• Developing a Meaningful EHR

    Apr 21, 2010

    These trail-blazing providers still have some work to do to qualify for HITECH meaningful use incentives. But their EHRs are already creating efficiencies-and, most important, improving patient care in meaningful ways.

    This is Section 3 of Leadership's Collaborating for Results report.

    Return to the full report.

    Electronic health records (EHRs) that span the entire care continuum-including hospitals, clinics, home care, and patients' homes-are often celebrated as the ultimate collaborative tool. The labor involved in building these massive IT enterprises, with the millions of implementation details and technological intricacies, is also a testament to teamwork.

    Case Study: Wringing Out Waste

    When CIO Deb Rislow, RN, first saw the dramatic decrease in laboratory tests at Gundersen Lutheran Medical Center, she thought there was something wrong with the data.

    "It was astounding," she says. "I was stunned at first because the reduction was so much larger than we had expected."

    Shortly after implementing a hospital EHR system in late 2008, Gundersen Lutheran introduced computerized provider order entry (CPOE). Almost immediately, the average number of inpatient laboratory tests per patient fell quickly by more than 16 percent across the system's 325-bed hospital.

    Reducing redundant orders. Rislow attributes the drop to a reduction in duplicate test orders. With the new CPOE system, physicians who order lab tests are automatically notified if a pending order for the same test exists. In the past, physicians would have had to take the time to flip through paper charts to see if another physician had already ordered a particular test.

    Gundersen Lutheran has also seen a sharp drop in redundant radiology orders since CPOE was introduced.

    "This represents a true reduction to the cost of care for patients because those tests did not need to be repeated," says Rislow.

    Creating a continuum of care. While this is the kind of efficiency that everyone wants from EHR technology, it only became evident at Gundersen Lutheran after years of work. The Wisconsin health system's IT journey began more than 15 years ago when it developed a rudimentary electronic medical record system for its ambulatory clinics.

    Today, Gundersen Lutheran has integrated the majority of hospital, ambulatory, laboratory, radiology, and other records-creating an almost complete continuum of care record for outpatient physicians working in 48 clinics. The EHR system also provides shared protocols and decision support for physicians.

    When Gundersen Lutheran went live with CPOE, it joined an elite group-about 5 percent of U.S. hospitals, according to HIMSS Analytics-in which physicians issue instructions and orders electronically.

    Engaging physicians. The success factors behind Gundersen Lutheran's EHR story are the same ones that many other EHR-savvy organizations report: strong executive leadership and physician engagement.

    Senior leaders made it clear to physicians that adopting EHR technologies was not optional, says Rislow. "When this went live, we were all going to use CPOE. There was not an opting-out opportunity here."

    However, many physicians participated in IT purchasing discussions. Rislow's IT team started by doing more listening to physicians than talking. "It was a lot of work, but it was good work in that the IT team needed to learn the physicians' work flow," she says. "We couldn't implement a system that was going to slow the physicians down. That was a real challenge."

    A number of physicians were trained as "superusers" with responsibility for training their colleagues and being part of the support team. "You can't have enough physician engagement," says Rislow. "The more physicians you have involved, the more successful the implementation will be."

    In addition to mandatory, medium-sized training sessions, Gundersen also used one-on-one training, small classes, and long-term coaching by super-users to support physicians learning the new technology.

    Going live-once and for all. Rislow strongly advises that hospitals should use a "big bang" approach to go live with EHR technology rather than phasing it in one department at a time.

    Using a phased-in approach, she says, raises the risk that new versions of the technology will be introduced before all users have been trained on the initial version, causing confusion throughout the organization.

    "Pick a date, get everything ready, and go," she says. "On that date, all systems are turned on. All end users are trained, and they start using the system that day. Even though it is painful, it is a one-time pain. It's like ripping the band-aid off, and you start the journey of resolving, maintaining, and fixing things while everyone is on the same version."

