Interviews with health centers covered the implementation of the Logician EMR and how administrators, researchers and clinical providers rated their experience with its implementation and use. We focused initially on particular key issues related to training and transition.
Implementation and Transition Experience
Customizations and template design. As with all advanced EMR systems, Logician allows users to customize screens and templates based on a range of options. In specifying customizations appropriate for the health center implementation, CHART benefited extensively from BMC’s prior experience with implementing Logician in an inpatient setting. BMC provided CHART with a summary of potential problems and issues with implementation and BMC’s inpatient templates provided a good starting point for designing custom health center templates. In addition, CHART and BHN convened a series of workgroups for health center IT and clinical staff to identify priorities and adopt general guidelines for template design that would allow basic level of consistency across implementation in each health center. For example, at this early pre-implementation stage, health centers agreed to bring terminals with the Logician software into each exam room. Although basic templates were developed for the initial implementation, the HCAP project is working with health center working groups on refining and developing additional templates, such as those specific to managing chronic illnesses. One chronic disease management template, for diabetes, is currently in use.
System integration. To ensure appropriate data sharing and integration between Logician and other applications, especially individual health practice management systems, implementation in each health center required development of a unique set of interfaces. Using funds from the original gift, CHART paid the vendors to build the necessary extracts, including those to stand-alone X-ray and laboratory systems. In many cases, interface development is ongoing. Several centers still lack interfaces to key functions such as billing, barring them from moving to an exclusively electronic system. Other centers lack a laboratory interface hindering their ability to participate in the HCAP Diabetes initiative which relies on tight tracking of Hgba1c laboratory values.
One stumbling block to data integration has been reluctance on the part of practice management vendors to provide their database specifications to outside vendors for interface development. As a result, health centers are now selecting practice management software based on its interoperability with Logician. In continuing to build Logician interfaces, respondents noted that they have benefited from being able to approach the vendor as a consortium, leveraging buying power when negotiating for the cost and timeline of building commonly needed interfaces.
Phased implementation. The Logician system was rolled out between 2001 and October 2003 on a staggered calendar, beginning with the Whittier Street Health Center. Full implementation in any given site took, on average, approximately six months. Implementation also occurred in phases within health centers, with each health center bringing individual sites or services on sequentially. This allowed each health center to trouble shoot and address problems related to the implementation in a single setting prior to moving forward with a broader center-wide implementation. As of our site visit in May 2004, some health centers had still not fully implemented Logician for all services, but were making substantial progress towards full implementation. CHART employed a standard implementation process in all of health centers that respondents characterized as generally successful.
Transition period. Not surprisingly, respondents described the transition from paper to electronic as being very stressful for providers. One health center prospectively decreased patient load during the transition to accommodate the slower pace of patient visits while physicians adapted to the new technology. Another site that reportedly did not have to slow down the pace as much as other centers reported that they preloaded as much patient information as possible into the system to minimize disruption to physician workflow when the system went live. At most health centers, the “transition” period was generally difficult for the first six months after implementation but stakeholders report that physicians have developed a dependency on the systems. Most centers saw a high rate of physician use of the system (although in some cases use is mandatory).
Staffing, training and support during implementation. Prior to and during the EMR implementation process, the BHN CIO designated a Logician coordinator as a point person for health centers on systems issues. This individual developed a personal relationship with health center leadership and IS staff. This coordinator oversaw the BHN set up T1 lines between the health centers and central servers and provided IS expertise during the beginning infrastructure-building stages. As implementation progressed, the CIO brought on additional technical staff such as the Logician analysts and assured that each health center had appropriate resources to support the implementation.
Logician analysts at each health center site performed one-on-one EMR trainings and group trainings with health center staff before, during and after implementation. As new features were adopted or enhanced, analysts conducted trainings during center-wide meetings as well as on a one-to-one basis as necessary. CHART/BHN staff also worked with individual health center leadership to develop a tiered support and problem triage structure incorporating “super-users”, the health center’s own technical staff, the Logician analyst, a central BHN help desk and, finally, the software vendor itself.
