In addition to extensive discussions with BHN and BMC leadership, we met with staff from five BHN partner health centers. Four of these health centers, Codman Square, Dorchester House, South Boston Health Center and Boston Health Care for the Homeless Program adopted the Centricity EHR supported through the BHN grant that is hosted at BMC. The fifth health center, East Boston, also had deployed an EHR, Epic, but conducted this implementation independently in the late 1990’s. In the paragraphs below we highlight key findings from our discussions with these health centers including opportunities and challenges presented by their use of EHRs, unmet needs and their vision for the future.
Sub-network collaborations and large health centers. We found that in Boston, as in other markets where there is a network presence, there are additional, sub-network collaborations across institutions where a high level of trust has been built over time. One example is the DotWell partnership, a small non-profit that jointly manages some administrative functions for Codman Square Health Center and Dorchester House Multi-Service Center. While each health center continues to maintain a separate board and institutional status, they have, over the last several years come together for the purposes of joint purchasing and administration. The extent of the collaboration has waxed and waned at different periods and is currently focused on IT staff and purchasing which is currently combined.
The large health center model. Some of the key findings from this site visit came from discussions with leadership at East Boston Neighborhood Health Center which had initiated an EHR program working with Epic prior to BHN’s purchase of Centricity and has continued to be an Epic user. East Boston was in a good position relative to other health centers in Boston to go it alone largely because of their size and level of sophistication. With over 300,000 patient visits annually, well over 500,000 encounters and 600 clinicians spanning a range of subspecialties, the health center is the largest in New England and offers a wider array of services than any other health center in Boston.
Unlike the health centers using the Centricity software, East Boston indicated that, from the beginning, they were able to use Epic’s reporting and analytic functions to support their participation in QI programs such as the health disparities collaboratives (HDCs), replacing their existing PECSYS and CV-DEMS registries . Because most of EBNHC prescriptions are routed through an in-house pharmacy, they also were able to adopt end-to-end e-Rx at a fairly early stage in their implementation and were able to roll-out EHR into specialty clinics such as pediatrics and OB-GYN as well as special facilities such as their 24-hour emergency department. Finally, there is some sense that they were able to get a better original deal from Epic because they adopted very early and were Epic’s first health center customer. EBNHC reports spending around $6 M in 1998 for their original purchase of licenses and implementation services including training and installation and that this original roll-out included most of their 600 clinician users, which BHN claims represents a lower cost per user than many of the other sites where we were able to get this information.
Challenges with using EHR for QI. The challenges articulated by many health centers in Boston, particularly those that accessed Centricity through BHN, was the difficulty in finding dedicated clinical staff to work closely with the BMC IT team to optimize the use of the EHR from the perspective of quality or clinical efficiency. There were both limitations on the extent to which health centers could offer staff to engage and the extent to which BMC had the resources to accommodate health center needs. For example, many of the BHN health centers continue to use CV-DEMS or PECSYS with manual data entry even following the Centricity implementation because they lacked the resources and expertise to develop custom screens to assure capture of all necessary variables in a structured manner at the point of care and were unable to create the reports necessary to effectively use the data that was captured. While BMC reports having approximately 2 IT FTEs dedicated to working with the health center EHR hosting, maintenance and support, there seemed to be relatively limited resources that regularly go into working with health centers to design and implement new EHR screens and design new reports. They noted that a priority for the CHCs and BMC is to configure the clinical forms developed in Centricity by BMC specifically for use by the CHCs.
Some medical directors noted that they were skeptical of the ability of the Centricity system as currently configured at each site to help them assess quality because of the variation in which data is entered in the system from health center to health center and provider to provider and the difficulty in enforcing a single approach to using the EHR to consistently capture the same data in the same place in the same way. They also noted extensive and complicated issues with defining appropriate populations and denominators to support key measures, noting for example, that there was no easy way to exclude a patient from being included in assessment for legitimate, but uncommon reasons (e.g., the lack of a dental visit may not be an issue for an individual with no teeth). They also noted that some of the measures they would like to assess, such as frequency of foot exams for diabetic patients, are typically very poorly documented regardless of whether the provider is using an EHR or a paper chart.
IT staffing model. One area where East Boston demonstrated success where other health centers indicated frustration was their ability to achieve synergies between their IT staff and their clinical staff both on designing and implementing ongoing enhancements that make the EHR easier to use and in terms of helping create reports and functions that allow the EHR to support QI. While East Boston reports having a relatively lean IT operation, fewer than 10 employees to support a health center with multiple sites and functions and over 600 EHR users, they are more of a driver of change and improvement within the health center than a typical health center IT department.
The CIO at East Boston is a former IT consultant who brings a focus on business process re-engineering. He noted that he typically hires business analysts into the IT department that often have little or no clinical or IT background, but are smart, capable and computer savvy individuals he can train to use MS Visio to document current processes in the health center, work with clinical and administrative staff to re-design those process and configure Epic or other software applications to meet the requirements of the new, optimized design. These staff, some of which comprise a dedicated “clinical applications team” work closely with clinicians in some cases doing extensive shadowing and observation of the workflow in a given area in order to achieve a solid understanding of the needs, frustrations and priorities of the clinicians and support staff.
