From the Consultant’s Corner 11/2/13

Change Management: The Path to EHR Clinician Adoption

Most of us are excited when we see provider order entry rates of 80-90 percent in our health systems. We should be proud of our users; it’s not an easy milestone to reach when transitioning from old systems or paper. Most of us also realize these target numbers are a poor indication of the overall performance and satisfaction of our clinicians. Let’s face it: we aren’t offering alternatives save for some scribes, emergent and transcribed orders, and perhaps we shouldn’t be.

Unhappy clinicians use the EHR because they have to. Happy adopters put the system to work for them, and demand results. They’re asking for the support to be efficient with the system, yet attentive with patients relevant and accessible data; timely, accurate and functional decision support;  the ability to personalize tools and content; feedback mechanisms driving content localization and formulary adaptation reflecting site needs. Where to begin?

We have strategy meetings seeking readmission rate reductions, clinical integration improvement, population health programs, business intelligence platform development and much more. Are we doing all we can to support EHR usability and functional flexibility with a true governance backbone?

Many of us are re-evaluating our approach to satisfaction or just starting down the path of improving adoption of the EHR. I’d suggest focusing on four themes to manage the change, identify resistance and provide the incentive for meaningful adoption.

1. Improve governance alignment. Many of us have too many committees. While that may not change, we can certainly align our leadership and communication. The Physician Advisory Council, P&T committee, Medical Group leaders, Medical Executive Chair, clinical CXOs, and clinician champions should have a shared adoption agenda and prioritization for improving the EHR. Disconnects between these groups lead to stagnant or slow optimization. Is your vision and elevator story for leveraging technology across the care continuum transparent and similar across your executive teams? Including representation on your EHR interdisciplinary leadership team from these groups brings speed and competency to decision making. We must align our agenda (and re-evaluate team membership) to reach our goals. For those large multi-hospital multi-practice sites, invest in and support a local governance structure that mirrors your corporate team. Build strong bridges with your sites. Develop a reputation of responsiveness and alignment.

2. Develop adaptation guidelines. What does standardization, localization, and adaptation mean in your organization? How much control do your practice sites and hospitals have to flex and evolve your clinical content tools? We have resource limitations, though we can be transparent about our aims. Perhaps you have four lab systems and have yet to standardize the ancillary approach. Perhaps evidence shows different patient population-based medication response so certain formulary variation is valid. Perhaps sub-specialty scope of practice demands different EHR design or content. Clinical evidence may drive order set template creation and the EHR note format may be in a standard design, but don’t wait to be asked for the rules of engagement. Educate your users on the rules of change, who to work with on feedback and why it’s for the benefit of all. Do your sites know your adaptation guidelines?

3. Define user segments and training needs. One-size-fits-all training? Yawn! Technology-savvy residents expect the high-powered EHR. Some long-time clinicians fear the computer mouse. Know your audience, customize your training approach and build a segmentation tool to help. Key segments include your usual hospitalists, PCPs, specialists, surgeons, floor nurses and LPNs, though getting granular is important. Work with your department heads to identify potential super-users, resisters, folks needing basic computer training, and more. Segment those who may act as mentors. Segment those needing 1-1 training support. Identify rare admitters. Flag who will need refresher training. Educate your EHR training team on your new powerful knowledge about your clinician population, and put it to work as you develop curriculum, training classes and agendas. Track proficiency and follow up with refresher courses and e-learning.

Enable practice and personalization. These steps are often forgotten. Get your users in an EHR playground before going live, and even before upgrades. Assist their familiarity with the new features, workflows and tools, but make it valuable time spent. Provide support to personalize their toolsets in the production environment before going live. Help them modify their note templates, add orders to preference lists and create personalized order set templates before working with patients. On day 1, they’ll hit the ground running and appreciate that the system can work for them.

4. Strengthen post go-live communication. Some parents compare an EHR go-live to child-birth; the hard work is just beginning. While you’re going to have frequent newsletters, emails and MEC presentations leading up to an EHR launch, don’t slow down. Gather feedback directly from users to determine key challenges and to prioritize change. Make it easy for clinicians to give feedback by connecting with them in the physician lounge or accompanying them on rounds. Do more than providing an issue or ticket tracking system – stay connected in their world, on the units, in the clinics. Your CMIO and CNIOs should be familiar faces at your sites bringing updates, feedback and asking for more. For those leaders who always wanted to be in a band and go on a road show, you’ve got your shot.

