Physician Practices are Pioneers in Electronic Health Record Implementation in Spokane, Washington

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1 Physician Practices are Pioneers in Electronic Health Record Implementation in Spokane, Washington A Case Study Analysis and Evaluation Physicians Clinic Spokane Internal Medicine Spokane Ear, Nose, and Throat

2 This Project is made possible through grants from: Spokane County Medical Society Foundation and Inland Northwest Health Services Supervision and Guidance by: Spokane County Medical Society Medical Informatics Committee and Inland Northwest Community Health Information Project (IN-CHIP) Conducted by: K.C. Nilsson Master of Health Policy and Administration Department of Health Policy and Administration Washington State University, Spokane 2

3 Acknowledgement The author wishes to acknowledge the contributions of the following individuals for their support and dedication to the successful completion of the project. Brian Seppi, MD and David Page Physicians Clinic of Spokane Gary Cantlon, MD and Craig Hult Spokane Ear, Nose, and Throat Tom Carli Spokane Internal Medicine Fred Galusha, Barbara DeWolf and Karen Hicks Inland Northwest Health Services Barry Hicks, Ph.D., Research Associate Professor Department of Health Policy and Administration Washington State University, Spokane 3

4 TABLE OF CONTENTS page Acknowledgement...3 Introduction..5 Spokane and Inland Northwest Health Services..6 Physicians Clinic of Spokane Spokane Internal Medicine 10 Spokane Ear, Nose, and Throat..13 Lessons Learned.16 Photo Gallery.18 References..21 4

5 Physician Practices are Pioneers in Electronic Health Record Implementation in Spokane, Washington INTRODUCTION Electronic Health Records (EHRs) are not new to the Health Care Industry. For more than 30 years health care professionals have been using computer technology to store patient information for later retrieval [1]. In the past decade, adoption of this technology has increased and is expected to continue to increase due to legislation introduced by the George W. Bush Administration. Dr. David Brailer, the newly appointed National Coordinator for Health Information Technology has been given the task of drafting standards for electronic interoperability of patient information. This is a step toward achieving President Bush s vision of having as many Americans health information in electronic form as is possible within 10 years [2]. Yet, this dream will not be realized without cost. Although estimates of cost savings have been reported in the literature upwards of $77.8 billion or five percent of annual health spending, developing the infrastructure for an interoperable system is estimated at more than $400 billion over five years [3]. The purpose of this paper is to document the experience of three pioneering physician practices in the implementation of an electronic health record and to share their successes and efficiencies as a result of being early adopters of the technology. This report finds that practices can expect efficiencies to come to many areas of the practice following adoption of an EHR [4]. Improvements to operational work flow, improved communication between providers, and the ability to accomplish more work in the same number of hours per day are just a few benefits discussed here. Physicians Clinic of Spokane, Spokane Internal Medicine, and Spokane Ear, Nose, and Throat all have unique success stories regarding implementation and use of electronic health records. 5

6 SPOKANE AND INLAND NORTHWEST HEALTH SERVICES The health care industry in Spokane is one of the leading markets between Seattle, Minneapolis, and Salt Lake City. There are nine health services organizations with more than 300 FTE employees each in Spokane County. As of September 2005, health care comprises 11 percent of the Spokane County employment base and 40 percent of the service job sector [5]. Inland Northwest Health Services (INHS) is a collaborative effort begun by the two competing hospital systems in Spokane: Empire Health Services and Providence Services. These two competing companies saw there were services that each company was trying to run separately and that great efficiencies could be realized if they could collaborate. Information Resource Management is one of those areas brought into INHS [6]. Today, 32 facilities are connected through a private network and utilize a standard information system. The Meditech Health Care Information System (HCIS) stores all patient records for those facilities under a unique Master Patient Index (MPI). Currently, more than 2.6 million patient records are contained in the integrated database [6]. In addition to improving delivery of care within each facility, the integrated electronic medical record system serves as a source of information for physicians and health care providers in the community. More than 20 clinics receive data from the integrated information system via standardized HL-7 electronic messages, allowing 6

7 direct integration of this data into their office-based electronic medical record system. Physicians Clinic is one of the clinics that receive data from this system. An electronic system must contain two vital components to allow information sharing: a Master Patient Index and standardized messaging. These requirements must be met by any system in order for an electronic health network to be operationally functional [6]. Understanding the interoperability nature of an EHR enhances the value of the relationship between INHS and health care entities in Spokane and the surrounding area of the Inland Northwest. 7

