At the start of this project, EHR was rare in health centers, but we witnessed increases in EHR investment as the study progressed. Three of the seven network sites we visited had begun the process of rolling out EHR systems in 2004 and all other health centers we spoke with expressed support for adopting EHR in the near future.
The EHR systems utilized by case study respondents provide a wealth of valuable clinical functions: the systems facilitate automated clinical assessment with built-in reminders for specified preventive and diagnostic services; allow for electronic communication with pharmacies and clinical laboratories; automate coding of clinical procedures, diagnoses and patient instructions; and support an electronic progress note. Some systems also notify providers of adverse medication interactions and facilitate patient tracking, diagnosis assistance, and electronic document and image management.
Health center respondents we spoke to that had implemented an EHR reported positive experiences with their particular system. For these health centers, the decision to implement EHR was aimed, to some extent, at improving the practice’s efficiency, workflow, and physician productivity. However, health centers focused on mission-related incentives to adopt EHR such as quality of care, effective management of chronic illness, and improved continuity of care. Although financial return on investment (ROI) may come in time, health center staff noted that financial gains, relative to systems costs for EHR, are difficult to demonstrate at the outset of implementation.
EHR vendors. Fewer EHR products are available on the market than are practice management products. The EHR vendor products used by this project’s respondents were GE’s Logician and WebMD’s OmniChart/OmniDoc, as well as the Dentrix oral health EHR. Most EHR systems are built to integrate with a particular practice management system marketed by the same vendor, and do not interface with other systems well. For example, to share data from different proprietary EHR systems or separate EHR and practice management systems, some health centers had resorted to building customized interfaces or re-entering data, both of which are frequently costly approaches.
EHR rollout process and training. Health centers’ approach to user training and EHR implementation varied considerably. Some networks opt for a slower, more deliberate approach than others. In Florida, which has opted for a slower approach, providers begin using the system with a small number of patients per day and gradually add more patients transitioning eventually, to exclusive use of the EHR. They report that this method facilitates take-up and limits productivity loss associated with the transition.
Other networks, where entire health centers were switched from paper to EHR overnight, reported adjustment periods of up to six months and planned for dramatic reductions in productivity during the initial roll-out. In all cases, staff and provider training was intensive early during roll-out and the first several months of using EHR. In some cases, EHRs were rolled out on a site by site basis within a single health center. This would allow each health center to address problems and ensure usability in a single setting prior to moving forward with a broader center-wide implementation. Respondents noted that providers transitioning to EHR almost uniformly grew to appreciate the systems’ benefits over time, in large part because of improved access to key data from the patient chart.
In many cases the roll-out model for EHR was influenced by factors of expediency and feasibility. For example, while the gradual approach employed by health centers in Florida proved beneficial according to respondents, they took this approach, in part, because health centers pulled together funds to buy software licenses one or two at a time (a combination of health center and network money was used to purchase the licenses).
Efficiency and productivity. Increased clinical efficiency and provider productivity were frequently cited as benefits of EHR. New Hampshire respondents reported that the piles of paper records previously taking up space on the physicians’ desks have been eliminated, making workflow more efficient. Transcription costs are also gone. Although New Hampshire and Boston health centers acknowledged experiencing some slowdown in provider productivity during implementation, most centers reported that as providers have gained familiarity with the systems, they have begun seeing similar numbers of patients as pre-implementation. None of the Florida health centers reported major problems with providers becoming comfortable using the EHR system after limited training and use. A provider from one health center noted enthusiastically that EHR has decreased the time it takes for him to review a patient chart.
Access to data and system stability. Both clinical and administrative documentation were reported to have improved dramatically with EHR. Many health centers agreed that EHR has improved the content of their medical records and the accessibility of reliable patient information. The systems allow each provider at a health center, or all health centers in a network, to generate reports assessing the progress of vulnerable patients (such as diabetics). One health center emphasized that the electronic reporting functionality has made it easier to complete and verify UDS reports. Providers in Florida also appreciated the ability to remotely access patient laboratory results and medications. One Florida health center reported that remote access to patient data was especially valuable after a hurricane forced the center to temporarily close. During this time, the health centers’ providers were able to treat their patients from an entirely different provider site with complete access to patient records.
