ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance

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ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
A PHYSICIANS INSURANCE PUBLICATION

   THE

                                                         SPRING 2021      PHYINS.COM

Closing the Loop on
 DIAGNOSIS
 ERRORS

         4 Closing the Loop:    8 Overcoming Systemic    24 Leader Insights:
           Safe Practices for     Challenges to Reduce      Navigating to
           Diagnostic Results     Diagnostic Errors         Avoid Care Gaps
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
Closing the Loop: An Opportunity                                                                         EDITORIAL STAFF
                                                                                                               PUBLISHER

to Reduce Diagnostic Error
                                                                                                             William Cotter
                                                                                                             SENIOR EDITOR
                                                                                                             David Kinard
                                                                                                           MANAGING EDITORS
Diagnostic errors are the most common,        possible, but it also represents a                           Catherine Kunkel
                                                                                                            Kirstin Williams
most catastrophic, and most costly of all     moral, professional, and public-
                                                                                                         CONTRIBUTING WRITERS
medical errors. Every year in the United      health imperative.” And despite the                       Paul Epner, MBA, M.Ed
                                                                                                              Anne Bryant
States, 12 million adults are impacted        complexities, there are immediate                       Patricia Giuffrida, MSN, RN
in outpatient settings alone by delayed       opportunities for improvement. For                             Robert Giannini
                                                                                                             Malia Jacobson
or inaccurate diagnoses. Approximately        example, many diagnostic errors are                          Jennifer Tomshack
                                                                                                          CONTRIBUTING EDITOR
250,000 harmful diagnostic errors are         caused by failure or delays in closing the                   James Carpenter
associated with hospitalized patients         loop (CTL) on specific processes, such                  CONTRIBUTING EDITORS—LEGAL
                                                                                                       Melissa Cunningham, JD
annually, and estimates of premature          as test ordering and result interpretation                     Nancy Pugh
deaths in all settings are in excess          followed by patient communication.                             ART DIRECTOR
                                                                                                      Jerry Kopec, Mortise+Tenon
of 300,000. Diagnostic error is the           Similar issues exist with initiating,
number-one cause of malpractice claims        completing, and communicating the                     EXECUTIVE MANAGEMENT
and is estimated to add $100 billion          results of specialty referrals.
                                                                                                 PRESIDENT AND CHIEF EXECUTIVE OFFICER
in unnecessary costs to the healthcare                                                                       William Cotter
system each year. And if these statistics     CTL has been studied and well-                             VICE PRESIDENT, CLAIMS
                                                                                                              Kari Adams
aren’t enough to motivate addressing the      described in the literature. There are
                                                                                            ASSOCIATE VICE PRESIDENT, DEPUTY GENERAL COUNSEL
problem, consider this: an inaccurate         a variety of reasons that test results                   Melissa Cunningham, JD
or delayed diagnosis is likely to lead to     do not receive timely and effective                   SENIOR VICE PRESIDENT, STRATEGY
                                                                                                           Christina Galicia
treatments or additional procedures that      follow-up, including transitions from
                                                                                                          SENIOR VICE PRESIDENT,
will be wasteful or harmful, while the real   inpatient to outpatient status, secondary          CHIEF FINANCIAL OFFICER AND TREASURER
                                                                                                             Kristin Kenny
underlying disease progresses unchecked.      or incidental findings that are not
                                                                                              SENIOR VICE PRESIDENT, BUSINESS DEVELOPMENT
                                              sufficiently prominent in reports or                           David Kinard
Improving diagnostic quality is not           appreciated by the ordering clinician,            SENIOR VICE PRESIDENT, GENERAL COUNSEL
                                                                                                          Mark Lewington, JD
simple. Diagnosis, by its very nature,        limitations on the designation of critical
                                                                                                       SENIOR VICE PRESIDENT AND
involves uncertainty. And there can be        value and its reporting imperatives,                     CHIEF INFORMATION OFFICER
                                                                                                            Leslie Mallonee
great heterogeneity in how different          split order result availability (especially
                                                                                                  SENIOR VICE PRESIDENT, UNDERWRITING
patients with the same problems               associated with “send-outs”), and failure                      Stella Moeller
present. Even pertaining to a single          to incorporate findings of specialty                     SENIOR VICE PRESIDENT,
                                                                                                 HUMAN RESOURCES AND ADMINISTRATION
patient, presentation can vary over           physicians into primary-care records.                          Alison Talbot
the course of the problem and lead
to diagnostic pitfalls.                       In this issue of The Physicians Report,                 BOARD OF DIRECTORS
                                              we’ll take a closer look at this important             David Carlson, DO, Chairman
Research into malpractices cases              opportunity to make a difference. In                          William Cotter
                                                                                                             Lloyd David
involving serious harm find that on           the area of diagnostic quality, there’s                     Joseph Deng, MD
average, there are more than three            not much low-hanging fruit, but closing                  Jordana Gaumond, MD
                                                                                                          Jennifer Hanscom
contributing factors to each case.            the loop is as close to that as possible.                 Chi-Dooh "Skip" Li, JD
With no consensus standards on                Readers are encouraged to seize that                      Shane Macaulay, MD
                                                                                                           John Pasqualetto
measuring diagnostic error—or even on         opportunity—their patients will be                           Ralph Rossi, MD
documenting diagnostic-safety events—         thankful for it.                                            Walter Skowronski

prioritizing and addressing sources of                                                               READ PHYSICIANS REPORT ONLINE
                                                                                                         phyins.com/magazine
error locally can be challenging.
                                                                                                       CONTACT PHYSICIANS REPORT
                                                                                                          editor@phyins.com
However, as the National Academy                                                                              HOME OFFICE:
                                                                                                              Seattle, WA
of Medicine asserts, “Improving
                                                                                                            Copyright 2021
the diagnostic process is not only                                                              Physicians Insurance A Mutual Company
                                              Paul L. Epner, MBA, M.Ed., CEO
                                              Society to Improve Diagnosis in Medicine
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
A PHYSICIANS INSURANCE PUBLICATION

     FEATURES
                                                                     8 Overcoming Systemic
                                                                       Challenges to Reduce
                                                                       Diagnostic Errors

                                                                    12 Case Study
                                                                       When Everything Is
                                                                       Done Right, Yet Stroke
                                                                       Diagnosis Is Missed

                                                                    24 Leader Insights
                                                                       Navigating to
                                                                       Avoid Care Gaps
     4 Closing the Loop
       Safe Practices for Diagnostic Results

MORE NEWS                             EDUCATION

20 Closing the Loop:                  19 Courses
   Considerations for How EHR
   Systems Can Help                   19 Resources

34 In the Chain of Communication:
   Reporting Results of Critical      GOVT. AFFAIRS
   Test Is Key
36 The Data Story: Diagnostic         30 Government Relations:
   Errors Account for Top Liability      2021 Legislative
   Claims and Lawsuits                   Session Update

MEMBER SPOTLIGHT                      MEMBER NEWS

16 Advancing Communication            40 2021 Physicians
   in a Growing Market: Idaho            Insurance Annual
   Urologic Institute                    Meeting and Proxy Vote
                                                                             SEND FEEDBACK
                                      40 Welcome to Our
                                         New Members!                       Tell us more about
                                                                            what you would like
                                                                            to see in upcoming
                                                                            issues. E-mail us at
                                                                            editor@phyins.com.
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
4

