Fletcher Allen, a Vermont university hospital and medical center, serves all of
Vermont and the northern New York region. Located in Burlington, Fletcher Allen is a regional, academic healthcare center and teaching hospital in alliance with the University of Vermont.
The Center provides providers and administrators with resources for special internal projects. Generally, these are student-led projects in collaboration with a business school faculty member. In some instances consultants are utilized for more specialized experience. These special innovation projects are designed to strengthen the financial sustainability of individual departments, clinics and sites at Fletcher Allen. It is the hope of the Center that by transferring the knowledge, learning and recommendations from these projects across Fletcher Allen that best practices will be continuously improved upon.
Recent Innovation Projects
Understanding Cost and FTE Implications Under Potential GME Federal Funding Cuts
Authored by: Sarah Lomas, MD; Abigail Trutor, MBA; Yuang Zhang, MS
Project Leads: David Adams, MD; Paul Taheri, MD, MBA
With the looming threat of federal funding cuts to GME programs nationally after the National Commission on Fiscal Responsibility and the Medicare Payment Advisory Commission issued a report on the state of indirect medical education payments, the Center for Health Care Management was asked to build a model that would help leaders better understand the cost and FTE implications in the event of such a cut.
The potential impact to Fletcher Allen’s GME program ranges from $2 million - $10 million, depending on the size of the funding cut. Using an online survey that generated a 72% response rate from residents and fellows, and other relevant data, the Center built a dynamic, flexible Microsoft Excel model to (a) define the work that residents perform, (b) identify substitute providers for the defined word, (c) respond to an unknown % reduction in funding, and (d) determine the cost and FTE requirements to either replace the residents with substitute providers or fund them internally. Findings show that on average, Fletcher Allen would need 1.8 substitute FTEs to replace 1.0 resident FTE, with costs almost triple the cost of a resident.
Analyzing Physician EHR Usage Patterns Utilizing Sequential Pattern Analysis
Authored by: Wuxia Hua, MS; Philip Maynard, BS
Project Leads: Abigail Trutor, MBA; Tim Burdick, MD; Dawn Godaire,Director Clinical Operations
The Physician Utilization of PRISM1 project was intended as a follow-up to previous projects at the Center for Health Care Management. These projects focused on the implementation of an Electronic Health Record (EHR) system and physician satisfaction with the EHR that was implemented in 2009. The scope of this project was to find identify difficulties that physicians encountered within PRISM, specifically those of attending physicians in outpatient departments using PRISM during patient visits. Audit Trail data was utilized and required rigorous preparation before it could be analyzed. This involved understanding how PRISM records activities, removing events triggered behind the scenes, removing repeating data, and selecting activities that were most frequently accessed and most pertinent to the users we were analyzing.
Using Sequential Pattern Analysis (SPA) with MATLAB software many common physician usage patterns were identified, some as long as eight events, but the majority of them were shorter sequences as they had higher frequencies. From these findings, we have four recommendations for areas of improvement. First, reorganize Visit Navigator and removed unused activities. Second, reorganize tabs in chart view based on common pairings. Third, make pinning the Progress Notes to the sidebar a default setting, allowing physicians the ability to navigate through PRISM while keeping their notes open. Finally, give “Pin to Sidebar” functionality to other commonly-used activities, such as meds and orders and level of service.
Physician Fee Schedule: Assessing the Level Playing Field of Band 'A' Payers
Authored by: Yuan Zhang, MS
Project Leads: Rick Vincent; Mike Barewicz, MBA
The goal of this project was to leverage a study completed in 2010 to re-assess our current fee schedule and identify major variations among Band A payers. Using CPT/ E&M codes with associated benchmarking we are able to assess our fee schedule to develop a model for scenario and sensitivity analyses that will aide in ongoing negotiation support. A conversion factor model was created that converts the RVUs for each medical service into a dollar payment amount. The conversion factor is calculated following a formula from Milliman consulting firm’s white paper, which is simply the total dollars divided by the total RVU for each category. We were then able to assess different opportunity costs by manipulating the conversion factor in certain categories to create a more equal playing field among the Band A payers.
Understanding the Financial Implications of the Medical Home Model
Authored by: Abigail Trutor, MBA; Caridee (Xiaohuan) Tang, MPS
Project Leads: Paul Taheri, MD, MBA; Jen Gilwee, MD
The purpose of this study was to assess and identify any impacts of NCQA Medical Home certification on changes in hospital admission and emergency department visits post certification. Our analysis consisted of evaluating two distinct primary care cohorts. These cohorts consist of three NCQA certified Medical Home sites and four non-certified primary care sites between 2007 and2011. The longitudinal component of our study evaluated the impact of NCQA certification on the change in hospital admissions or emergency department visits after certification was received. Our analysis also evaluated any difference in ED visits and hospital admissions across the cohorts of NCQA certification and the other primary care sites that were not certified. NCQA Certification does not appear to impact either hospital admissions or emergency department visits. There was no trend within the individual site or across sites in hospital admissions or emergency visits from before certification and after certification.
Analytical Frameworks to Understand Physician Productivity in Prism
Authored by: Jeremy Fortune, MBA; Caridee (Xiaohuan) Tang, MPS; Yu Zhang, ME
Project Leads: Tim Burdick, MD; Dawn Godaire, Director Clinical Operations
With Fletcher Allen’s electronic medical record fully implemented, the organization expected that there could be ways in which physician utilization of the system could be improved in order to decrease health care costs. The goal of this project was to identify some of these improvements and to recommend alterations to business process and the system’s user interface that increase performance and utilization of PRISM. The project determined efficient usage patterns by Fletcher Allen physicians by comparing usage statistics with system-measured efficiency metrics, organizational productivity metrics, and physician satisfaction. The system-measured efficiency metrics, known as Physician Pulse, evaluates outpatient physicians on thirteen pre-defined metrics.
