As noted above, one arm of our site visit focused on HCN’s presence in Utah. UHCN dates back to 2002 and since 2004 has provided health centers in Utah access to HCN services including networked practice management and EMR systems.
We conducted four total meetings on site in Utah, three with health center leaders mainly in the Northern and Eastern parts of the state starting in Salt Lake City and stretching out to rural mining communities of East Carbon and Green River. The Salt Lake City health center, Wasatch Homeless Health Care, Inc. (WHHC) is a health care for the homeless (HCH) program grantee that treats approximately 6,000 patients annually, totaling over 25,000 visits. WHHC provides primary care as well as extensive case management and outreach. The center also provides specialty services of particular importance to homeless populations including mental health, dental and dermatology services. Like many HCH grantees WHHC relies extensively on volunteer physicians.
Green River Medical Center (GRMC) is located in a town of approximately 1,000 individuals in Eastern Utah. In 2007, GRMC served approximately 1,000 patients in over 2,985 encounters. In addition to providing comprehensive primary medical care services, the health center offers radiology and dental care services, and serves as an emergency medical services provider and triage point for motorists who are injured on nearby U.S. Route 70, the major freeway going through Eastern Utah. Finally, we visited Carbon Medical Services Association (CMSA) located in two sites, one in East Carbon, UT and another in Helper, UT. Both locations are small mining towns also in the Eastern part of the State. Although CMSA sees the fewest patients of the health centers visited, they offer a similar set of services as GRMC. CMSA also provides pharmacy services for multiple counties as they have a pharmacist who fills prescriptions in multiple counties using a tele-pharmacy system.
As part of these meetings, we explored health center leaders' motivations for joining HCN and adopting EMRs, their experience with EMR implementation and use, the impact of the EMR on their practice and their overall experience (e.g. challenges and opportunities) working with a network based in a different part of the country. Although a limited number of health centers in Utah took part in the initial EMR roll-out of OmniDoc, the UHCN centers that we visited have recently adopted the newer, Intergy application that combines practice management and EMR functionality.
Motivations for Health IT Adoption and Network Participation
Health centers in Utah cited the ability to benefit from economies of scale and coordinate among each other as their primary motivation for creating UHCN. All UHCN health centers had an existing relationship through AUCH and noted that vendors and suppliers of IT services, including practice management software vendors, offered very different pricing plans to different health centers. They also noted wide variations in their ability to maintain IT staff and obtain the necessary level of service and support.
Finally, health centers noticed that they were unable to provide a consistent set of data on utilization and cost to their state Medicaid agency. Under Medicaid rules in Utah, the state was able to negotiate individually with each health center on cost-based reimbursement formulas. Because they lacked common systems and consistent data, AUCH members could not share information on costs with each other, eliminating any collective leverage that they may have had with the state and their ability to demonstrate inconsistency in the state’s application of rules from health center to health center.
Noting potential inefficiencies and unfairness in this situation and building on the example of NMHCN, several health center members of AUCH approached Kevin Kearns to discuss the potential of setting up UHCN. Although they had considered other networks, the Utah group believed that their immediate focus on achieving economies of scale with core IT applications and establishing a common baseline for cost accounting, lent itself to involvement in HCN. The Florida-based network which focused on IT infrastructure, support, billing and finance and served as a networked provider of an established practice management application seemed like a logical fit. Overall, the three health center leaders that we spoke with indicated that their engagement with HCN had borne the intended benefits, particularly with regard to practice management, billing and the ability to establish consistent reporting of accounts. Discussants in Utah felt that by virtue of HCN’s experience expanding outside of its state of origin, HCN would have cultivated the adaptive skills needed to face unique challenges that a network unfamiliar with Utah’s payer environment would encounter. Utah has a unique payer environment due to its small population and because the payer scene is largely dominated by Intermountain Healthcare, which is comprised of 21 hospitals and more than 150 clinics in Utah and southeastern Idaho. While the motivation for joining HCN overall was clear and consistent, health centers in Utah did vary considerably in their level of enthusiasm for adopting EMRs. The most enthusiasm for EMRs was voiced by the one urban health centers we visited, WHHC, which noted that as a health care for the homeless in Salt Lake City they saw so many patients with long, complicated medical charts, that having an electronic replacement for the paper record would substantially reduce time and work associated with finding a specific piece of clinical information in a timely fashion.
Other health centers had recently adopted EMRs at the time of our visit and had differing views on their expectations. Executive Directors at both East Carbon and Green River indicated that they anticipated improvements in efficiency of clinical operations and that they felt that moving towards EMRs was an inevitable result of progress in their field. However, one of the providers we spoke with in East Carbon, heavily resisted the idea that having EMRs substantially improved her ability to deliver health care now or in the future. In this case it was the executive director who had led the effort to implement the EMR. Leaders of the Green River health center expressed the belief that EMRs could improve the quality and efficiency of care, but also noted problems with the manner in which EMRs had been implemented at that site.