    CLOSING THE LOOP
    Safe
    Practices
    for
    Diagnostic
    Results
    By Patricia Giuffrida, MSN, RN, CPHIMS,
    and Robert C. Giannini, BS, NHA, CHTS—IM/CP

    In 2015, Improving
    Diagnosis in Health
    noted that 5% of U.S.
    adults seeking outpatient
    care experienced
    a diagnostic error.1
    A review of inpatient event reports indicates that diagnostic errors     Consider the following examples.
    account for 6–17% of reported adverse events,1 and failure to
    respond to new, actionable information is a frequent cause of            DELAYED DIAGNOSIS
    diagnostic error in both the outpatient and inpatient settings.          A patient was seen for evaluation of testicular pain from possible
                                                                             testicular torsion. An ultrasound was performed. The initial verbal
    Closing the loop means that all mechanisms are in place to               report stated that no torsion was seen. One week later, the final
    ensure that any patient data and information that may require            report noted a “suspicious mass,” with recommendations for the
    action are delivered and communicated to the right individuals,          patient to follow up with a urologist. The report was signed by
    at the right time, through the right mode, in order to allow for         both the nurse practitioner and the physician.
    interpretation, critical review, reconciliation, initiation of action,
    acknowledgement, and appropriate documentation.2 Failure                 Unfortunately, the patient was never informed, and returned
    to close the loop on diagnostic test results is one example              seven months later complaining again of pain. A large
    of a failure to respond to actionable information.                       testicular mass was discovered on physical examination.
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                                                                                                                                      THE PHYSICIANS REPORT | SPRING 2021
                                                 “Any failure to close these
                                                  loops holds the potential
                                                 for patient harm through
                                                     delayed, missed, or
                                                    incorrect diagnoses.”
                                            IT to close these loops? (See “Closing         In 2017, the Emergency Care Research
                                            the Loop: Considerations for How EHRs          Institute (ECRI) Partnership for
                                            Can Help” on page 20.)                         Health IT Patient Safety convened the
                                                                                           Closing the Loop Workgroup, chaired
                                            Failures to close the loop are                 by Dr. Christoph U. Lehman. The
                                            multifactorial and range from a test not       workgroup was comprised of health
                                            being performed at all, to a test not          IT vendors, clinicians, healthcare
                                            performed as ordered, to the results not       organizations, malpractices insurers,
                                            being returned to the clinician, to the        patient advocates, and representatives
                                            clinician failing to acknowledge those         from professional organizations and
                                            results. Each of these chains of events        societies, and held a goal to develop
                                            creates a loop with the potential for a        health IT safe practices for closing the
                                            break, with the patient being central to       loop to mitigate delayed, missed, and
                                            all the loops involving diagnostic testing     incorrect diagnoses.
                                            (e.g., provider to provider, provider to
                                            patient or caregiver, facility to provider).   ECRI and the Institute for Safe
                                            Any failure to close these loops holds         Medication Practices’ PSO analyst
                                            the potential for patient harm through         reviewed more than 800 relevant events
                                            delayed, missed, or incorrect diagnoses.       from the PSO database and performed
This example shows multiple points of                                                      an additional review of more than 80
failure. First, the verbal report had not   MISSED DIAGNOSIS                               medical malpractice closed-claims
provided all the information. Second,       A routine mammography was ordered.             reports. The analysis revealed that
despite the fact that the written report    The patient failed to have the test            failure to close the loop on diagnostic
was signed, its recommendations were        performed, but continued with her              testing is primarily seen with six types
not acknowledged. Finally, no actions       routine visits.                                of information (Table 1). The most
were taken—and as a result, the patient                                                    common failures for safety events
was not made aware of the “suspicious       Five years later, another routine              occurred in laboratory testing (61%),
mass” for seven months.                     mammogram was ordered for the                  followed by events related to imaging
                                            patient. The results indicated a breast        (12%). Data from closed medical
Failing to close the loop on diagnostic     lump with infiltrating ductal carcinoma.       malpractice claims suggest that
testing is not a new problem. While         Unfortunately, a chart review uncovered        imaging was the information most likely
the introduction of health information      a note from five years earlier, stating,       to not be communicated (at 36%),
technology (IT) was thought to be a         "Mammo pending; no result." This               followed by laboratory testing (23%)
ready remedy, the issue persists. The       indicates the patient was never followed       and pathology (18%).
question facing healthcare providers        up with, and thus the breast lump went
today is, how can they leverage health      undetected for five years.                                        (Continued on page 6)
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
6

    (Safe Practices, continued from page 5)
    Table 1. Prevalence of Reported Safety Events and Closed                                                      DIAGNOSIS NOT COMMUNICATED
    Malpractice Claims                                                                                            A patient admitted with shortness of
                                                                                                                  breath was diagnosed with pneumonia.
              AREA FOR FAILURE                                                MALPRACTICE CLOSED CLAIMS           The radiology study identified a lung
                                               EVENTS (%) (N = 848)
             TO CLOSE THE LOOP                                                      (%) (N = 82)
                                                                                                                  lesion; however, these findings were not
               Laboratory testing                        61                                23                     communicated to the patient. There
                                                                                                                  was no documentation of a follow-up or
                    Imaging                              12                                36                     workup related to the lung lesion. The
                                                                                                                  patient was admitted to the hospital six
               Other diagnostics                          5                                 8
                                                                                                                  months later, and was diagnosed with
                   Pathology                              2                                18                     an adenocarcinoma.

                   Treatment                              2                                 5                     Eliminating diagnostic error requires
                                                                                                                  closing the loop on diagnostic results—
                     Other                               18                                11                     adding a plethora of technology
                                                                                                                  alerts and reminders to an already
    Sources: Data were presented at the Closing the Loop Workgroup, July 11, 2017.
    Note: Event reports in the ECRI and Institute for Safe Medication Practices PSO database disproportionately
                                                                                                                  dysfunctional process for result
    represent the acute-care setting, as opposed to the ambulatory-care setting. Malpractice closed claims were   management will only obfuscate matters.
    primarily from the ambulatory setting.