These metrics were reduced to five principle components of operational efficiency: Ideal Work Habits, Standardization, Documentation, Advanced Tools, and Medication to provide an analytical framework for targeting physician training. This represents a unique, focused, methodology for assisting physicians in PRISM proficiency. Conclusions suggest that Fletcher Allen should focus on making progress notes more efficient, getting users to spend more time inputting data rather than searching for it, and enforcing data availability throughout the organization. A potential implementation plan included hiring department super users that would help individual physicians build customized smart phrases for note building and add commonly used items to their preference lists for quicker search times.
A Study of Patient Flow Through the Dermatology Clinic
Authored by: Stephanie Mariorenzi, BS Candidate; Abigail Trutor, MBA
Project Leads: Glenn Goldman, MD; Tammy Stockton, Practice Supervisor
The purpose of the patient flow study was to identify bottlenecks in the system and better understand workflow efficiency to increase patient flow and appointment capacity. A time and motion study was conducted in fifty-six clinics randomly selected and observed. The patient was watched from the time he entered the clinic with the medical assistant (registration was excluded for this exercise) until the time the physician or physician’s assistant left the patient’s room. There were a sufficient number of observations to allow for statistical conclusions to be made. After analyzing the data some findings were significant.
These findings include the difference in scheduled and allotted appointment times, the number of no shows, factors that affect the actual length of the appointment (such as labs, status of patient—new vs. established, etc.), overall differences between physicians and physicians assistants (such as proportion of new patients), the average time each stakeholder spends with the patient, scheduled vs. actual clinic hours, provider time spent in PRISM, and bypassing of residents. Recommendations include; standardization of clinic hours in order to have a uniform number of appointments within the assigned clinic hours to increase the number of patients who can be seen each year. Second, lengthen appointment slots to 20-minutes and add resident clinics to make up for any appointment loss and provide additional capacity in the appointment system. Finally, decrease the no shows rate by utilizing the reception staff for calling patients two days prior to an appointment and charging a fee for no shows.
Analysis of E & M Coding Practices in Gastroenterology
Authored by: Abigail Trutor, MBA
Project Lead: Nick Ferrentino, MD
In examining evaluation and management (E&M) coding practices there are issues of both compliance and maximizing utility. Due to the many changing rules on documentation requirements, many physicians defer to lower E&M levels of severity to ensure compliance, while not maximizing utility. Fletcher Allen’s gastroenterology department wanted to review their E&M practices for these types of issues. This project had two distinct phases; first, to understand Fletcher Allen’s E&M coding practices against other similar medical centers, and second, to understand the revenue implications behind their coding decisions.
In the first analysis Fletcher Allen physicians erred on the side of caution and generally defaulted to a severity level of three, while data from the University Health Consortium database showed a much wider variation of levels of severity. In order to understand the revenue implications of, “playing it safe”, the gastroenterology coding practices of FY 2010 were re-coded to match the frequency of codes submitted by similar academic medical centers. The change in frequency between coding levels was then matched to a reimbursement rate based on payer mix at the physician level. Findings showed that the opportunity cost of coding below utility was approximated at $152k additional revenue annually, after hiring a coder to specifically work in the unit to ensure compliance and utility maximization. Update: A professional coder was allotted to the GI team for a pilot-study in early 2012. Preliminary results show additional income as expected from analysis.
24/7 Intensivist Coverage in the Medicine Intensive Care Unit: A Business Plan
Authored by: Abigail Trutor, MBA
Project Leads: Anne Dixon, MD; Allen Mead, Director of Medicine
Based on the MICU Patient Flow Study completed in December of 2010 (see below), a comprehensive business plan was created to address the need for a 24/7 intensivist staffing in the Medicine Intensive Care Unit (MICU). To provide a thorough plan a number of steps were taken, including; a literature review on best practices in MICU staffing, research on current Fletcher Allen MICU quality statistics, a financial analysis of additional staffing requirements, a comparison of alternative solutions, and an implementation plan. This plan was presented to a number of committees, including the physician hiring committee for the UVM Medical Group. The plan was approved by management and three additional FTE’s were budgeted for MICU staffing purposes. Update: As of July 2012, the MICU has 24/7 in-house attending coverage.
Optimizing Physician Scheduling Practices in Pathology
Authored by: Abigail Trutor, MBA
Project Lead: Pam Gibson, MD, Medical Director, Anatomic Pathology
The pathology department represents a somewhat unique service in health care in that it does not frequently interact with patients. This anomaly makes it difficult to utilize standard methods in health care for demand planning (e.g. RVUs, patient visits, LOS, etc). Further exacerbating the problem is the different types of pathology; surgical, anatomic and cytological, and their individual practices within the hospital setting. It is impossible to parse these services into individual services as Fletcher Allen pathologists are often asked to perform in more than one specialty area. After completing a literature review on other pathology departments scheduling model, a hybrid-model was created using the best practices in all studies. The model utilizes a number of databases to understand the holistic measure of work being completed in the pathology department to build a true representation of demand for services. The model then breaks the services down into specialty departments to define optimal clinical staffing by area. Over a scheduling period, the model tracks each physicians work in specified areas to more accurately model their demand.