Community Health Center Information Systems Assessment: Issues and Opportunities. Final Report. Electronic Health Records and Electronic Oral Health Records

10/30/2005

In 2002, the BHPC funded a pilot program to help HCN implement EHRs at 4 Florida centers. The pilot program met with mixed success, and important lessons learned.  Based on their experience from the pilot, HCN received a four year, $4.4 million Information and Communication Technology (ICT) project award from HRSA to roll out EHR and Electronic Oral Health Records at all Florida centers.  HRSA funded this and five other ICT projects to support health center participation in the development of integrated business and medical technology systems.  HCN bolstered these funds with a commitment of $8 million from participating centers.

Pilot experience. The Board of Directors and Clinical Committee identified centers and providers appropriate and willing to serve as pilot sites.  All pilot providers are champions of EHR and now help with training in their respective centers.  The initial pilot test involved four providers, three tech-savvy and one technologically inexperienced, across three Florida health centers. Although HCN did conduct a limited assessment of vendors prior to conducting the pilot, it was clear, given their existing relationship with WebMD and the potential for integrating the EHR with Medical Manager, that WebMD’s Omni Chart system represented the best business fit for the network. 

Omni Chart provides a suite of EHR functionality including electronic prescription writing, clinical task management functions and electronic lab orders and results. Additional EHR functionality is provided through OmniDocs, a system for electronic capture of open ended progress notes. In addition, HCN has worked with the WebMD’s Document Image Manager for document and image management and Dentrix Systems for electronic oral health records. A full description of the EHR functionality available through HCN is provided in Table 2 below.

Application Functionality
Table 2: HCN EHR Products and Functionality
Rx-Writer * Allows electronic prescription writing and transmission to pharmacies
Clinical Task Manager * Tracks items requiring follow-up (e.g., labs, patient instructions)
Transcription Manager * Stores transcribed notes in patient’s electronic charts
E-Encounter Allows electronic selection of visit procedure and diagnosis code(s)
WebMD’s OmniDocs Provides user friendly graphical user interface for progress notes
Document & Image Management System Stores scanned clinical images for inclusion in patient record
Dentrix Electronic Oral Health Record system
* Each of these functionalities is included in the WebMD OmniChart Suite

As preparation for the pilot began, it became clear that key features of the software were not ready for implementation. Although the backbone of the software was written; WebMD had very little experience supporting the tool in real world settings. For example, there were very few default forms available and standard drop down menus and templates were cumbersome and inappropriate for use in a health center setting without further customization. As a result, the pilot began with limited roll-out of the prescription writing functionality.

After several months of working with WebMD and a new Medical Director hired by the vendor to handle customization of the OmniChart product, templates were developed that enhanced the usability of the system and gradually additional functionality was added. Overall, the pilot experience highlighted the importance of conducting extensive assessment of usability by working directly with providers, identifying physician champions who would be willing to “tough it out” in the early stages of an implementation, and connecting providers directly to staff at the vendor to tailor applications.

Ongoing roll-out.  In 2004, having secured funding for a broader EHR implementation through the ICT grant, HCN began working closely with WebMD on additional customizations.  As with Medical Manager, HCN’s significant market share allowed the network to negotiate a strong partnership with WebMD around EHR. WebMD has subsequently used customizations developed in conjunction with HCN to expand the scope of functionality it can make available to the wider health center and private provider market.

Over the past year, HCN has gradually increased the scope of its EHR activities, steadily adding to the number of providers using EHR, as well as the functionalities used by those providers. As in the pilot, providers and health centers tend to start with limited functionality in order to gain facility with the initial user interface. Providers then move on to using the task manager and computerized progress note applications.  Table 3 below highlights the status of EHR roll-out at several of the health centers visited as part of the study.