                                                                                                                  The Closing the Loop Workgroup offers
    A critical result is defined as a result from a test that must be reported immediately                        the following three recommendations
    to a care provider, because it may require urgent therapeutic action. (See “Critical                          for communicating, tracking, and
    Results Testing” on page 34.) Using this definition, we also grouped information                              linking, along with references and tools
    that was not communicated by criticality. Both for events and malpractice claims,                             to facilitate their implementation:
    significantly abnormal noncritical results were more likely to not be communicated
    (see Table 2).                                                                                                SAFE-PRACTICE RECOMMENDATIONS
                                                                                                                  • Develop and apply information
    Table 2. Events and Claims by Criticality                                                                       technology (IT) solutions to
                                                                                                                    communicate the right information
                                                                    EVENTS (%)              CLAIMS (%)              (including data needed for
                               RESULTS
                                                                     (N = 848)               (N = 82)               interpretation) to the right people,
                             Critical value                              28                       0                 at the right time, in the right format
                                                                                                                  • Implement IT solutions to track
        Noncritical value but significantly abnormal result              55                      84                 key areas
                                                                                                                  • Use health IT to link and
               Critical value with test not specified                     5                       0
                                                                                                                    acknowledge the review of
                                                                                                                    information and documentation of
                                 Other                                   12                      16
                                                                                                                    the action taken

    Most failures to close the loop had multiple targets for notification. In reported                            Communicate
    safety events, staff were the most common target of communication (at 65%),                                   The recommendation to communicate
    followed by physicians (62%). However, for claims, the most common target                                     encourages stakeholders to design,
    was the physician (89%), followed by the patient (71%) and staff (46%).                                       test, deploy, and implement health IT
                                                                                                                  solutions that improve communication
    Not surprisingly, only 19% of reported events resulted in a delay in treatment or                             pathways and make closing the loop a
    diagnosis, while 96% of malpractice claims included a claim of delay in diagnosis                             seamless and elegant process, with all
    or treatment. In the case of events, this delay was triggered mostly by failure to                            diagnostic tests communicated to the
    report or communicate (80%) and lag in reporting or awareness (19%). For claims,                              provider, the pharmacy, and the patient
    the most common reason was that a provider acknowledged information and failed                                in a timely manner.
    to follow up (39%), followed by failure to report or communicate (30%), delay
    in reporting (21%), and unclear/ambiguous communication (16%).
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
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                                                                                                                                  THE PHYSICIANS REPORT | SPRING 2021
                   To guarantee closed-loop communication,
               it is essential to notify the patient of test results,
             including the follow-up plan, treatment, or therapy.
                   The loop begins and ends with the patient.

The lack of standardization in             To ensure successful communication,         Track
healthcare creates a dangerous             functionality must be available to          It is essential to implement health
inconsistency across systems. One          generate reminders and disperse             IT solutions to track key areas in
basic requirement for effective            information as needed. This                 the results-management process.
communication is the use of standard       functionality may require providers and     Providers, healthcare organizations,
nomenclature and structured data           provider organizations to reevaluate        and leadership all need to know when
(e.g., SNOMED CT, LOINC) to improve        their systems to ensure that all systems    a loop remains open. Accurate tracking
the overall efficiency and usability of    are working as intended. EHRs and           and monitoring of diagnostic results—
transmitted test results for reporting     clinical workflows must align to ensure     including occurrence, transmission
diagnoses. Today, providers work in        that work is being performed as             of information, acknowledgment,
multiple electronic health records         intended. Adopting and implementing         documentation, and responses—are
(EHRs) as they move from the inpatient,    standard nomenclature and terminology,      essential to identify closed loops.
ambulatory-care, and surgical centers.     display icons, and reporting criteria—
Information contained in records in        including the timing and results            The safe-practice recommendation
these various settings is not often        priority for reporting findings—will        suggests that tracking and monitoring
kept in the same location, formatted       make the process of closing the loop        of test results is critical to identify
the same, or readily retrievable; this     more efficient and effective. Finally, to   interruptions and potential failure
compromises safety, timely information     guarantee closed-loop communication,        points in the process, including the
gathering, and readiness to action. Well   it is essential to notify the patient of    ability to react to and remedy failures
thought-out and agreed-upon standards      test results, including the follow-up       to close the loop. Results that do
can help reduce the cognitive workload     plan, treatment, or therapy. The loop       not reach the intended recipient, or
of physicians.                             begins and ends with the patient.           that are not reviewed or acted upon,

                                                                                                         (Continued on page 28)
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
8

    Overcoming
    Systemic
    Challenges
    to Reduce
    Diagnostic
    Errors

                                                                     As part of its efforts to support higher quality and safety
    Medical errors are a leading                                     standards in healthcare, the Washington State Hospital
    cause of death in the United                                     Association (WSHA) performs ongoing work to discover the
                                                                     root causes of diagnostic errors, which may occur in up to
    States, causing preventable                                      15% of medical diagnoses, according to Johns Hopkins
    harm to around 400,000                                           Medicine. When the causes of diagnostic error are examined,
                                                                     some clear patterns emerge, says Trish Anderson, WSHA’s
    Americans annually, at a cost of                                 senior director of safety and quality.
    approximately $20 billion per year.
                                                                     “Some of the many causes of diagnostic error that we’ve been
    In "Preventing Medical Injury," published in the Quality         able to identify throughout healthcare settings are episodic
    Review Bulletin, researchers define four types of medical        care and limitations to clinical assessment, which affect
    errors: diagnostic errors, including missed or delayed           subsequent decision-making,” says Anderson. “Additionally,
    diagnosis; treatment errors, which include medication            there can be a lack of time for sufficient communication
    mistakes; preventative errors, or the failure to provide         between patients and providers and between clinicians.”
    protective monitoring or care; and other errors, which include   By addressing these core contributors to diagnostic error,
    communication failures.                                          organizations can make progress toward closing the loop.
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
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                                                                                                                                THE PHYSICIANS REPORT | SPRING 2021
                                           “You can have a spotless process
                                           with a beautiful checklist, but are you
                                           communicating well with the nurse
                                           or with the patient in terms of what
                                           needs to be done next?”
                                                                                            “Communication is
                                           Replacing face-to-face communication
                                           between providers and staff with                 where it really falls
                                           digital data stored in electronic health
                                                                                           apart. You can have
                                           records (EHRs) won’t solve systemic
                                           communication problems, notes Doten,             a spotless process
                                           who previously served as Chief of
                                           Emergency Medicine at Swedish                      with a beautiful
                                           Medical Center in Seattle. “I think            checklist, but are you
                                           electronic health records make some
                                           communication easier, but sometimes             communicating well
                                           it’s not effective because the signal-
                                           to-noise ratio is off; the piece of
                                                                                          with the nurse or with
                                           information that I need from the                the patient in terms
                                           patient’s medical history is in the
                                           EHR, but so is all of this additional           of what needs to be
                                           information. If I’m in the emergency
                                                                                               done next?”
                                           department with a patient and there are
                                           two pieces of medical information I need
                                           to make a decision, that information can        IAN DOTEN, MD, PHYSICIAN
                                           easily get buried in the data.”                  AND MEDICAL DIRECTOR,
                                                                                               INSYTU ADVANCED
                                                                                                 HEALTHCARE
                                           Reducing communication lapses                     SIMULATION, SEATTLE
                                           in medical settings remains a
                                           persistent challenge, in part because
                                           communication styles and preferences
                                           vary from person to person, says
                                           Ben Wandtke, MD, BMS, Vice Chair,          single communication touchpoint—
                                           Quality and Safety, and Chief of           for example, communicating with
CHALLENGE: COMMUNICATION                   Diagnostic Imaging at FF Thompson          patients about follow-up care via an
Miscommunication between providers         Health in Canandaigua, New York.           electronic patient portal—Wandtke
is a leading cause of diagnostic errors,   In his study “Reducing Delay in            found that establishing a series of
particularly during shift changes when     Diagnosis: Multistage Recommendation       different types of communication
caregivers hand off medical information    Tracking,” published in the American       interventions—including letters, phone
about patients to other providers.         Journal of Roentgenology, multiple         calls, and reminders from primary-
According to Stanford Medicine             communication interventions were           care providers—was most effective for
research, shorter shifts for medical       assessed to determine the most             closing the loop.
residents are increasing such              effective ways to communicate
handoffs, along with the risk for          with patients and providers about          A SYSTEMIC SOLUTION FOR
preventable errors.                        recommended follow-up care. “When          COMMUNICATION LAPSES
                                           we worked with patients, we found          Improving team communication through
“Communication is where it really falls    that they have variable preferences in     the creation of small work groups,
apart,” says Ian Doten, MD, a Seattle-     how they want to be communicated           teaching teamwork behaviors and
based emergency-department physician       with, so there’s not one communication     skills, and developing communication
and Medical Director at InSytu             method that works for everyone,”           habits for teams can help reduce
Advanced Healthcare Simulation.            he says. Rather than relying on a          communication-related errors,