8 PHYSICIANS CLINIC OF SPOKANE Physicians Clinic of Spokane (PCS) is defined as a mid-size clinic and consists of 18 internal medicine physicians and eight nurse practitioners. PCS s anchor site is situated in a prominent location adjacent to Spokane s two major tertiary medical centers. Ancillary services include: urgent care center, clinical research center, laboratory, X-ray, pulmonary function laboratory, and bone density center. The electronic health record system by Logician was implemented in 1999, and in the years since it has been upgraded with many more features. There are three external interfaces: radiology, external laboratory, and hospital; as well as three internal interfaces: practice management, internal laboratory, and the billing system. Physicians must be on board PCS implemented the electronic health record system in February of Following a standard in the industry, this implementation was phased in over a period of time. Throughout the first year, physicians and support staff became comfortable with the system. Luckily 95 percent of physicians were on board with the implementation. According to the literature, physician buy-in is critical to successful implementation [7]. The process went so well, PCS was able to stop printing office visit notes in 2000, just one year following the initial launch. Dr. Brian Seppi, a physician at PCS and advocate for electronic health records says that in order to bring physicians on board, one must show positive financial returns and create template forms that make documentation and data retrieval simple. At PCS, this was key to successful implementation. 8

9 Financial Benefits Although other financial benefits have been realized by PCS, the highlight has been the reduction in costs associated with transcription. In 1999, the year of implementation, PCS spent a total $330,058 on transcription services alone. Just one year following implementation, spending on transcription fell to $147,009 and in 2003, spending was just $56,465. This finding is congruent with current reports found in the literature [8]. Cost reductions have also been realized in the laboratory. The number of FTE employees working in the laboratory at the time of implementation was Today that number has fallen to 9.12 notwithstanding a 25 percent increase in the number of lab orders from the year 2000 to This is due to the efficiencies gained from laboratory order entry and because results are sent to the ordering physician electronically. It is impossible to quantify all of the benefits that have come to the practice through everyday operations. Communication between providers as well as between providers and support staff has improved dramatically. This in turn has enhanced the quality of care patients receive at the practice. Concluding Summary Physicians Clinic is prepared for the demands that will be placed upon it as standards are mandated federally. It is also prepared to work in concert with other health care entities in using information technology to provide high quality care to patients in the Inland Northwest. 9

10 SPOKANE INTERNAL MEDICINE Spokane Internal Medicine (SIM), as defined by the Medical Group Management Association is a single-specialty primary care practice located in a mid-size metropolitan area of the Pacific Northwest. SIM is made up of 10 physicians specializing in Internal Medicine. In the early 1990s, SIM foresaw the benefits to be realized through adoption and use of an EHR system. At this time in the industry, potential benefits of EHR adoption, such as easier access to information and increased patient safety, were evident, but the financial costs and benefits of EHR implementation for an individual medical practice were not yet known [8]. Today it is evident that benefits from early adoption of an EHR system have been realized by this pioneering internal medical practice. However, the greatest benefit has been the increase in quality and efficiency due to process changes in daily work flow. Work Flow Redesign The over-arching goal of SIM following implementation of the EHR was to always have all of the health care information a provider would need for a patient right at the provider's finger tips. This required installation of a personal computer in each exam room. Here the physician and nurse work side by side to input information to a patient s digital record as well as retrieve past notes and current literature from a plethora of databases. He or she can also order and view results of laboratory tests and radiology exams online from this room. At SIM, the improvements to daily work flow have been the greatest benefit from the Electronic Health Record. Eight administrative support staff members have the 10

11 following responsibilities, all of which are now performed electronically using digital templates for input to the EHR: Scheduling patients Check-in (Front Desk) Check-out (Back Desk) File Clerk There are three telephone positions where all incoming calls are answered and routed. These calls include appointments scheduling, medical record requests, preappointment patient information requests, appointment reminders, and referral requests. When scheduling an appointment for a new patient, an employee prepares a packet of information to be sent to the new patient. Included in this packet is a welcome letter to the practice, a patient history form, a demographic form, a promise-to-pay contract, as well as a self-addressed, stamped envelope. These forms are arranged in the same order as the digital template. When this information comes back to the practice, an employee inputs the information into the EHR system. A goal of SIM was to be able to treat a new patient on their first visit as if they were a long-established patient of the practice. A patient s first impression means a lot, according to Group Practice Administrator Tom Carli. One employee checks nearly 175 patients in at the practice each day and the average check-in time is one minute. This is accomplished by having patient information ready and in the digital record prior to the appointment. The waiting room at SIM is furnished with 45 chairs. Yet, due to the efficiency of the electronic check-in process, there are rarely more than 10 individuals waiting for appointments at one time. 11

