HIStalk Interviews Larry Garber, MD, Medical Director for Informatics, Reliant Medical Group

Lawrence Garber, MD is medical director for informatics at Reliant Medical Group (formerly Fallon Clinic) of Worcester, MA.

Tell me about yourself and the group.

I’m a practicing internist. I’ve been at Reliant Medical Group for 27 years. We are a multi-specialty group practice, about 250 physicians, covering big hunk of central Massachusetts. I’ve been working in computers since high school in 1972 with my first computer that had 8K of core memory. I’ve always continued to do computers and medicine at the same time.

You’ve said that the difference in overall cost between the cheapest and the most expensive EHR is probably five or 10 percent of the total project cost. Are practices focusing too much on the licensing cost and not looking at the long-term cost and benefits?

Yes, absolutely. A lot of practices, especially the smaller ones, don’t have time to think of the total cost of care and the long-term picture. A lot of people are just budgeting to get them live. So much needs to be spent on even the optimization that you need to continue to do after you are live.

What are the top two or three innovative ways that you’re using Epic to improve care, reduce cost, or both?

One of the best ones we’ve done is our medication refill smart tool. When our medical assistant receives a request for a medication renewal, they put in the orders for those medications. Then they pull up a smart tool that recognizes which medications are about to be reordered. It pulls in all the appropriate information that I as a physician want to see, including the last appropriate lab tests for monitoring how they’re doing on that medication, what upcoming tests are appropriate for those meds that have already been scheduled or need to be scheduled. It tells me last visits, upcoming visits. It also even suggests to the medical assistant how many refills would be appropriate for that medication.

For instance, some high-risk medication and I haven’t seen the patient for a year, it suggests that we just give them a month and tell them to make an appointment. Whereas someone who is being followed regularly and they’re getting all the monitoring tests, we’ll recommended that they get a year’s worth of refills . It’s really nice. We don’t need to have a pharmacist or a nurse staging the prescriptions. We can have a medical assistant pull it all together and I can see it all in one screen and sign it with one click.

Is that all straight Epic setup? What’s your organization’s level of expertise with Epic that you’re able to make all that work?

That one is pretty straightforward using standard Epic tools. That is why we had gone with Epic in the first place. They’re incredibly powerful and configurable and so that even using their standard tools ,you can do incredible things. We do also do some Cáche programming where we get behind the scenes since Epic does share with us their source code. There are two of us, myself and one of the other physicians, John Trudel. The two of us are able to do Cáche programming. There are about 30 routines that we’ve tweaked to be able to do some stuff so that they work perfectly for our needs.

A simple example is their standard inbasket report. For a lab result, it will show you, here are the new labs. There is a little line that says “previously viewed.” All of the results that you’ve already seen on that patient and that that were previously viewed was tiny. We went in and updated their programming point to make it a big, prominent line so it’s very easy to see what’s new versus what’s old. It’s a minor tweak. It took an hour, but it dramatically improves our usability.

Not many organizations, even hospitals, would have people available to do Cáche programming, although they could hire consultants. Would you have been happy with Epic without that ability, or would you have been happy with other products that don’t allow you to make those changes?

We’ve had a homegrown system for many years for something called Quick Chart. We were used to having the ability to put things exactly where we wanted them and exactly how we wanted them, based on what we felt was important for usability. We would probably not have been happy stepping back to a system where we didn’t have that level of control. 

That’s actually one of the big factors in us choosing Epic in the first place, because we knew we would be able to do that. I don’t know about other EHR vendors as to whether you can get access to the source code, but I would recommend any shop that’s an Epic shop, since it’s mostly large customers, try to get at least get one person who is Cáche certified.

You’ve been on Epic since 2007. Are you happy with the way that the product and the company have progressed since then and the way that you think they will progress in the future?

