California-based Memorial Healthcare is a four-IPA organization that includes a 35,000-visit-a-year urgent care clinic and a disease management center. The four IPAs represent 220 primary care doctors and 400 specialists – across North Orange County, Anaheim and Long Beach – centered around four hospitals. Primarily handling at-risk contracting with health plans, the IPA has begun working to bring EHRs to its providers. Recently, HCI Editor-in-Chief Anthony Guerra talked with CEO Patty Page LaPenn to learn just want IPAs want, and don’t want, from hospitals.
GUERRA: Are you negotiating with different EHR vendors on behalf of your doctors, are you working with the hospitals?
LaPENN: We are negotiating with different vendors, but we represent our largest practice. Our largest geographical location is 10 doctors, and so we represent a lot of independent physicians. We are actually rolling out a modular application we have built that will go a long ways towards meaningful use, because the cost of rolling out an EMR in a practice of one or two doctors is almost impossible to support.
The large vendors don’t want to deal with them, first of all. We are creating interoperability. So we’re using applications that do one thing well and cobbling them together. We have our own automated eligibility system that pulls data from their appointment systems. We’re then taking that system and adding on an e-prescribing system, and then adding on a lab data system.
The biggest problem with rolling out an EMR in a medical group is doctors care the most about the way they have to create their chart note, because that slows them down. That’s the thing that is most frustrating and the hardest to deploy. The thing they like the most is having ready access to all the information from anywhere. And so what we’re doing is trying to put together all of those things that give them rapid access to the data they need, and we’re leaving the actual chart note until later because it’s the expensive part, it’s the fragmenting part, and it’s the thing that changes the interaction between the doctor and the patient the most and makes them nasty.
So we’re leaving that until the end, and when we find a system that makes it easier for the practicing physician, we’ll look at it. What our doctors who have deployed EMRs have found is that they have to do things themselves which they used to delegate, so it’s taking them longer at the end of their day. We’re focusing on what takes them longer at the end of the day and trying to actually automate this stuff.
There are a lot of EMRs out there that will automate things. For example, take our diabetes program. If you know what their A1C is, LVO and blood pressure and their microalbumin, you can bifurcate your patients, and you should be able to just have the system give you a list of patients that are doing well, send out a note telling them they’re doing well by just hitting one button. Then all the ones that are really doing poorly, you just click a button saying, “Schedule this patient in my office.” The ones that are in the middle, you should be able to click one button and say, “Here are your values, here’s where you’re falling short, please do these following things to improve. We’re going to redo these tests in six months and, if you’re not better, we’re going to change your medication,” because 40 percent of all patients are noncompliant on their medications.
Most of the EMRs that are out there, it’s like they have programmed what the doctors do now rather than thinking about how we can make it easier for the doctors to do things. There’s been no paradigm shift creating built-in intelligence.
GUERRA: The chart note is a very complicated area.
LaPENN: Yes. There’s lots of documentation doctors do that’s not an actual chart note, but the thing with some systems is they’re very tightly programmed. So it’s designed so the nurse comes in, she has to get through about 10 questions. So if you walk in and say, “I’m in total liver failure, total renal failure, I’m going to be dead in three months,” they ask you the same questions as if you’re a 40 year old that doesn’t have any of those problems. It’s designed to not miss anything.
When a doctor walks in an exam room, they get a gestalt for what’s going on with the patient. Like, for example, if you’re working with a patient who is demented, to worry about an A1C on a patient that’s in congestive heart failure and demented is meaningless. The doctors wouldn’t do that. They probably wouldn’t do mammograms on them. Why would you take someone who doesn’t understand what’s going on and torture them any more than you have to? Because I tell you it is torture. Taking someone who doesn’t know what’s going on and giving them a prostate exam or giving them a mammogram is torture.
So the doctor goes in and gets a gestalt. What they do in their visit is totally different once you have a certain diagnoses onboard, which covers a huge percentage of the Medicare population. The well patients come in, they get the medicines, they leave, you don’t see them very much, it’s the last 18 months of life where doctors encounter people the most, because who else is the family going to take this patient to?
GUERRA: You’re talking about alert fatigue.