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Using Electronic Health Records for Quality Improvement in Community Health Centers

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Title: Using Electronic Health Records for Quality Improvement in Community Health Centers


1
Using Electronic Health Records for Quality
Improvement in Community Health Centers
  • Robert H. Miller, PhD
  • Professor of Health Economics in Residence
  • University of California, San Francisco
  • March 16, 2006

2
Overview
  • Information sources
  • Problems EHRs attempted to address
  • How CHCs used EHRs for QI
  • Obstacles to using EHRs for QI--and some solutions

3
Tides/UCSF survey of CHCs with EHRs
  • 6 CHCs with EHRs, 2 part of networks
  • Institute for Urban Family Health, NY City
  • Heart of Texas CHC, Waco, TX
  • Waianae Coast Comprehensive, HI
  • Community Health Association of Spokane (CHAS)
  • Lamprey Health/Comm Health Access Network (CHAN),
    NH
  • Family Health Centers Southwest Florida/Health
    Choice Network (HCN)
  • 2 network application service providers (ASPs)
  • Network ASP provides EHR services to CHCs
  • Chicago Alliance, OCHIN
  • gt60 interviews of managers, gt85 hours
  • PLUS some data from 3 previous EHR studies

4
Characteristics of EHR implementers
  • 1 ½ to 7 years experience with EHRs
  • Health Choice Network/Fort Myers still
    implementing
  • Early adopters
  • Expect them to be different
  • Larger 15-50 provider FTEs
  • More resources than the typical CHC--important
  • Leadership, management expertise, IS technical
    expertise
  • Good shape financially
  • Great at getting grants

5
Problems IT implementation tried to address
  • CHCs wanted EHRs to improve
  • Quality (all CHCs)
  • Efficiency (2)
  • Coordination of care (2)related to access to
    care
  • Reimbursement from plans
  • The message I pound home is its all about
    quality. Its not about automation. Its about
    quality. CHC medical director

6
So how does the IT solution work?
  • 5 of 6 CHCs used EHR capabilities for systematic
    QI
  • Keep in mind Systematic QI varied

7
CHCs identified chronic care areas for QI
  • Diabetes (5 of 5)
  • Asthma (4 of 5)
  • HIV, hypertension, CAD (3 of 5)
  • ALSO
  • Depression, congestive heart failure
  • All working on adding moreserious efforts

8
CHCs identified preventive care priority areas
  • Childhood immunizations, flu vaccine (4 of 5)
  • Mammograms, pap smears, pneumovax, LDL screening
    (2 of 5)
  • ALSO
  • Screening for lead, childhood development, colon
    cancer, metabolic syndrome, hypertension, mental
    health
  • More on the way

9
CHCs used 4 key EHR capabilities for QI
  • Data capture
  • Reminders
  • Reporting/feedback
  • Patient self-management

10
Use of EHRs for QIElectronic data capture
  • Documenting using coded electronic lists
  • Diagnoses, allergies, smoking.
  • Documenting with templates (electronic forms)
  • Condition specific
  • Drop-down menus, auto-fill, radio buttons, boxes
  • 3 CHCs lots of coded, reportable data
  • Data from other information systems
  • Interfaces to labs, billing, scheduling,
    registration

11
Electronic data capture (2)
  • Improves viewing, ordering, messaging
  • Generates automatic QI benefits
  • More data, more legible, accessible, organized
  • Not easy
  • One-on-one training, time needed
  • Providers must get up on learning curve--hard
  • But enables key benefits
  • Enables reminders, reporting, self-management
  • Starting point for effective EHR use

12
Use of EHRs for QI Reminders
  • Reminders for mammograms and pap smear based on
    age/sex
  • Reminders for creatinine microalbumin based
    diagnosis of diabetes
  • Reminder requires MD response
  • If MD clicks yes, order set appears

13
Use of EHRs for QI Best Practice Order Sets
  • The physician can proceed with ordering the
    appropriate test(s) and associating the order(s)
    with the corresponding diagnosis by clicking the
    accept button
  • Defaults are indicated by the check marks

