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Patience Is a Virtue
Health Data Management Magazine, November 1, 2008
When he is treating patients, internist Mike Kerkering, M.D., shows up empty-handed every time - so to speak. Rather than toting in a paper chart, Kerkering swings out a monitor mounted on a flexible arm in the exam room. "It's in the periphery so I can maintain eye contact with the patient," he says. "Every piece of data I need is there for me."
Kerkering is an anomaly in the highly under-automated world of physician group practices. He's one of 10 physician members of Spokane (Wash.) Internal Medicine who, along with three advanced nurse practitioners, are electronic health record veterans.
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For more than a decade, the group practice has made clinical documentation a routine part of the operation. Every day, some 300 patients come through for treatment. Many of them have a complex array of illnesses, including diabetes and congestive heart failure. And the EHR has proven to be a useful tool in taking care of them. "Accessing data is the number one benefit of the technology," Kerkering says. "It makes it easier to follow complicated patients."
Maximizing the utility of the EHR, however, is only part of the long and winding story at Spokane Internal Medicine. The group's success embracing the technology-which only a minority of group practices have done-has not come easily. If nothing else, the group practice reflects the patience required to maximize the value of clinical I.T.
After launching the technology in the mid-1990s, the practice spent several years setting up electronic data capture from the wide array of outside sources on which it must rely, including specialists, local hospitals and labs. "When we bring on a new application, we don't just turn the switch on," says Tom Carli, clinic administrator. "We find one physician and one nurse to test it, and when we have it to a fine art, we will release it to everybody else."
The group's patience is beginning to pay off with incentive bonuses from local payers as a result of improved clinical quality. In 2007, the practice earned a $25,000 bonus from Premera Blue Cross for chronic care follow-up. Nearly 90% of the diabetic patients under its care had an HbA1c blood test taken in the preceding year, and three-fourths of these patients were deemed to have their diabetes under control.
Despite its progress, the group is still looking to rectify remaining pockets of under-automation, including electronic prescribing and patient communications. The key, Carli says, is eliminating paper records. "We recognized that to get adoption in the clinic, we had to have every bit of information on the patient at the point of contact available electronically, or else we could not move forward with the EHR," he says. "If the physicians needed to carry a paper chart, we would not get adoption."
A Stream of Information
On a typical day, the practice receives 500 documents from outside sources that must become part of the patient chart. "Only about 20 of these come in paper form," he says. The rest, he adds, arrive via a variety of different electronic methods, including interfaces, HL7 feeds and encrypted e-mail.
The practice imports several large categories of data into its electronic health record, from Practice Partner, now owned by San Francisco-based McKesson. These include:
* Hospital data. The practice imports consults, discharge summaries and ER documentation from 38 area hospitals.
* Reference labs. The practice receives searchable discrete data from three primary sources in HL7 format.
* Imaging. The practice gets imaging reports from local radiology groups and some hospitals. Images themselves are available through a PACS server set-up, which the group can access through local viewing stations.
* Specialist reports. These include consults and progress reports from local specialists, including oncologists and pathologists, who report back on tissue biopsies and pap tests.
Much of the data exchange, Carli notes, was facilitated by a local consortium of hospitals, the Inland Northwest Health Services, which was formed in 1996. The local county medical society spawned the effort.
"Competing hospitals saw the value of sharing data," he says. "We knew a collaborative effort was needed. Twelve years later, we are still meeting once a month." The cost of the data sharing infrastructure, which is maintained by the consortium, is borne by the hospitals.
Importing data from specialty groups required extra effort, Carli recalls. "We personally visited all the specialty groups," he recalls. "We were dying to get their information electronically. So we went to their offices, saw how they output files, and came up with a solution. Whether it was encrypted e-mail, an FTP server, HL7, or Microsoft Word document, we didn't care. All we cared about was if they could make it available electronically. We are the holder of all the information for the patient."
Tools within the EHR ease the analysis of the data, Kerkering says. "I can see flow charts of the progress of lab values," he says. The system includes health maintenance templates for various diseases, such as diabetes, Carli adds. A generic template for a healthy patient changes as the patient ages. For example, when a man hits 40, the system will update the template to include a prostate cancer screening reminder. Later, at 50, a colonoscopy reminder is added.
Disease-specific templates, including diabetic care, remind physicians when certain tests are needed. The system will fire alerts if a patient is overdue. Such built-in alerts raise the quality of care, Carli contends. "If a patient is due for labs, it kicks up when the physician opens the chart."
A Hybrid Approach
The technology is a hybrid system that encompasses both clinical documentation and practice management features, such a scheduling and billing. Thus, when a patient calls for an appointment, the scheduler will see if a certain test is overdue as well and can remind the patient when they call in.
Hammering out such workflows is a critical part of any EHR deployment, Carli says. Gaining access to the hospital and lab data electronically, an effort which was wrapped up in 2000, was a big first step in maximizing the system's utility. However, Carli adds, "you are not close to done. You then have to look at workflows and how to use the information."
Despite all its headway, two big projects loom on the horizon for Spokane Internal Medicine. First is e-prescribing. This past summer, Practice Partner upgraded its software to enable direct electronic feeds of prescriptions to local pharmacies. The practice is registering with local pharmacies, and it will join the SureScripts-RxHub network, an Alexandria, Va.-based clearinghouse of electronic prescriptions. That will replace printing out the prescription, which patients tote to the pharmacy for fulfillment. "You never know if they got to the pharmacy or not," observes Kerkering.
The new system will incorporate enhanced drug-drug interaction checking, the internist adds. In addition, the practice stands to qualify for Medicare bonuses that reward e-prescribing.
Beyond that, the practice is looking forward to adding a patient portal to the technology mix. Using the portal, for example, patients could retrieve their own lab results and perhaps communicate electronically with the practice. Patient communication constitutes a "big unpaid workload," Carli observes. "We get paid when we see you face to face. But it is anticipated that we are supposed to provide services over the phone. But if we don't see you face to face, we don't see a dime for it."
Some payers are recognizing that "e-visits" - clinical exchanges between patients and their physicians - warrant reimbursement, Carli adds. The practice would need to be certain that such reimbursement would occur before embarking on a major online visit initiative, he adds. The practice also would need to assure the security of such exchanges. "This is the next segment of the modern health care era," he says. Phone calls just waste too much time.
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