                                                                                                       (Continued on page 10)
ERRORS DIAGNOSIS Closing the Loop on - THETHE - Physicians Insurance
10

     (Overcoming Systemic Challenges, continued from page 9)
     according to research supported by the       a patient’s hospital care contribute to      improve communication. But while
     U.S. Army. In their study of emergency-      the risk for medical error, particularly     information technology may support
     department malpractice incidents at          diagnostic errors and treatment errors,      patient safety in some instances, it
     eight hospitals, published in the Annals     during care transitions, says Wandtke.       has also been shown to contribute
     of Emergency Medicine, researchers           “There may be two or three hospitalists      to medical errors. According to
     judged more than half of the deaths or       making recommendations for follow-up         research published in the Journal of
     permanent injuries to be preventable         care, but only one puts in discharge         the American Medical Informatics
     through improved teamwork. The study         instructions for the patient,” he says.      Association (JAMIA), healthcare
     found an average of 8.8 teamwork             “So there are inherent risks in the          information technology can have
     failures per care episode.                   transition of care from hospital care to     unintended consequences that
                                                  outpatient care, and hospital offices are    contribute to diagnostic errors, from
     Collaborative goal-setting is another        not equipped with resources to provide       disrupting existing communication
     strategy that’s been shown to improve        appropriate safety nets to engage a high-    processes, to offering flawed decision
     communication between patients and           reliability approach to their healthcare.”   support, to overburdening providers
     providers and reduce the likelihood                                                       with tiring data-entry responsibilities.
     of inaccurately reported medical             A SYSTEMIC SOLUTION FOR
     information. In this model, patients         TRANSITIONS                                  “Electronic health records were built
     work with their providers to monitor and     Patient-centered approaches to error         for billing, not for patient care,” says
     report their progress toward personal        reduction are the key to reducing            Doten. “The challenge is designing
     health goals.                                medical errors, according to a study         tools that provide meaningful, real-time
                                                  published in Australian Prescriber.          information. With healthcare, especially
     CHALLENGE: CARE TRANSITIONS                  Actively involving the patient in            in the emergency room with a patient in
     The risk for medical errors doesn’t end      discharge planning and double-               cardiac arrest, a lot of the meaningful
     when patients leave the hospital or          checking prescription-medication             communication is in real time.”
     clinic. In fact, more than half of medical   instructions after each episode of care
     errors take place outside of a clinical      can reduce the risk of medication errors     While EHRs can support early diagnosis
     setting. Research shows that the risk        and adverse drug events. “Our health         by flagging certain patients for
     for medical error increases significantly    system needs to keep an eye on these         recommended cancer screenings, other
     after hospital discharge or episodic         patients,” notes Wandtke. “It is really      patients are easily missed. “EHRs have
     care: a study published in the Annals of     a chain of communication, and it can         been successful at identifying patients
     Internal Medicine found that more than       break at any point in the process.”          for breast-cancer screening and colon-
     50% of hospital patients experienced                                                      cancer screening, because it’s very easy
     a clinically significant medication error    CHALLENGE: ELECTRONIC                        to find patients in the system who are
     within 30 days of discharge.                 HEALTH RECORDS                               the right age and gender for screening,”
                                                  Electronic health records (EHRs)             says Wandtke. “For lung cancer, it
     Disjointed or nonexistent communication      can support more accurate medical            hasn’t been as easy, because it’s harder
     between the many providers involved in       diagnoses, create efficiencies, and          to identify a patient’s smoking history
11

                                                                                                                                         THE PHYSICIANS REPORT | SPRING 2021
in an EHR. As a result, there has been
slow uptake and low participation
[in lung-cancer screening] without
adequate tools in the EHR. We know
                                             Resources,
that about 5% of eligible patients
are receiving their screening for lung
                                             education, and tools
cancer, and that is concerning.”
                                             for closing the loop
A SYSTEMIC SOLUTION FOR EHRS
The JAMIA researchers focus                  NATIONAL ORGANIZATIONS                       Public Health Accreditation Board
their discussion on latent or silent         Agency for Healthcare Research and           A national non-profit accreditation
medical errors that result from a            Quality (AHRQ)                               body dedicated to improving quality,
mismatch between the function of the         The federal agency leading nationwide        safety, and performance among
information-technology system and the        efforts to improve diagnostic safety,        tribal, state, local, and territorial
day-to-day demands of healthcare work.       the AHRQ offers a Diagnostic Safety          public health departments.
This mismatch contributes to two main        and Quality Toolkit and measures state
categories of errors that organizations      performance on quality and safety            Surgical Outcomes & Quality
must address to effectively improve          metrics in its State Snapshots.              Improvement Center (SOQIC)
quality and safety: errors in the process                                                 Created to drive safety and quality
of entering and retrieving information,      American College of Radiology                research and develop improvement
and errors in the communication and          Commission on Quality and Safety             strategies for surgical care across the U.S.
coordination processes the system            The Commission on Quality and Safety
is designed to support. Information-         provides oversight and management            The Joint Commission
technology systems must address              for all radiology quality and safety         The nation’s oldest and largest
these two main categories of errors          programs and initiatives of the ACR.         standards-setting and accrediting
to facilitate safer care.                                                                 body in healthcare, the Joint
                                             Child Health Patient Safety                  Commission offers patient-safety
Involving the EHR’s end users—doctors,       Organization                                 education and resources.
nurses, and other key personnel—in the       The only patient-safety organization
system’s design and implementation           dedicated to children’s hospitals that is    ARTICLES AND TOOLS
can facilitate a better match between        recognized by the AHRQ.                      Denver Health Medical Center.
the system and the needs of its users.                                                    Improving Patient Safety Through
“As medicine gets more complex, we           Emergency Medical Error Reduction            Provider Communication Strategy
need to make sure it works for the end       Group (EMERG)                                Enhancements Toolkit.
user,” says Doten. “The people closest       Part of the non-profit Center for
to the work should design the work. You      Leadership Innovation and Research           AAP News. “Improve Patient Handoffs
can set goals as an organization, but        in EMS, EMERG promotes continuous            to Prevent Medical Errors, Reduce
what’s meaningful is how you actually        improvement within the field of              Malpractice Risk.”
execute them when you get down to the        emergency medicine.
doctors and nurses.”                                                                      EHRIntelligence. “Reducing Medical
                                             Institute for Healthcare Improvement (IHI)   Errors with Improved Communication,
CHALLENGE: COVID-19                          Created as part of the National              EHR Use.”
The COVID-19 pandemic is likely to           Demonstration Project on Quality
increase rates of diagnostic errors for      Improvement in Health Care, the IHI          Pocket Guide: TeamSTEPPS. Agency
several reasons, according to 2020           offers education and resources on            for Healthcare Research and Quality.
research from the Society of Hospital        reducing medical errors, including its       “Team Strategies & Tools to Enhance
Medicine. Early in the pandemic,             Triple Aim framework for optimizing          Performance and Patient Safety.”
rapidly evolving diagnostic information      health-system performance.
for COVID-19 made missed or delayed                                                       HealthIT.gov. “Improved Diagnostics and
diagnosis more likely. Situational factors                                                Patient Outcomes.” U.S. Department of
including staffing shortages, staff                                                       Health and Human Services.