14
EHR use for QI Lists of patients needing services
15
EHR use for QI Feedback to providers
Diabetes Surveillance Reports
From Heart of Texas Community Health Center
16
(No Transcript)
17
Use of EHRs for QI Patient self management
  • Visit summaries
  • Patient to do lists
  • But capabilities are limited now

18
Obstacles to EHR use as solution for QI
  • Cost is high, benefits vary
  • 50k /- provider initial, 15-20k annual
  • 0-20k on-going benefits
  • EHRs affect providers work and time
  • Implementation can be exhausting.
  • Assemble IS technical expertise
  • Configure, host software, design templates
  • Install hardware, software at sites
  • Provide training, get providers to use
  • Provide help desk support
  • Redesign workflow.And much more!

19
But even if you have get through
implementation.
20
Main obstacle IT alone is not solution for QI
  • EHRs/CIS just one part of Care Model

21
Implementing Care Model is solution for QI
  • EHR means changes in all Care Model elements
  • Including organization policies, procedures,
    culture
  • Relationships with external organizations
  • Many complementary changes/innovations needed
  • Its is one damn thing after another
  • EHRs most complex CIS requires most complex
    changes
  • Advanced registry systems (e.g., MediTracks) work
    with paper
  • Basic registry systems (e.g., PECS)--less
    flexibility, changes
  • Practice management systemsfewest capabilities,
    changes

22
Barriers/facilitators to using EHRs to implement
Care Model
  • Resources/readiness
  • Focus on QI
  • Network application service providers
  • Policies that support QI

23
Resources/readiness needed for implementation AND
for QI
  • Clinical/administrative leadership
  • Functioning governance
  • Communication with providers
  • Managerial expertise in process change
  • IS technical expertise
  • Money (always!)
  • Past, successful experience with QI
  • Process, culture change

24
Leaders must keep eye on the prize (QI)
  • Implementation diminishes QI focus
  • Consumes much time, effort
  • Can create exhaustion
  • Successful CHCs focused on QI -- kept
    focus
  • Had enough resources for implementation
  • Already had a QI culture, QI experience
  • Had respected clinical leader with protected time
  • Started quickly to use EHR for QI

25
Network application service providers are key
  • Most CHCs are too small to adopt EHRs themselves
  • Network ASPs reduce implementation pain, risk
  • Contracted with member CHCs
  • Selected EHR, negotiated and monitored EHR
    contract
  • Configured and hosted central software
  • Developed templates
  • Trained providers/staff
  • Installed EHR software at sites
  • Provided help desk support
  • Assisted with EHR-related process/workflow
    redesign
  • Assisted with QI activities at least convened
    QI discussions

26
Network application service providers (2)
  • Creates some benefits of large groups
  • Better software prices, IS staffing, learning
  • Reduces importance of technical piece
  • Helps keep leadership focus on QI
  • Network ASPs are emerging
  • Health Choice Network (FL, UT, NM)
  • Oregon Community Health Info Network (OR, CA)
  • Chicago Alliance (IL) others
  • Future prerequisite for grant funding?
  • Reduces risk of moving too quickly, failing

27
Policies can support EHR use for QI
  • Grants with QI targets
  • Network ASP support (especially for QI)
  • Medicaid pay for performance
  • Hospital gain-sharing
  • Safety-net delivery system coordination
  • Effective data use common measures, reports
  • QI Measurement System
  • Can help pressure agencies to adopt P4P
  • Learning groups

28
Summary
  • EHRs capabilities can increase quality.
  • But implementing EHR alone is not solution to
    quality problems
  • Implementing Care Model is solution
  • EHR is part of Model, affects other parts
  • Many, many changes needed
  • Leadership/resources, network ASPs, policy
    changes are key

29
  • Thank you!
  • Robert H. Miller, PhD
  • robert.miller_at_ucsf.edu
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