EMR Implementation, Opportunities and Challenges
Implementation of the Intergy combined practice management/EMR application in UHCN health centers has created interesting opportunities and challenges. As noted above, the ability of the network to build enthusiasm for EMR implementation among providers was highly variable. In addition, respondents noted that a handful of UHCN sites, not among those we visited, decided to skip the Intergy implementation having decided that another EMR vendor, eClinicalWorks, would better meet the needs of their organization. The health centers that eventually moved to adopt Intergy, expressed mixed feelings regarding the quality of the implementation and the system itself. They also ended expressed different opinions regarding the level of customization support provided through HCN. Each of these themes is reviewed below.
Laying the groundwork for EMRs. One of the greatest benefits of HCN membership according to administrative leadership at all three health centers was the standardized way in which HCN helps health centers to prepare their IT infrastructure for EMR adoption and to assure a consistent level of service from vendors. Health centers that were UHCN members reported that they would not have access to the expertise or staff capacity to investigate different practice management and EMR products or research and execute necessary upgrades to their computing and connectivity environment without the support of HCN. Still, they noted important differences in their ability to comply with HCN guidelines prior to implementation of specific applications such as EMRs. For example, HCN’s implementation approach includes a period of documentation and assessment of clinical workflow followed by a re-configuration of workflow to achieve gains through EMR implementation.
One health center was able to take this process very seriously and, in the end, was extremely pleased with changes they made as a result of workflow assessment (some of which had nothing to do with EMRs per se). In this case, the workflow assessment showed that the practice of scheduling prioritized appointments over walk-ins was inefficient. Under the appointment system, sometimes both providers and patients would be waiting for scheduled clients that were late or no-shows. That health center moved to a complete “walk-in” system to better meet the needs of a population (the homeless) with inconsistent access to transportation or the means to keep appointments. Additionally, WHHC's patients often face acute health care needs that are properly handled promptly in an outpatient setting (e.g., a worsening skin condition or wounds that require care).
Other health centers did not feel they had the time and expertise to effectively document their workflow, let alone assess it and make appropriate changes. These centers were smaller, had fewer resources and had a less clear vision of what they wanted from an EMR. In addition, they found that HCN made some challenging assumptions with respect to health centers’ ability to re-configure workflow, such as the ability to assign a physician extender to record some basic clinical information and conduct intake using the EMRs. Rural sites in particular did not always have access to staff that would allow for these changes.
Another area that posed a challenge for health centers prior to implementation relates to the guidance that they scan all prior medical records going back one year into the electronic chart prior to going live. The health centers we visited did not have enough staff to efficiently scan all prior records and have only been able to scan prior records incrementally. WHHC noted that they have made a special effort to manually enter lab values from the old paper chart directly into the medical record because they feel it is important to be able to pull up the last set of lab values rather than having to pull up a scanned version of the full chart. They have done very limited scanning, opting instead to selectively enter historical lab values from the paper charts into the EMR as patients are seen.
Finally, HCN makes specific assumptions regarding the need for reliable connectivity for EMR adoption that are relatively stringent relative to practice management. The rationale for robust and reliable connectivity for EMRs is clear as down time makes it impossible to access clinical information and treat patients. Still, we found that not all rural health centers were able to afford the recommended form of connectivity, T1 lines, and were using less reliable forms of connectivity such as frame relays and DSL. This may have contributed to some complaints from the rural health centers regarding system down time with their EMRs.
Rolling out the EMR to clinicians. Each health center discussed the HCN EMR rollout to clinicians as occurring in two phases: an initial education and orientation phase which took place over the course of several weeks, primarily via WebEx, and a second in-person training phase which took place over the course of several days and coincided with the official rollout of the application. While this approach was generally seen as adequate, it was clear that some clinicians had an easier time adopting the EMR than others.
For example, while WHHC discussants indicated that the training was intense, sometimes going up to 16 hours in a day and requiring the health center to shut its doors to patients for two days, they believed that they were able to effectively use the EMR basically right away and were able to return to full productivity within a few weeks of implementation. Also, WHHC leadership noted that a commitment on its part to educate clinicians regarding the rationale for adopting EHRs, separate from the training offered by HCN, led to faster adoption and greater receptivity on the part of providers.
Clinicians at CMSA and GRMC did not express frustration at the training and roll-out approach per se, but they did indicate a higher level of discomfort with using the system. One provider, a nurse practitioner in her 70’s, felt that there were no computerized clinical features that could improve care, that the process of documentation took her longer because of the EMR and that use of the EMR required her to stay late in order to enter data in the system. She noted that there was not an adequate level of responsiveness from the network to assuage her concerns regarding the usability of the software.
