Clinical case study

Red River Family Clinic Case Study

In 2006, Dr. Jaxson Scherzer opened the Red River Family Clinic, a small family medicine practice, in an area with an increasing number of new family residences. Dr. Scherzer has been the owner and manager of the medical practice, as well as its only practitioner. He has two nurses, Tamara and Sophie, to help him. Usually, one nurse takes care of the front desk responsibilities while the other nurse assists the doctor during the patient visits. They rotate duties each day.

Front desk duties include all administrative work from answering the phone, scheduling appointments, taking prescription refill requests, billing, faxing, and so on. If on Monday, Tamara is helping the doctor, then it is Sophie who takes care of the front desk and all office work. On Tuesday, they will switch duties. The two nurses are constantly busy and running around, and patients are now accustomed to a minimum 1-2 hour wait before being seen by the doctor. If one nurse is absent, the situation is even worse in the Clinic. The Clinic has three examination rooms, so Dr. Scherzer is now considering bringing a new physician or nurse practitioner on board. This would help him grow his practice, provide better service to his patients, and possibly reduce the patients’ waiting time. Dr. Scherzer knows that this will increase the administrative overhead, and he knows that the two nurses will not be able to manage any additional administrative work. He faces several challenges and cannot yet afford to hire any additional staff, so Dr. Scherzer has to optimize his administrative and clinical operations. The practice is barely covering the expenses and salaries at the moment.

Dr. Scherzer’s practice operation is completely paper-based with traditional paper medical records filling his front office shelves. The only software the doctor has on his front office computer is a stand-alone appointment scheduling system. Although the medical practice has the one PC with the scheduling software and an Internet connection, it does not have a Web site or any other technology, and essentially still operates the same as it did in 2006.

Even billing insurance companies is done in a partially-manual way. For billing insurance, the front office nurse has to fax all the needed documentation to a third party medical billing company at the end of the day. The medical billing company then submits the claim to the insurance company and bills the patient. The Clinic checks the status of the claims by logging into the medical billing system, through a login that the medical billing company has provided the Clinic to access its account. There is no billing software installed at the practice, but the nurses open Internet Explorer to the URL of the medical billing company and then use the login provided by the third party medical billing company. Of course, the medical billing company charges the Clinic a percentage of the amount that the Clinic is reimbursed by the insurance.

One problem that is immediately noticeable is that there is no quick way to check patients in. If the front desk nurse is on the phone while a patient tries to check in, then the patient has to wait until she has completed her call. The doctor could be also waiting for the patient to be checked in, wasting the doctor's valuable time. Many patients experience long waits on the phone when they are trying to schedule an appointment, while the front desk nurse is checking in patients or responding to another patient’s request in the office. In addition, every year the Clinic requires its patients to complete a form with their personal and insurance information, rather than have them just verify what is currently in their file. This form completion annoys some of the parents when they have to fill out all this paperwork, especially if they are taking care of their sick young child in the waiting room.

When a patient's laboratory test results are received in the office, the paper copy has to be filed in the patient's folder. Lost and misfiled reports are a big concern to Dr. Scherzer, as is his inability to quickly and easily share patient data when he makes a referral to a specialist. He believes that he and his staff are spending too much time handling paper and not enough time improving patient care.

All of the medical records, lab results, and financial and payroll accounts are kept on paper. There is not a quick way to look up a patient’s history or current prescriptions during office visits, or when the doctor gets a call while he is away from the office. At the beginning of each day, the nurses pull the files for all patients who have appointments scheduled for that day. However, the Clinic also accepts walk-in patients.

At a recent medical conference Dr. Scherzer learned about how Electronic Health Records (EHR) can be shared among health care providers to improve patient outcomes. After attending several demonstrations by the different vendors, including ClinicalWorks, AthenaHealth, and Cerner, he realized how inefficiently his practice is running and realized many of the opportunities that EHR systems can bring.

Dr. Scherzer recognizes many of the benefits of moving to electronic medical records but feels very overwhelmed about how to start and what to do. He is also concerned about disruption to his practice which may negatively affect his patients’ care experience. Moreover, neither the doctor nor the nurses have any knowledge or experience when it comes to information technology. Upon the recommendation of a fellow doctor, Dr. Scherzer has decided to hire an independent EHR consultant to help him select the best EHR for his practice.