Absolutely. I feel they really do listen to their customers. They are trying to balance the desire for innovation against regulatory requirements. They did slow down when Meaningful Use came along in terms of their level of innovation. They’ve clearly put a focus on that. They feel now that they’ve got that under their belt they’re moving along with a lot of cool new functionality. That is why we love going to the user group meeting each year to see what’s coming. Then we come back and we say, we need to upgrade now and skip a year. [laughs]

Other than Epic, are you using any interesting technology in the group?

We have a couple of hundred patients now who use home blood pressure monitors. After they do their readings, they plug the monitor into their home computer and it uploads it automatically through Microsoft HealthVault and then loads it right down into their Epic record. We’ve set it up using standard Epic functionality to batch the readings, so that if someone is uploading their blood pressure readings twice a day, we don’t want to generate two messages a day on them. We can pick the timeframe for each patient. We might want to batch their blood pressure readings together, and then at the end of two weeks, one message is sent to my nurse saying, here are the blood pressure readings. Here is the average over this period of time. 

My nurse can decide if there is something that needs my attention or whether they can just let the patient know that they are doing great. With any of their uploads, if there is a critically high or low value, that automatically gets sent right away. It doesn’t wait for the two weeks. That works out very nicely.

You’ve had some thoughts about how to get physicians to use the technology in more than just the minimal way and to get them excited about it. What are your secrets?

Some of it has to do with feeling of ownership. Our physicians, nurses, and the clinical staff – the medical assistants — were all involved in the selection process from Day One. They felt that this wasn’t something that was being done to them, this was something that they had chosen. 

We try to give them as much control as possible. When they come up with an idea saying, hey, why doesn’t it do this or this seems to be wrong, we try to respond to those very quickly and fix things and make them better. We try to make our physicians and staff feel loved and owners of the system. When you feel like it’s your baby, you tend to work better with it.

Your group is financially at risk with 70 percent of your patients and is also a non-profit. What technology conclusions have you reached from being in that position?

That you can be successful. That using clinical decision support is important.

When we first implemented Epic, we looked at our HEDIS measures and other measurements. Not much really changed with just the implementation of the electronic health record. But turning on the clinical decision support with the alerts and the reminders, setting up interfaces to other parts of the healthcare system…  we’re interfaced to several hospitals in our area that we sent our patients to. We’re interfaced to a health plan. We load claims data on those 70 percent of patients. We load those back right into Epic, so that if a patient of mine has a mammogram done across town by some outside gynecologist and they order it, I get that loaded automatically to my record. I know who truly has had their appropriate health maintenance and disease management and who hasn’t so I can target my effort on those people who haven’t.

I think that it’s important — that you can be successful, but you need to do the whole thing in turning on the clinical decision support, getting connected to health information exchanges, interface to the rest of the healthcare system.

One of the black holes is when the patient gets discharged and nobody knows who’s doing what. You have an ADT feed to let you know that’s happened so you can initiate follow-up. What do you do?

When the secretaries see that there has been a discharge, they try to book a follow-up appointment. If it turns out that it didn’t take place, they get an alert three days after the discharge saying, it looks like this person isn’t scheduled for a follow-up appointment and hasn’t had one yet, please make sure you schedule it. Both from the actual discharge instructions that we get immediately followed up by three days later another alert saying that this doesn’t look like it’s taken place, make sure you book it – that that works well.

The nice thing is that we send the message to the right people, so that three-day alert saying this hasn’t been happening, you haven’t booked a follow up — it doesn’t come to me, it comes to my appointment secretary. I also get notices three days after discharge that the patient is on new medications that require some intervention, either that there should be some monitoring test that doesn’t appear to be taking place — whether it hasn’t been ordered or it’s not already resulted — or there seems to be a new drug interaction that I ought to be aware of and that maybe I need to adjust the dose of the medication. We wait three days on that because we use the claims data to let us know what new medications have been prescribed and that the patient went home to the pharmacy and got a new prescription. We get the claims data about a day and a half later. Then we can see what’s new and what the implications are for that.