Improvements in patient safety and care processes. Respondents reported important improvements in quality of patient care following EHR implementation. Health centers noted that electronic patient charts are far more legible than handwritten notes, reducing potential for error. For New Hampshire centers, 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 occur more frequently. EHR systems with a tracking component improved outcomes for some health centers by systematically prompting follow-up for patients with chronic illness or patients indicated for diagnostic screening. At one Boston health center, follow-up features helped bring the mammogram return rate up to 80 percent. Other health centers have benefited from the e-prescribing function, which led to a reduction in the unsafe use of drugs that interact unfavorably with ACE inhibitors.
Links with hospitals and laboratories. EHR-facilitated electronic linkages with labs and hospitals have proven valuable to health centers. In Boston, the EHR has enhanced coordination of care between the hospital and health centers and increased the availability of patient information. In New Hampshire, linkages between the network’s members, local hospitals and a diagnostic testing facility allow the health centers to obtain encounter information when their patients visit one of the participating hospitals or need a routine laboratory test. However, these interfaces currently work only in one direction (the network’s IT system captures electronic data from the hospital and laboratory systems and imports it into the EHR).
Clinical outcomes improvements. Although many respondents were hesitant to point to concrete clinical outcomes improvements stemming from EHR implementation, some reported observing important improvements. For example, one Boston health center cited that after six months of reports and tracking of the diabetic population through their EHR, their HgbAlc measures decreased from 8.6 to 8.01 and the patients’ blood pressures had markedly improved. A Florida health center described a similar experience during the months following implementation. Because all of the EHR implementations studied as part of this project are at their early stages, respondents indicated that they expect to monitor and report on more tangible improvements in clinical outcomes in the coming years.
Barriers and challenges. Costs, training, and provider comfort remain the primary barriers to EHR adoption for most health centers. For all the reasons described above, EHR systems are prohibitively expensive for the average health center and those we spoke with that had implemented EHR noted that they would never have been able to do so individually — network membership provided the financial resources to invest in and support such sophisticated applications. Training providers and other staff to use EHR is an ongoing and costly process, one that networks are generally in a better position to coordinate.
Health centers also report that provider buy-in and the presence of clinician champions are extremely important for successful EHR implementation. Clinician champions at health centers who understand the potential for EHR to greatly improve the efficiency and quality of care and are willing to put in the arduous effort necessary for working with skeptical fellow clinicians to redesign care delivery are invaluable to such efforts. Providers’ learning and productivity curves can be slow during the implementation process, but most see the benefits of using EHR including improved efficiency and decision-support.
Costs and benefits. Health centers implementing EHR reported seeing immediate benefits. Respondents noted improved clinical and administrative documentation, better quality of patient care, greater reliability around patient records and services, and a variety of process and outcome benefits. Health centers also acknowledged the substantial cost associated with EHR. Aside from the financial cost of software licenses, health centers reported other significant start-up costs including procuring appropriate hardware and connectivity, customizing and designing the initial implementation of the software, building clinician buy-in and training users.
In addition, there are the ongoing costs of reporting, analysis and change management necessary for using EHRs to improve care delivered. Even in the most successful implementations, we found that robust buy-in and benefits from EHR implementation were experienced as a result of ongoing, detailed engagement and investment on the part of both IT and clinical staff to design, discuss and refine the EHR functionality and settings. Initial loss of provider productivity during the first six months after an “overnight” implementation is another type of start-up cost associated with EHR.
Respondents also acknowledged the difficulty in quantifying ROI from EHR implementation. While many feel strongly that the systems represent important savings through health benefits and decreased utilization over an extended period of time, health centers typically did not have adequate data to determine whether EHR has resulted in cost savings at an institutional level. 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. Some New Hampshire centers reported that quality improvements hastened by the EHR have resulted in increased provision of services for which payers provide little or inadequate reimbursement. Respondents expressed optimism that the ROI was significant, but hard data on whether using EHR saves more than it costs health centers is not available at this time.