Many of us have a future vision of powerful data warehouses, predictive analytics, evidence-based practice driving improved financial and clinical performance with improved patient satisfaction and care. We’ve seen the bells and whistles of EHR systems, and we have IT teams eager and ready. Let’s show our users we’ve heard them – how can you improve your clinician adoption?

Jaffer Traish is director of Epic consulting at Culbert Healthcare Solutions.

News 10/31/13

CareCloud will integrate ZocDoc’s appointment booking app into its platform, allowing patients to book appointments online with CareCloud providers via ZocDoc.

WebMD jumps into the patient engagement space with the acquisition of Avado, a developer of patient relationship technologies. Avado offers an EMR-agnostic patient portal that includes messaging, reminders, and appointment scheduling tools.

Rush Health (IL) endorses the eClinicalWorks EHR solution for its 300 affiliated private physician members.

SuccessEHS will integrate the DataMotion Direct secure messaging service into its EHR platform.

Vitera announces the availability of Intergy Mobile 2.0 in the Apple Store.

Physicians continue to be uncertain about how the ACA rollout will impact their workloads or wallets, according to a USA Today news story.  Physicians point to the need for increased efficiencies and a shifting of non-clinical tasks to administrative staff.  AAFP president Reid Blackwelder, MD adds that medical teams need to learn how to “work smarter, not harder” and use electronic systems better.

I am looking for a few volunteers from HIT vendors to participate in a Q&A for HIStalk Practice. Specifically I would like a few sales types (or even former salespeople), as well as implementation and training experts that work with physician offices. I can’t guarantee that your few minutes of  time will result in fame and fortune, but be assured I would be very grateful. Email me for details.

As you get ready for your Halloween office party or a night of treat or tricking with the kids, here are a few Halloween health hazards you may want to avoid – unless you work in a hospital or practice with medical staff close by. Crazy-colored contact lens that may damage eyes are a top concern, as are skin-irritating makeup, pumpkin-carving injuries, and general candy overload. Personally I plan to play it safe and stick with my stand-by Wicked Witch costume and limit my evening intake to chocolate and a side of wine.

Send Inga treats or emails.

News 10/29/13

Athenahealth will implement Safety Event Manager, a safety reporting solution from Quantros, allowing athenaClinical users to submit patient safety data as part of their EHR workflow to the federally sanctioned Quantros Patient Safety Center

The Government Accountability Office reports that general practice physicians were 1.5 times more likely than specialty practice physicians to have been awarded a MU incentive payment in 2012. A total of 183,712 EPs were awarded payments in 2012, representing 31 percent of all EPs and an increase from the 53,331 (10 percent) of EPs awarded incentives in 2011; 75 percent of EPs awarded incentive payments in 2012 were new to the program.

Greenway Medical Technologies is named a finalist for the 2013 Intel Innovation Award in recognition of its PrimeMOBILE app for Windows 8.

A pediatric mental health study using athenahealth claims data reveals a 29 percent increase in the rate of mental health diagnoses between 2009 and 2013. ADHD accounted for more than half of all pediatric mental health diagnoses.

In 2011, office-based physicians using an EHR were more likely than non-EHR users to exchange lab results, send prescriptions electronically, and provide patients with clinical summaries, according to a study conducted by the CDC’s National Center for Health. Specific data exchange functions included:

• Viewing lab results online: 87 percent with EHRs vs. 67 percent of all physicians
• Sending prescriptions electronically: 78 percent vs. 55 percent
• Incorporating lab results into an EHR: 73 percent vs. 42 percent
• Providing patients with clinical summaries: 61 percent vs. 38 percent
• Sending lab orders electronically: 54 percent vs. 35 percent
• Exchanging clinical summaries with other providers: 49 percent vs. 31 percent.

Not surprisingly, data exchange capabilities varied significantly depending on the EHR: the ability of providers to exchange clinical summaries, for example, ranged from one-fourth of all physicians to three-fourths, depending on the EHR.

In an interview, eClinicalWorks CEO Girish Navani shares various observations and predictions for the industry. Some notable comments:

We are headed for consolidation, without a doubt. It’s not just going to be the smaller or the insignificant. I think you will find companies that have not built customer bases or are strongly relying on investors to fund their next generation of products having to either consolidate or merge. It happens in every industry, and it’s going to happen in our industry. I wouldn’t be surprised if you see some reasonably large businesses next year get acquired or merge with each other.