                  (Continued on page 38)
12

                      You could do everything right.

      You could make a judgment that isn’t questioned by your peers.

                   You could meet the standard of care.

     But the patient could still be harmed—and then you could be sued.
13

                                                                                                                                    THE PHYSICIANS REPORT | SPRING 2021
Having strong backup support can make or break the outcome.
That’s what happened to Dr. Dalvi, a Seattle radiologist.         her head hurt so badly. Then she couldn’t speak clearly for
And what happened to his patient, Allison Carter, baffled the     two minutes. 911 was called immediately, but her speech
many medical providers she encountered in October 2014.           was normal by the time the paramedics arrived. Carter, who
                                                                  had a previous history of anxiety, stated that she must have
In the following case, the names of people and facilities         panicked. She was transported to a local hospital.
have been modified for privacy protection. Consider how
each component affected the diagnostic process and the            No Signs of Stroke
eventual outcome.                                                 The doctor who evaluated Carter at the hospital suspected
                                                                  dissection and/or stroke, so he initiated an MRI stroke
Puzzling Pain                                                     protocol, which is a diagnostic imaging order set. The set
At the time, Carter was a 26-year-old assembly mechanic in        was read by Dr. Dalvi. Of the 1,600 images generated, Dr.
manufacturing at Boeing. Her health odyssey began when she        Dalvi found no signs of stroke and concluded there was no

              Carter returned to the local hospital the
           next morning, after waking up unable to speak.

experienced neck pain for several days, followed by a headache    dissection present. Based on Dr. Dalvi’s findings, the doctor
for 24 hours. On October 12, she went to the urgent-care clinic   prescribed a migraine cocktail, and Carter was discharged.
and was diagnosed with sinusitis and discharged.
                                                                  Carter returned to the local hospital the next morning, after
But the headache continued for three more days. In fact,          waking up unable to speak. The doctor who evaluated her
it was severe enough to keep her awake at night. On October       discussed her condition with a hospital neurologist, who
15, she visited her primary-care physician. The doctor ordered    agreed to see her for an outpatient evaluation.
a CT to rule out a hemorrhage, which was performed later that
day at a local hospital. The physician who interpreted the        In the meantime, Carter’s primary-care physician consulted
CT saw no acute disease or source at the root of                  with the neurologist at the local hospital about Carter’s
Carter’s problems.                                                condition. Carter met with the neurologist on October 24 for
                                                                  an urgent neurological evaluation. She now also had weakness
Carter’s headache continued for six more days. On October         and numbness on the left side of her face and in her left leg.
21, she saw a chiropractor near her home. She told him she        He noted that “although symptoms are suggestive of a cortical
had sharp, shooting pains in her neck when she moved her          process, such as a brainstem stroke, her MRI brain stroke
head, and that her primary-care physician had told her that       protocol was unremarkable.”
her headache was probably coming from her neck.
Based on her symptoms, the chiropractor diagnosed her with        He later testified that he’d reviewed the actual imaging read
a cervicogenic headache.                                          by Dr. Dalvi in detail, and not just Dr. Dalvi’s report of the
                                                                  same. He testified that he agreed with the report and that
He performed a diversified-technique adjustment to her            he felt there was no evidence of dissection or stroke on the
cervical spine. When Carter sat up, she started crying because    imaging. Based on his review of the imaging and his exam,
                                                                  he ruled out dissection and stroke.

                                                                                                           (Continued on page 14)
14

       “The lesson is, even
     when you do everything
      right, you can still get
        sued—but having a
     strong supportive team
     makes the difference.”
            LAUREN HALEY, CLAIMS MANAGER,
                PHYSICIANS INSURANCE

     (When Everything Is Done Right, continued from page 13)

     Mental-illness Diagnosis                                             who agreed with the night-read and also found “no acute
     Later that day, Carter went to the emergency department at a         intracranial process.”
     Seattle tertiary-care hospital. She told medical professionals
     there that she had fallen to the ground after her visit to the       Carter was admitted to the Seattle hospital in the early
     neurologist. A neurology consult was ordered, and neurologists       morning of October 27. Later that afternoon, while still in the
     there also suspected dissection, but ruled it out because            hospital, Carter was suddenly unable to speak or swallow. She
     it wasn’t found on the previous radiology reads. Doctors             could move her left extremities but nothing on her right side.
     discussed the possibility of anxiety affecting her presentation of
     symptoms. She was discharged with a diagnosis of a mental-           She had another CT in the middle of the night, and her
     health condition.                                                    symptoms continued to wax and wane. After the CT was read in
                                                                          the early morning hours, the radiologist reported to her doctor
     Rapid Decline                                                        “a critical result,” namely, there were bilateral vertebral artery
     In the evening of October 26, while watching TV at home,             dissections/occlusions in the distal ends at the V-4 segments,
     Carter started drooling, lost bladder control, and became            as well as a complete occlusion of the basilar artery.
     unresponsive for several minutes. Her husband took her to
     the emergency department at the local hospital. There was            At 6 a.m, Carter was intubated and Code Stroke was
     no available on-call neurologist at that time, so she was            initiated. An MRI showed an acute infarct of the pons. The
     transferred via ambulance to a Seattle hospital. A repeat head       on-call endovascular neurosurgeon decided to perform a
     CT was ordered prior to transfer.                                    cerebral angiogram with acute stroke intervention. Catheter
                                                                          angiography revealed dissection of the bilateral vertebral
     The remote night-read radiologist found “no acute or active          arteries and occlusive thrombus in the basilar artery. The
     intracranial process” and “no change” compared to the October        surgeon removed the blood clot from the basilar artery, with
     15 CT. The CT was subsequently read by Dr. Dalvi’s partner,          some difficulty.
15

                                                                                                                                       THE PHYSICIANS REPORT | SPRING 2021
                                            Lawsuits Filed                                 The plaintiffs’ attorneys tried to argue,
                                            Carter sued three hospitals and                using expert testimony, that Dr. Dalvi
                                            seven different medical providers,             should have recommended additional
                                            alleging medical negligence and loss           imaging. However, defense experts did
                                            of consortium claims against each              not identify any findings of dissection
                                            defendant, including allegations that          on the stroke protocol and found that
                                            Dr. Dalvi breached the standard of care        the standard of care didn’t call for
                                            by failing to identify dissections.            additional imaging.

