The Patient Centered EHR. How do you like your EHR? How did we get here? What s wrong? Is this fixable? 9/2/2015

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1 The Patient Centered EHR How do you like your EHR? Evidence-based practice in using the EHR to engage patients and improve the patient/clinician care experience September 10, 2015 AHEC Statewide Conference Steven Crane, MD Cathy Nielson, MPH What s wrong? Increasingly the EHR is seen by clinicians as a burden, and not a tool. Many patients are uncertain why or how to use the EHR. How did we get here? Traditional Paper Record SUMMARY of a patient s encounter with the practitioner Medical/legal documentation Current Electronic Health Record COMPLETE documentation of EVERY element of the patient s encounter with the medical system. Basis for coding/billing Quality reports Population management Incentive payments Is this fixable? Nobody really wants to go back to this... There has to be a better way. 1

2 If we re the hamster, our patients are the wheel If is doesn t feel good to us, how does it feel to our patients? Patient Centered EHR Project Funded by NC AHEC 3 stage quality improvement project based on these assumptions: positive & effective models of shared EHR use exist; best practice guidelines can be derived from those models; clinicians and patients can be educated to be proactive users of the EHR; widespread implementation of the shared use model can lead to measurable improvement in patent/clinician satisfaction & patient engagement. 3 Phases Phase 1: Best Practice Guidelines Phase 2: Multi-media Products & Curriculum Phase 3: Pilot Testing Literature review Direct Observation Structured Interviews Focus Group What we did Patient Centered Human Centered Design Physicians Physicians are less enthused about the EHR for their own use, and as an engagement tool. Physician encouragement is a key factor in promoting use by patients. Physicians who share the EHR with patients report improved satisfaction and engagement What we read Patients Most patients are enthusiastic about having access to their record (77-99%) Very few actually do (3-9%) Most patients think the EHR can improve their care (75%) Most don t mind having the EHR in the exam room (80%) EHR Myths Dispelled Older patients or low-socioeconomic patients won t/can t use a portal. If patients have open communication with their PCPs they will abuse it. Engaging patients through the EHR is just one more thing PCPs/staff need to do. 2

3 What we heard - Students told us With the EHR it s harder to connect with patients; the notes aren't helpful; the templates control what is documented; clinical reasoning is limited. Physicians Highly valued by patients for their medical expertise, time spent listening, and the relationship that spanned visits. Frustration as they struggle to incorporate the EHR into their practice Efficiency/productivity Autonomy Practicing good medicine What we observed Patients Patients consistently positive about the shared EHR during the visit. Appreciated functional aspects: Prescription refills Access to health information across the continuum Patient education information First Order Change: simple steps that can improve the patient experience today Second Order Change: rethinking the care model to address cost effectiveness for the practice quality of work and life for the physician quality of care/outcome for the patient A few simple things can make for a better care experience The 10 Tips 1. Take a quick look at the EHR before entering the room. 2. Lead with 3 minutes of uninterrupted face time for the patient. 3. Acknowledge and introduce the computer. 4. Place the computer so that it isn t a barrier. 5. Own and use the whole exam room with the patient 6. It s OK to type ask permission, tell the patient what you re doing, stop and pay attention. 7. Silence is fine when you are thinking & typing. 8. There s no role for the computer in the physical exam. 9. After the exam record your findings again, silence is OK. 10. Recommendations & treatment plan this is the time for typing & talking - sharing, explaining, educating, reinforcing. Remember to ask about the Extra Credit Tip! Adapting the EHR for Learners Students: Consider read-only access Student notes created in Word; scanned into chart. Residents: Patient centered EHR practice as part of orientation Direct observation; video precepting, in-room precepting; master class Dictation (Dragon) 3

4 First Order Change is Simple Change Put the tips into practice. Second Order Change: A new care model Find out who is using the EHR well. Time to complete a note per RVU Performance on quality measures Quality of the note Empathy and patient connectedness Watch to see how they do it. Make the Switch Here s the extra credit tip! The patient portal is the ideal tool for practice redesign our entire workflow is designed around the portal Mark McNeill, MD Trillium Family Health Asheville, NC Trillium Family Health So does it work? Concept Low-overhead model Whole person care Highly engaged patients NOT a concierge practice Function Total 1.75 FTE support staff 30 min appts for all patients; average 14 a day; fully open access Previsit preparation; homework ; intervisit communication Takes Medicare, Medicaid, uninsured Measurable Outcomes Level III PCMH and Stage II MU a breeze enhanced revenue 92% of patients use the portal; 75% of appts made on-line by patient 5-20 secure messages a day; <2 min MD time; response time <2 hours 98% of the time Patient satisfaction 4

5 The Sell Making the sell New Staff train Patient patients to Orientation use the portal Physician encouragement is key Let s Check it out Video Link Handouts/posters are ok. Staff involvement even better. Nothing beats the physician s endorsement of use. Start change on parallel tracks Start with the easy wins Reconnecting with patients without losing efficiency First Order Change Train staff and providers in the simple steps to improve in-room EHR use. Measure important factors that improve engagement Face time Time with EHR Empathy Second Order Change Make sure your portal is user-friendly. Identify a champion and small team to test and implement change. Be bold; go for the full Monty Measure outcomes Questions and Comments? Steven Crane, MD Cathy Nielson, MPH The Patient Centered EHR Project: MAHEC Asheville, NC steven.crane@msj.org Cathy.nielson@mahec.net 5