    Qualifying for incentives. Despite its robust use of technology, Gundersen Lutheran does not yet qualify for Stage 1 meaningful use incentives under the Health Information Technology for Economic and Clinical Health (HITECH) Act (see the exhibit below). For one thing, the outpatient information system cannot meet the data interchange requirements and some of the standards required to be a certified EHR system. One specific upgrade needed: up-to-date, electronic problem lists of patient diagnoses.

    2011 Meaningful Use Objectives

    The 2011 deadline for Stage 1 incentives has forced a decision: Should the health system upgrade its existing ambulatory care EHR technology or buy a new system that would fully complement the hospital EHR system? After Rislow and a team of physicians presented the options to Gundersen Lutheran's administrative leadership, they decided to make the decision in collaboration with medical staff.

    "We went out to each ambulatory department to review the options with the physicians and the support staff, demonstrate the hospital information system, and call for their feedback through a survey," she says.

    The result: Gundersen Lutheran will acquire the ambulatory EHR system produced by the same vendor that provides its hospital system.

    Resolving ROI. Like other healthcare leaders who have built robust EHR systems over many years, Gundersen Lutheran executives no longer worry about proving the ROI in financial terms.

    At press time, Gundersen Lutheran was analyzing data to determine whether quality and safety measures-such as medication-related errors-have improved since the adoption of CPOE. But these improvements can be difficult to quantify. "You can't even begin to put a ROI on the avoidance of potential errors and so forth because we cannot know what those were," says Rislow.

    In some cases, beneficial changes for patients translate into financial losses for the health system. For instance, reducing duplicate lab orders has resulted in a significant reduction in gross billable charges for laboratory services.

    On the flipside, Gundersen Lutheran is also eliminating some costs. The EHR system changes the way many administrative functions-such as coding, billing, transcription, and documentation-are accomplished, eliminating staffing costs. For example, fewer than 11,000 paper charts were moved from one location to another at Gundersen Lutheran in November 2009, compared with more than 55,000 in November 1999.

    "And our transcription costs have been reduced by $600,000 a year-just in the hospital," Rislow says. "While that doesn't pay for the EHR system itself, it is a significant amount of money that goes toward the ROI."

    Case Study: Following the Evidence

    If The Everett Clinic meets the government's meaningful use criteria by 2011, as expected, the check it receives will exceed $1.5 million. But that pales in comparison to some of the other numbers associated with the clinic's EHR technology use.

    By supporting a generic-drug program, the EHR system has helped save two commercial health plans more than $35 million on drug costs last year alone. The EHR also supports an initiative to restrict MRI and CT scans to appropriate indications, saving payers $1.5 million a year.

    Most significant, the clinic has documented a substantial increase in the number of patients who have achieved targets for chronic disease management, says the clinic's president Harold Dash, MD.

    Tracking patients with chronic diseases. EHR information is used to create electronic disease registries, which allow Everett clinicians to easily track patient care and health status. "We can pull the information on whether our patients are getting the appropriate care for diabetes, coronary artery disease, or hypertension and whether they are at goal for their illnesses," says Dash. Physicians and nurses can also see at a glance whether patients are up to date on preventive screenings, such as colonoscopies or mammograms.

    That capability makes a big difference in patient care. When the clinic started tracking, only about 17 percent of primary care patients were up to date on disease management and preventive care measures. Today, more than 50 percent are current.

    "We will never achieve 100 percent because some patients either will not comply or cannot get to the goals, says Dash. "Given that, we think we are doing pretty well with this measurement, having started this work just a few years ago."

    Building for future exchanges. Located in Everett, Wash., the multispecialty clinic includes more than 300 physicians and some 80 mid-level practitioners working in 16 locations. The clinic started its EHR journey in the 1990s, when it collaborated with another large multispecialty clinic to develop a documentation system.

    When clinic leaders decided to acquire a more robust EHR system, they saw an opportunity to be collaborative with the greater Seattle medical community. Many hospitals and clinics in the Pacific Northwest have purchased information systems from one particular vendor, says Dash. "We thought it would be an added advantage if we used that same system," he says.