                                            At the outset of the case, all of the          Strong Support Is Key
                                            defendants and their attorneys planned         The jury agreed with Dr. Dalvi’s
                                            to work as a team against the claims.          defense, and he won the case.
                                            The plaintiff voluntarily dismissed the
                                            cases against the emergency-room               “The lesson is, even when you do
                                            doctors. The rest of the defendants            everything right, you can still get sued—
                                            settled—except Dr. Dalvi, leaving him          but having a strong supportive team
                                            as the only remaining defendant.               makes the difference,” Haley says.

                                            Lauren Haley, Claims Manager at                And if you do get sued, Aye says, trust
                                            Physicians Insurance, who worked on            your defense team. “Understandably,
                                            Dr. Dalvi’s case, had to decide whether        it’s hard for a doctor to be in the role
                                            she and Dr. Dalvi would settle as well,        of ‘patient’ in the hands of other
                                            or take their chances at trial.                professionals,” she says. “They’re not
                                                                                           used to that. But working together as
                                            “Of course, when all the other defendants      a team is the best way to help us build
                                            settle, you have to consider doing the         the strongest defense possible.”
                                            same,” Haley says. “Sometimes it does
Slow Recovery                               make sense. But we don’t take a seven-         Being sued is always devastating to
Following surgery, Carter developed         figure settlement lightly.”                    a doctor, Haley notes. “They’re being
acute respiratory failure and remained                                                     told someone suffered because of what
in a coma. On October 30, a neurologist     Once Dr. Dalvi’s defense team got              they did or didn’t do,” she says. “It
noted an improving exam but gave her        feedback from other experts, they knew         leaves a scar.” As evidenced by Dr. Dalvi
a poor prognosis. She was taken off         his actions were defensible. “He did           messaging both Haley and Aye on the one-
the ventilator on November 15, then         everything right,” Haley says. “Three          year anniversary of the verdict to thank
was discharged to a skilled-nursing         different hospitals and seven different        them again, it sticks with you—even when
facility on December 2 and transferred      doctors didn’t catch it. The reality is, her   it ends as well as it could have.
                                                                                                                         PR  PR

to inpatient rehab on February 10. She      presentation was atypical, and despite
remained there until March 3, when          everyone’s best efforts, the medical
she was finally discharged home. She        professionals were unable to identify the                           Miranda Aye, JD,
received rehab services at home until       root of the problem. Unfortunately, this                            Partner, Johnson
switching to outpatient therapy in April.   sometimes happens.”                                                 Graffe Keay,
                                                                                                                Moniz & Wick
She plateaued with occupational and         Still, it was a risky stance. According
physical therapy in 2016. She now           to Dr. Dalvi’s defense counsel, Miranda
walks slowly with a walker or four-point    Aye, the plaintiffs’ legal representation
cane, and has a speech impediment.          and expert witnesses were very strong.                              Lauren Haley, JD,
She was unable to return to work at         Additionally, “the plaintiff was very                               Claims Manager,
Boeing. In 2018, she gave birth to her      sympathetic at trial,” Aye says. “She                               Physicians Insurance
first child, a healthy girl. Her mother     was young, with a new baby, and she
and sister help her with housework and      had worked so hard to recover.”
childcare, while her husband works.
16
     MEMBER SPOTLIGHT

     Advancing
     Communication
     in a Growing
     Market
     Idaho Urologic Institute

     With clinics in Boise, Nampa,
     and Meridian, Idaho Urologic
     Institute (IUI) serves one of
     the country’s fastest-growing
     populations.
     According to the latest U.S. Census, the Boise metropolitan region     men, women, and children at three clinics and collaborates with
     is the eighth fastest-growing area in the country. The influx of new   more than 20 surgeons of varying specialties at IUI’s ambulatory
     patients makes effective communication an evolving challenge,          surgical center in Meridian. Since taking the helm seven years
     says Gregory Feltenberger, Ph.D, IUI’s chief executive officer.        ago, Feltenberger has implemented continual communication
                                                                            improvements to keep up with the region’s dynamic needs.
     “Our region is experiencing rapid growth, with about 150 people        “Communication is a forever project, and it is consistently the
     moving here each day,” he says. “The majority of them are over         biggest area of focus for improvement and change,” he says.
     50, and we don’t know what kind of care they had previously—
     each one is like a brand-new patient in our system.”                   Here, Feltenberger highlights some key communication
                                                                            initiatives that have allowed IUI to provide world-class care
     Communicating across disciplines and locations is critical to IUI’s    for its growing community.
     success, because its staff of 14 dedicated providers cares for
17

                                                                                                                      THE PHYSICIANS REPORT | SPRING 2021
                                               providers can easily communicate with
                                               one another. Our radiologists are onsite
                                               doing their reads and collaborating with
                                               physicians, which is far more streamlined
                                               than what you might find elsewhere.
                                               We’ve got a medical director who oversees
                                               the surgical center and the IUI ancillary
                                               space, one of the physicians oversees           “Communication
                                               another clinical quality zone, and another
                                                                                                   is a forever
                                               physician is our lab director. As a result,
                                               we’re far more agile and communication            project, and it
                                               is far more efficient—and this shows in
                                               our statistics and outcomes. Our 2020
                                                                                                 is consistently
                                               infection rate was 1 percent, whereas            the biggest area
                                               typical rates in hospitals are in the
                                               2 to 4 percent range.                               of focus for
                                                                                                 improvement
                                               HOW DO YOU ENSURE THAT
                                               NEW HIRES THRIVE IN THIS                           and change."
                                               HIGHLY COMMUNICATIVE,
                                               EFFICIENT ENVIRONMENT?                         GREGORY FELTENBERGER,
                                               With new hires, we’re looking for a great         PH.D, CEO, IDAHO
                                               fit with our professional family. So much        UROLOGIC INSTITUTE
                                               of their success is based on fit. I hold
                                               a 30-day meet-and-greet with all new
                                               employees where I ask them, what’s
                                               going well? What do you need? What’s
                                               not going well?

                                               Because our physicians are owners,
                                               they are truly invested in the success
                                               of the organization, their relationship
                                               with their patients, and their connection
                                               to the organization.

