Making the case for the Adoption of an Electronic Health Record (EHR)

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Making the case for the Adoption of an Electronic
Health Record (EHR)

• David B. McClure, MD
• Associate Medical Director
• Director of Informatics
• The Medical Group of Ohio

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Whats In A Name?

• EMR or EHR

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Core Functions and Benefitsof an EHR

• 1. Health Information and Data
• Lack of information reduces quality and
  efficiency of care
• Availability, Legibility and Completeness
• Organization of data ?missing information 30 of
  the time in a paper-based system
• HIPAA compliance
• Reduction or elimination of transcription

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Transcription reduction
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Core Functions and Benefits of an EHR

• 1. Health Information and Data (continued)
• Reduced risk of ADE
• Well-designed interfaces needed

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Core Functions and Benefits of EHR

• 2. Results Management
• Urgent abnormal tests addressed in a timely
  fashion
• Quicker recognition and treatment of problems
• Ability to create graphs that show trends in lab
  results ( Ex. HgA1C)
• Ensures appropriate follow-up

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Core Functions and Benefitsof an EHR

• Order management
• CPOE Benefits are well-documented
• Eliminates lost orders
• Eliminates ambiguities caused by illegible
  writing
• Monitors for duplicate orders
• Reduced time to fill orders
• Test order tracking

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Core Functions and Benefits of an EHR

• 3. Order Management (continued)
• Published reductions in medication errors up to
  83
• Automatic checking of drug-drug interactions and
  drug allergies
• Reduced time for Rx refills
• Reduce spent on preprinted forms and through
  formulary compliance
• Potential to increase productivity

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Core Functions and Benefits of an EHR

• 4. Decision support
• Prevention such as vaccinations, cancer screening
  and CVD reduction improved
• Detection of ADE and disease outbreaks
• Computer-assisted diagnosis and management
• Compliance with EBM guidelines and protocols
  through recalls
• Coding assistance

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Coding Slide
Sample Effects of Right-Coding
Zaroukian, M, EMR Cost /Benefit Analysis, CHUG,
2004.
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Core Functions and Benefits of an EHR

• 5. Electronic communication and connectivity
• enhances patient safety and quality
• essential for populating systems
• e-mail and web messaging improves timeliness of
  interventions
• Real-time communication with staff
• Create reminders for yourself and communicate
  with colleagues
• automated alerts of abnormal labs

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Core Functions and Benefits of an EHR

• 6. Patient support
• improved control over chronic diseases
• patient education
• interactive interventions
• home monitoring with data entry

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Core Functions and Benefits of an EHR

• 7. Administrative Processes
• electronic scheduling
• on-line insurance eligibility
• access anywhere
• reduction in medical records staff
• reporting tools for drug recalls
• identify patients for clinical trials

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Core Functions and Benefits of an EHR

• 8. Reporting, Analysis and Population Health
  Management
• Benchmarking
• QI-routine reporting of quality indicators is
  more efficient, less costly and less error-prone
  than chart abstraction

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Barriers to EHR Implementation

• 1. High initial cost and uncertain financial
  benefits
• 2. High initial physician time commitment and
  decreased productivity concerns
• 3. Technology challenges
• 4. Difficult complementary changes and
  inadequate support

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Barriers to EHR Implementation

• 5. Lack of systematic approach to office
  management and workflow
• 6. Inadequate electronic data exchange
• 7. Lack of incentives
• 8. Physician attitudes

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Key Elements for Successful Implementation

• 1. Physician leadership
• 2. Physician and staff buy-in
• 3. Effective planning
• 4. Willingness to use the EHR to enable
  changes in office workflow and processes
• 5. Excellent training and support
• 6. Pre-loading the system
• 7. Interfaces
• 8. Learn from others

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EHR Selection and Implementation Sample Timelines

• 5 Physician, 1 NP primary care practice
• October-November 2003
• EHR Project team meets
• Developed list of desired features and
  requirements
• Set goals
• Decide client-server vs. ASP
• Discussed different products
• Sent defined set of questions to vendors-RFPs
  available from several organizations
• (adapted from Collins, Kneibert Clinic, LLC)

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Timeline (continued)

• December 2003
• 5 vendors demonstrated their products to the EHR
  Project Team
• January 2004
• Evaluated vendor demos
• February-March 2004
• 3 vendors selected to give full day hands-on
  demos for the EHR Project Team

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Timeline (continued)

• April 2004
• 2 vendors asked for references
• Calls and emails to references
• May 2004
• Site visits made
• Cost evaluation and potential ROI prepared

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Timeline (continued)

• June 2004
• Proposal submitted to executive board
• July 2004
• Approval given
• Kick off meeting- vendor meets with all providers
  and staff
• Go Live set for February 1, 2005.