12 Another employee is at the check-out desk. This employee collects payments and that ensures the patient has taken care of all information needed for the visit. The other three employees are responsible for relieving the phone and desk positions, filing, faxing, and ensuring the physicians and nurses have everything they need. Also, in order to avoid staff burnout, each staff member is trained in each of the aforementioned administrative support functions and they rotate among the positions weekly. Concluding Summary When asked for advice on selecting an EHR, Tom Carli, the Group Practice Administrator of SIM states, I try to give simple advice. He also says that you should look at the company offering the product and make a judgment as to how long you feel they will be around. You want a company that will be around a while to provide support and upgrades, he says. Carli also advises one to examine how easy it is to view and upload information in the system. Many systems allow the user to customize their screen to view information that is most useful for their particular job. Overall, the financial benefits, the quality of the employees' work environment, and the enhanced quality of care to the patient have made the adoption of the EHR a success for Spokane Internal Medicine, its patients, employees and vendors. 12

13 SPOKANE EAR, NOSE, AND THROAT Spokane Ear, Nose, and Throat (SENT) is a single specialty clinic and ambulatory surgery center as classified by the Medical Group Management Association (MGMA). The practice is comprised of 12 physician specialists, 11 nurses, and seven audiologists. As an effort to minimize transcription and medical records costs and to improve clinical processes, SENT began investigating a possible implementation of an electronic health record system in mid-1990s. This was no small task for a specialized practice such as SENT. Finding a system that provided a high degree of customization was challenging. Yet since implementation in 1998, SENT has experienced many benefits, such as increased efficiencies in daily work flow and improvements to its profit margin. System Requirements and Implementation Customization capability was the major prerequisite for SENT in choosing an EHR. Each physician wished to be able to customize program screens for entering encounter notes and ordering labs. Another requirement was the EHR must be able to interface with SENT s practice management system as well as the local hospital system. The implementation process took place over a seven month period. Within four months of adoption, three physicians were actively using the system, and within seven months all nine physicians in the practice were. Today, all physicians, nurses and audiologists are using the system. According to SENT s Director of Information Systems Chris Youseph, over the past seven years the only frustrations with the system are enduser problems. Proper training on the software is imperative for all users. The system is very reliable and has not experienced problems. 13

14 Benefits SENT has achieved benefits in many areas. First, the EHR has created great cost savings. Prior to implementation, SENT was spending approximately $144,000 per year on transcription services and $120,000 per year maintaining paper medical records. In the first year following implementation, SENT was able to reduce its spending on transcription by $120,000 or 83 percent. Today, the costs to maintain paper records have been eliminated. Since implementation, SENT has added an additional three physicians and five audiologists at minimal cost to the practice. Had the practice still been employing transcriptionists and maintaining paper records, overall costs to the practice would have increased dramatically. This is consistent with other reports in the literature [9] [3]. Yet, SENT has experienced an increase in revenue that is not only attributable to an increase in providers. With the elimination of paper medical records, SENT has increased the amount of office space used to produce revenue. Prior to the EHR, SENT dedicated 10,000 square feet of space for medical record storage. This area can now be used for exam rooms, which allows more patients to be seen. Another benefit of the EHR is that providers are much more productive. One employee states that anywhere from one to two hours per day is saved in looking for missing charts as patient information is always available. Another provider states that he can see an additional one to two more patients each day and is still able to leave the office by 5 p.m. Additionally, if a physician needs to access patient information outside of the office, this can be accomplished by connecting to the system through a Virtual Private 14

15 Network (VPN) via the Internet. In order to maintain HIPPA compliance, SENT provides the equipment only to the providers so they can access the system from their own homes. One physician, Dr. Gary Cantlon, has completely given up his private office at the practice due to the efficiencies of the EHR. Because each exam room is equipped with a workstation, the providers can document the patient encounter right at the point of care. As this is accomplished, charges are captured and fee tickets are generated through the documentation at the point of care. According to the providers, the quality of documentation and charge capture is much better this way than waiting to the end of the day, as critical information can easily be missed or forgotten. Documentation and charge capture are accomplished in the exact same way in the surgery center. Concluding Summary The financial savings and the quality of life in the work place that have been fostered at SENT is a direct result of implementation of an EHR. Physicians, audiologists, and nurses are able to provide higher quality patient care and be more productive during the work day [10]. SENT provides an example to other practices of how to be effective at implementation and use of an electronic health record and is well prepared to face the challenges that lie ahead as national standards for information interoperability are mandated [11]. 15

16 LESSONS LEARNED Based upon the experiences of the three practices documented in this report, the lessons learned by these practices are valuable to other practices implementing EHR technology. First, make sure the physicians in your practice are on board with the adoption and obtain a commitment from each one that they will embrace the technology in their daily operations. This will aid in making the transition more smooth and prevent a great deal of chaos. Second, ensure the product that has been chosen enables providers to customize templates to their own liking. When providers have choices, the likelihood that they will embrace and use the features of the EHR is much higher. SENT learned this lesson during the adoption and implementation of its EHR. Third, make certain you are investing in a system that is compatible with other systems, or has the ability to interface with other systems. Each of the practices documented has the ability to exchange information with various entities. The INHS system Meditech is especially important in this region. The current presidential administration has placed a high priority on the interoperability of health care information systems and standards for information sharing will be mandated shortly. Next, obtain a commitment from the vendor that training on the system is a part of the package. Proper training is essential for each user of the system. Finally, choose a company that has a solid business structure and appears to be a company that will be around for years. Volatility in the technology sector is high. Mergers and acquisitions are occurring each day. Take the time to attend a convention and try out different products before making the purchase. Invite vendors to your 16

