Trial Runners

Health Data Management Magazine, October 1, 2009

Olive Branch (Miss.) Family Medical Center looks small, but when it comes to using electronic health records, it acts big.

The two-physician practice uses an EHR system from NextGen Healthcare Information Systems, a vendor often associated with serving much larger groups. Despite its size, Olive Branch has poured considerable resources into developing the technology - to good results. It has an in-house programmer who invents add-on applications.

Those applications have enabled the practice to reap hundreds of thousands of extra dollars in income. That windfall came partly from documentation for pay-for-performance programs, but mostly from being able to easily identify patients who qualify for clinical trials. The practice participates in 15 to 25 clinical trials at any given time on a variety of conditions, including diabetes, gout, hypertension, shingles, erectile dysfunction, atrial fibrillation, flu and sinusitis.

Clinical trial payments have routinely boosted the practice's revenue 10 to 12% annually since it started using the EHR. The extra payments might add 15% this year, says CFO Joe Huling. That can mean anywhere from $550,000 to $700,000 in extra revenue annually for the practice, which gets paid to provide exams, tests and care required by the trials. "We go after the trials that are beneficial for our patient population," Huling says. The practice has anywhere from 50 to 200 patients enrolled in clinical trials at any given time - usually a maximum of 10 per study. But it contributed 100 patients to a flu study two years ago.

Patients receive fees ranging from $300 to $1,000, depending on the amount of time and inconvenience involved. Moreover, they have access to treatments that they couldn't get otherwise. One patient got a life-saving fringe benefit when a trial-related imaging study found an aggressive lymphoma that would probably have gone unnoticed during a routine exam.

 

A Spinoff

Olive Branch's EHR tweaks - the clinical trial application and several others that help providers keep up with care protocols for various types of patients - have generated enough interest that it has spun off a software company, Simbiote Development. The spin-off markets the applications to other physicians using EHRs. Although its applications now work only with the NextGen EHR, Huling says they're designed to be compatible with most industry-standard database platforms and can be adapted to other EHRs.

When Olive Branch chose software from Horsham, Pa.-based NextGen in 2000, it was a part of larger group - a 10-physician practice with three locations that frequently had to share charts. Randall Huling, M.D., a family physician (and Joe's brother), was a key EHR champion for the practice. He had spent 11 years as an Army doctor during a period when the Department of Defense had started to move toward electronic records. By the time he was discharged in 1992, he could already see the benefits of portability for medical information.

"It made perfect sense that we needed to improve our connectivity, so that when we moved between locations, we could keep up with the records without a huge nightmare of faxing," he says.

At the same time, the practice had started to explore participating in clinical trials. However, it found participation a time-consuming challenge. The practice had to keep track of the inclusion and exclusion criteria, disseminate the information to the providers and the patients, and make sure participating patients got the tracking they needed under the study protocol without accidentally receiving treatments that would disqualify them. Huling saw that an EHR would be an enormous boon to this activity.

 

Dispute over EHR

Ironically, the implementation of the EHR was a factor in the 2003 split-up of the larger group into three separate practices. "The software was not nearly as sophisticated as it is now, and we got into a dilemma," recalls Joe Huling. "As flexible as it was in templates and workflows, it was a two-edged sword. Trying to get 10 physicians and all the nurse practitioners to agree on the best way to work created disagreement and dissension, and the group evolved into three different thought processes about how to use the EHR."

Possession of the paper records became an issue in the break-up. The faction of the original practice that became Olive Branch took about 14,000 patient records in the departure and scanned them into its NextGen system. The practice then returned the paper charts to the original entity, which is paying to store them, and Olive Branch was happy to see them go. "The one thing we no longer have to do for our providers here is to encourage EHR use, because there's no paper record available," Joe Huling says.

Freed from paper, the newly constituted Olive Branch Family Medical Center wanted to pursue clinical trial participation in a more methodical way. It directed its programmer to coming up with ways to identify and track candidates. The result was a Research Candidate Evaluation System, or ReCES, which enables the practice to input the inclusion and exclusion criteria for a study. Then it sorts through the patient database and flags likely prospects. The flag appears on the patient's record.

The physician or nurse practitioner goes over the study details at the next office visit and assesses the patient's interest. If the study sponsor is in a rush, the practice may contact all the prospects right away.

The practice has a research coordinator who works with patients who want to participate in a trial. Olive Branch used to work with a company that specializes in coordinating clinical trials, but found it more convenient to bring the function in-house. The practice has now participated in enough trials that it's on several notification lists and routinely hears about new ones.

The research coordinator sets up the patient's care schedule, making sure the patient isn't receiving any tests or treatments that would disqualify him or her from a study.

 

A Complex Task

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