FREE Health Data Management e-newsletter 
High Stakes, Difficult Choices
Health Data Management Magazine, October 1, 2008
Long choked with paper, and burdened with workflows that they don't fully understand, physicians in group practices have good reason to embrace electronic health records and integrated practice management systems. No wonder they may think of the automated chart as digital candy. And they want to try as many high-tech features as possible.
"There are many more priorities than anyone could actually do," sighs Carol Dresser, system director of information systems at Boston-based Hallmark Health. The two-hospital community delivery system is in the early stages of delivering EHRs to its 400 affiliated physicians. But as Dresser-and many other EHR veterans-point out, the sky is not the limit when it comes to selecting vendors, deploying systems and figuring out long-term strategic goals.
Advertisement
Following are snapshots of six group practices, ranging from newcomers to grizzled veterans, each of which has tackled the what-do-we-do-next question in unique ways.
AN I.T. NEWCOMER FACES 'BIG TIME' RESERVATIONS
Practice: Park City Healthcare
Location: Park City, Utah
Type: 10-physician family medicine
EHR Experience: Just beginning
Priority 1: Get the right vendor
When Bill Pidwell began the hunt for an EHR vendor for Park City (Utah) Healthcare early this year, he knew exactly what he wanted. Doubling as CFO at the 10-physician family practice, Pidwell wanted a system that was: a) affordable; b) user-friendly; and c) integrated clinical documentation with practice management functions.
After considering some 10 vendors, Pidwell opted for Carrollton, Texas-based iMedica. Although Pidwell's contract prohibits him from revealing the cost, he did say that the vendor's initial quote-about $37,000 in start-up costs-was "steeply discounted." That was largely his own doing, as the cost-conscious CFO pitted iMedica against runner-up Greenway Medical Technologies, Carrollton, Ga. "The two systems were close enough, so I played hardball," he recalls. "iMedica decided they wanted a foothold in Utah and figured we would be a good starting point."
But money was not Pidwell's only priority. He knew that any system would need to be easy to use, or it would never fly among his colleagues. "They had big-time reservations. They worried it would slow them down."
The vendor left a tablet PC loaded with the system at the group's disposal. The soft sell worked. "I was happy with it after two hours, so that was a good sign," Pidwell says.
Other software vendors, including Westborough, Mass.-based eClinicalWorks and Waukesha, Wis.-based GE Healthcare, did not pass muster, so they fell by the wayside during the evaluation.
Park City's new software, which the practice is rolling out now, easily swaps data between the clinical note and the practice management side. For example, it has a feature that enables the front desk staff to scan the bar code on a patient's driver's license and import the data automatically. Because the practice serves many tourists in the ski resort, that feature is valuable, Pidwell says. He also was lured by the technology's built-in patient education materials.
Despite the potential, Pidwell knows the next few months will be challenging. "Our first priority will be getting physicians comfortable with the EHR. We want them to go from paper charts to the EHR without throwing the tablet across the room."
Pidwell's already cooking up ways to accomplish that. Using practice management data, he wants to revamp the group's compensation scheme to include production-based bonuses. His other long-term goal is wrapped around quality. "The EHR will provide electronic reminders for health maintenance, such as follow-ups for labs and annual physicals. We want to enhance our patient call-back system. Right now we have no way of doing that. That is poor medicine."
EHR 'WENT IN BACKWARDS,' BUT WORKED OUT
Practice: Huntington Internal Medicine Group
Location: Huntington, W.V.
Type: 60-physician, multi-specialty
EHR Experience: 2.5 years
Priority 1: Proper staging of modules
When Huntington Internal Medicine Group moved to a new facility in the beginning of 2006, it saw EHR technology as a way to avoid moving paper charts. Thus, it implemented clinical documentation software first, later abandoning its legacy practice management system for integrated technology. "We went in backwards," says Jonna Huges, director of clinic operations. "I would not recommend doing it that way, but it worked out OK."
The group wound up carting paper charts to its new offices. And it is still relying on transcription to get encounter notes into the electronic record, from Tampa-based Sage Software. Yet, Hughes prioritized the roll-out of clinical documentation modules in a way that facilitated physician acceptance.