The right to earn a physician’s business is going to get harder, because you will be in what I would call a replacement market. You need to have a better product and a better service, and you need to be able to keep your customer base. I think size will matter, at some point, just like it did in the cell phone business. Verizon and AT&T built more connections, so they got more subscribers. I think you’ll see some of that, as well. I wouldn’t be surprised if a larger business that can’t invest in research and development, and can’t show the same top line growth will get pressured by stock prices or investors to merge with something else

I think in 2013 we are still amidst the transition where we now understand that our reimbursements will be tied to outcomes. I don’t think we have yet changed the consumers’ behavior around looking at those indicators in terms of how and where they derive their quality or care. But if you ask me, the question over the next 5 years, we’re definitely moving to consumer-centered care. The patients will make decisions based on price, quality, and also convenience in terms of how and where they get their care. Again, it will go faster than you and I expect. My gut tells me if we look back within 12, if not 18 months, we will be pleased that healthcare has moved past digitization of technology to using it as a vehicle for better decision making.

Email inga.

News 10/24/13

A Forbes article highlights Practice Fusion’s possible privacy problems stemming from  their practice of emailing patients to request physician reviews. This is a topic we mentioned a couple times on HIStalk Practice, including in this post by Dr. Gregg. The article criticizes Practice Fusion for possible HIPAA violations, drawing the above response from CEO Ryan Howard. While Howard contends the accusations are “false,” Forbes’ Kashmir Hill stands her ground and a few other readers pile criticisms on as well (check out the comments at the end of the article.) Practice Fusion has added a new blog post further clarifying their patient survey policy, but I doubt we’ve heard the end of this story.

Rush Health (IL) endorses athenahealth’s EHR and PM services for its 300 affiliated private physician members.

CMS publishes the 2013 Interim Feedback Dashboard User Guide to assist EPs with accessing and interpreting the status of PQRS data to monitor claims-based individual measures and measures group reporting.

The 150-provider Rothman Institute (PA) selects White Plume’s ePASS product suite to automate the charge capture process and prepare for ICD-10.

More than three-quarters of parents participating in a University of Michigan poll would likely seek email advice for their children’s minor illness if that service were available, though almost half feel the consult should be free. What’s unclear from the report is whether parents think physicians should not charge for this service, or, if they believe that insurance should pick up the tab for the consult. Regardless, we are clearly a society that believes we are entitled to many things.

The clever folks at NueMD produce a Miley Cyrus “Wrecking Ball” parody that satirizes how doctors at small medical practices are being knocked out by a “wrecking ball” masquerading as government regulation and payer obstacles. It might be funnier if it didn’t hit so close to home.

Email Inga.

HIStalk Practice Interviews Linda Fischer, EMR Manager, Boulder Community Hospital Physician Clinics

Linda Fischer is EMR Manager of Boulder Community Hospital Physician Clinics, Boulder, CO.

Tell me about yourself and your practice.

I have been with the hospital for almost 15 years. We’re part of Boulder Community Hospital. We have a subset that owns our practices, Boulder Community Hospital Physician Clinics. We have 17 clinics that are owned by the hospital that are multi-specialty, ranging from family practice, internal medicine, infectious disease, travel clinic, an endocrinology clinic, and we just added a trauma clinic and a neurology clinic. We also have sports medicine and occupation medicine and pain. The clinics are located within a 30 to 40 mile radius around the hospital and serve the local patients of the community.

What type of healthcare technology software do you have in place right now, and how long have they been in place?

We’re currently using Greenway for both practice management and EMR. We’ve been on it for almost four years. We converted in April of 2010. Just a couple of those clinics are not on Greenway currently. They are still using paper because they are recent acquisitions and we have not brought them up yet on Greenway. But they are in process. The hospital uses Meditech, and we do have some interfaces that run between Meditech into Greenway.

Were you involved with the selection of the Greenway system?

Yes. In fact, I implemented the legacy system that we had. And then I was part of the selection committee to bring on Greenway including the review process and then of the orientation to Greenway.

Tell me a little bit about the more recent selection process.

We had a legacy system at the existing clinics that we were on for five years. The providers did not have a choice in that system, and it interfaced directly with our hospital system. When we got a new CIO, she gave them the opportunity to stay with what we had or to do a selection process. They opted to do a selection process. So, we went through a two-year selection process where we had a number of stake holders all on the team, including IT, providers, medical assistants, front desk, and billing staff. All were on the team as stakeholders.