17 practice and view demonstrations of how the product operates. You want to make sure you have the right product. This is an expensive investment, yet the benefits can be substantial if the right product is purchased. Taking the time to educate the providers, researching different systems and choosing one that is compatible with the operations of your practice will save much time and frustration as the implementation is accomplished. CONCLUSION Physicians Clinic, Spokane Internal Medicine, and Spokane Ear, Nose, and Throat each provide a fine example of how to implement and operate with an EHR. The cost of implementing this technology is a major investment for a clinic, yet the potential for benefits, both economic and non-economic is great. Having as many patients medical records stored in an EHR in the next 10 years is the goal of President Bush. Adopting an EHR is one of the first steps in the process of achieving that goal. This report shares the experience of how three clinics have been champions in this area and provides lessons to others embarking on the same venture. 17

18 Physicians Clinic of Spokane At Physicians Clinic, the EHR is used in every aspect of the practice. Here, at the front desk, patients are checked in for appointments, co-payments are collected and return appointments are scheduled. Each exam room is equipped with a computer workstation where the patient s medical record is retrieved. From this station, the provider is able to review past notes and laboratory and radiology reports in the patient s record. He can also document the encounter as well as order prescriptions, laboratory tests and radiology tests. The nurses station pictured here is one of several stations located throughout Physicians Clinic. The station provides another terminal where a provider has easy access to a patient s record. 18

19 Spokane Internal Medicine The exam rooms at Spokane Internal Medicine are all equipped with computer workstations. From here, the provider and nurse work together to provide high quality care to their patients. The workstations give the provider access to a plethora of databases where current literature can be searched and printed for the patient. The Network/Server room is large enough to house the equipment necessary for the system, yet much smaller than the traditional chart rooms of the past. Spokane Internal Medicine has been able to increase the amount of space used for exam rooms and minimize its non-revenue producing space. To further emphasize the goal of having the physician and nurse work together, each team shares an office. With this setup, collaboration is encouraged, which adds to the quality of care patients of Spokane Internal Medicine receive. 19

20 Spokane Ear, Nose, and Throat At Spokane ENT, physicians also use the EHR in the exam room with the patient. This way, the patient s record is always right at the physician s fingertips. The days of spending hours looking for lost records are gone. The EHR has made it possible for many physicians to do away with personal offices entirely. At Spokane ENT, each physician has a cubicle adjacent to the exam rooms. Here the physician can dictate or type the encounter, order prescriptions, laboratory and radiology screenings and search through past notes. Charges are captured as the physician documents the encounter. Providers have access to the system in the surgery center as well. Shown here is an operating room, and upon completion of a procedure, the provider can immediately generate the operative report and have it filed in the record. Charges for procedures are also captured when these reports are generated. 20

21 REFERENCES 1. Goldsmith, J., Digital Medicine. 1 ed. 2003: Health Administration Press Brailer, D., Testimony Before the Subcommittee on Health of the House Committee on Ways and Means. 2004: Washington DC. 3. Baron, R., et al., Electronic Health Records: Just Around The Corner? Or Over The Cliff? Annals of Internal Medicine, (3): p Nilsson, K., A Longitudinal Cost Analysis of Implementation of an Electronic Health Record in a Medical Group, in Department of Health Policy and Administration. 2005, Washington State University: Spokane. p Schmidt, W., Letter to Prospective Students. 2005, Washington State University: Spokane. p. Letter to Prospective Students of the Health Policy and Administration Program describing the Health Care Industry in Spokane. 6. Inland Northwest Health Services (INHS), About INHS. 2005: Spokane. History and Services Provided by Inland Northwest Health Services. 7. Miller, R. and Sim, I. Physicians' Use of Electronic Medical Records: Barriers and Solutions. Health Affairs, (2): p Barlow, S., Johnson, J., and Steck, J. The Economic Effect of Implementing an EMR in an Outpatient Clinical Setting. Journal of Healthcare Information Management, (1): p Sangster, W. and Hodge, R. Electronic Documentation vs. Dictation: How do they compare?, in The Physician Executive p IOM, Crossing the Quality Chasm, ed. IOM Brailer, D.J., Interoperability: The Key To The Future Health Care System. Health Aff (Millwood),

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