Dr. Scherzer’s friend also advised him that the Clinic should not just buy any package from a vendor but should have the EHR consultant analyze the workflow processes at the practice first, then optimize the processes, and then look at various EHR systems. The new EHR system needs to work with the optimized processes of his practice. Dr. Scherzer needs to get his staff’s acceptance and involvement in the EHR adoption process from Day 1, if the process is to succeed. Dr. Scherzer realizes that EHR adoption may add significant costs to his practice, which he cannot afford. Therefore, he will go for the EHR adoption at this point only if he can find an affordable system.

Based on his fellow doctor’s recommendation, Dr. Scherzer has contracted with an independent consultant, who is not associated with any vendor, to advise him through this process. Throughout this course you will be the professional EHR consultant.

STRATEGIC GOALS

Dr. Scherzer has several strategic goals in mind that he shares with you during your first meeting with him as his consultant.

Primarily, he would like to see his medical practice operate more efficiently to enable him to meet these goals. This effort will allow him to make some financial profit that could be invested into the Clinic to upgrade and expand it. In a few years, he will need to invest some funds in a major renovation, primarily in the examination rooms and the waiting area. If he had extra money, he could also rent the apartment next to his Clinic and open up the space to make a larger Clinic. More space could let him expand the Clinic into a 3-physician group practice or allow him to rent out some space to a physical therapy physician to generate some additional income. After much discussion with fellow MDs, he realizes that he can use technology to improve the quality of care, safety, and financial management decisions of his practice, while also meeting the legal and regulatory requirements for health care and health care systems. Implementing an EHR system for these purposes has now become another strategic goal for the practice.

Your task is to help Dr. Scherzer understand the process that occurs during a patient visit to the practice, how that process should be improved to make it more efficient, and then recommend a certified EHR system for him to implement. You are not expected to solve all of the problems identified or address all improvements that could be made at the Red River Family Clinic.

The following is an example of how a process is identified and optimized using a technology solution: Last year, the medical practice had no effective way to schedule appointments. The front desk nurse used a paper calendar to write in appointments. Obviously, as appointments were cancelled and re-scheduled, the paper calendar became almost unreadable. It was also taking a long time for the nurse to record the patient name, phone number, and other critical information. That was when Dr. Scherzer and his nurses decided to implement the scheduling system on the PC. Now, the patients are all listed in the system, with the pertinent information, and the scheduler can quickly search for an open time and enter the patient's appointment on the schedule. This has significantly improved the scheduling process, but it has done nothing to help with all of the other activities involved with a patient visit to the Clinic.

As you approach the case study assignments, you will find it helpful to think about your own experiences with a medical practice. Some things work well, others are frustrating, and some desperately need improvement. Visiting a small medical practice may help you think about the processes, challenges, and opportunities.

STAGED ASSIGNMENTS

The case study and assignments address the Course Outcomes to enable you to:

· Evaluate the organizational environment in the health care industry to recognize how technology solutions enable strategic outcomes

· Analyze the flow of data and information among disparate health information systems to support internal and external business processes

· Evaluate technology solutions in the health care industry to improve the quality of care, safety, and financial management decisions

· Examine the implications of ethical, legal, and regulatory policy issues on health care information systems.

Upon completion of these assignments you will have performed an array of activities to demonstrate your ability to apply the course concepts to a “real world situation” to:

· (Stage 1) Analyze an organization's strategies and processes to determine how a technology solution could help

· (Stage 2) Analyze the data flow among a Clinical practice and external organizations

· (Stage 3) Identify and explain the legal, ethical and regulatory considerations for a system

· (Stage 4) Propose an appropriate certified EHR technology solution

As explained in the Stage 1 assignment document, you will create a System Recommendation Report (SRR) for Dr. Scherzer, using each stage to develop a section of the report. The staged assignments are designed to follow the relevant readings in the course content, and they are due on the dates assigned in the class schedule. These assignments are designed to help you identify how to effectively analyze and interpret information to improve a medical practice using technology. This is an opportunity for you to apply critical thinking skills and think like a professional medical consultant.

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