We break up discussion of DCPCA’s EHR adoption experience into several phases articulated by the DCPCA project leadership: planning, training, data transfer and implementation.
Planning. DCPCA partnered with Cumberland Consulting throughout the training and implementation process. At the earliest stages, Cumberland did an assessment of the six participating clinics’ infrastructures focusing on hardware, software, connectivity, building set up and other relevant parameters. Participants noted that process and workflow at the sites were not assessed at this stage, although they were assessed later as part of product customization.
Following the initial assessment, all of the clinics came together to develop user and functional requirements for a PMS/EHR system. That list of requirements became the request for proposals (RFP) that was sent to vendors. The participating clinics continued to meet at DCPCA throughout the planning process to discuss what reports and summary data would be useful outputs. Member centers noted that Cumberland Consulting’s role early in the project, even before vendor selection to guide discussion leading up to and including functional requirements, was very useful as it provided an outside perspective and seeded some consensus around the benefits of collaborating and finding common needs across sites.
From the initial stage of assessing needs, DCPCA narrowed the field of vendors to a smaller group. As the list of vendors shortened, health centers were encouraged to bring staff to view the finalists, eClinicalWorks (eCW) and Centricity. There was a final discussion of the pros and cons of both finalists and then one representative from each member health center voted to select a vendor. In voting, members considered the following criteria in particular: user friendliness, the details of training processes, Spanish language functionality (particularly for those with differing levels of education and computer literacy), the experience of other health centers with these vendors and the ability of the product to support the needs of all center users including front office, back office, case managers and providers. While member center representatives expressed doubts that one EHR could fulfill all their requirements, they indicated that both finalists represented a marked improvement over their previous systems, citing an inability to capture simple demographic information like ethnicity before implementing the EHR. DCPCA members selected eCW and chose to implement it using both standard desktop PCs and tablet PCs.
Functionality, customization and implementation planning. Once eCW had been selected, Cumberland Consulting worked closely with staff across implementation sites to understand their clinical workflow and processes and develop a set of customizations of the basic eCW software that would meet requirements across providers. Discussants noted that given the differences in services and operations, this proved to be a challenge and they had to find ways to make the same software usable for a variety of workflows. For example, one clinic’s workflow involved shorter and higher intensity patient encounters where detailed documentation had to be done after the visit rather than during the visit as would be considered the usual optimal use of the application.
In addition, in the initial implementation, DCPCA noted that there were not sufficient funds or time to make effective use of all the functionality available through eCW including clinical reminders. They were able to make use of basic forms for specific types of clinical as well as different patient panels (e.g., diabetics), but that the development of disease and assessment specific forms needs to continue as the clinics learn more about how to operate in an EHR environment. The initial implementation included automation of laboratory interfaces with the EHR and three health centers are making use of the e-Prescribing (eRx) functionality built into eCW while another three continue to rely on in house pharmacies.
Training. Participants noted that training was particularly important in their eyes because of the high levels of staff turnover at their centers. Super users, primarily clinicians from various health centers, were trained first with trainings on the PMS preceding EHR training by two months in some cases. Having more experienced super users on hand during general staff training proved helpful. Super users asked questions of staff and assisted trainers when necessary. Despite this, training was not entirely successful at first, as some staff members needed more individual attention from the trainers. One participant noted that staff would leave the training, and when the trainers would come back, the staff would have forgotten everything that had been covered previously. Others suggested that trainings occur a bit later in the process, roughly a month before go live, rather than soon after selection. Some health center representatives added that trainings were not particularly interactive and that combining workflow exercises with eCW trainings would have helped staff apply trainings to their everyday work. One participant suggested using old (de-identified) patient notes during trainings to make them more useful.
Some changes were made to the original trainings, with eCW trainers tying their trainings to specific tasks and DCPCA assisting when possible. While member center representatives agreed that the more tailored trainings were an improvement, some felt that Cumberland Consulting would have been better suited to conduct the trainings than the vendor because of their familiarity with center processes. Alongside the eCW trainings, DCPCA organized after-hours training for staff unfamiliar with basic computer use and email. In addition to initial training, some groups attended “refresher courses” to provide additional training opportunities.
Members noted that while helpful, these types of supplementary trainings amounted to a big time investment. Some participants expressed concerns about ongoing training, indicating that that the initial training had been successful but ongoing training sessions have not been discussed and could amount to a significant time and resource burden, with providers presumably training constantly rotating public health service corps members and other volunteers. Others suggested that web seminars conducted by the vendor had not proved helpful, particularly in moving beyond the basics of EHR usage. In discussing EHR implementation, one participant noted that more comprehensive trainings would have been helpful but that members did not know exactly what they wanted or could ask of the system. One participant noted that front desk staff would need to be well-trained in the future, saying “They are doing more than just checking in patients.”