The main direction from IT was that the system had to be CCHIT-approved. We went through the list and people had some things that they had already researched and really wanted to look at. We grabbed about 35 of them to look at initially. We also created a list of must-haves, and then things that we would like to have. Every stakeholder put in things that the new system absolutely had to have, based on what our legacy system could already do. The dream things were things that we wished that our legacy system could do, but it doesn’t. We traded those lists, then we started to review those 35.

We looked at KLAS reviews and narrowed the list down to about ten. Did more intensive KLAS reviews and narrowed that list down to four. Then we had a vendor site fair for those four. The vendors came onsite and we had all the stakeholders as well anybody else that wanted to participate, come look at the systems that were being demonstrated, as well as maybe do a little hands-on play. We kept our legacy system as one of the four that made it that far in the selection.

What was your legacy system?

It was called LSS and it interfaced with our Meditech system that the hospital has. It was the outpatient division for Meditech and we kept that as one of the top four. Then after the vendor fair we narrowed it down to two, which did not include the legacy system.

We sent teams out to do site visits with those two systems to see how actual clinics used the systems. And, we did an RFP for both of those systems. Those come back in and then we compared and contrasted those. After we had done all that, the site visit, and the RFP, we came to a consensus as a team with all the stakeholders and we selected Greenway.

Tell me a bit about the implementation process for both the practice management and EHR.

Since we had so many clinics already up on the legacy system, we felt like the best way to do it was more of a big bang approach. When we brought on the legacy systems I was able to stage it because they were all on paper, so I did one clinic every six weeks. I brought them up on the PM first and then I did the same process and brought up each clinic on the EMR.

But, because they were already all on an electronic medical record, we felt like we needed to do it big bang, so we did all the PM first for two weeks. We created all the schedules, migrated all the patients, and did double entry for about two weeks, scheduling patients in both systems. Then we went cold turkey and everything was in Greenway. Then two weeks after that was done, we did the EMR.

Again, we had migrated as much data as we could. There was very little structured data that could fill in to the same fields, so we did have to re-enter a lot of data. But that happened over time. We obviously weren’t able to do that initially. We migrated all the chart notes and then as the patients came in, we started putting in the new structured data in the new fields in Greenway. Because we had so many sites and doing the big bang, we did bring in contract work from Greenway so that we were able to have support at every site, when we went live.

So you electronically migrated of some of the EMR data?

Yes, as much of it as we could. We were able to get in the progress notes, allergies, and medications. Those were things that we felt like we absolutely had to have, as well as the registration data for the PM side. They weren’t able to migrate any of the scheduling, so we had to rebuild all the schedules.

What about scanned documents on the medical records side?

Well, we never scanned in all the paper record on the legacy system because at that time, we did not have the storage for that. So, we still have paper charts, but since we were on the legacy system for five years all those progress notes converted electronically. Now that we’ve been on Greenway for three and a half years, there’s very little that needs to be done in the paper chart, at least for the existing clinics that we brought up at the time. We do have more scanning to do with the brand new clinics that we have since purchased and with clinics that we had but didn’t bring up at the time. With those they have more scanning to do because they were on paper initially and went from paper to Greenway.

Tell me how you get physician buy-in in terms of you changing the workflow from the old system to the new system and just using the computer in general?

Well initially, they were all on the legacy system before we went to Greenway. But to get a buy-in on the legacy system, it was a lot of one-on-one attention and training with them, and support to help them through all that. On Greenway it’s the same thing: we give them a lot of individual training. We do additional training as Meaningful Use changes have come out. We’ve needed them to step up and do a few more things that maybe they didn’t use to, like check a box, or we will help them with workflow changes so that we can get the reimbursement that we need.

I understand that several of your practices are participating in the CMS comprehensive primary care initiative project for Colorado. Tell me about the decision to participate in the program and what that entails.

The decision was made by our COO. She wanted to see if our family medicine and internal medicine practices could participate in that program. She felt like it would help us in our move towards a patient-centered medical home, which is another direction that we are going. We do have some narrow level contracts that are also geared toward patient-centered medical home and we are moving all of our family practice and internal medicine clinics to patient-centered medical home.

When we did the application to be part of the CPCI initiative, we had to apply for each clinic individually. They did select five of our eleven. We do have some different things that we need to do for those CPCI clinics that’s a little above and beyond what we do for the regular patient-centered medical home clinics. But we are trying to keep things standard across the board. The differences that we do are more for initiatives that are being looked at and tracked on the CPCI level that we are not necessarily tracking on the rest of the patient-centered medical home clinics.

