Given that EHR implementation is a major focus of the Alliance and is central to the purpose of our broader project, in this section, we summarize findings from our meetings on the motivation and approach for health IT adoption in general and EHR implementation in particular. We provide this overview as a precursor to a more detailed discussion on enablers, barriers and impact of health IT adoption in subsequent sections.
EHR implementation process. The Alliance's standardized rollout occurs in three phases: pre-implementation phase, implementation and full functionality. The rollout process begins with the designation of an Implementation Team including staff from the health center and an Implementation Specialist from the Alliance. Because of the need for heavy involvement from staff at the health center and because these staff have limited time away from clinical and administrative responsibilities, the planning and roll-out for an implementation often takes place over a series of months with long weekly meetings serving as the central management vehicle to map out tasks and responsibilities and develop a site specific Implementation Plan.
Among the first tasks is conducting a comprehensive review of clinical workflow. This process helps the team identify areas for improvements and allows the center to use the implementation to address overall efficiency objectives. The workflow assessment also sets a benchmark so that health centers can look back after the rollout and see how changes in workflow facilitated by the EMR either improves or does not improve efficiency.
Drawing partially on the workflow assessment, the Implementation Team develops a set of requirements for the roll-out. While core system requirements were worked out on the Alliance level with input from all Medical Directors, there are always some changes to settings, menus and interfaces based on the specific needs at the health center level. The need for health center or even site level customizations may be driven by characteristics of the population being served, the suite of services offered by the site or workflow limitations that are driven by the space and appointment schedule of the site.
Staff at the health center are introduced to the EHR over a series of meetings where basic concepts are laid out and staff at all levels that will actively use the application have an opportunity to contribute to customizations and ask questions regarding the impact of the system on their work processes and responsibilities. All forms of communication ranging from emails to lunch time meetings have been used to make sure that staff are aware that change to their work process is coming, allowing them to prepare for the change and get questions answered up front. Some centers also indicated that they posted signs and provided flyers for patients, so they would also be prepared to see clinicians interacting with computers in the exam room. Training occurs in the weeks immediately prior to implementation. The Alliance typically requires 16 hours of training for all users and has established separate curricula for all types of users.
Before implementation there is often a "dress rehearsal" where the center closes and simulates implementation for part of a day. Implementation Specialists from the Alliance remain on site throughout the rollout's first few weeks of implementation. In some of the health centers "super users" were assigned to receive advanced training so that in the future these users could answer day-to-day end user questions. Super users serve an important part in ensuring that clinicians can ask questions and receive timely answers from a colleague, they also serve as clinician champions and it is envisioned that they will play a leadership role in evaluating the use of the EMR over time. It should be noted that the super user role is sometimes formally assigned; alternatively, super users can be clinical staff (often nurses) that take it upon themselves to engage in the implementation process. While the implementation process varies from center to center and site to site, the steps outlined above were fairly consistently reported across the four centers we visited. Currently, the Alliance is live with the Centricity product in all four health centers and is supporting approximately 325 clinician users.
Motivation for health IT adoption. All of the health centers in the Alliance provided relatively consistent answers to the question regarding their motivation for adopting health IT and their answers also confirmed g. the vision for increased quality, transparency, safety and efficiency of care outlined by Alliance leadership. We provide detail on specific thoughts offered by meeting participants below.
Quality of care. Almost all participants explained that improving the quality of health care delivery and outcomes was their primary motivator for adopting health IT. Many health centers look to analyze patient clinical data using nationally recognized quality measures and benchmarks between centers as well as national standards. Multiple participants indicated the need to strive for greater consistency and adherence to guidelines for care to patients with chronic conditions such as HIV and diabetes. Also, many participants wanted to be able to proactively identify adverse drug interactions. The FQHC Medical Directors and leadership discussed the benefits of advanced reporting and dashboard functionality that the Alliance had customized within the Centricity System. A key metric for the Alliance has been monitoring the extent to which this dashboard is being used. They are finding that in the initial months following go-live, dashboard reports are primarily used to establish use of the system and answer questions such as, "Do all patients who should have an electronic record based on practice management data, actually have a record?" and "Are forms being used for structured documentation of care to specific populations?" The Alliance reports that some health centers, specifically those that implemented early, are just now at the point of being able to identify baseline levels of clinical indicators for key populations and consequently look at how the baseline has changed with increased use of EMR functionality. We provide more details on impacts observed to date later in this report. Although still in early stages, discussants indicated that having center and provider level reports on quality and efficiency metrics encourages and rewards quality improvement and will continue to do so over time. Several participants also mentioned opportunities to conduct research in the area of disparities using the clinical data warehouse application.