East Boston also noted that they always have a dedicated member of the clinical applications team that was a former clinician at the health center and can represent that perspective directly during discussions and planning around adaptation of the technical design and play the role of clinician champion when new features are rolled out. Over the years, East Boston reports using these types of processes to design new functionality such as the clinical lab ordering and reporting modules that work with interfaces to Quest and other laboratories as well as in working with their medical director to set up alerts within the EMR. They indicated that the need for alerts is driven by problems or areas for improvement that are prioritized by the clinical committee.
Use of EHRs for panel management and quality reporting. Again, unlike other health centers East Boston indicated extensive use of their Epic package to define panels of patients, design screens to consistently capture key information on those patients and track that information over time. In addition to using Epic from the start to support their participation in the Health Disparities Collaborative in diabetes, they also report using reporting and analytic functions in Epic to track immunization rates and to track information about basic preventive care and screenings for their general population. They note that when a new area is identified by clinical leadership as needing to be tracked more effectively, they convene a meeting of the clinical applications team and key clinicians in the relevant departments and go through both the workflow that would support better capture of data or capture of new data as well as the existing “screen” where data would be entered. They are able to review several options for changing the screen or workflow and discuss how the new tools and processes should be adapted to the appropriate clinics.
Benefits of the EHR .Interestingly, the BHN health centers using Centricity did report extensive benefits following the adoption of their EHR. Although they acknowledge that they face limitations in terms of their ability to use the tool to track quality, they point to benefits in efficiency and work flow that they believe have improved care. Although they acknowledge that forms are being used inconsistently, most did indicate that their measures of quality, even if they are based on manually entered registries, have improved since adopting EHRs and they attribute this to an increased focus on documentation, the use of some alerts and in some cases, health center and provider report cards.
By far, however, the benefit that the Centricity health centers described were the ability to accomplish their tasks without having to find and access patient charts, the efficiency of being able to route prescriptions without printing and faxing and the general conveniences with having adopted an EHR. All the clinicians we spoke with indicated that there was very little remaining “dissent” regarding the use of EHRs and in fact, having EHRs served as a good recruiting tool. The convenience issues were particularly important for the Boston Health Care for the Homeless Program. The staff explained that they had been able to work with BMC to use small laptops and tablets in their mobile vans and satellite clinics to wirelessly access patient records which greatly facilitated their ability to deliver and document care and health status among Boston’s homeless.
East Boston Neighborhood Health Center was able to make more specific claims than others regarding quality improvement. They indicated that they had seen a significant improvement in the number of diabetics that are receiving HbA1cs on a regular basis as well as the numbers of patients that have their HbA1c values. They indicated that in 2005 they had over 2,000 patients with HbA1c’s over 8.5 and that, tracked as a panel, the average HbA1c for this group has decreased to 7.5 currently. They attribute this to their focus on translating their panel identification and tracking work to case management.
They note that they do not view registries and databases for analysis but as lists of patients that are the target for specific types of outreach via phone or mail. For example, outreach workers monitor the high risk diabetes group identified above and send out regular reminders for the need to have HbA1c tests conducted and, in the case of those who are out of control, having intensive visits with nurse diabetes case managers to review the need to modify their therapy, diet or exercise regimen.
Costs associated with the EHR. Not surprisingly, no health centers described a positive relationship between financial costs and benefits associated with EHR use. By and large, health centers described costs in the range of $500 to $1,000 per year per user as the average cost of renewing licenses, adding functionality, training new employees in the system and upgrades. Importantly, the extent of these costs vary from year to year and do not include the periodic upgrades of hardware that are sometimes seen as more important for health centers that are using EHRs and those that only use computers for billing and administrative purposes.
East Boston Neighborhood Health Center also noted that following adoption of EHR their clinicians were working harder to document care they receive and that the time required to document care typically increases as they add new features, forms and alerts to their base EHR application. They emphasized their sense improving quality through EHRs requires more focus, attention and time on the part of clinicians and that there is no way around this reality. They also noted that since adopting EHRs they have conducted a far more extensive set of outreach activities and employed more individuals in this function which typically is not reimbursed.
They did not feel that there was potential for ROI through increased throughput that allows the same number of clinicians to treat and document more patients in a given amount of time. They did seem to indicate, however, that effective use of EHRs could lead to more visits overall and the need to expand their health center because the enhanced ability to follow-up with patients leads to more frequent and more extensive visits. They also indicated that their use of EHR to track care to patients and re-design workflow has led to an increase in the use of mid-level clinicians to help manage and counsel patients and that the numbers of nurses, nurse practitioners and physician assistants they employ has increased relative to the number of physicians.