                                               HOW HAVE YOU WORKED TO
                                               IMPROVE COMMUNICATION
                                               BETWEEN PROVIDERS, STAFF,
                                               AND IUI LEADERSHIP?
IDAHO UROLOGIC INSTITUTE                       We have implemented increased
PROVIDES COORDINATED UROLOGIC                  rounding among our staff and improved
CARE FOR MEN, WOMEN, AND                       communication with our leadership team,
CHILDREN, FROM DIAGNOSIS TO                    from a weekly meeting with physician and
TREATMENT TO RECOVERY. HOW DOES                staff leaders to a monthly meeting with our
THIS MODEL CREATE EFFICIENCIES                 board. Additionally, over the past two years
FOR PATIENTS AND PROVIDERS?                    we have implemented a transition to a new
We’re a lower-cost provider of high-quality    electronic health records (EHR) system
care. Our services generally cost 50 to 80     to facilitate improved communication
percent less than if the patient were to get   throughout the organization.
the exact same treatment in the hospital.
We have created an environment where

                                                                  (Continued on page 18)
18

           For patients with
          advanced prostate
          cancer, IUI’s linear
         accelerator provides
             more precise
            treatment with
            less damage to
         surrounding tissues.
                                                                                                   FAST FACTS
                                                                                                   ESTABLISHED: 2005

                                                                                                   LOCATIONS: 3

                                                                                                   PROVIDERS: 9 physicians
                                                                                                   and 5 PAs (across three clinic
                                                                                                   locations)

                                                                                                   MEMBER SINCE: 2010

     (Member Spotlight, continued from page 17)

     WHAT FACTORS DID YOU CONSIDER                 a year, but of course we did not anticipate    involved our PAs and scribes in designing
     BEFORE DECIDING TO TRANSITION TO              the COVID-19 pandemic. Pre-pandemic,           templates within the EHR to streamline
     A NEW EHR SYSTEM IN 2020?                     we had planned to transition to the new        patient visits. It is an ongoing process;
     When I first arrived at IUI, they were        system in April and May, and temporarily       we’re still optimizing our templates based
     using an EHR system that was a complete       lower our patient volumes during the           on our physicians’ preferences.
     suite of modules for billing, practice        rollout. We planned to be back at normal
     management, and scheduling. Our practice      volumes within a month, but then COVID         HOW DID YOU KEEP CLINICAL
     was one of the first to use the system,       hit and naturally decreased our volumes        STAFF INVOLVED AND UP-TO-DATE
     so we were instrumental in helping its        for a longer period. We were changing a        DURING THIS TRANSITION?
     developers by sharing our comments and        lot of our workflows in response to COVID      Going into this transition, I knew that I
     feedback. But we found that that company      just as everyone was learning the new EHR      wanted to have clinical staff be closely
     wasn’t as responsive as we’d hoped, and       system, which was a challenge. Hindsight       involved. When you have an IT professional
     that the system was based on antiquated       is 20/20, and had we known about               who spends most of their time writing
     programming language. We saw the need         COVID’s impact, we might have delayed          code and then has to come out as part
     to move to a cloud-based system for a         the launch. But by the time the pandemic       of an EHR implementation team and
     higher level of security, where we would no   hit, we had been planning the transition       train physicians on clinical workflows,
     longer need to house our servers onsite.      for 18 months, so that train had left the      there’s a huge gap in communication,
     We rolled out the new system in spring of     station, so to speak.                          understanding, and frame of reference. I
     2020 during COVID-19, which posed an                                                         didn’t want IT professionals determining
     additional challenge.                         However, with lower patient volumes            our clinical workflows in the EHR system
                                                   during the spring, we were able to involve     without appreciating what real clinical
     HOW DID IMPLEMENTING A NEW                    more clinical staff in the transition, which   workflows should look like.
     SYSTEM DURING THE PANDEMIC                    was important to the project’s success.
     IMPACT YOUR EHR TRANSITION?                   We shifted the bulk of our physician-          It made all the difference in the world to
     The transition was planned for more than      assistant visits to physicians and             have clinical staff become super-users
19
                                               EDUCATION
of our new system—the individuals who
can take the lead on the implementation         COURSES
from the clinical side. Our medical
director, Dr. Todd Waldmann, became            We’re continually adding courses and        settings. You will explore the types of
a super-user, as did one of our more           other resources to our library—all free     medical errors, including error-prone
experienced PAs, Missy McClenahan. I           to our members. Visit phyins.com/           situations, and use of root-cause
recommend for others that someone with         courses to search for a wide array of       analysis to determine why and how an
a clinical background take a leadership        titles, including:                          error has occurred. You will also explore
role in the entire process, from planning                                                  best practices that will help improve
to implementation. If I ever go through        Medical Error Prevention                    client safety and outcomes within your
another EHR transition, that is definitely     for Healthcare                              organization. Finally, you will learn your
something I’ll do again.                       Professionals (1 Credit)                    responsibilities regarding the reporting
                                               Given the significant impact that           of medical errors.
WHAT OUTCOMES CAN YOU SHARE?                   medical errors can have on health and
Our transition is ongoing, because we are      safety, all licensed professionals caring   phyins.com/courses
still refining our new system and running      for patients must understand how these
it in parallel with our legacy system, which   errors occur and how to prevent them.
was part of our plan. We are still using the   This course will discuss the factors
billing module in our legacy system, and       that increase risk for medical errors,       RESOURCES
plan to transition completely to the new       and how root-cause analysis and other
system by the end of this calendar year.       evidence-based strategies can aid in        • Steps-In-Dealing-With-An-
                                               preventing them. In addition, five of the     Unanticipated-Event_0.pdf
But anecdotally, physicians have shared        most misdiagnosed medical conditions
that the new system, in combination with       will be reviewed, along with strategies     • WA-OR-ID-WY-Response-To-A-
the use of medical scribes by some of          for preventing misdiagnosis.                  Subpoena-For-Medical-Records-Or-
our physicians, has created significant                                                      Deposition.pdf
efficiencies. Physicians were spending         Reducing Medical
two to three hours at night inputting          Treatment Errors                            • Utilizing-Curbside-Consults.pdf
patient data into our old EHR, and that        in Behavioral Health
burden has been dramatically reduced.          (1 Credit)                                  • Moving to Dismissal of Care.pdf
We have created the capacity for two           In this course, you will learn the
additional patient visits per provider         scope of medical treatment errors           • Upset Patient Letter
per day. Additionally, we have the cost        within the overall healthcare system
savings of not needing to house servers        and specifically in behavioral-health         phyins.com
onsite. COVID-19 threw us a curveball,
but overall, this has been a positive
change, and one that has enhanced
communication among physicians and
between providers and patients.

ABOUT IUI
Idaho Urologic Institute provides advanced
urologic care for men, women, and
children, including diagnostic imaging,
minimally invasive surgery, and radiation                          VISIT PHYINS.COM/COURSES
oncology. Providers care for patients at
three locations in Boise, Meridian, and
Nampa, and perform surgical procedures                                  to learn about the CME that is
at a multispecialty ambulatory surgery                                  included with your Physicians
center on the Meridian campus.
                             PR   PR                                Insurance policy at no additional cost.
20

     CLOSING THE LOOP
     Considerations
     for How
     EHR Systems
     Can Help
     When correctly implemented,
     electronic health record (EHR)
     systems can help physicians deliver
     safe, quality care. In a national survey
     of physicians conducted by the U.S.
     Department of Health and Human                                  Economic Journal, EHR system adoption resulted in “a 27%

     Services, 75% reported that their                               reduction in aggregated patient safety events, a 30% decline
                                                                     in negative medication events, and a 25% decrease

     EHRs improved patient care, and 88%                             in complications regarding tests, treatments, or procedures.”