What kind of results are you seeing in terms of the quality of the care that’s being provided, both for the clinics that are part of the CPCI and the regular medical homes?

We feel like we’ve really been able to step up the quality of care that we’ve been able to provide. The CPCI has given us some initial start-up money that we wouldn’t have had if we had stayed with trying to implement patients that are in a medical home on our own. We have used that start-up money to create care coordinator positions that we never had before. They aid the physician by working with high- risk patients and getting the high-risk patients more outside care and better coordinated care that we just didn’t have time to do in the past. Things like follow-up for mental health or abuse, as well as additional follow-up for our patients that have been hospitalized. We just didn’t have the bandwidth beforehand to be able to follow up with all of those patients.

Now we can contact those patients that have been hospitalized and find out how they’re doing.  If they need to see the physician we get them in to see that provider in a more timely basis. We have done a better job at trying to make sure we have same day appointments to get our patients in. That’s especially been helpful in our internal medicine clinics because often there had been quite a wait to get in to see some of our providers.

And, we are implementing another analytics system that’s due to come online very soon. All the data’s in and we’re just working on the finishing touches which will allow us to really work with registries and more of our high-risk patients preemptively and be able to call on those patients again. Before we didn’t have the bandwidth to do these things or have some of the analytics capability to find those patients. Now we’ll be able to find them much more easily and then work with them preemptively, before their visit, to make sure that they’ve had the labs that they need, that we’re calling them, that they’re doing their blood pressure checks or their sugars checks for diabetes, or those types of things.

What is the analytics program and does it interface with Greenway?

It’s Wellcentive and it does interface with Greenway. All that data has been loaded in from Greenway. I call it kind of an EMR light, but we will not be documenting with Wellcentive. We are using it for the analytic and the registry portion.

What are some of the things that have made participating in quality initiatives easier because you have an EMR and practice management system in place?

The ability to create structured data and then capture that so that we can track trending issues, follow conditions better, create payment models with the payers, and know beforehand when we’re negotiating those contracts, and knowing that we can meet their requests for the different payment models that are coming.

Are you currently using a patient portal?

We’re going to roll it out and start in two weeks. It is from another third party that interfaces through Greenway called Intuit. It is actually live now; we just have not rolled it out to the patients yet. We’re finishing up the legal and the risk assessment on it before we do that.

What is your plan for getting patients to actually use it?

We’re first going to pilot it at two sites, and work with just some specific providers and their care teams. We will, one on one, really try to engage the patient when they’re in there for their visit and see what kind of patient engagement we can have. We’ll let them know that they are part of a pilot so that we can get feedback from them on how we could do it better and determine things that we could improve upon before we roll it out again. Because we have so many clinics, we want to make sure that we do a good job and really make it useful for our patients.

Well, I just want to throw in here, quell some of our provider fears around the portal as well. Our providers are very anxious that it will increase their workload, as opposed to just changing their workload and the way that they’re seeing some things.

Tell me about the innovation award you recently won from Greenway. What specifically was the practice being recognized for?

I think for the way that we are using Wellcentive to meet the needs around patients at our medical home and CPCI. And, from a Greenway standpoint, we’ve also done some work to help them create a GL utility that they never had before, because being part of a hospital system, we have a much more in-depth need for GL than they had ever run into before. As well as our recent implementation of our occupational health clinic and Boulder Center for Sports Medicine using Greenway. Again, therapies that they had not used in the past on their system. And we’ve done it quite successfully; they’re doing really well.

Anything else that you’d like to add or advice that you’d like to give other practices looking to increase their use of technology?

Some of our lessons learned were related to working with a vendor that had not been used to something quite our size. We did have some early growing pains with the way we were scoped from a server size. We didn’t have an adequate number of servers and so we experienced some system slowness that could have been prevented had that been done better. As well as load balancing – just more some technical things that maybe we didn’t scope or communicate as effectively with the vendor as we needed to.

Another lesson learned that we picked up is because we did the big bang and we brought in all the outside contractors that they didn’t necessarily buy into our processes and our workflows. So, there was some subterfuge there when they would be in the clinic and we’d ask them to do things ABC; as they’re rolling them out, the staff would ask questions and they’d go, oh, well, you can just do it CBA. You can reverse the order and it’ll work fine in Greenway. Which is true, but that’s not our workflow, to make sure that things aren’t forgotten and that we’re following all the processes that we need to mitigate patient risk or things like that. So that’s again another lesson learned: to have those people for support on the same page.