Data transfer. In moving toward eCW, member centers’ patient demographic information was transferred from existing systems. After review by health center providers, select clinical information was entered manually “as if they were new patients.” Participants noted that providers were very concerned about condensing patient information from the paper record to the EHR. While some noted that this process was not as time consuming and difficult as they had imagined, others indicated that the process was as difficult and lengthy as they had expected. One participant noted that not all data were entered manually and that the center needed to enlist the help of volunteers to scan hundreds of patient records.
Implementation. Directly following the initial migration of data, staff did not begin entering encounters, instead starting with basic patient scheduling. Some participants noted that this helped staff adjust to the new system gradually. Health centers generally extended appointment times and reduced overall patient throughput during implementation. DCPCA recommended a 50 percent reduction in patient appointments, but many felt that such a large reduction was unrealistic. The exact strategy in reducing patient appointments was left to the discretion of member health center leaders.
One participant noted that increasing access to the system (via trainings or some other means) might have improved implementation. This health center continued to use parallel systems concurrently beyond the initial training and go live period. Others pointed to the important role played by super users. They indicated that while these staff are integral to a successful implementation, health centers should expect that the super users will experience reduced productivity for a longer period of time than other staff. Super users spent significant amounts of time addressing colleagues’ needs in the absence of actual trainers and support personnel. Similarly, some felt that Cumberland Consulting should have been asked to stay to help with implementation for a longer period of time, particularly to support super users. One super user explained, saying “After the consulting group left… there were times I didn’t do work for a couple days. I had my own questions as well [as addressing other staff members’ question].”
Some participants noted specific issues encountered by staff during implementation. For one health center, attaching a funding source to every encounter has proven problematic. Linking funding sources (whether that be a health plan, Medicaid or a grant program) often requires several attempts and identifying encounters that lack funding sources takes additional time. One participant noted that users must remember funding sources when switching between relevant screens in the system. Others noted that staff remain frustrated with the system’s performance, particularly its speed, propensity to log users off or freeze and difficulty scheduling specific providers for specific appointment times.
While a number of panel participants expressed frustration with attaching funding sources to encounters under eCW, others felt that this requirement motivates providers to “work for their money,” knowing that their income comes from specific funders. Others noted that eCW’s ability to suggest coding levels helped providers to reconsider documentation in some cases. One participant suggested that eCW has helped their clinic track spending on specific groups such as Ryan White grant patients.
Many health center representatives indicated that they had not begun using all of eCW’s features, particularly relating to automation and reminders. One health center noted that reminders for preventive medicine are always “in the back of their mind,” but they have yet to implement them. Some health centers have begun using alerts. One center has begun tracking missed appointments using eCW, taking action after three consecutive missed appointments.
Staff satisfaction. Staff have voiced varying levels of satisfaction with eCW. Some have complained that things are not easy to see in the EHR. Others have indicated that eCW has been somewhat disappointing, noting “everyone says the system could do things, but what it ended up being didn’t help me to do my job better. There were things we thought would help that didn’t.” Other participants indicated that providers appreciate being able to see what they have and have not done in a single place and the system encourages writing notes effectively after each visit. They also indicated that some providers see the EHR as a customizable tool. While greater transparency offered benefits for some (primarily managers), others noted that having productivity numbers available on the EHR makes some providers uncomfortable.
One area where there were particular concerns was with eRx. The eCW eRx solution used by DCPCA members relies in part on faxing and this has proven problematic for DCPCA members engaged in eRx, with some faxes not transmitting successfully. Others noted success with eRx saying that under the previous system it would take a full 24 hours to process and send a prescription. This process takes approximately 1.5 minutes under the new system. One participant noted increases in patient safety as well, especially in identifying drug interactions. Having an EHR has negatively affected the health centers that chose not to implement eRx because they had their own pharmacies. These centers have experienced increased costs in integrating eCW into their existing pharmacy and prescribing processes.
Another area of concern is related not to the clinical application but to billing. Some discussants felt that eCW has caused a number of problems for members in billing for services. Some health centers noted that they had seen more denials than expected under eCW, as a result of supposedly invalid insurance or inadequate follow-up. These denials have decreased revenues and increased workloads for billing staff. DCPCA is investigating these problems.
Financial implications. Some noted direct financial implications of moving toward eCW. Requiring that all procedures be linked to a payer, including vaccinations, has improved reimbursement for at least one center. Services that previously went uncompensated are now being linked to a payer. Others said that third party reimbursement had increased, but that other factors like decreased grant funding, increased demand on billing staff to follow-up with payers, and greater demands on IT support staff generally had increased costs. In discussing the increased IT needs, one participant noted, “Our IT person on staff had to increase their time in the clinic because of eCW. It won’t decrease now, it’s a daily need.” One participant noted that having greater access to financial data had amounted to a motivating factor for his center to pursue payment, saying “You know how much money you are leaving on the table. From that point of view, it’s a motivator. Every duck has to be in a row.” It should be noted that almost all comments related to financial benefits at this early stage referred to the practice management application rather than the EHR.