We found that health centers and network staff had differed somewhat in their motivation for adopting a new health IT system. Overall, comments regarding motivation on the health center and regional level fell into two categories: those commenting on negative aspects of the current system and those articulating anticipated benefits of switching to Epic.
Problems with existing systems. Some leaders saw inefficiencies in the existing system. Access’s regional managers (charged with managing a cluster of health centers’ administrative operations) repeatedly noted that Meditech did not meet their practice management needs. Primary problems included: a cumbersome navigation system, a steep learning curve (particularly detrimental given high turnover in front-end positions at Access) and general system slowness. Meditech’s slowness often results in excessive wait times for patients registering and checking in. Some managers indicated that this can create bottlenecks, forcing providers to wait for patients as they register. Others noted that Meditech does not allow scheduling across Access sites. This is a significant barrier given that many Access providers rotate across various centers within a close geographic area. These concerns contributed to a general belief that Meditech does not meet Access’s IT needs, especially relating to practice management tasks. In addition to management concerns, comparing Meditech with other, newer EMR systems made it clear to Access network and clinic-level staff that Meditech did not have comparable clinical functionality. While these clinical functions did not push the network away from Meditech in the same way that practice management concerns did, they combined to motivate the network to consider other options. Additional detail on such clinical functions is described below. The problems with Meditech, on both the operations and clinical sides, emerged as the primary justification for the switch to Epic among regional leaders.
Clinic level management. Many discussants expressed hope that Epic could add value in certain areas of management operations and clinical practice. With respect to operations, comments focused primarily on internal operations and financing issues. Some discussants mentioned the possibility that Epic could help improve communications internally. It was noted that clinical and operations staff often use different forms of communication under the Meditech system, with physicians relying primarily on the MOX (Magic Office) messaging system within Meditech and administrative staff using Microsoft Outlook for email. Some staff noted that having one system for all functions would consolidate communication systems and help bring together the operations and clinical staff at all levels.
One physician noted that Epic could help to allocate resources between Access sites in a more efficient manner. With Epic, regional managers will be able to monitor patient flow in real time, allowing them to shift staff and other resources more effectively. Another discussant indicated that scheduling would be more efficient under the new system, noting that patients would not need to schedule follow-up appointments to refill prescriptions. Others mentioned basic benefits such as moving away from illegible patient logs and reducing the number of lost charts.
Access staff also saw a potential to increase their patient throughput with Epic. Some spoke specifically about the potential to increase patient volume, especially after the first few weeks of implementation. Others thought that improved wait times would help to keep patient flow moving more efficiently. One discussant expressed hope that moving to Epic would help Access secure reimbursement faster. While details relating to how data would be exchanged with payers and the state were not discussed, the potential to increase reimbursement speed could be a significant benefit and motivator for networks such as Access that rely heavily on Medicaid payment.
Using data better. As noted above, Access touts its commitment to using data and quality metrics to drive operations. Metrics used by Access fall into four categories: patients/customers, employees, financial and quality & patient safety. Currently, data to support these metrics are generated through Meditech, as well as manual data entry conducted at the site level. The primary motivating factor for health IT adoption articulated at the network and clinic level was the promise of allowing center staff to more efficiently generate data for metrics and make more effective use of these data at all levels within the organization. Some Access staff members specifically mentioned the ability to more easily extract and use clinical and administrative data as a possible benefit. One discussant mentioned the ability to improve data exchange efforts both internally and with external partners, including academic medical centers, health systems, labs and pharmacies. Physicians with academic and research appointments in local hospitals focused on the potential to use aggregated Access EMR data for population-based health research. One discussant mentioned how difficult it had been to pull data for research under Meditech. Others discussed efficiencies related to data in a broader sense. The potential to manage a higher quantity of medical images and to automate exchange of data with labs were both were mentioned by discussants. While some Access sites have experience with e-prescribing through a PocketScript pilot, regional leaders at these centers noted connectivity problems (causing delays for providers) and high costs related to the effort. Network officials have not yet implemented e-prescribing through Epic, but moving toward a more integrated health IT solution such as Epic represents an opportunity to transition away from standalone systems and update infrastructure to accommodate more robust data exchange applications. Access plans to pursue a SureScripts interface in the coming months, although network leaders anticipate that creating an interface would take five months and indicated that they would not allow the e-prescribing module to delay the wider EMR implementation. In this way, Access staff felt that Epic could tangibly improve the utility, accessibility and efficiency of clinical information.
A tool for improved quality of care. Network leaders view health IT applications as tools that can support QI initiatives rather than drive the QI initiatives. Access leaders indicated that they have effectively used their existing Meditech system and a manual process to track quality measures established by their Medical Director and based on evidence-based guidelines for years. At the clinic level, these measures include compliance with recommended pain assessments and screening, “do not use” abbreviation guidelines and medication management protocols. At the regional level, metrics include the percentage of bonded diabetic patients with HbA1c < 7, up to date childhood immunizations at 24-months and regional HEDIS indicators. Unlike other FQHCs that we have met with for this project, Access staff indicated that they are currently able to track measures on a site and provider level and have used this reporting process as a way to reward sites and clinicians based on performance. Although they anticipate clinical improvements with Epic through use of clinical decision support, better coordination and increased efficiency, they also acknowledged that special efforts will be required to re-create the quality improvement culture in the context of an EMR. While network leaders acknowledge that the EMR will change quality improvement initiatives to a degree, they also indicated that the metrics they use are not unique and would be accessible under Epic. It may take time to develop a coherent QI strategy under Epic, but Access believes that the EMR will allow them to do more in this area, potentially reassigning staff who had abstracted charts to areas such as health informatics and epidemiology.
While they plan on taking advantage of point of care decision support tools over time, Access clinician leadership emphasizes that providers are likely to make the same clinical decisions that they would have made without Epic, but that they will spend less time trying to locate and verify the data they need to make those decisions.
An opportunity to realize new efficiencies. Network officials signaled the possibility of realizing efficiencies at the practice level, particularly with respect to relationships to ancillary care providers like laboratories. For example, as a part of its clinic acquisition process, Access network leaders allow new clinics to maintain relationships with their previous laboratories. Network officials see this as a workable concession to help make the transition into Access a bit smoother. Over the years, this policy has resulted in Access working with 14 different lab providers, creating inefficiencies that network officials would like to address using Epic. Network officials indicated that the Epic implementation could provide a justification for streamlining and reducing the number of lab providers. The onerous process of creating 14 different lab interfaces could provide a reasonable rationale for reversing the open-ended lab provider policy.
Network officials also noted potential administrative benefits. Access’s Medical Director explained their reasoning this way, “We have a growing cost per visit. I see efficiencies we can gain through the electronic system.” For example, under Meditech 33% of visits to Access resulted in lab orders. Each order comes back at different times creating coordination and organizational inefficiencies which are exacerbated by the multitude of lab partners (14 total). Moving to an EMR will allow for greater organization and tracking of returned lab results and because so many visits go to labs, network officials and regional mangers anticipate that this increased efficiency will significantly reduce the cost per visit. The cost per visit represented a significant metric for many of the clinic sites NORC visited and framing the decision in these terms may have been persuasive for some staff. Reducing the cost per visit is also a relatively unthreatening goal for Access staff, as many recognized the growing importance of payment and uncertainty surrounding future Medicaid reimbursement policy.
Finally, Access leadership sees health IT advancement as an essential cost of doing business in the future. The network’s CIO put it this way, “In the future, EMRs will be like oxygen.” Overall, Access sees the EMR as a tool that will empower them to transform centers, both administratively and clinically.