Another clinician indicated that the system for designing and implementing customized forms did not work well for rural health care providers who need different kinds of forms than the core-HCN health centers in Miami (e.g., forms to evaluate patients coming in after automobile accidents). Discussants were unclear as to whether these types of issues could be addressed through better training, although they did note that there could be improvements in the process for creating new forms and for customization.
These comments reflected both natural apprehension of EMRs as well as some perceived lack of responsiveness to the needs of rural providers using EMRs.
EMR functions. All three health centers employed a similar level of functionality through Intergy. Specifically, they had access to the basic EMR and practice management application including the ability to document patient encounters, use population-specific forms pertaining to individuals with chronic illness or patients with specific symptoms. They also had some form of e-prescribing, either electronic fax transmission of prescriptions to retail pharmacies or direct messaging of prescriptions to in-house pharmacy systems (both WHHC and CMSA maintain in-house pharmacies) and bi-directional exchange of lab data. Finally, they have access to a series of standardized reports on utilization and expenses from the practice management database, provided on a monthly basis by HCN, and to separate reporting modules that allow them to run health center level reports on quality of care outcomes.
Practical issues in EMR use. Health centers reported that they were able to actively use the lab interface and e-prescribing functionality without a problem. They also noted that the monthly reports provided by HCN were useful, primarily to track productivity and utilization rather than report on clinical outcomes. Clinicians noted that they were still in the process of working with HCN to adjust their clinical templates, clinical reports and reminders to meet their specific needs and that their staff was still working on being able to document all aspects of a visit comprehensively and appropriately using the EMR. There seemed to be greater demand for templates that were organized based on a patient’s chief complaint in rural areas, compared to the disease and diagnosis based templates that were developed by the clinical committee in Florida.
Others felt that the clinical committee as a whole and the subcommittee that deals with forms in particular, was largely oriented to the needs of the Florida HCN members who were able to attend the meetings in person and that, consequently, the forms were not particularly well-suited to the population served in rural Utah, including a disproportionate share of elderly individuals and accident victims. Still, one health center, WHHC did note some improvements in processes that would improve quality over time; those findings are detailed in a subsequent section of the report.
Finally, there were some uses of technology at the rural Utah health centers that had pre-dated EMR implementation and were not yet integrated into Intergy. For example, they noted that because health centers in rural areas are often the only location where X-rays can be performed and there are very few radiologists in close proximity, having a robust picture archive and communications system (PACS) is critical to assure efficient transmission of images and timely assessments. Currently, the PACS applications being used at both CMSA and GRMC are not interfaced with Intergy and, although there was a plan to create this interface, the health centers reported that this effort had been delayed. In addition, they note that the Intergy EMR and the telepharmacy system are not integrated. This telepharmacy system, used by health centers in Eastern Utah, allows pharmacy orders to be placed by clinicians in location A, approved and “filled” by a pharmacist in location B and then dispensed back in location A using a machine that automatically packages with the correct dosage and medication based on the pharmacists direction. This system allows the pharmaceutical dispensary at location A to be staffed by a surrogate such as a medical assistant rather than a pharmacist or provider.
Quality Improvement and Return on Investment
Because they are relatively early in their use of EMRs, health centers were unable to provide solid evidence of quality improvement as a result of EMR implementation. However, staff at WHHC did note a number of process improvements such as more detailed and complete documentation and the ability to track medications and laboratory results electronically that they felt were bound to improve quality over time. WHHC felt that in their environment, where individuals with complex health care needs are seen sporadically by a myriad of clinicians both paid and volunteer, having a complete, well-documented and legibly presented medical record in electronic format was crucial to providing good care efficiently.
WHHC noted that they have done some studies of care efficiency and patient satisfaction pre and post EMR adoption and found improvements in both areas, however, they were quick to point out that there were other changes that happened concomitant with EMR adoption (re-configuration of the center and the move to a “walk in” model) that could have also contributed to these improvements. Other health centers did not express the same level of optimism regarding the potential for EMRs to improve quality within the current HCN environment. This was either because they had not bought into the benefits of using EMRs in general or had not bought into HCN’s approach to develop EMR based QI tools through its clinical committee. The model for enhancing QI benefits of EMR suggested by HCN, the formation of a state-specific organization of medical directors to develop EMR-based tools for Utah was met with skepticism on the part of medical directors who were already apprehensive regarding the benefits of the EMR. The WHHC medical director has tried to organize other UHCN leaders using Intergy, but there has not been enthusiasm for coordinating around this task partially due to the perception that each health center has its own unique QI needs, the differences in the populations they serve and the long distance between centers.