Out of the gate, the practice deployed the system's e-prescribing module, which dispatches prescriptions directly to local pharmacies. "It is something the staff can help facilitate," she observes. "They could enter the meds from the paper chart, the physicians could look at them easily and they only needed a quick click to send."
That feature helped improve the exchange of information in the multi-specialty group, where patients often see a primary care physician and sub-specialist during one visit. "The meds can be updated and in the hands of the next physician right away," Hughes observes.
At the same time it enabled e-prescribing, the practice fired up a tasking feature, which it uses to document phone calls and route orders. A patient requesting an office visit, for example, may need a CT scan. Using the technology, the nurse could set up the test using the tasking feature.
"We began to fill the record with day-to-day information-all the things that used to go on post-it notes," Hughes recalls. "It became a permanent part of the record and it was easy for physicians to use."
During the first year of the roll-out, the practice imported historic records that dated back five years. Some records, such as lab data and transcription, were imported through interfaces. Other paper records, such as encounter notes and externally generated documents, had to be scanned. Hughes set up 15 stations, using document scanners from Secaucus, N.J.-based Panasonic, throughout the facility. "It is important to keep the outside flow moving," she says. In the end, the group imported about 1 million lab reports.
Now that the system is in place, Hughes is shifting her priorities. The EHR enables electronic documentation of the office visit, but most of the physicians are still dictating. As a result, the practice continues to absorb a $750,000 annual transcription tab. If doctors used the electronic charting functions, they could do more than save money. The electronic encounter form automatically imports meds, which, Hughes points out, "are cumbersome to dictate."
ADVICE: BE WARY THE EHR 'JUMP-START'
During her 10-year career advising group practices on I.T. purchases and related management issues, Rosemarie Nelson has encountered plenty of misconceptions. As principal for the MGMA Health Care Consulting Group, Nelson works with about 30 groups annually, ranging from solo physicians to large academic groups. It's easy for them to become enamored with EHRs, she says.
"They see a product at a trade show and then try to jump-start the implementation without asking what they are trying to fix," she says. "Many groups do not set goals around what they are trying to achieve."
It's a crucial step, the Syracuse, N.Y.-based consultant adds, particularly when prioritizing criteria against which to evaluate vendors. "There is no 'one size fits all' technology," she says. "Some physicians will never chart right after every visit. So you can't have a system that blocks the patient from checking out until the chart is completed. That can become a 'gotcha' when they put the system in."
Nelson urges group practices to analyze their workflows in the paper world before they try to automate them. Physicians accustomed to signing off on labs may be inundated in an EHR set-up that is not carefully orchestrated. Surrogate review may be called for, she observes, even in the electronic world.
"In the paper world, a nurse may sort the labs and only give the doc the results that need attention. The doc may feel overwhelmed if he starts to get them all."
HOW PARTNERS' EHR MANDATE ROILED I.T. PRIORITIES
If nothing else, Boston-based Partners HealthCare System controversial decision to mandate its 5,000 network physicians to adopt EHRs cleared the air.
With a deployment deadline of next January, Partners gave the physicians two options: either use the technology or drop out of the network, which includes managed care contracting services. The health system gave another mandate: Physicians had to choose between Partner's home-grown system, called the LMR, for longitudinal medical record, or GE's Centricity, an EHR designed for ambulatory care. "That made it easier for us, not to go through the vendor selection process," says Carol Dresser, system director of information systems at Hallmark Health, a Partners affiliate.
The Boston-based community hospital system employs some 45 primary care physicians, all of whom are using GE, Dresser says. In addition, Hallmark has some 400 affiliated physicians with admitting privileges to its two hospitals. They participate in a managed care contracting group run by Partners, and as a result, are also under the gun to deploy EHRs. "We have negotiated several quality indicators, and the EHR is one of them," Dresser says.
The Partners-negotiated contracts call for EHR deployment across the Hallmark affiliates, with targets for the number of practices deployed each year. Hallmark is in the midst of complying with the requirements now, Dresser says. The effort began in 2006.
But how can Hallmark facilitate the adoption among independent physicians? The answer, Dresser says, is by adopting the application service provider computing model, in which Hallmark will remotely host the GE software for the physicians. As of late summer, Hallmark had most of its affiliated primary care physicians on the GE software, turning its next focus to specialists.