    While the clinic does not yet exchange information with other providers, that day is inevitable if America's health IT journey progresses as planned.

    Calculating costs versus savings. The EHR system has been fully implemented at all Everett Clinic locations since November 2008. While the financial benefits primarily accrue to payers, Dash expects the investment to prove financially worthwhile for The Everett Clinic as well.

    The clinic budgeted $18 million over three years to purchase and implement the system. That amount, along with the annual maintenance costs, are expected to be offset in part by significant reductions in transcription costs. Since implementing the new system, medical transcription expenses have fallen by 84 percent, saving $3.6 million per year. The savings come from the use of standard EHR documentation tools and voice recognition software.

    Costs associated with creating, maintaining, storing, and shuffling paper medical records have also gone down. Paper charts have been removed from all satellite locations, freeing space for clinical areas or other uses. At the main campus, paper records are being discarded after they are scanned so that the clinical information is digitally available.

    "At the moment, except in rare instances, the entire organization is now paperless in terms of charts," says Dash.

    Believing the EHR system can provide even more benefits, the vendor's team is going back to each Everett Clinic department to look for ways to improve templates or create short-cuts. Dash wants to increase the use of standard order sets for common medical situations embedded into the EHR. For example, when a patient presents with a sore throat or back pain, the physician would be alerted to the evidence-based course of treatment.

    "Of course, a physician may want to adjust the recommended treatment given the specific patient's symptoms, etc.," says Dash. "But just think how much faster and more efficient it will be for the team if we have electronic treatment recommendations all tee'd up."

    Within 10 years after the implementation began, The Everett Clinic expects to see an annual ROI of about 8 percent-not including the $44,000 per physician for meeting the HITECH meaningful use criteria.

    The clinic is still addressing the interoperability requirements of the meaningful use criteria, including the ability to seamlessly receive immunization data and communicate critical clinical information with other healthcare providers. Beyond that, its EHR use meets all meaningful use criteria.

    Passing savings onto payers. Of course, the total return on The Everett Clinic's EHR investment is much greater than 8 percent per year.

    The clinic banned drug representatives from its office years ago and started encouraging physicians to prescribe generics, when appropriate. The EHR system supports those initiatives because when a physician prescribes, say, a blood pressure medicine, the system defaults to a generic option.

    "Everett Clinic physicians are now prescribing about 81 percent generic, which is one of the highest rates in the country. The savings to our two biggest health plans this past year was $35 million," says Dash. "That gives you an idea of the power of that capability."

    While the insurers do not share those savings directly with The Everett Clinic, the clinic's value-added programs, including generic prescribing, have resulted in better negotiated rates with its health plans.

    Still, Dash says additional payment reforms are needed to address the problem of misaligned financial incentives.

    For example, The Everett Clinic's EHR system is embedded with restrictions regarding the use of advanced imaging studies so that, for example, physicians cannot order an MRI scan if the evidence-based guideline recommends general radiography. Over a two-year period, The Everett Clinic's use of advanced imaging studies decreased by 39 percent-and related profits fell by $1.5 million during that same period.

    Case Study: Achieving Big Gains

    Citizen's Memorial Healthcare (CMH) in Bolivar, Mo., is the smallest hospital in the country to make it to the top of the EHR mountain.

    Its EHR system, called Project InfoCare, connects all components of the CMH system, which includes a 74-bed hospital, outpatient and emergency services, 23 physician clinics, five long-term care facilities, a residential care facility, and a home care/hospice agency.

    CMH is one of only 39 hospitals at the top rung-Stage 7-on the Healthcare Information Management Systems Society (HIMSS) EMR Adoption Model, alongside such giants as Kaiser Permanente and Stanford Hospitals and Clinics.

