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.
LaPENN: In the major systems that were rolled out here, the first thing the doctors did was shut all those alerts off. They pop up so frequently, for so many different things, that they would never get through their day, and they don’t read them, it’s too much read.
Let’s say you had to do a calculation that had 15 steps, and you had to do it all in your head, but someone comes and interrupts every five seconds to ask you a different question. When they’re diagnosing the patient it’s like having something in RAM memory. And so you get all these pop ups. They’re dealing with such life threatening things, it’s not conducive to doing well thought-out documentation on a patient that’s sick.
GUERRA: What are some areas alerts can be of use?
LaPENN: In the area of e-prescribing. Patients get drugs from a lot of places, and we started to actually pull out of SureScripts all, and not just what I, prescribed. With a lot of the systems, you have to go in and put in what you prescribe, but you don’t know everything the patient is getting. It will find errors that you have in your system. But if the patient is going out of town, or if the patient shows up in an ER and someone gives them a drug that you don’t know about, and for whatever reason the patient doesn’t tell you (and they don’t tell you a lot of things), then you’re not going to find those errors. I think that the alerts that matter most to doctors and that provide the best opportunity for reducing medical errors are the e-prescribing errors.
The other thing that’s off track are the discussions around wellness. Do you think the only reason people don’t do what they’re told is because the doctor didn’t tell them to do it? That is so ridiculous. We’ve got all the advertising from McDonald’s, all the advertising on TV about all these drugs, and compare that to the fact you spend 30 minutes a year with your doctor. Do you think the reason patients aren’t complying with these things is because the doctor doesn’t say the right things? If everybody feels it’s really important for women to have mammograms, women to have pap smears, and men to have prostate exams, then charge them a different insurance rate if they don’t do that, and give them direct referrals. Don’t interrupt the doctor when they’re in the middle of talking to a complicated patient to say, “The patient hasn’t had a mammogram.”
GUERRA: That’s where we get into these difficult debates about P4P and quality, how much can you hold physicians accountable for what happens after the patient leaves? If they’ve given proper instructions and proper medications but the patient is completely noncompliant, how should that be handled by these new reimbursement programs?
LaPENN: Forty percent of all new prescriptions are never filled. Don’t get me wrong, I love technology, I love computers, I love some of the stuff we’re doing. It definitely decreases overhead and improves patient care but, man, we get some angry patients. We have 2,600 diabetics, 800 of them have A1Cs over eight, which means they’re really out of compliance. I’m also a dietician, and I teach this class called “Better, Not Perfect,” because the noncompliant patients are different.
In our patient panel, there’s a fair amount of alcoholism, there’s a fair amount of mom and dad and three kids and the grandkids living together and maybe everybody has lost their job, but there’s one who’s a diabetic cake decorator. That’s an absolute case out of my panel. Regarding these noncompliant patients, the issues why they don’t follow doctors instructions are not because the doctor doesn’t tell them. To say that 40 percent of all patients are not filling their medication, and then there’s an additional 25 percent who don’t take them as directed, technology will help identify them, technology will help instruct, but technology will not change patient behavior.
GUERRA: What do you think of the ability for physicians to be alerted by the pharmacy when a patient has not filled a prescription?
LaPENN: We manage the whole continuum of care. About two or three times a year, we have a diabetic who ends up in the ER with really low blood sugar, and what’s happened is they’ve been a patient in denial for a long time and the doctor doesn’t know they’re not taking their medication. And so then the patient shows up, their A1C is high and, for whatever reason, that day the patient is interested in taking care of their diabetes, so they go and see the doctor, but they’re not honest with the doctor. They don’t admit they’re not taking their drugs.
We have them in our classes. We have to bring them back four times. There are patients that sit through the first two classes and swear they’re taking their meds. By the third time, one of them breaks down and says they’re not taking their meds, and then they all say they’re not taking their meds. They don’t like to tell doctors that they’re not taking their meds. So this patient shows up to the doctor and says, “I’m ready to take care of myself. I’m going to do what it takes.”
The doctor looks at it, the doctor ups their medication. Well, then that patient starts taking the full dose of the upped medication and they actually end up over-correcting because the doctor made a decision assuming that the patient was taking the previous prescription as directed. So they’ve increased the dose, when actually the problem was the patient wasn’t taking it at all.
Part II Coming Soon