Table 3: Status of EHR Implementation at Selected HCN Health Centers
HealthCenter EHR Status
Community Health of South Dade (CHI) Six providers are live on the full HCN EHR package (including OmniDoc), and four more are up to the Rx-writer stage.  Ten more medical providers will be added in the future, but CHI’s 20 behavioral health providers are not currently slated to join the EHR until 2006.
Camillus Health Concern (CHC) All providers at CHC are currently using Medical Manager’s administrative and practice management functions, and the center was just beginning to implement EHR at the time of visit.
Helen B. Bentley Family Health Center (HBB) All 20 of HBB’s providers are using Rx-writer, and are at various stages in adopting the full EHR.
Economic Opportunity Family Health Center (EOFHC) 3 medical providers are fully live on the EHR, and all 5 dentists are fully live on Dentrix, with the rest coming on shortly.
Broward Community & Family Health Centers (BCFHC) All 3 providers are using Rx-writer and are in the process of going live with the rest of the EHR components.
Family Health Centers of Southwest Florida (FHC) (Interviewed by telephone conference) This center participated in the Pilot program of HCN’s EHR system, and all of its providers use some aspect of it, including 20 providers fully live on all components.  47 total providers, including six dentists, use some modules of EHR. 

Although the systems can be installed on stationary terminals in exam rooms, most health centers are implementing the system using the Lifebook wireless tablet PCs that their providers carry. The cost of purchasing this hardware falls largely on the health centers. These computers connect to the HCN network through secure wireless network access points (WAPs) installed at each health center site. 

Training model.  While specific training programs vary from center to center, the basic approach is the same across HCN.  First, the network works with health centers to select the providers that will participate in the initial roll-out. The goal is to start with at least two or three patient and enthusiastic providers simultaneously at any give site. Once providers are selected, they attend an intensive training either at HCN headquarters or on-site. After the initial training, local IS staff are supplemented by a dedicated on-site HCN trainer who comes to the center for several days to help providers transition to using the system.

Depending on a given center’s needs and logistical considerations, follow-up training may be conducted online using WebEx (online training software) or subsequent visits back at HCN.  In addition to training activities coordinated through HCN, each health center has identified physician champions and peer trainers (generally highly respected colleagues) who continue to support use of the application by their fellow providers. At one center, the physician champion meets with providers over a series of dinners to discuss their experiences with EHR.

Phased-approach.  Unlike other networks implementing EHR, where a large infusion of private sector dollars led to relatively rapid implementation of EHR across a series of health centers, HCN has slowly phased in EHR use among health centers and providers. Health centers can take advantage of having the network infrastructure to support electronic records for some patients even as most of their patient records continue to be paper-based. In addition, HCN does not ask providers to switch exclusively to using the EHR “over night.”  Instead, providers begin by using the system for a limited number of their patient visits in a given week (e.g., one or two visits per day out of a total of six). 

Most providers begin by using only the Rx-Writer and clinical task manager for lab orders and results.  These modules are simple to use, and their benefits are immediately clear.  HCN finds that starting with these modules promotes initial buy-in and interest among providers. HCN is now in the process of moving to full EHR — all providers using all functionality — in several of its centers.  The overall goal is to implement the full system with all 200 Florida providers by December 2007. 
Clinician Involvement.  Key to HCN’s success in implementing EHR has been clinician involvement at all levels of the process.  The initial discussions around EHR implementation during the pilot phase prominently featured the clinical committee, composed of the medical directors from each member center. These clinical leaders were involved at all steps of EHR selection, customization and implementation.  In addition, the use of clinician champions across health centers has markedly enhanced take-up.

In addition to allaying concerns and encouraging clinicians through difficult steps, medical directors and champions, through the clinical committee, regularly report challenges or issues with EHR use back to the CEO, CIO, and EHR project managers at HCN for quick resolution. The consistent level of buy-in from clinical leadership across health centers has greatly mitigated physician resistance to EHR in the health centers. The general experience is that once a few providers at a given center go live on the EHR, the others — including many of those initially most resistant — become very interested, and want to get on board.

Importantly, clinician input drives all customizations of EHR tools, including setting “pop-up” reminders to encourage appropriate delivery of diagnostic or preventive services as well as other clinical decision-making features. Recently, a network-level medical director has been hired to coordinate quality improvement and prevention programs that leverage the availability of EHR and build close relationships with other community stakeholders.

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