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Timeline (continued)

• August 2004
• Project manager and Champion physician named
• Hardware purchased- tablet PCs
• Developed plans for pre-load and training
• Reviewed and suggested customization with
  physicians for encounter forms, custom lists and
  workflows

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Timeline (continued)

• August 2004
• Super-users trained by vendor and will train the
  remainder of the staff
• Workflows and custom order lists completed
• September 2004
• Hardware and Software installed
• Vendor training of Project team
• Super-user training continues

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Timeline (continued)

• October- November 2004
• Nurse training begins
• Interfaces built and tested with PMS and LIS
• December 2004
• Preload training
• Loaded EHR with patient demographics and
  appointments

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Timeline (continued)

• December 2004
• Interfaces Go Live
• Begin preloading patient information problems,
  medications, allergies and preventative care.
• Scan selected information (ex. Consultations)

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Timeline (continued)

• January 2005
• Training and practice on the training database
  continues
• Physicians begin documenting 1 or 2 visits a day
  in the EHR on January 18, 2005.
• Go Live occurs smoothly and is essentially a
  non-event.

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Go Live, What does it mean?

• The EHR is now the legal chart
• Nurses begin every visit in the EHR
• Physicians document all visits in the EHR
• Physicians reduced their schedules by 1/3 for two
  weeks
• Paper charts were still pulled for each visit
• All tests were ordered in the system
• Patient photos were captured at check-in

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Three Months Later

• Paper charts only pulled if patient not seen
  since Go Live
• Champion physician met with each other physicians
  individually for feedback, suggestions and
  further training as needed

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Six Months Later

• Paper chart pulls stopped unless provider
  requests chart
• Medical records department reduced from
• 8 to 3
• EKG and Spirometry interfaced to system

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One Year Later

• Have not done an R.O.I. though there was over
  100K saved in the Medical Records Department
  alone
• Physicians are pleased with the improvements made
  in patient care, preservation of total patient
  visits and getting home earlier every night

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Mid-Ohio Internal Medicine Experience

• 1 Physician, 1 NP, 6 support staff
• 3 Month Implementation
• 3 full days of training in the first three
  months-
• 6 weeks prior to Go Live we began using Phone
  notes and the systems internal messaging all
  staff and providers begin practicing on training
  database
• 5 weeks prior, scanning begins with emphasis on
  diagnostic tests and consultations

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Mid-Ohio Internal Medicine Experience

• 4 weeks- pre-loading began starting with charts
  from the Go Live date forward with the goal to
  always stay one week ahead Preload Problems,
  Medications, Allergies and Preventative Care (ex.
  Mammography, PAP tests, Colonoscopy and
  Immunizations)
• 3 weeks- providers utilizing problem and
  medication lists in the system
• 2 weeks- 1 patient per day annotated with
• ROS and PMH
• 1 week- super-users fully charting in the EHR

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Mid-Ohio Internal Medicine Experience

• Lessons we learned
• Pre-load as much as you can initially and
  schedule time for pre-loading for the first 3
  months
• Analyze all work flows
• Communicate often with staff
• Be realistic and patient
• Practice, Practice, Practice!

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References

• Adler, MD, MMM, Kenneth G., How to Select an
  Electronic Health Record System, FPM. 2005 12
  (2) 55-62.
• Leavitt, MD, PhD, FHIMSS, Mark, Business Case
  for EHR in Small Physician Offices, National
  CallJan. 11, 2005, HIMSS Archives.
• Tang, MD, Paul, Key Capabilities of an
  Electronic Health Record System, Letter Report
  to the Institutes of Medicine, 2003.

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Questions?

• Call MGO
• 614-223-3333
• Thank You!