To pull this off, Dresser had to rearrange her own priorities. First, Hallmark had to make sure its own infrastructure could support the remotely hosted practices. "This is new technology for us," she says. "And GE is not used to building technology like this either. They are not used to putting this many physicians on one box."
Once her own network was shored up, Dresser turned to creating interfaces between Hallmark's core hospital information system, from Westwood, Mass.-based Medical Information Technology Inc., to the GE software. These included links to lab, radiology and physician documentation. "It took several months to do and we are still working on it," Dresser says.
Next, Dresser's I.T. department had to figure out the management of multiple databases for the groups coming onboard. Hallmark is leasing both the clinical documentation system from GE and an adjoining practice management module, which is optional. That required partitioning the databases for the participating physicians, who, despite using the same system, want to keep their data private.
Dresser's last big implementation priority was establishing a reliable help desk. For that she turned to Stoughton, Mass.-based Concordant Consulting. The consultancy recommended that Hallmark rely primarily on its own staff to run the help desk, but steered the community health system to a new call management system.
Medical groups directly under Partners' umbrella have had to rethink I.T. priorities as well.
"Some of our physicians had no desire whatsoever to use the electronic record, but all of them are now," says Matt Nivison, director of administrative services at Hawthorn Medical Associates. The 60-physician, multi-specialty group has been using the Partners LMR for 30 months, Nivison says.
To facilitate adoption, Hawthorn took several steps, some of which required supplementing the Partners' system.
First, Hawthorn put computers in every exam room-and outfitted each with a biometric finger scanning device physicians use to log on. The devices, from Redwood, Ca.-based DigitalPersona, have been "instrumental in getting physicians to use the system," Nivison says. Next, Hawthorn created interfaces to its lab system and its picture archiving and communications system, from Ridgeland Park, N.J.-based Agfa-Gevaert. As a result, the physicians can pull up X-rays, MRIs and other images with the patient in the exam room.
Hawthorn has no set I.T. operating budget, Nivison says. Instead, it buys technology on an as-needed basis, looking to Nivison to provide ROI steerage. His latest venture is an electronic charge capture component, from Boston-based MedAptus, which tracks the visit, diagnoses and certain orders. A few physicians have been using the tool for more than a year.
The system speeds up posting of bills, Nivison says. For physicians using the charge capture tool, "our lag time from date of service to date of posting has gone from six days to zero," he says.
Future Tense Priorities
Now that their EHR deployments are well under way, both Hallmark Health and Hawthorn Medical Associates have a number of long-term I.T. priorities. Here's a snapshot:
Hallmark Health
1. E-prescribing
2. Clinical messaging
3. Orders interface from ambulatory to inpatient
Hawthorn Medical
1. Scanning for discharge summaries, other external paper
2. Improved template for encounter documentation
3. Expanded electronic charge capture
VOLUNTEER CLINIC KEEPS EYE ON BOTH MONEY AND MEDICINE
Practice: Good Samaritan Health Center of Cobb
Location: Marietta, Ga.
Type: Low-cost clinic for uninsured
EHR Experience: 3 years
Priority 1: Measuring quality
Larry Hornsby, M.D, wears more hats than most physicians. His official title is medical director. But he also serves as volunteer recruiter, fund-raiser and technology evaluator.
Hornsby is the mainstay at Good Samaritan Health Center of Cobb, a Marietta, Ga.-based clinic that serves the uninsured and working poor. Opened in April 2006, the clinic treats up to 25 patients a day, who pay a sliding scale that averages about $40 per visit. No insurance is accepted-nor usually offered by the patients, many of whom are undocumented workers, Hornsby says. "This practice is a mission for me."
The clinic also is fairly sophisticated in its use of I.T.-at least compared to the majority of U.S. medical practices, which rely on paper charts. Perhaps inadvertently, Hornsby is serving as a one-person test case of the efficacy of the electronic chart in upholding quality. That, he says, was his foremost goal in automating the clinic's documentation. After considering six vendors, Hornsby opted for software from Practice Partner, an ambulatory EHR that is now sold by San Francisco-based McKesson.
Aside from upholding his quality goals, the system needed to be both affordable and easy to use by the 50 volunteers, physicians and nurses among them, that staff the clinic, Hornsby says. The system cost the clinic $40,000 for "computers, servers, everything," Hornsby says, adding that he tapped a single donor to cover the cost. McKesson has donated $25,000 in free licenses and other supplies.
