YMG moves ahead on space planning and selecting an EMR

Letter from the CEO

Yale Medical Group CEO News is a newsletter from David J. Leffell, MD, deputy dean for clinical affairs for the Yale School of Medicine. He covers topics of interest to the practicing physicians. Write to Dr. Leffell at david.leffell@yale.edu.

Almost 15 years ago, we began publishing the Yale Practice newsletter to improve communication among faculty and staff who work within the clinical practice of the School of Medicine. As the practice has grown and changed, so too has the need for communicating all of the complexity of the academic and medical worlds in which we live.

When I talk to faculty it is clear that the single biggest challenge we face is communication. The nature of academic medicine is that we practice and work in very specialized environments even though the effectiveness of our efforts is facilitated by functioning within a broad and complex world. Reducing barriers to the flow of information is one way to improve our productivity and professional satisfaction.

We will continue to publish Yale Practice for the broadest audience possible. However, this newsletter is for you, the faculty. In it, I will discuss a wide range of issues in greater detail than is available through other venues. It is my attempt at creating dynamic channels of communication with each of you at a unique juncture in the history of academic medical centers in general and our own in particular.

The clinical practice is evolving

The evolution of clinical practice at Yale over the past three decades reflects a growing recognition of the importance of clinical medicine in a research medical school. This role is highlighted by the success of the CTSA grant, the 12 percent annual growth rate of the practice and our close collaborative relationship with Yale-New Haven Hospital (YNHH).

In my first newsletter, I want to discuss two strategic questions that impact the growth of our practice and our closer collaborative relationship with YNHH: first, how do we practice, and second, where do we practice.

Selection of an ambulatory electronic medical record

In 2009, we engaged as wide a range of stakeholders as possible to help narrow our choice of an EMR. Vendors demonstrated their products on campus, and every faculty participant had an opportunity to provide feedback. We are focusing our attention now on EpicCare, because both we and our partners, YNHH and the Yale New Haven Health System, are attracted by its functionalities.

While we think of an EMR as an information technology product, it is, in fact, a work redesign enterprise. Every aspect of clinical practice will be affected by the EMR, and the data it provides will allow us to take a closer look at how we practice, how departments relate to each other in the clinical environment, and how we can enhance quality and reduce costs.

The EMR will be a fundamental data source for clinical research, and we carefully evaluated the ability of each potential EMR product to ensure that clinical research needs will be met. Ultimately, data collected through the EMR will populate a clinical research data repository.

Timing is right for EMR: I believe the time could not be more propitious to begin implementation of our EMR. We will not face the resistance to change that plagued so many early adopters. You are eager for an EMR that will interface with the research data repository, the federal government is providing financial incentives, and there is a mandate for the use of such systems in medical practice with a clear deadline. Importantly, the school and the hospital are joined at the hip in pursuing a solution for an ambulatory EMR.

Once the contract is signed, our consultants estimate that it will take approximately nine months to prepare our EMR for sequential rollout to our practices. We hope to be up to speed before the October 2012 deadline set by President Obama's American Recovery and Reinvestment Act 2009, which contains the HITECH Act and economic incentives for adoption of an EMR.

Our success with this timeline will depend on the identification and recruitment of physician champions. Please begin to consider what role you may be able to play in your department or section when it comes time to implement the EMR.

You can read an article about how the ambulatory EMR has impacted ColumbiaDoctors, the practice at the Columbia University College of Physicians and Surgeons, which inaugurated its ambulatory EMR in 2008, in the January 2010 issue of Yale Practice.

Growth of the practice and future space

We know Yale Medical Group is growing at a rapid pace, yet we don't have a good sense of where this practice growth could take us in the future, and we are not certain that it will continue.

Years ago, the Dana Clinic Building was the first institutional effort at creating an environment for faculty to practice. In the late 1980s, the Yale Physicians Building (YPB) was opened as the clinical practice began to develop a more substantial presence at the medical school.

However, the YPB building quickly proved insufficient as the faculty clinical activity increased. While that building was intended as a flagship facility, because of inadequate space, a majority of the faculty's ambulatory clinical practice now takes place at Temple Medical Center, which is currently home to Digestive Diseases, Ophthalmology, Neurology, Dermatologic Surgery, Child Study and G.I. Surgery.

The geographic distribution of our practices is a major challenge. In fact, we really don't have a front door to which we can direct patients. In addition, we have not planned our clinical space with clinical research and clinical trials in mind, even though these represent core elements of our mission and key reasons why we practice medicine at Yale.

A flagship facility would allow us to achieve more efficient customer service and enhanced quality of care through closer interaction of faculty and staff across specialties. It would provide an opportunity to think in a new and innovative fashion about how we integrate clinical research into the practice environment. Currently, the absence of a flagship facility, a front door so to speak, exacerbates the confusion about the Yale Medical Group identity. While people feel that they are getting the best possible care when they come to us, many are not sure what Yale Medical Group is.

Our space planning process: Last year, we embarked on a space planning process with the consultant team, HDR-Kaufmann Hall. These firms are helping us understand both the market distribution and demographics of the potential patient base. The studies will inform decisions both about where to practice and which services to offer in the future. Should we be on the medical campus? Should we be in downtown New Haven? Should we have multiple satellites or should we be at the West Campus? These are just some of the questions that we need to address at this time.

One of the reasons why we are currently faced with a balkanized clinical practice environment is because the practice has grown beyond what leadership in the past might have anticipated. As a result, they did not pursue comprehensive space planning for the clinical practice. It is our goal, through this effort, to anticipate changes over the next decade or more and ensure that future generations of physicians and staff will be able to practice in environments that are planned in a clear and strategic fashion.

Phase One results: Phase One of this project used three years of historical billing data to define our service area, and overlaid census trends on its population for the next ten years. The service area runs from New London, down the Connecticut coastline to Westchester, and up into the Hartford and Litchfield areas. In our state of 3½ million people, the findings were enlightening and confirmed some of our preconceived notions:

  • 95 percent of our activity originates in this defined service area, and there is significant opportunity to increase market share here.
  • Solo and small group practices account for more than 50 percent of the provider base in Connecticut. Many physicians in these practices are nearing retirement, which presents significant opportunities for consolidation.
  • There are several pockets of population growth in our market, notably in the 45-64 and 65-74 age brackets. The 45-74 group especially will drive health care demand in our region, particularly in areas north and west of New Haven, north of Fairfield and in Middlesex County.
  • Primary care accounts for 51 percent of total physician visits.
  • Our patient base is projected to grow by 4 percent over the next five years.

Proceeding with Phase Two: Our consultants will use this data for Phase Two of their process to paint a picture of our position in the market, and provide a list of strategic opportunities and a clear picture of our optimal bricks-and-mortar delivery system. They'll consider three different scenarios, testing and refining them through the development of ten-year utilization and financial projections. The scenarios include:

  • A central location for YMG, serving all patients in one building.
  • A distributed model with different specialties situated in the most strategic locations.
  • A hybrid plan that features both a central location, and smaller centers and satellites throughout the designated region.

We expect to complete Phase Two of this process by June 30, the end of Yale Medical Group's fiscal year, and you can look forward to results sometime this summer.

New website launched

In January, we launched a redesigned Yale Medical Group public website.
Please take a few minutes to visit the site and look around.