Where do you think analytics fit in all the things a practice or hospital should be doing?

I think it’s a little bit overhyped. The reality is that analytics running on the back end in the business office or the administrator’s office does not help the patient when they’re sitting in front of me, or help me when the patient is sitting in front of me. It’s really most important to get that intelligence right there at the front line at the point of care. That’s where most decisions are being made and whether they are good or bad. It’s our opportunity to do the right thing.

I am a big advocate for first getting your front-end decision support working. Get the data to the front end, so that when I’m seeing the patient, I know what happened in the hospital, I know what happened with the specialist who saw the patient. Get those ducks in a row. After that, then you can start thinking about maybe doing the analytics on the back end to try to find sicker patients who may need more intensive care. Somewhere in between is doing the registries — finding patients who are falling through the cracks. But again, it’s being hyped as the nirvana, and there’s some very good practical stuff that people should be doing that they are not even doing right now.

Are you mining your Epic data to look for trends or evidence-based medicine opportunities?

We use the data for research studies. We also use the data to identify what we think are our higher-risk patients so that we can set them up with care managers. We are doing that sort of mining. Of course, we do look for trends. Since we are at risk financially, we look for areas where we may be doing better or doing worse financially to try to stay on top of those areas as well.

One of the other cool things I didn’t mention when we were talking about at the hospital discharge. One thing that we’re about to turn on is when one of our patient is seen at our local emergency room, we automatically get one of those ADT notifications that our patient is there. We are going to echo back a CCD summary document right back through the state health information exchange back to that hospital. They’ll be loading that into their emergency room system, so that on the big dashboard that they have in the emergency room that shows which patient is in which bed, there will be a little icon that shows that there is an outside record now available for that patient. Within a minute of the patient being registered, there will be a summary document sitting in the emergency room record and letting them know the latest information on that patient.

The SAFEHealth HIE works differently than the typical HIE. What are the lessons that other HIEs might take from how it works?

Don’t make people think. [laughs] That’s probably the most important thing.

It’s a federated health information exchange, but most important is that Massachusetts is an opt-in state, which means patients have to give consent. We make it simple for the registration person, who is doing what they normally need to do to take care of the patient, to get them checked in. As a by-product of doing that, SAFEHealth checks and sees whether a consent is necessary and whether it’s already been obtained. If it hasn’t been obtained, it just prints it out right next to the registrar. No one actually has to think about SAFEHealth or whether consents are necessary, just the consent form automatically prints. That’s a clue so the clerk can say, oh, wait, let me tell you about SAFEHealth and let me get your approval to participate in it. 

The key thing is that you have to think about workflow. You have to make things happen automatically so that people don’t have to be consciously thinking about how to do the right thing. It should just be easy and automatic to do the right thing.

Even though your group is not affiliated directly with or owned by a hospital, you seem to have a closer working relationship than a lot of practices that are. How did that happen, and what are the lessons learned?

It’s the alignment of incentives. As a group practice with a high level of risk contracts — we’ve always had a high level of risk contracts for 20 years — we’ve been incentivized to make sure that we give high quality, cost-effective safe care. We know that it’s important to get that connectivity to the hospital in order to do that.

From the hospital perspective, they know that we’re going to send our patients to them if we’re happy and we know that we’ve got good connectivity. From their perspective, they want our patients, so it’s in their best interest to keep us happy and do the connectivity. Also in part, we are lucky that we’ve had good partners. These are hospitals that didn’t feel threatened by our physician practices. They had the technological skills to be able to interface with us.

What do you see as the most important thing that you will have to address in the next five years?

As a nation, we’re going to see the evolution of what I call hassle-free HIE. That is going to be a whole new world. We’re good at our silos, but to do health information exchange is a hassle right now. What we all need to work on is making health information exchange something that is easy and automatic and part of the normal care that we give. The era of hassle-free HIE is coming.