A considerable portion of our New Hampshire interviews were spent discussing the implementation of the Logician EMR and how various stakeholders in the health centers — administrators and clinical providers — rated their experiences with utilizing the system.
EMR history and vision. Lamprey Health Care, New Hampshire’s oldest and largest community health center and CHAN member, began looking into EMRs as far back as the early 1990’s. At that time, Lamprey was part of an integrated delivery system composed of private physicians’ offices and hospitals (called the APEX network) that conducted a review of EMR vendors and selected the Logician EMR system as one of two top choices. APEX disbanded before acquiring an EMR, and Lamprey subsequently joined with the Dartmouth Family Practice residency program, which was also pursuing EMR. Through their collaboration, Lamprey and two other New Hampshire health centers received a grant from the New Hampshire Blue Cross Blue Shield Association that allowed them to independently purchase the Logician EMR. Therefore, at the time of CHAN’s formation, three of its five members had already acquired the same EMR system.
One of CHAN’s original goals in 1995 was to leverage and expand existing EMR capabilities at member health centers through a shared EMR application that could produce population-level information regarding clinical experience across state and support greater efficiency and higher quality of care at the health center level. Lamprey, as the largest and most technologically sophisticated of the members, agreed to host the network’s servers and supply technical expertise. Over the next several years, CHAN, working with funding from state, federal and private sources to develop the design for a shared EMR application, purchased additional servers and assisted their health centers in acquiring the infrastructure to support such an application. A concerted plan to implement the shared EMR application began in 2000 and is now complete. All five CHAN health centers now have equivalent access to the Logician application. Lamprey continues to host the server and network applications. Lamprey is also the physical location of the CHAN offices, from which the network’s IT support services are run.
Organizing for implementation. Health center respondents indicated that once the decision had been made to move ahead with expanding Logician into all five CHAN members, each center made some initial financial investments (generally around $150,000) and began the process of internal reorganization, which primarily consisted of reconfiguring staff duties. Early capital investments included terminals for exam rooms, training time, physician licenses, and other equipment. In addition to SIMIS money, grants received from Pfizer, Inc. and the State of New Hampshire assisted with these investments. Although private grants formed an important funding source early in CHAN’s existence, ongoing funding from Bureau grants has been a crucial backbone throughout the organization’s subsequent years. Health center and CHAN leaders reassessed staffing needs at the centers and shifted many administrative staff into EMR-related positions after they had gone through appropriate training. Center staff also pre-loaded a selection of available patient chart information into the system.
Provider buy-in for EMR setup. Health center directors and CHAN leadership recognized that provider acceptance of the new system was vital to the long-term viability of the initiative. To this end, the health centers held off the network wide go-live until they had ensured that the product was user friendly, avoided double data entry, and made patient data easily accessible. They also tested and confirmed the feasibility of including computer terminals in each exam room to aid with recording clinical information in real time and in supporting patient education through use of graphs and charts. The Logician system is highly customizable and respondents agreed that the extra time CHAN invested in custom-designing their system paid off in physician enthusiasm for the project.
Training and support. CHAN IT staff trained all providers in the network on use of Logician and continue to perform training for new providers. Training for physicians is one-on-one and training for other clinical staff like nurses is done in group sessions. One health center reported that providers trained for a half day while other clinical staff trained on the system for a full day. In addition, training was conducted on an as needed basis during early phases of implementing the system. CHAN IT staff provide support remotely for issues that go beyond day-to-day needs (which are dealt with in house at each center). When the health centers began going live with Logician, CHAN staff provided intensive support during the implementation process: the stakeholders involved held weekly conference calls and CHAN dedicated its staff and expertise to ensure that the transitions went smoothly. The network also provides coding audits, utilization review, customer satisfaction auditing and compliance audits for each site.
