark Hagland regarding his group’s use of evidence-based order sets (from the Lowell, Mass.-based DiagnosisOne), and the broader issues around the use of clinical information systems in the IPA setting. Below are excerpts from that interview.

Tell us about your group practice?
Rhode Island Primary Physicians Care Corporation consists of 160 physicians and encompasses internal medicine, family practice, and pediatrics. That’s our clinical arm. And our IT arm is Polaris Medical Management—we’ve developed the EpiChart system.

Albert J. Puerini, M.D.
So you self-developed your EMR?
Yes. We developed it because seven or eight years ago, we saw the writing on the wall that EMRs were on the horizon. We didn’t like any of the commercial ones out there, so we developed our own, web-based solution—EpiChart 6.0, web-based. About 100 of our own doctors use our own system, and another group of docs around primary care also use it.

What has been your experience in using the DiagnosisOne evidence-based order sets within the EMR?
Using an EMR is challenging, let alone developing one. And we realized we needed to get out of a server-based system and develop our own system. We did have some decision support, but it was very elementary. And we needed something robust and something most helpful to primary care doctors. So when we saw their clinical rules engine, we felt it would close a lot of gaps in our system. The thing we liked about it is that it’s extremely user-friendly. What really works for our physicians is that not only are we using a system that’s evidence-based; but when I use it, a window will pop up, and a message will tells me why a drug I’m about to prescribe is incompatible, and it will explain why that drug is incompatible, and then I can decide, is this something I need to worry about, or not? So it allows the physician to be alerted, and to make a decision based on evidence-based medicine.

So number one, it reduces the time involved; and two, it reduces costs, because you’re altering what you need to do, based on evidence. And obviously, it reduces errors, and the bottom line is that you’ve just improved the quality of care. And we’ve looked at others, but we just felt that their system was more user-friendly; we liked the user interface, and especially liked the ease with which you can make decisions.

So many things are happening now in medicine that physicians need tools to practice, correct?
You don’t think I can remember the 30,000 prescription drugs on the market right now? [laughs] And new meds are coming out all the time, and new versions of old meds are coming up. And with the evidence-based order set solution we’re using, everything is being upgraded on a real-time basis.

Tell us about your group’s use of alerts around gaps in care?
First of all, our organization has always based its contracting and its work on quality; we always approach our payers with the premise that we want you to give us the resource to practice better medicine, and if we do, then we want some kind of reward for the quality of care. We want to be accountable for what we do, but then we need those resources. And we’ve had several different contracts with payers based on those premise over the years. And the evidence-based ordering solution we’re using recognizes gaps, and if there’s a problem with what you’re doing, it helps you out.

Let’s say a patient comes in with a newborn, and the mid-level professional takes the baby’s vitals, and then all the pertinent demographic and clinical information for the patient comes up. And if the patient hasn’t had an MMR [measles, mumps and rubella vaccine] yet, a real-time alert will pop up with a course of action and references, and the ability to override it if you wish, and the ability to order the immunization.
The beauty of this is that we had been doing this with our older version, but it was much more work-intensive and manual; we had different boxes to click on, but now it’s all done in real time, and you’re able to act on it right in the moment.

How does clinical decision support with evidence-based medicine change how physicians practice?
Every physician wants to practice at the top of his or her ability. And every physician likes to think they’re practicing great medicine, but when you see the evidence or get support, you can see where the gaps are. And we meet on a monthly basis, and can see the value of systems. And even though it’s a little bit labor-intensive, it helps you close those gaps and benefit over time, such as the situation with the kid who didn’t have his MMR. So over time, doctors embrace it, because it helps them improve the practice of medicine.

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