On the quality side, the EHR enables Hornsby to track more than 50 quality measures, such as lab scores for diabetic patients, blood pressure measures and cholesterol scores. A health maintenance section alerts him if someone is overdue for a test. Hornsby also participates in a user group, which shares quality metrics and best practice advice among 120 practices.
Despite the headway, the medical director has targeted three priorities to improve care delivery at the bustling clinic. First, he wants an interface with the local hospital's lab system. Getting the hospital to agree may not be easy, he concedes. Second, he wants to improve the EHR's quality reporting tools to drill down to outcomes measures for highly defined populations, such as black women ages 40-49 who have received mammograms. "That would help cater to grant-issuing groups, which are quite specific." Finally, he'd like to use the system to engage patients more directly by using system features to boost what he calls "proactive scheduling," or calling patients for appointments based on certain clinical metrics or due-dates. "We'd like to make sure that people are not lost in follow-up."
SURGICAL GROUP LOOKS FOR WAYS TO ENHANCE PATIENT SAFETY
Practice: Health Central
Women's Care
Location: Dallas, Texas
Type: 10-physician OB/GYN
EHR Experience: 4 years
Priority 1: Catering to specialists' needs
Like many specialists, Jay Staub, M.D., understands the advantages of electronic documentation systems. In theory, that is. In practice, Staub says, most EHR systems are designed with primary care physicians in mind. "Obstetrics is unique," contends Staub, who has researched the technology for several years. "We are surgeons."
That's why Staub's interest was piqued when he attended an EHR lecture at the 2004 annual meeting of the American College of Obstetrics and Gynecology. The presenter was Bill Bates, M.D., a fellow OB/GYN specialist who had veered his career into the software development business, launching DigiChart, a company based in Nashville. DigiChart's software is OB/GYN-specific.
Staub returned from the meeting, set up a demo with a group practice using the EHR, and soon was on his way. "We felt we could provide better health care and save money," he recalls. "We were overwhelmed with paper."
Since deploying the software in December 2005, the practice has met those goals, Staub attests. Through a set-up with the local hospital, Staub and his colleagues enable surgical support staff to gain access to the system during deliveries and other surgeries. "Unless you make an effort to take an updated record to labor and delivery, you have old information," he says. "The prenatal record is embedded in our system."
Abandoning paper charts meant the practice could get by with fewer staff members, he adds. Since deploying the technology, the practice has reduced its staff by six FTEs, primarily medical assistants and others devoted to chart pulls. The software is remotely hosted by DigiChart, which charges the practice a monthly leasing fee of approximately $400 per physician per month, Staub says. The set-up includes an interface to the practice's lab, which returns most results in one day and pap smears within five. "If the specimen is lost or a result has not posted, the systems gives an alert," he says.
The initial capital outlay for computers and wireless routers was less than $75,000, he adds. The system provides strictly clinical documentation, although the practice has built an interface to its practice management system, from GE. The group still uses a paper billing form for encounters. That's a pre-electronic era habit that Staub has identified as the group's next top automation priority. "We need a way to generate billing codes," he says.
Beyond that, Staub would like to create an interface to the hospital to enable downloads of discharge summaries, mammogram reports and pathology studies. "We could avoid scanning," he says. "We would love to have it all in place tomorrow, but it will take several years."
COPING IN A 'BEST-OF-BREED' WORLD
Among medical groups, Carle Clinic stands out on several fronts. Its size-330 physicians, 104 mid-level providers, and 13 locations-ranks it among a minority of large-scale operations. Formed in 1931, the Urbana, Ill.-based multi-specialty practice can provide just about any medical service. "We don't do transplants, but just about everything else," says Mike Sutter, director of clinical systems.
One of four directors who report to the CIO, Sutter has his hands full managing technology. I.T. resides in practically every nook and cranny of the private, for-profit group. Beginning about four years ago, Carle embarked on a journey to improve patient care and overcome the hurdles of delivering it to a widespread population. That has necessitated linking its remote sites -which cover a 60-mile radius in downstate Illinois-to common electronic record systems (see box). Its imaging modalities are advanced as well, as many feed directly into the enterprise EHR. Now that Carle has embraced digital mammography, the clinic, Sutter says, "uses no films at all for any study."