Key Logician Functionality and Benefits
Respondents universally suggested that GE’s Logician EMR is a robust and versatile EMR product. Although CHAN staff noted that the network has not made use of all the available program functions, they indicated that the set of tools they do utilize has virtually eliminated the need for paper charts. Respondents were also enthusiastic about the program’s highly customizable structure, as well as the support provided by GE (including for any client customizations). One respondent from Lamprey Health Care described CHAN’s Logician as “a first class system that answers our needs and is cost effective.” CHAN attributes the following benefits as resulting directly from the implementation of the Logician system:
Population-based reporting and tracking. CHAN respondents identified benefits gained from use of Logician data for reporting and patient tracking. Reports on utilization for specific populations, once handled through practice management systems, now derive from the cleaner and more complete EMR data. The information is easier to access and analyze. CHAN stakeholders noted that the ability to readily identify clinical areas in need of improvement facilitates tracking of key public health issues. They cited one experience where centers noted low childhood immunization rates across the network and have subsequently begun to program Logician to attach pop-up messages to patient medical records so that a physician would be alerted when the patient being seen had not been immunized. In another example, Manchester Community Health Center recently implemented a program to reform the prescription of intrauterine devices (IUD) in their center based on EMR data showing inappropriate use of the device for contraindicated patients.
Improved patient care. The EMR has improved many aspects of patient care quality. Electronic patient charts are far more legible than their handwritten predecessors, facilitating general comprehension and reducing potential for error. Medication management has been enhanced, lab results are now automated and more quickly accessible, the rate of compliance with screening exams for all patient populations has improved, and routine patient follow-ups are addressed easily. The system generates treatment reminders and patient evaluations as well as providing vital information for patient outreach and health-risk prevention efforts.
Chronic disease management. EMR strongly supports health center efforts to manage chronic disease. The health centers have a large diabetic patient load, most of whom are uninsured. Most CHAN members are part of the Health Disparities Diabetes and Asthma Collaboratives, as well as the CDC’s Diabetes Translation program. Lamprey Health Care alone has 900 patients enrolled in the Diabetes Collaborative. Respondents from Lamprey noted that the Logician EMR allows each provider to generate a monthly report assessing the progress of their entire diabetic patient load. The network can also produce reports giving detailed statistics on clinical indicators for their chronically ill population — this functionality has enabled CHAN to demonstrate to the State Medicaid program that average hemoglobin levels across the network’s diabetic patient population are better than those under commercial insurance statewide.
Hospital and laboratory linkages. One of the network’s most important current projects is to provide health centers an electronic link to local hospitals and laboratories. These linkages allow the health centers to obtain encounter information when their patients visit one of the participating hospitals. Not all the seven acute care hospitals in the area are currently involved: the linkage with one hospital is fully functioning, three are in progress, one hospital has just begun discussions with CHAN about participating, and one decided not to participate at all. CHAN stakeholders noted that each linkage requires a different interface because all the hospitals use different clinical and administrative systems. Respondents were complimentary of the hospitals’ willingness to share their information — CHAN staff recognized that “there really isn’t anything in it for the hospitals.” Privacy concerns do not constitute a major issue in establishing the data linkages; most discussions that arise focus on negotiating who will bear the cost of the direct link. Thus far, hospitals provided free staff time to create interfaces and the hospitals do not get access to CHAN’s patient data due to privacy concerns. One hospital is negotiating with MCHC to allow access by its Emergency Department staff to the health center’s primary records for patients who present for care. The network has also established a linkage with Path Lab, a diagnostic testing facility owned by LabCorp and used by most of the member health centers for routine laboratory tests. For now, these interfaces work in one direction: CHAN’s IT system captures electronic data from the hospital and laboratory systems and imports it into Logician.
Stakeholder satisfaction with the Logician EMR
Conversations with our New Hampshire respondents indicated that implementation and utilization of the Logician EMR system has been a predominantly positive experience for all stakeholders in the network. The interviews revealed that the complaints and problems that surfaced early on in the process have now all but subsided, as providers and administrators begin to see the benefits of the system. The issues that remain are reportedly being actively addressed by the CHAN staff.
