Health centers reported positive experiences with initial roll-out of EHR in Florida and a high level of enthusiasm in expanding take-up of EHR within their center with the goal of improving the quality of care as well as the overall efficiency. After some struggles at the pilot sites, center staff all report being very pleased with the system and multiple respondents reported that interest grows with each additional provider who goes live. In the paragraphs below we highlight significant aspects of health center experiences with EHR in Florida as recorded during our site visit.
Clinical decision making tools and patient safety. Clinical staff interviewed indicated a high level of comfort with the customization of clinical decision support functionality. Many mentioned that “pop up” notification of laboratory results in a problematic range has allowed for quicker clinical response. They also praised the usefulness of drug interaction and allergy warnings. In addition, several respondents mentioned having an increased level of comfort with prescriptions that are electronically prescribed due to the elimination of legibility issues.
One clinician noted that his health center has benefited specifically from the reduction in unsafe use of drugs that interact unfavorably with ACE inhibitors. Health centers are involved in ongoing customization of the pop up message functionality so that it provides appropriate levels of clinical decision support with out overburdening the provider. Clinical leadership across the health centers indicated that HCN has used these tools effectively to date, working closely with clinicians to adjust settings over time. Finally, health centers noted the safety benefits of having easy access to patient-level medication data. For example, following the recall of Vioxx, health centers using EHRs were able to query their EHR data to quickly identify and notify affected patients.
Quality of care benefits. Although most health centers are early on in their implementation of EHR some did indicate that they are already able to see outcomes and process improvements. In particular, one health center noted that their average HbA1c for diabetic patients went from 8.5 to 7 during the months immediately following implementation of EHR. Currently, HCN only maintains a limited set of the EHR data in a format available for query by health centers and use of EHR data to monitor and support quality of care occurs largely on a center by center basis. At this time, a limited percentage of patient encounters across the HCN network are facilitated by EHR. The HCN medical director is working with clinical leadership across health centers to develop HCN-wide disease management and quality of care programs to be rolled-out as use of EHR expands across the network.
EHR effects on productivity. Unlike other settings where an “overnight” approach to EHR implementation results in substantial decreases in productivity over the course of several months, HCN’s approach of incremental roll-out results in relatively small, short term reductions in productivity at the time of implementation. HCN recommends that centers plan for about 90 days of decreased productivity; so far they have mainly seen 5-10% reductions for 60-90 days, after which productivity returns to and, in some cases, exceeds previous levels.
Usability and patient response. Although clinical leaders indicated some apprehension on the part of clinicians, none reported major problems with providers becoming comfortable with using the EHR system after limited training and use. Health center staff reported that even the least computer savvy clinicians have adjusted to using the application after overcoming the initial fear of not being able to adopt. Several clinicians noted that the electronic record was more usable than the paper system. For example, the application allows them to review multiple parts of a patient’s record on the same screen reducing the time it takes to “flip back and forth” in a paper chart. One clinician indicated that using the EHR has dramatically decreased the time it takes for him to review a patient chart.
In addition, health centers note that patient response has been positive. Clinicians introduce and explain the EHR concept to patients during the first encounter facilitated by the application. Many indicated that patients take comfort in observing that their physicians are using advanced computing. Some clinicians indicated that the Lifebooks offer a wonderful opportunity to educate patients in the exam room — by pulling up graphics of key clinical indicators or diagnostic images at the point of care. However, some clinicians indicated this type of patient education was not possible given the current setup in their health center. Overall, there were no indications from our interviews that use of EHR has detracted from patient satisfaction with the quality of patient/clinician interactions.
System stability and access to data. Because the HCN envisions a completely paperless environment in all health centers following complete roll out of all EHR functionality, great care has been taken to assure system stability and reliability. These investments are particularly important in Florida where during hurricane season, health care providers often scramble to provide care after a portion of their facilities have been destroyed. During the 2004 hurricane season, the HCN network stayed functional with no downtime. The only downtime was experienced at the centers directly affected by the storms). After having to temporarily shutdown specific health center sites with EHR, patients who served at those sites were treated seamlessly at other network sites where providers had complete access to their EHR. This experience increased enthusiasm for EHR across the network and motivated health centers to step-up their plans for investment and implementation.
Supporting various care needs. HCN health centers have successfully customized the applications they use to facilitate specific primary care services, including pediatrics and chronic care management. Current efforts are directed towards Network-wide implementation of quality care guidelines, case management systems, disease management initiatives, and network-wide quality improvement. Health centers have also considered instituting use of the EHR among their behavioral health providers. Although health centers indicated that these providers would be able to use EHRs to an extent, there is some skepticism regarding the ability to customize forms and templates to deliver behavioral health care. Individual centers participate in a number of disease management collaboratives of their own choosing, including a Diabetes Consortium, Cancer, Depression, Asthma, Medicaid/Medicare, and BPHC performance benchmarking, and HCN has developed customized forms for a few of the more common ones within Medical Manager. Some centers use stand-alone PECS, but they have moved to a new network version which allows HCN to support the databases. HCN staff report that their long-range plan is to create the collaborative reports from Medical Manager and submit them electronically, eliminating the need for PECS and CV DEMS. They are currently testing an export program that will take lab results from Medical Manager and export them to a file that is then imported into the PECS software.
HCN’s system is able to track patients who are seen at various participating centers, and the EHR has been able to identify patients who move from center to center “drug seeking.” Presently, they do not share EHR or administrative data for security reasons, but in the long-term they plan to share data not only between centers, but with hospitals and private practices, creating a “true continuum of care” for patients.
Costs and future uses. HCN health centers were overall very positive regarding EHR use citing the cost of licenses and hardware being the greatest barriers to adoption. Although there are still some reluctant providers, there was an overall willingness and enthusiasm to learn. Critique of the EHR centered on unrealized potential benefits. For example, although some health centers are able to access inpatient data on their clients through Jackson Memorial Hospital, there is no two-way electronic communication on client issues across non-HCN health care providers. In addition, some indicated that they would like to see greater compatibility between Medical Manager and the progress note functionality of the EHR. Finally, some health centers indicated that the Rx-writer’s formulary functionality was not compatible with the format in which several health plans provide their formulary data. HCN continues with its implementation of the EHR products, and respondents say they plan to have 200 providers in Florida live on the full EHR by 2007.