The clinic's "best-of-breed" approach means it can add boutique products that cater to specialists. For example, Carle is about to deploy a specialty EMR for ophthalmologists, from Charlotte, N.C.-based Medflow, that will capture data from various medical devices. The approach, however, brings its own challenges. It means the clinic's 150 I.T. staff must tend to a multitude of interfaces. And training has become an absolute must.
"We have two full-time educators in our I.T. department," Sutter says. "We are constantly making sure our physicians are well-trained. It is hard to remember all the minute commands." He would like to do away with some commands.
Sutter's top priority is to deploy a single sign-on technology, which will enable physicians to access multiple information systems with just one password.
After considering five vendors, he's in the final stages of negotiation with Andover, Mass.-based Sentillion to set up a pilot program as part of a long-term deal.
Sutter's already in the thick of another pilot, with Microsoft Corp., Redmond, Wash. Carle wants to host its own video conferencing services and will test the vendor's teleconferencing software. "We could have meetings without having to drive long distances," he says. The videoconferences would be scheduled through Outlook, and images would be transmitted via Web cams.
In 2009, Sutter hopes to test a patient portal. It would enable the clinic's clientele to request appointments or even see portions of their own record online. With 332,000 patients who account for more than 1 million annual visits, that technology could be very busy.
Hi-Tech Docs
Here's a list of a few of the key systems in place at Carle Clinic:
* EHR (from InteGreat)
* Practice Management System (from Epic)
* PACS/RIS (from GE)
* Oncology/radiation system (from Varian)
* Digital echocardiogram (from Phillips)
COMPUTER-WARY INTERNISTS SEEK LONG-TERM PREPARATION FOR P4P
Practice: Carraway Internal Medicine
Location: Birmingham, Alabama
Type: 3-physician group
EHR Experience: 4 years
Priority 1: User-friendliness
By her own admission, Beverly Carraway-Handley, M.D., is not tech savvy. The 50-year-old internist, lacking typing skills, cheerily concedes that prior to deploying an EHR in 2004, she had "no computer experience. Zero."
Carraway-Handley is the founder of her eponymously named group practice. Before launching a two-physician group (which has since grown by one internist) that year, she had worked at a large group practice for more than a decade. "I wasn't getting younger, so if I was going to do something like this, I had to do it then," she recalls. Adding electronic documentation in a smaller group, she adds, "is easier. You have fewer people to agree on things."
Carraway-Handley's priorities in choosing a vendor for her new venture were straightforward. First, the system had to include integrated practice management and clinical documentation features. Moreover, it needed to be simple to use. Carraway-Handley and her practice manager, Sharon Pizzato, considered some 15 vendors, opting for Sage. The runner-up, Pizzato says, was MicroMed Healthcare Information Systems. Other vendors - were simply too expensive for the group. "We're just little peanuts here," Pizzato says.
Sophisticated salesmanship is what won over Carraway-Handley. The Sage representative merely handed over a computer and let her fiddle with it. Carraway-Handley, in turn, created her own encounter note on a trial fibrillation "that made sense without my having formal instruction. That was a big plus."
In contrast, other vendor agents wanted to control the demo, invariably focusing on simple patient scenarios that did not reflect the internist's day-to-day encounters. "The internist treats people who say their ear hurts, they have diarrhea and their sibling was just diagnosed with cancer, all in one breath. I need to create a record quickly that could quickly intertwine multiple areas."
Using pull-down check-offs, the internist is able to note a number of complicating details about even common conditions, such as headaches. If she documents "headache" in the note, the system presents a number of qualifying characteristics in an adjoining box, where the internist can denote such factors as duration, severity, accompanied by, preceded by, or blurred speech. "I can sit and punch buttons and generate a note," she says.
Carraway-Handley, who cheerfully concedes her own compulsion in capturing such nuances, says the templating feature sets the stage for her long-term priority. "I want to improve the way we practice medicine and perhaps participate in pay-for-performance programs," she says. The practice may purchase Sage's data analytics module, Pizzato adds. "We could retrieve data for payers or for the government. That's like finding needles in the haystack."
(c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved.
http://www.healthdatamanagment.com/ http://www.sourcemedia.com/
For more information on related topics, visit the following channels:
