• Describe the EHR vision in the case study
  • List and discuss the core clinical applications present in the case study
  • Discuss the examples of benefits identified by the awardee.
  • Be sure to include an introductory slide as well as a conclusion or summary slide.

Case Study

Executive Summary

Unity Health Care, Incorporated is a Federally Qualified Health Center, serving nearly 95,000 underserved residents in 30 sites throughout the District of Columbia.In 2009, Unity implemented an electronic health record (EHR). Before implementing EHR, patient scheduling was done at each site because there was no practical way to communicate enterprise wide providers schedules that changed moment-to-moment. Implementing an EHR allowed Unity to revamp processes for handling patient scheduling and therefore increase patients access to care. We have seen a 21% increase in overall provider productivity since 2012. (see Chart 1) Because of this increase in productivity, we have

realized $122 million dollars in additional revenue. No show rates, near 36% in 2009, have fallen to 28% in 2012. Background Knowledge Unity Health Care, Incorporated (Unity) is a Federally Qualified Health Center (FQHC) serving low-income, homeless, and uninsured residents of the District of Columbia (District). Founded in 1985, Unity is a 501(c) (3) non-profit organization and is the largest private organization providing primary medical care to homeless, low-income, and uninsured District residents. We served nearly 95,000 patients in 2011. Our target population is racially and ethnically diverse and largely minority. Substantial health disparities and poor health outcomes exist among our patients, highlighting the need for accessible and comprehensive primary care services.Unitys health centers are in medically underserved areas of the District where there is a scarcity of primary and specialty care. In the communities we serve, the medical need outstrips the number of providers and services available to residents. In this environment, it is critical that our resources be used efficiently. In early 2009, we were using advanced access (reserving appointment slots for same-day appointments, rather than booking appointment slots weeks or months in advance) to schedule patients, but our no-show rates averaged 36%. Our practice management system was not Windows based and therefore did not allow the patient registration clerks (PRCs) to toggle between the phones and registering patients. Patients complained that they were unable to reach the health center by phone and that they were being placed into anabyss of eternal hold.

In order to better meet the needs of the communities we serve, in 2009 Unity implemented anelectronic health record (EHR) system throughout our 30 sites and various programs. The EHR has helped Unity to improve efficiency, effectiveness, patient safety and quality of care, whichhas ultimately improved clinical outcomes and business processes. Currently about 200 providers and 900 employees use the system. Local Problem Being Addressed and Intended Improvement Implementing EHR opened the way for us to extensively revamp our process for handling patient scheduling. The goal of this intervention was to leverage the EHR to improve the patient scheduling process, therefore increasing patients access to care. We utilize a medical homes model, where patients have a primary care provider and are seen by a medical team. Patients can choose where they want to receive care and select any of our health centers for their health care. Because patients can make their own choice, it increases their access to care. However, this approach is much more complicated for the health centers to manage because it is difficult to optimize dynamic patient schedules. Before implementing EHR, patient scheduling was done at each site because there was no practical way to communicate enterprise wide schedules that changed moment-to-moment. This meant at appointment time we were at risk of missing one of the three things essential to patient care-the patient, provider or information (the medical chart).

Design and Implementation

The major goal of this intervention was to leverage EHR to improve patient scheduling. This project was led by the V.P. of Clinical Support. Because the phones were an enormous problem, we decided to hire a consultant to map the phones and identify where the problems were. This intervention took place in a series of seven steps over threephases.

Phase 1

The consultant had identified three types of problems to be addressed, people, process and equipment problems. During the first phase the focus was on creating or improving the infrastructure to begin addressing consultant findings. During this phase we fixed the equipment problems and implemented EHR.

1. Implemented a new phone system.

The consultant concluded that our phone system was inadequate and needed updating. Installing the new phone system fixed the technical problems, but caused the volume of calls to skyrocket because patients could finally get through with their calls. It became apparent that we were receiving a far greater volume of calls than what we previously thought. At that point things seemed to be going backwards as we had to suspend advanced access and return to a traditional scheduling model because we had so much unmet demand.

2. Piloted centralized scheduling.

Centralizing scheduling was piloted with one health center for 3 months prior to the EHR implementation. During the pilot the scheduling was done by our off site billing company. The billing company received over 24,000 calls

during the three month period. The pilot showed no improvement in no show rates, quality of registration or patient satisfaction. The pilot did demonstrate that it would be more cost effective, 1/3 the cost, to create a scheduling center in-house.

3.Implemented EHR and practice management.

We implemented an EHR and practice management system (PM) in 2009. The EHR is able to support new roles, workflows and reports that were developed in Phase 2.

Phase 2

With the EHR and new telephone equipment installed staff had adequate equipment to do their job. During this phase we rolled-out centralized scheduling and began optimizing workflows to

provide patients better service and make the health centers more efficient.

1.Creation of In-House scheduling Center.

