Independent Emergency Physicians

Great Culture, Great Analytics, Great ‘Aha’ Moments


  • Improved patient flow in the ED
  • Better ability to manage care transition
  • Optimized staffing which reduced costs

A great business culture can lead to high-performing and happy physicians, who in turn generate great results, happy patients, and happy hospital partners. But, how can a medium-sized, independent Emergency Medicine (EM) specialty practice maintain a great culture in an atmosphere of widespread dissatisfaction and physician burnout?

Burnout can have a negative impact on quality of care, which can be compounded by metrics intended to drive physician performance. When performance analytics are used correctly, they can actually empower and motivate physicians.

Independent Emergency Physicians (IEP), headquartered in Farmington Hills, Michigan, was founded in 1997 by 11 like-minded EM physicians with the goal of taking care of patients by taking care of providers. Today, IEP has more than 200 providers and has expanded into six practice areas that span the continuum of unscheduled visits:

  • Emergency Medicine
  • Hospital medicine
  • Observation Medicine
  • Long-Term Acute Care
  • Urgent Care
  • Telehealth
  • Scribe services

Because IEP defines culture by actions, not words, the company has built a culture of ownership through cultivating, retaining, and promoting outstanding clinical leaders and the very best providers. Doing this while operating at peak efficiency and effectiveness requires a commitment to continuous improvement. Performance analytics reinforce this high-performance culture.

In 2014, IEP turned to d2i as its performance analytics partner, an effort led initially by its president and CEO, Dr. David Hall, MD, FACEP; its executive director, Julie Susin, MBA; and its vice president of operations, West Region, Dr. Rami Khoury MD, FACEP. Khoury said:

“Our view is that other houses of medicine don’t always understand Emergency Medicine. We operate very differently than our colleagues in other specialties. EM provides care to the most vulnerable and is the front door to higher-margin inpatient and ancillary services. We see things differently. With payers trying to put us at odds with our mission, we need to collaborate better with all the houses of medicine.”

Dr. Khoury, whose day job is EM practice, also leads the IEP Operations Team in its performance and process improvement efforts, which are driven by data and analytics from d2i.

The team uses analytics to drive high-impact and relevant conversations between IEP providers and other hospital departments, reinforcing a collaborative culture geared toward continuous improvement. When data is trusted and analytics are truly relevant, positive behavior is reinforced. Khoury said, “… since our physicians are all high achievers and scientists by nature, the response has been great.”

Performance Review

The first thing IEP does when reviewing performance is to look at volumes, LWBS, and LOS to see where it stands in comparison to historical trends and current goals. Khoury said:

“Before the team does a deeper analysis, we want to be certain that these high-level numbers make sense. We then blind the scorecards and send the results to the providers, who can see how they are performing compared to practice averages and their own historical performance.”

Then, a secondary analysis looks at efficiency metrics such as turnaround times (TAT)s, examining underlying causes by using filters to determine, for example, whether cases are psychiatric or not. Armed with that information, the Operations Team guides providers on opportunities for improvement. Khoury explained:

“We use the same dashboard to investigate factors such as census and arrivals, case mix by diagnostic subgroup, service utilization (for CT scans and other tests) with a keen interest in APP utilization. The team specifically mines data for cost-savings and opportunities to improve scheduling and standardize processes.”

‘Aha’ Moments

Dr. Khoury warned that high-level measures alone tell only part of the story and can sometimes be misleading. For meaningful analysis, performance analytics need detailed Emergency Department (ED) operations data to understand patient flow, department productivity and precisely where bottlenecks persist. But also, clinical and financial data can be mined to understand outcomes, utilization, practice variation, and E&M codes.

Khoury shared a story about how one physician who saw 2.5 patients per hour — superior performance — had lower revenue per physician-hour than another doctor who saw 2.3 patients per hour.

What IEP learned is that the number of patients seen per hour doesn’t tell the whole story. The “aha” moment came upon further investigation using d2i’s 360-degree storyboards. d2i’s purpose-built analytics assemble all relevant information regarding a given metric. With a few clicks, the team was able to see that the physician with 2.5 patients per hour had an average length of stay (ALOS) of 225 minutes, much higher than the 150-minute ALOS of the physician who saw 2.3 per hour.

On one hand, higher ALOS can indicate poor resource utilization, which can drive up costs, create bottlenecks, and lead to poor patient satisfaction. However, too low an ALOS can indicate a lower level of care, which can result in higher return rates and other adverse outcomes. “We seek just the right balance so we make the most effective use of available resources and space,” Khoury said.

Hospital Medicine Analytics

IEP recently added the d2i Performance Analytics Application for hospital medicine. With its additional capabilities, IEP not only is improving patient flow in the ED, but also can better manage care during transition and throughout the entire inpatient visit.

From a planning perspective, d2i data helps IEP better match schedules with anticipated volumes, which helps reduce unnecessary costs and ensures an optimal mix of physicians and APPs. To support this type of planning, IEP tracks data on patient arrival and when it’s decided whether to admit or discharge the patient, and then leverages a predictive algorithm to optimize the staffing mix and ensure smooth transitions of care.


Soon IEP plans to employ additional capabilities available in the d2i Performance Analytics Application for resource planning, process improvements, and promotion of quality programs.

Using a broad range of diagnostic, patient management, and disposition metrics, IEP has developed its own scoring method across a set of balanced and weighted metrics. IEP plans to use the tool to help reduce unnecessary utilization, to promote quality programs that monitor timeliness of antibiotic administration for sepsis patients, to reinforce its Alternatives to Opioids (ALTO) program, and to track and optimize MIPS metrics at individual and group levels.

Positive, Data-Driven Approach

IEP delights in finding ‘aha’ moments during its monthly internal operations reviews and quarterly client success meetings with d2i. Because d2i’s work is transparent and collaborative — and not used in a punitive way — the IEP Operations Team looks forward to sharing opportunities for improvement with providers and their hospital partners’ administrations.

IEP’s data-driven approach not only helps define what performance excellence means, but it also reinforces the company’s culture and contributes to its success. Khoury summed it up:

“We have found that our transparency and willingness to share our performance analytics with our hospital partners’ leadership has led to fewer surprises and less contentious negotiations as we look to renew and expand our contract.”

The d2i ED Performance Analytics Application is a cloud-based tool based on a data platform that integrates, cleans, and harmonizes data from EHRs, billing, scheduling, and patient satisfaction surveys, storing the patient’s journey down to the lowest level of detail. The result is a trusted source that provides answers to questions about ED performance and supports a conversation within and across departments to drive collaborative performance and process improvement. Contact d2i for more information on how we can help your organization, or to schedule a 30-minute demo.

Annual ED Visits:

280,000 across four facilities

EHR System:



d2i’s ED Performance Analytics

What d2i does better than any other solution that I've seen is that it helps us identify the causal factors that explain why the performance issue is happening. When I share the analytics and data we get from d2i with others in the hospital, they are envious of what we have in the ED.

Peter Viccellio, MD Vice Chairman, Department of Emergency Medicine, Associate Chief Medical Officer Stony Brook University Hospital October 19, 2017