    Meeting meaningful use. Despite that, CMH will not meet the meaningful use criteria without some extra work, says CIO Denni McColm. To that end, it is upgrading to the certified version of its hospital information system this year. And it is working on interoperability so that data can be shared via freely available personal health records-Microsoft Health Vault and Google Health-and eventually a statewide health information exchange.

    CMH, which started its EHR adoption in 2002, is happy to deepen its investment to qualify for HITECH funds, says McColm. "Our ROI, which we think could be between $3 million to $4 million over time, will be greatly enhanced with the incentive funding," she says.

    Taking advantage of being small. To hear CMH's story is to wonder if EHR adoption is more manageable for a small hospital than for a huge system. For one thing, its smaller leadership staff has a level of cross-training and multidisciplinary understanding that would be unthinkable in most healthcare organizations. McColm, for example, served as the system's human resources director for several years before becoming finance director and eventually CIO.

    For another, providing one-on-one training for a small medical staff is actually feasible. Only about 30 physicians needed to be trained when the hospital EHR system went live.

    When physicians were resistant to scheduling training sessions, the project leader could call their bluff. "Some physicians tried things like, 'The only time I have is 11 o'clock on Sunday night,'" says McColm. "And the project leader would say, 'Oh, OK. Do you want to meet at your house?'"

    Coping with adoption struggles. Today, about 100 physicians-half are CMH employees and half are independent community physicians-use the EHR system. McColm says the hospital has good relationships with its physicians, but even those who supported adopting CPOE struggled to learn it.

    McColm compares physician CPOE training to K├╝bler-Ross' five stages of grief. Healthcare leaders and trainers should expect to see denial, anger, and bargaining and know that a physician's well-intentioned enthusiasm may be replaced with despair.

    "They went through a phase of, 'Yeah, I can do this pretty easily.' Then after a few days, we would hear, 'I don't know if I can do this,'" she says. "You must be ready to respond: 'OK, this is hard. But what specifically is too hard-and how can we help?'"

    Improving cash flow. The EHR system has also helped the hospital improve cash flow and efficiencies. For example, thanks to a master patient index, the hospital has decreased dollars lost to denials due to incorrect insurance information by 27 percent. More than 95 percent of CMH patients are now identified in the index, which links to all patient encounters in the EHR.

    CMH preregisters patients for radiology and ambulatory surgery services using the insurance and demographic information on file in its master patient index. This saves the patient from having to supply the same information every time for every appointment, and it saves staff time from calling patients to verify information already in the system.

    Similarly, the EHR system reduces hassles related to scheduling, preauthorizations, and test results reporting. When an outpatient physician uses the EHR to refer a patient to the hospital's radiology, cardiology, surgery, or other outpatient services, a pending appointment is created and scheduled by the clinic staff. Before the patient leaves the clinic, he or she knows the appointment time and date for the services and receives an instruction letter.

    Meanwhile, preauthorizations are queued in the EHR system so they don't fall through the cracks before the patient's appointment. And referring physicians are notified about the patient's test results via the clinic's EHR.

    Another benefit: Hospital supply charges are captured more accurately, so CMH is being paid for more supplies than under the previous system.

    The EHR system allows hospital supply charges to be automatically created as a byproduct of clinical documentation. When a nurse documents the insertion of a Foley catheter, for example, the supply charges associated with that procedure are automatically created.

    More than 80 percent of supply charges are created this way. That leads to a reduction in the number of bills awaiting finalization, the amount of data entry support needed to complete bills, and the burden of rework because of late charges.

    Reducing adverse events. In keeping with its original vision, CMH prioritized its EHR decisions around the primary focus of improving quality and patient safety, says McColm.

    The clinical benefits of the EHR system showed up immediately. In the first quarter of 2005, clinicians received 329 electronic alerts about a possible medication allergy or interaction. In 105 of those situations, the clinician erased or replaced a previous order- averting 105 potential adverse drug events.

