Baylor Health Care System is rapidly implementing an ambulatory electronic health record (EHR) that is required for its success as an accountable care organization (ACO).

The ACO model creates value for patients by improving the quality of care while controlling costs, largely through improved coordination of care. That coordination can only happen when all caregivers have simultaneous access to current information about the patient's diagnoses, laboratory and imaging results, medications, and care plans.


This case study appears in the Leadership special report, Creating Value for Patients for Business Success.

See the related case study in this same report about Baylor's ACO plans.

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So far, about 220 of the 485 physicians employed by Baylor's HealthTexas Provider Network are hooked up to Baylor's new ambulatory EHR. The group is the largest employed physician group in Texas, serving patients in nearly 150 locations. By the end of this year, all those physicians will be using the EHR technology, says David Muntz, Baylor's chief information officer.

The 3,000 independent physicians who choose to participate in the ACO-called the Baylor Quality Health Care Alliance-will also be required to use EHR technology, although it does not have to be the same system that the HealthTexas physicians use. These physicians will be able to communicate via a health information exchange that Baylor is creating (see the exhibit below).


 sec3_baylor-ehr

"We would expect independent physicians to have an EHR attached to the health information exchange and be able to exchange meaningful information on a very timely basis," says Muntz.

Improving Patient Care

Baylor chose two EHR systems-one for inpatient care and another for outpatient physicians-in 2005. The system will invest $28 million on the ambulatory EHR over the 10-year period ending in 2013, says Muntz.

The project recently finished working through some issues that put the project on hold for about a year. HealthTexas was one of the largest physician networks to use the ambulatory EHR software product in the Windows environment and, after implementation began, performance problems began to surface.

Now on a fast-track to full implementation, the system includes:

  • Clinical decision support
  • Standardized clinical protocols
  • Standardized documentation
  • Data feedback for certain diagnoses

The EHR supports Accelerating Best Care at Baylor (ABC-Baylor), a rapid-cycle process improvement program. That program uses the Plan-Do-Check-Act improvement model made popular by Edward Deming.

For example, an analysis of EHR data revealed that only 51 percent of diabetic patients over the age of 40 were taking a daily aspirin, which has been shown to reduce heart attacks and strokes among patients with diabetes. One physician set a goal that all his type 2 diabetic patients in that age group would be taking aspirin (unless it was contraindicated)-and have that documented in the EHR-within six months.

A pop-up reminder in the EHR prompted him to educate patients during their office visits, and relevant patients received a letter reminding them about the aspirin recommendation. The result: Within four months, 100 percent of the targeted patients were documented as taking aspirin.

Although Baylor's inpatient EHR system does not exchange data with the ambulatory EHR, physicians can view information from both records with a single login via the health information exchange. Similarly, physicians can see all medications prescribed to patients by any physicians, ambulatory or inpatient, within the Baylor system. This helps avoid adverse events, such as drug-drug interactions, duplicate prescriptions, and inappropriate dosing that are a common side effect of uncoordinated care.

"We can display all of a patient's medications on a single screen so physicians can do the medication reconciliation in real time while interacting with the patient," says Muntz.

Satisfying Patients

More than 40 percent of HealthTexas patients have received secure messages-generally lab or other test results-from their physicians, courtesy of the EHR system.

When the results are ready to view, patients receive an email message that includes a link to the HealthTexas website that allows them to read the report. Some physicians also use secure messaging to exchange information with physicians who do not use the EHR.

"We have found that patients love it," says Philip J. Aponte, MD, vice president of informatics for the HealthTexas Provider Network. "That is because patients do a lot less waiting for their results."

Planning the Rollout

The key to a successful launch starts with being clear about priorities, says Lee McMillian, HealthTexas' vice president of information technology.

"If your goal is to have all physicians on an EHR by a certain date, then other things have to take a back seat. And if your goal is to have 100 percent of the content done first before you get physicians on the EHR, then your time frame is going to be much longer," he says.

Physicians typically resent the extra time it takes to use the EHR-until they receive some benefits from the technology. McMillian recommends quickly adding features, such as e-prescribing, secure messaging, and electronic access to images/test results- but not on day 1.

"You don't want to change too much at one time and disrupt the way that the physicians practice medicine," he says. "You want to take a graduated approach."

Primary care physicians and those who treat patients for chronic diseases derive much more benefit from the EHR than some specialists.

For neurosurgeons, as an example, the EHR represents a time-consuming responsibility of entering patient data. Because they will see the patient only a few times, they don't benefit from the longitudinal record of care provided by others.

"It is not as valuable as it is for the primary care physician or the endocrinologist who is seeing the patient on an ongoing basis and is really using the power of refilling medications, analyzing data over time, and being able to easily coordinate information from all the providers who have seen the patient," says Aponte.

Thus, he advises that the EHR implementation be staged strategically. In addition to those specialties like neurosurgery that see patients only a few times, HealthTexas' experience has shown that certain specialties-ophthalmology, dermatology, medical oncology, and obstetrics/gynecology, in particular-find the systemwide EHR technology less worthwhile than those who see patients for primary or chronic care.

"I would shift those subspecialists to the end of your rollout-until the system has been perfected with specialties who are going to get a lot of benefit," says Aponte. "All their information will still flow to the subspecialists."

In fact, McMillian says, health systems should evaluate whether it is essential that all physicians use the same EHR system. For those specialists that Aponte mentioned, a specialized EHR might be more appropriate.

Publication Date: Thursday, April 28, 2011