Ramp-up issues. Health center respondents acknowledged several difficulties related to implementation. Staff from Manchester Community Health Center (MCHC) noted that physician productivity was affected more than they had anticipated: clinicians saw fewer patients per hour than the pre-EMR average for several months after the go-live, and providers worked longer hours while they learned their way around the data entry requirements of the system. Some providers, depending largely on age and computer literacy, adapted more quickly than others.
Unsurprisingly, some providers expressed initial frustration with learning a new system and a new way of working. They were resistant to the idea of entering data into a computer instead of dictating notes, and worried about the slowdown in their productivity during the training phase. Respondents estimated the full learning curve to be between six and eight months. Physicians also complained that the patient record screens were not free-text: data has to be entered for numerous values, leaving little space for subjective comments and “unique patient information.” However, this criticism seems to have faded as providers gained familiarity with the system. Also, although the electronic patient records are template-driven and the screens are heavily utilized, free-text input does remain a component of the system. One stakeholder said providers recognized that the process was a commitment with costs but also considerable benefits.
Screen templates. One of the few outstanding EMR implementation issues relates to the use of Logician’s desktop documentation screens. Some of the forms have been modified with embedded logarithms to support evidence-based protocols, which are intended to aid provider clinical decision making. In some cases, the system requires providers to click through numerous screens to enter in patient data during an encounter. However, physicians have objected that they often don’t need to ask every question on the screens. CHAN staff agreed that the number of information queries contained in the forms can be fatiguing and cumbersome — they described the problem as “information overload” and said that the network is currently conducting pilot projects that will alleviate the situation, such as consolidating screens and having nurses enter in essential data before the physician sees the patient.
Data security and privacy. CHAN respondents also raised the issue of Logician’s security system. Currently very few network staff can access the patient data set. The Logician application restricts user access on a broad “all or nothing” basis, so system administrators can’t give different users access to some fields but not others. CHAN’s Executive Director indicated that a more flexible security system, with an expanded option for individual page lockdown, would be preferable. However, she seemed confident that the next version of the software program will address this problem.
Increased efficiency and economies of scale. Despite these issues, CHAN respondents generally thought that Logician’s advantages outweighed its drawbacks. Computer data entry means that the piles of paper records taking up space on the physicians’ desks have been eliminated, making workflows more efficient. Radiology results, consultations, and referrals come in to the office on paper, but administrative staff scan them in to the EMR. In addition, the EMR has eliminated transcription costs, improved the quality of the medical records, and allowed physicians to access patients’ records through a remote Internet connection. Health center respondents also indicated that participation in the network has led to savings through economies of scale. All CHAN respondents agreed that “it could have been the ruination” of the centers had they attempted to acquire the EMR individually, given the significant development and implementation costs. In addition to reducing the cost of setup, the five consolidated health centers working together have gotten vendor discounts on software, licenses and IS support that they could not have obtained as individual clients.
Return on investment. In general, respondents acknowledged the difficulty in quantifying return on investment (ROI) from the EMR implementation. While they feel strongly that there have been significant social savings, documented savings specific to the health centers themselves have been modest relative to fees they pay to CHAN for access to shared applications. While the greatest tangible savings to health centers have come from the elimination of transcription services, health centers did not have adequate data to determine whether they have seen an increase in reimbursement for preventive care and chronic disease management visits as a result of EMR-facilitated improvements in care. In many circumstances, quality improvements hastened by the EMR have resulted in increased provision of services for which payers provide little or inadequate reimbursement.
The network has reportedly held discussions on ways to more inclusively collect and document cost savings accrued from EMR-related quality of care benefits such as reduction in visits to the hospital emergency departments, but so far CHAN’s capacity in this area is limited. Respondents pointed out that it is difficult to tie a dollar amount to some core benefits like the replacement of illegible handwriting with typewritten notes. Respondents expressed optimism that the ROI was significant, but hard data on whether using an EMR saves more than it costs is not available at this time.