    CMH's move to EHR technology was driven by the desire to provide seamless care across its various services. In the pre-EHR era, patient medical records were maintained by 30 different units. "I think patients had the mistaken thought that physicians had access to all of their information. But when records are on paper, that is not possible," says McColm.

    Next: People and Processes

    Successfully coordinating care across care sites requires more than an EHR. Go to Section 4, Coordinating the Doctor's Orders, for more.

    Or return to the full report, Collaborating for Results.

    Sidebar: Assessing ICD-10 Impact

    ICD-10 is much more than just another coding update. It will affect every hospital information system and every departmental function that currently uses or generates ICD-9 codes. In addition, ICD-10's multiaxial design will require extensive early education and real-world application by physicians, coders, nurse case managers, and other staff members.

    • Assess your readiness with the following checklist:
    • Does the department code health data or use coded data?
    • Does the department use retrospective coded data? If so, what is the specific timeframe for use? 1-2 years, 3-5 years, > 5 years? And by whom?
    • What are the qualifications or certifications of the staff members performing coding?
    • What department information systems hold coded data? What other systems are interfaced to the department systems?
    • What software or system vendors does the department work with regularly?
    • What is the extent of codes used? For example, are codes used for multiple body systems, or is coding limited to only one or two body systems?
    • Are coded data used both internally and externally to your department? If so, outline information dissemination (to/from, uses of data, whether historical data are required).
    • Do department staff require education in conjunction with another department?

    The ICD-10 implementation date has been extended to Oct. 1, 2013, to give providers, payers, and vendors more time to prepare. Early assessment and planning will help organizations identify potential challenges that could cause a difficult and costly transition.

    Source: Excerpted from Piselli, C., Wall, K., and Boucher, A., "A New Language for Health Care?" hfm, January 2010. Available to HFMA members.

    Sidebar: Improving Data Quality

    Forward-thinking healthcare leaders are making data management a top priority.

    Using clinical data in new ways. The range and amount of data collected via EHRs offer new ways to improve patient care. Physicians can use EHR data to conduct comparative effectiveness research, and researchers will have access to much more data for clinical studies, says John Glaser, vice president and CIO at Boston-based Partners Healthcare.

    EHR data are also enabling new payment structures. For example, Swedish Community Health, a medical home clinic, must capture, analyze, and report clinical data so that payers know whether the clinic is hitting patient care targets. "We're going to get paid based on whether we are lowering hemoglobin A1Cs and whether we are keeping people out of the emergency department," says Jay Fahti, MD, Swedish's medical director of primary care and community health.

    The clinic plans to hire a data analyst to support its business model. "We have to have a dedicated data department to manage the interface between the finance and clinical sides," says Fahti.

    Supporting the revenue cycle. "The need for standard definitions is increasing as healthcare delivery changes," say Glaser. "For example, what is a visit? Is it when the patient physically shows up? Is a telephone call a visit? Is it a visit when a group of five patients meet with a doctor or nurse practitioners to talk about an issue?"

    To solve these issues, Partners Healthcare is introducing a set of standard processes for collecting, defining, and editing financial and administrative data. "Data are never going to be perfect, but we must at least understand the nature of the imperfection," says Glaser.

    Building BI capacity. The Everett Clinic is preparing a business intelligence (BI) strategy that centralizes data collection, analysis, and presentation. "In the past three to five years, we have acquired more end-user reporting tools available for various applications," says CIO Becky Hood. "But we need a broader BI capability to answer questions that require data from multiple sources, and to build dashboards and balanced scorecards."

    At Partners, John Stone, corporate director for financial and administrative systems, is developing a corporate center of business analytics and business intelligence. Some 12 to 14 financial executives will oversee the center, define Partners' strategy for data management, and determine data-related budget priorities.

    "Our analysts spend the majority of their time gathering, cleaning, and scrubbing administrative data and less time providing value-added analytics and insight into what the data is saying," says Stone. "We want to flip that equation so our analysts are spending more time producing a story that goes along with the data."