Administrative efficiency. Participants also cited administrative efficiency as a rationale for adopting health IT. In particular, they sought to eliminate the burden associated with locating charts and providing visit summaries for referrals. Though we did not learn of efforts to document or measure these improvements formally, discussants did provide some anecdotal information. One discussant commented that the system has "revolutionized the role of the nurse." By this she meant that workflow analysis done before the EMR implementation had dramatically improved old processes that had required more onerous verbal coordination and exchange of paper documents. For example, where intake may have previously required several conversations and exchange of paper records between front office staff, medical assistants and nurse practitioners, to verify that specific information had been collected, the process of planning for and using the EMR helped to streamline this coordination. Through this process health centers had the opportunity to reevaluate each step of key processes, such as patient intake, history and physical, clinical evaluation, vital signs monitoring and close out to assure that the appropriate individual conducts the appropriate activity in the appropriate order. In some health centers this has increased the level of involvement of medical assistants and allowed clinicians to be more focused on direct care delivery. Some health centers, particularly those that have implemented the GE Centricity system for both practice management and EHR, mentioned efficiencies in complying with the HRSA Uniform Data System reports required for all FQHCs and other funder reporting requirements.
QI support. The Alliance staff has worked with GE to incorporate key decision support and QI elements into the EHR application being implemented in their health centers. In particular, they created a format where health center providers can continue to focus on chronic disease treatment by designing special disease management screens for patients with diabetes, heart disease or other chronic illnesses. These screens list required preventive and treatment services, such as specific blood tests or exams, the last record that each of these services were provided, the associated clinical data, evidence-based guidelines and normal ranges for each clinical indicator and decision support flags in red font for services that are "due" based on the guidelines. While providers are not required to go to and use the disease management screens at the point of care, the approach does support disease-specific quality initiatives, such as the Health Disparities Collaboratives and allows health centers to actively manage specific groups of patients. Exhibit 3 below shows an example of a disease management screen for diabetes. Data from the EHR are also maintained in a data warehouse that supports the advanced quality reporting feature described below.
Exhibit 3 below shows an example of a disease management screen for diabetes.
Exhibit 3: Alliance EHR Disease Management Screen
Reporting using the EHR. Because the Alliance was able to work with GE to establish a clinical data warehouse populated using clinical data from each EHR implementation, they are able to produce a variety of reports that track utilization and outcomes at the network, center, site and provider level. While there is a level of basic reporting that can be conducted directly from a given center's EHR, more complex reporting is conducted using the clinical data warehouse where de-identified utilization and outcomes data are maintained.
The Alliance built and designed the warehouse reports in close collaboration with Medical Directors and other clinical leaders. Because of the design of the EHR application itself, there are also opportunities for Medical Directors and staff to develop and run their own reports, though most of the Medical Directors reported that their staff are only beginning to learn how to generate reports and then use the data effectively. Many Medical Directors noted that sharing data on quality with clinicians is an important part of establishing a culture of quality and that over time they looked forward to using the reports to create incentives for quality improvement.
Alliance staff noted that in addition to diabetes there are ten other areas where formal quality measures have been established, along with forms in the EMR and reports generated out of the data warehouse. For each of these efforts, the metrics were identified through consultation with the American Medical Association and National Quality Forum as well as peer reviewed literature and HRSA-wide quality reporting targets. Other focus areas of quality for the Alliance include depression, smoking cessation, well child care and other clinical priority areas identified by the Medical Directors.
Exhibit 4 below provides an example of a quality report generated by the data warehouse for diabetic patients. The report shown is for the Alliance as a whole, but the same report can be generated at the center and provider level. The report demonstrates how the EHR and data warehouse can be used to support the Health Disparities Collaborative.
Exhibit 4: Example Diabetes Report
Process for enhancements. Although the EHR implementation at Alliance sites is relatively recent, they have a robust process in place for users to communicate with each other; share lessons learned and suggest recommended enhancements to the Alliance. Mechanisms for this communication include regular meetings of the users group and a user's portal for online collaboration. Because the Users' Committee is a formalized part of the Alliance governance, their concerns are usually prioritized by the Board of Managers and the Operations Committee. The Alliance reported using a transparent process for analyzing requests for enhancements based on the level of importance and the level of difficulty and costs. For several areas, including eRx (discussed below), desired enhancements are not available through GE Centricity. In order to expedite and facilitate health center focused enhancements to the core GE product, several Alliance staff are active in the user community for all GE Centricity customers.