All of the sites share the same EHR and PM which allowed us to centralize scheduling. Following the pilot of the scheduling center discussed in Phase 1, an in house scheduling center was created. The function of scheduling patient appointments was shifted from staff at the health centers to a centralized scheduling department. The centralized scheduling department is located at one of our health centers. It handles phone calls patients make to schedule and cancel appointments. This was rolled out site-by-site over a time frame of about one year.

2.Developed scheduling experts.

The patient scheduling clerk (PSC) position was created to staff the scheduling center.The positions were filled by PRCs from health centers that had two or more on staff, therefore we did not have to hire to fill the positions. The PSCs primary responsibility is to schedule patients appointments. Creating the PSC position siphoned off much of the load on the sites from incoming calls from patients about appointments. This gives PRCs more time to address the needs of patients that are at the health center. This change decreased some of the multi-tasking PRCs did to toggle between the phone, the computer and the patient. Additionally, the PSCs are trained to provide specialized phone support for special populations such as adolescents or Spanish speakers.

Phase 3

With an EHR in place and our workflows established we were able to further refine and optimize patient schedule, making it more effective and efficient.

1. Implemented a patient reminder system

In 2010, we began sending patients automated appointment reminders.A report of patients, appointments is generated from the EHR. Reminders are sent to patients by phone and text, three days and one day ahead of their scheduled appointment. Patients can cancel an appointment during the automated. The reminder system generates a report of patients who cancel their appointments. This list is used to call patients and reschedule them for appointments. We can fill openings created by cancellations with other patient appointments.

2. Improved scheduling rules.

Because of the centralized schedules that the EHR affords, we have been able to better understand scheduling patterns. We developed more refine scheduling rules.PSCs can schedule the patients at any Unity site. For example, we developed rules to reduce the amount of double booking, therefore we double book less often. How was Health IT Utilized. The EHR was leveraged to create new roles, workflows and reports that were needed for this intervention. The EHR allows us to do centralized, enterprise wide scheduling. All of our health centers share the same EHR so now we are able to access all provider schedules online. The data for patient automated appointment reminders are generated daily from the EHR. This report is sent to our vendor whose software calls and texts our patients.A cancelation report is created from the patients responses to the calls. This report is worked by the PSC, to schedule patients inopened appointment slots. The EHR has allowed us to create and keep current scheduling templates for each of our over 230 providers and case managers. PSCs know the scheduling rules for each provider and case manager. The PSC can view the slots for cancelled appointments and fill them. The EHR also allows us to complete pre-registration when scheduling, reducing the amount of information that has to be collected from the patient when they arrive at the clinic for their appointment.

The EHR is used to communicate information between the PSC and the providers. For example we use action items to alert the provider about the patients need for a referral prior to their visit, so that the provider or the health center team can make sure the patient has that at the time of their visit. EHR has eliminated the need for chart pulls, making it easier to see walk-in or transient patients who are nearly 30% of our patient visits. This further supports our goal of providing patient center care in that patients are able to receive care at a health center of their choice. The EHR has improved the quality of the registrations. We believe this is two-fold, first we have centralized scheduling done by experts who have more time to focus on scheduling patients. But second, we have seen an improvement in quality because of our use of mandatory fields within the EHR. Setting fields as mandatory has improved our rates of collecting demographic information, which we now collect on over 98.5% of patients. Reporting this information about our patient population to the Health Resources and Services Administration is a major requirement for FQHCs and is a measure for the EHR Center for Medicare and Medicaid Services EHR Incentive Program (Meaningful Use or MU), which Unity has qualified.

Value Derived/Outcomes

This intervention, aimed at improving patient access through improving scheduling efficiency, has had a tremendous impact on provider productivity. We have seen a 21% increase in overall provider productivity since 2012. (see Chart 1) Because of this increase in productivity, we have realized $12.1 million dollars in additional revenue. We have significantly decreased our no show rates. In 2008, we had no show rates near 36% and were at 32% in 2010 just before we implemented automated reminders. As of mid-year 2012, no show rates have averaged 28%. (see Chart 2). We have seen a decrease in the abandoned call rate, which we believe translates into higher patient satisfaction. In 2009, we had an abandoned call rate of nearly 40%. The abandoned call rate is declining and has been cut in half to about 20% (see Chart3). Additionally, average call wait times have decreased From 4.21 minutes in May of 2009 to 2.4 minutes in June 2012 (see Chart 4). Before this intervention, we had no way of measuring how many calls were being lost or how long patients were on hold.

Patient satisfaction has increased. In a 2007 survey

when patients were askedHow would you rate your ability to get an appointment with the provider of your choice? Only 39% of patients responded that they would rate it excellent or poor. But by 2011, 85.5% of our patients agreed with the statement that it was easy for them to make the appointment. The EHR is the major technology making this intervention possible. Our investments were $5.5 million-EHR implementation, $75,000scheduling center pilot, $13,000-phone consultant analysis. Our returns are $1.98 million grants from HRSA for our implementation, $2.66 million-Meaningful Use through 2012, $12. 2 millionthrough 2012 from increased revenues due to Increase provider productivity.