Exam room setup. All of the health centers we spoke to had EMR terminals set up in patient exam rooms. Others had the system set up next to intake and receptionists desks as well. In the Harvard Street CHC, 17 inch flat screen monitors were placed in each exam room and were mobile so that the screen could be turned towards the patient for educational purposes or to verify information accuracy. Respondents indicated that many physicians use the system during the patient visit, entering information, reviewing previous test results and demonstrating to patients trends in their health over time. Relatively few physicians did not feel comfortable using the system during the interaction. These physicians typed their notes into the system after the patient visit.
Key EMR Functionality and Benefits
While important obstacles exist, health center use of GE’s Logician has virtually eliminated the need for paper charts at most sites. While system use is robust, most health centers so far are only taking advantage of a small portion of potential EMR capabilities. In the paragraphs below we describe specific EMR functionalities and benefits highlighted by health center leadership.
Medical record content, quality and accessibility. Several health centers agreed that EMR has improved the content of their medical record and the accessibility of reliable patient information. Respondents at the Whittier Street Health Center commented that their providers value their ability to open up a patient chart and get a complete picture of the patients’ recent visits with various providers without having to delve through a more cumbersome paper chart. Physicians are generally satisfied with improved access to high quality, comprehensive medical records. One physician reported that he is “less dependent on his colleagues” by being able to access patient information, including laboratory information, at anytime.
Quality of care, coordination. All health centers agreed that EMR has enhanced coordination of care between the hospital and health centers and increased the availability of information to improve quality. One administrator indicated that the EMR allows him to define and track the standard of care rather than relying on a provider’s perception of the standard. Other centers reported that the system’s tracking component improved outcomes by systematically prompting follow-up for patients with chronic illness or patients indicated for diagnostic screening. At the Dorchester House CHC, follow-up features helped bring the mammogram return rate up to 80 percent.
Tracking and improving clinical outcomes. Before the implementation of information technology, centers lacked the data necessary to assess the clinical outcomes of their patients. After using the technology, several centers cited that their outcomes have improved with their ability to track patient care and response. Whittier Street Health Center cited that after six months of reports and tracking of the diabetic population through Logician, their HgbA1c measures decreased from 8.6 to 8.01. They also reported dramatic improvements in blood pressure for their diabetic patients during the same time period.
Customized templates for chronic disease management. As described above, development of disease specific templates is ongoing. For the diabetes template, which is currently in use, physicians are reminded to check for Hgba1c and blood pressure, check BMI, LDL, smoking status and other measures at various established time intervals. After physicians enter the resulting data in a standard format, data can be pulled over time that indicates their performance in managing their diabetes population. Most templates are currently still in the trial phase although more are being developed. Some physicians found the templates to be burdensome but indicated that workgroups are in the process of planning necessary improvements to the system’s design. According to an HCAP project report, 75 percent of PCPs at each CHC site use the diabetes template, with some physicians still resisting its use. Several health center administrators looked forward to implementing more disease management templates to gain a better understanding of the effectiveness of disease management on their center’s population.
Reporting. Health centers generally run standard and simple custom reports in-house using Logician’s built-in reporting system. In addition, a Crystal reports application is used to pull complex reports and is used by HCAP Staff to pull information from the EMR for the diabetes project. Most health centers had adequate capacity to pull the information necessary to comply with reporting requirements. For most participant health centers, all reports except for the standard UDS reports, billing and productivity reports, are new reports made available through Logician. One center emphasized that the electronic reporting functionality has made it easier to complete a UDS report and that it offers them the capability to verify the data they thought to be true. Several health center administrators also mentioned pulling reports on billing, utilization and costs to manage their practice. Other custom reports and population-level reports are supplied to health centers by HCAP IT Staff who pull data from Logician and the data warehouse, which are described below.