     found that their system generated                               But EHR systems are most effective at reducing errors
                                                                     and improving safety when they fit seamlessly into an
     clinical benefits for the practice.                             organization's goals, culture, and clinical practices. When
                                                                     they don't, substantial risk-management and reimbursement
                                                                     challenges can arise, according to Bret Connor, senior vice
     Research that shows the right EHR system can reduce risk and    president and chief customer officer with Athenahealth, a
     save money for healthcare organizations. A study published in   provider of cloud-based EHR technology. “The closure of key
     Healthcare Financial Management reported that a community       care gaps has become much more complex than in the past,
     hospital saw a 60% decrease in near-miss medication events      so it’s critical that the EHR tool can keep up,” he says.
     after implementing an EHR system. Another study published
     in the Southern Medical Journal found that using an EHR         The following considerations will help organizations
     facilitated improvements to documentation and coding that       select, integrate, and employ an EHR system that delivers
     yielded a cost savings of more than $100,000. In a seven-year   multifaceted value, both as an enhancement to clinical
     study of Pennsylvania hospitals published in the American       practice and as a valuable error-prevention tool.
21

                                                                                                                                      THE PHYSICIANS REPORT | SPRING 2021
                                              The selection of an EHR system should be a
                                              multidisciplinary process involving clinicians
                                              and support staff, along with administrators.

                                              administrators. Allowing the end users       group and $5–20 million for a hospital.
                                              of an EHR system to provide input in         But implementation costs are only one
                                              the selection process helps eliminate        part of the system’s long-term costs.
                                              unwanted surprises down the road, notes      To accurately compare pricing between
                                              Tennant. He also recommends speaking         prospective EHR systems, organizations
                                              with colleagues in other organizations       must consider maintenance and other
                                              who have successfully selected and           fees associated with the system’s total
                                              implemented an EHR system, particularly      cost of ownership.
                                              those with firsthand experience related to
                                              systems you’re considering.                  “Critical for the practice, as you
                                                                                           develop your project budget, is
                                              “In addition to discussing the products      clearly understanding your financial
                                              with the vendors and viewing demos,          commitment in terms of both the
                                              we recommend reaching out to                 up-front price of the software and
                                              colleagues in similar-sized practices        the ongoing maintenance fees,” says
                                              and in the same specialty who have           Tennant. “Also, inquire about any
CONSIDERATION 1:                              implemented an EHR,” says Tennant.           potential add-on expenses, such as the
STAKEHOLDER SUPPORT                           “Talking directly to end users, not just     cost for additional training or fees for
The first challenge for practices is          to sales representatives, will give you      modifying clinical templates.”
determining which EHR system to               more unbiased perspectives on the
select, says Robert Tennant, director of      performance of the software in real-         An EHR’s hidden costs are any
health information technology policy for      world applications, and a better insight     expenditures not included in its
the national Medical Group Management         into the vendor-contracting process.”        up-front pricing, from licensing and
Association (MGMA). “We’re talking                                                         maintenance to consulting and labor.
about an enormous change to both              CONSIDERATION 2: SUSTAINABILITY              Even less obvious are the costs like
the administrative and clinical sides         A sustainable, safety-enhancing EHR          decreased revenue or reduced patient
of the organization, and a significant        system must fit comfortably within           volumes during EHR implementation or
investment for the practice in terms of       an organization’s budget, both now           transition. “Inevitably, however much
staff time and financial resources,” he       and for years to come. Costs for EHR         you expected to pay, you always end up
says. “With this in mind, it is critical to   implementation and maintenance vary          spending more,” says Tennant.
make the right software choice.”              widely, depending on the needs of each
                                              healthcare organization. According to        CONSIDERATION 3: SCALABILITY
The selection of an EHR system should         research and consulting firm EHR in          The ideal EHR system is both
be a multidisciplinary process involving      Practice, a typical EHR implementation       reliable and responsive, serving an
clinicians and support staff, along with      costs $162,000 for a small physician         organization’s current needs with the

                                                                                                             (Continued on page 22)
22

             “For a doctor to have the ability to use an EHR to access insurance
           authorizations, potential medication interactions, and other medical
       information during a patient visit, in real time, means that physician can
                                  offer better, safer guidance to the patient.”
                                                   ROBERT TENNANT, MA, DIRECTOR OF HEALTH
                                                    INFORMATION TECHNOLOGY POLICY, MGMA

     (Considerations, continued from page 21)
     ability to adapt rapidly to growth,             these legacy models.” When evaluating       “An EHR solution needs to integrate
     regulatory changes, and emergency               prospective EHR vendors, inquire about      with an organization’s practice-
     scenarios. “When a medical practice is          how the system is updated, scaled,          management system and its revenue-
     making technology decisions, I suggest          and modified. Do system updates or          cycle process,” agrees Connor. “It
     they choose a platform that is modern,          additions take place on-site, or in the     needs to be able to share clinical data
     scalable, and easy to use for both              cloud? Additionally, inquire about          with other systems. This connectivity
     providers and staff, and that will deliver      how data from another practice or           is critical to success, providing a
     great outcomes,” says Connor.                   organization might be integrated into       more holistic view of medical-practice
                                                     the system in the event or a merger,        performance and contributing to
     Modern cloud-based EHR systems offer            acquisition, or consolidation.              the delivery of high-quality care
     maximum flexibility for growth and                                                          to patients.” Incorporating staff or
     organizational change, notes Connor,            CONSIDERATION 4:                            administrators from an organization’s
     because adjustments and updates to              REVENUE MANAGEMENT                          billing department into the selection
     the organization’s system can be rolled         Securing medical records for billing and    and implementation process can help
     out across an entire health system              Medicare reimbursement are critical         ensure that a new EHR system fits an
     almost immediately. This allows multi-          for healthcare organizations, notes         organization's business practices as
     hospital systems to operate seamlessly          Tennant. “Patient medical and billing       well as its clinical needs.
     and continuously as updates take place.         records are the lifeblood of the practice
     But most healthcare systems still use           and must be protected,” he says. “If        CONSIDERATION 5:
     on-site hosted EHR systems that differ          you’re moving to an EHR, you need to        CLINICAL INTERFACE
     from clinic to clinic or hospital to            work with your vendor to determine the      The most technologically advanced
     hospital, making them more difficult to         most appropriate approach to backing        EHR won’t help reduce medical errors
     scale, adjust, and maintain.                    up these data. With the two most            if it interrupts a physician’s preferred
                                                     important words in practice management      workflow or contributes to fatigue.
     “Healthcare lags behind other industries        being ‘what if,’ the practice must          By adding to a physician’s burgeoning
     in the adoption of modern technology            establish protection and contingency        workload, EHR systems can escalate
     solutions,” Connor notes. “As far               protocols in the event of the data being    physician burnout, according to
     as EHR, practice-management, and                compromised due to cyberattack, theft,      research published in the Annals of
     revenue-cycle solutions go, most                and natural disasters such as fires or      Internal Medicine. “We know that EHR
     healthcare providers are still using on-        floods. Preferably, your data should be     fatigue is contributing to burnout,
     premise technology or hosted versions of        backed up in the cloud and immediately      so we’re thoughtful in the way we’ve
     on-premise software. I would estimate           accessible, should it be needed.”           designed our EHR platform,” says
     that 90% of the industry is still utilizing                                                 Connor. “We want to minimize the
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