Memorial Hermann Medical Group in Houston keeps growing. With more than 200 providers at 65 sites, it has tripled in the past three years and will do so again during the next three years.

The group practice of Memorial Herman Health System uses the Centricity electronic health records system integrated with practice management software from athenahealth Inc. As more physicians came into the fold, it became apparent that EHR use had to be optimized, says Alan Weiss, M.D., director of medical informatics for the practice. Regardless of the vendor physicians had used or the Centricity system they were migrating to, they were not happy with the speed and simplicity of getting data they needed and writing SOAP notes documenting the patient assessment and treatment plan. They just didn’t like how EHRs work.

About seven months ago, Weiss teamed physicians with information technology staff to work toward making the EHR more user-friendly and efficient. While the task is not yet complete, the results are impressive with physicians on average closing their notes five minutes faster yet also seeing 65 percent more patients. Provider complaints about the EHR have dropped to a quarter of previous levels and the number of physicians logging in at night to do work is down 25 percent.

Establishing a governance structure for selecting and triaging improvements to the EHR and standardizing workflows--through a consensus-driven process--account for the success of the initiative, Weiss says. The physicians and IT staff established a governance structure to develop a shared vision of the help physicians needed so that those in the same practice didn’t have conflicting requests for changes in the records system. They reached compromises and standardized workflows and certain EHR functions.

Before the governance structure was in place, content was often developed for a specific region or practice. This strategy created redundant content, all of which required maintenance, Weiss explains. Those maintenance efforts grew so that IT could not keep pace with new practices and new initiatives.

So, the group turned to data, looking at three years of orders for medications and labs and how physicians put orders in, and came up with standard medication/lab test lists and workflows by specialty that were familiar to everyone. That was done by getting rid of unused medications and tests--still available in a searchable database--but focusing on having the common medications and labs at physicians’ fingertips. And the lists got cleaned up. Many medication lists, for instance, did not include the daily dose or approved refills or a stop date for using the medication, and that information now is right in front of the physicians.

Problem lists also got cleaned up. Stop dates were implemented for medications prescribed for colds and other common short-term illnesses so that the list wouldn’t be cluttered with minor items that physicians really didn’t need to know about. A cold medication may be on a patient’s problem list for a short period, and then automatically drops off. Common treatments are at the top along with standardized treatments, such as a three-day course of antibiotics for urinary tract infection.

Improving the quality of lists was also part of the optimization. The laboratory list included two tests for Vitamin D levels, but one test is better so that was kept near the top and the other dropped lower so a physician still could select it if that treatment was deemed appropriate. The same happened with urinary tests, which were put high up but a urinary culture was moved down.

Physicians still have the options to make other treatment decisions; the goal of medication/lab/problem list optimization was to take the most common selections on the lists, put them at the top and give a little more information at the same time. “Optimization was huge,” Weiss says. “There is always a push in EHRs to optimize by adopting cool new functions like natural language processing and mobile apps. We took a different approach; we wanted our EHR to do the simplest things as easily as possible.”

To improve SOAP notes for documenting patient assessment and treatment plan, Memorial Hermann Medical Group created a new form that enables physicians to write the note while viewing vitals, problem list, medication history and allergies, and have a box to put in new orders--all on a single screen. The new form also supports dictating the note rather than typing it. Acceptance was rapid, with 20 percent of visits documented with the new form within the first week of its use, Weiss says. “To have a new form like that was a big deal.”

Lessons learned so far during the project include:

* The work was tougher and longer than envisioned as members learned they had to be patient and double-check everything;

* Physician members on the governance committee became owners of the project and sold it to peers;

* Gathering good data on who used 800 different types of forms and how often they were used  enabled 70 percent of them being cut and not being missed; and

* Most of the optimization work is applicable to any EHR, including a single-screen SOAP note.

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