Strategies for adopting electronic health records in community health centers

Transcription

1 Ohio Association of Community Health Centers Strategies for adopting electronic health records in community health centers September 2006 Using electronic health records benefits and barriers How do I know if my center is ready to adopt an EHR? How can I use an EHR to achieve my vision, mission and goals? How do I select an EHR product? What should I expect from the vendor? What does it cost to implement an EHR? Community health centers generally view electronic health records (EHR) as essential to supporting their commitment to provide high-quality health care. EHR systems link and potentially integrate clinical, administrative and financial information to improve health care delivery, enhance the opportunity for improved health outcomes, and address costs and effectiveness through administrative efficiencies. EHR systems create an opportunity for community health centers to improve quality, cut costs, and maximize service delivery efficiencies. While such technology exists, it remains far from universally deployed throughout the health care system. In particular, community health centers report major barriers to adoption, including cost and doubts about achieving a return on investment, the inability to integrate the EHR with claims submission or billing systems, concerns about decreased productivity during implementation, and legal concerns. As a result, community health center EHR adoption rates are low and significantly lower compared to other providers with only 8% reporting the use of a full EHR. Despite the significant barriers associated with adopting health information technology, 60% of community health center directors nationally report plans for installing a new EHR system or replacing the current system within the next three years. Some of these centers will be ready to adopt an EHR and some will not. Fortunately, over the past few years, a number of community health centers have learned how to mitigate the risk of EHR implementation and derive a meaningful return on investment. This report includes some of the lessons they ve learned. Inside: What is an EHR? Step One: Preparation Step Two: Selection Step Three: Implementation Step Four: Utilization Electronic health record (EHR) is a patient s medical record in an electronic format, accessible by computers on a network for the primary purpose of providing health care and health-related services. In addition to direct patient care, an EHR enables data collection for quality improvement, outcome reporting, and resource management. According to the Institutes of Medicine, an EHR should include: Health information and data Results management Order/entry management Electronic communication and connectivity Clinical decision support Patient support Administrative processes Reporting and population health management

2 Page 2 Strategies for adopting electronic health records in community health centers Networks increase benefits and spread costs going it alone is risky Seek partners to implement an EHR across a network of centers this is the strongest and most consistent advice about adopting an EHR from national experts and leaders in community health centers that have already invested in EHR technology. However, partnerships do not always come naturally for community health centers. We know from experience We can do anything alone and that is a strength, says Dr. Fred Rachman, CEO of the Alliance of Chicago Community Health Services. But with EHR, learning together is strength. The benefits of creating an EHR network or joining an existing network are related to economies of scale. EHR systems are complex and costly. While a single-center installation may have some benefits like total control the risks are greater, the costs are greater, and the likelihood of a return on investment is further away. Networks have many benefits related to scale overhead costs are spread across centers, increased purchasing power leverages better product prices and customer service from EHR vendors, complicated tasks can be divided among centers, greater efficiency allows more of the EHR budget to be spent on functionality, changes in the system can be piloted and then quickly taken to scale and, true to the spirit of community health centers, a network creates a framework for sharing expertise and staff for the benefit of the community. Electronic health records are complex and costly expect the unexpected A poorly-conceived EHR plan can have catastrophic consequences for community health center operations, finances, and patient care. One of the most important and variable factors is cost. Community health center leaders with EHR experience consistently report that they underestimated the cost to start-up and use an EHR, and that product cost is small compared to the total financial and human resource commitment that s required. There are obvious costs to include in an EHR budget hardware, software, communication costs, installation fees, and data migration fees. These costs are the easy part, according to Dr. Neil Calman, CEO of the Institute for Urban Family Health in New York City. The hard part, he says, is estimating additional hard-to-predict costs that can easily double an EHR budget. These costs, which will vary significantly based on the centers involved and the scope of their EHR implementation, include: Only pursue an EHR from a position of strength. An EHR won t save a struggling center and could put it under Loss of productivity during start-up, Need to employ specialized information technology staff, Training costs, Retraining costs, Need for ongoing consultants, Decrease in flexibility to use temporary help in all roles, Need for staffing new roles, and Estimating the useful life of the system. Unexpected costs can potentially throw center operations into turmoil and jeopardize the EHR implementation. Any center or network of centers that decides to implement an EHR needs to plan for the costs listed above, secure a stable source of funding and, ideally, set aside a healthy cash reserve to cover additional, unexpected costs. According to the leaders of best-practice sites interviewed for this report, the best strategy to mitigate risk is to join or form a network to achieve economies of scale and spread costs across participating centers.

3 Strategies for adopting electronic health records in community health centers Page 3 Step One: Preparation Key Questions: How do I know if my center is ready to adopt an electronic health record? Who should I involve within my center? What external partners need to be involved? How long does the preparation phase take and what does it cost? What are the most important goals? What outcomes should we try to achieve? Can our existing staff handle an EHR implementation or do we need help? How does an EHR interact with practice management and existing clinical processes? How do I know when my center is ready to select a vendor? The Issues Up-front planning is the key to determining whether or not your center is ready to implement an EHR. Investing as much as possible in this critical first step will increase benefits and decrease risks in later phases. The first important question to ask is, Why do we need an EHR? The answer will drive all subsequent decisions. You need to discuss it thoroughly and provide an answer that motivates your staff to persevere through the many challenges they will encounter during EHR implementation. Improving patient care is the best objective to build support for an EHR, say the EHR pioneers who were interviewed for this report. Other priorities can be accommodated such as revenue maximization but better patient outcomes needs to be the ultimate goal to drive decisions about infrastructure, product selection, customization, staff training, and roll-out. If you decide your center needs an EHR, then the question becomes, Are we ready? The answer here requires total organizational commitment and understanding that EHR is not just a technology project it will result in fundamental change throughout the organization. You need to assess your readiness and capabilities organization-wide to identify strengths and weaknesses. The EHR Readiness Assessment and Starter Assessment listed as a resource at the end of this section is a great place to begin. Readiness requires leadership. EHR project leaders must articulate a clear vision that engages staff participation and EHR champions throughout the organization. Clinical involvement and support is especially important. So is a combination of leaders and operations staff who represent both... Many of the recommendations in this report result from interviews with the following community health center leaders and EHR pioneers: Neil Calman, MD Institute for Urban Family Health New York, New York Diane Gaddis Community Health Center Alliance Tampa, Florida Kevin Kearns Health Choice Network Miami, Florida Joe Liszak Community Health Services Fremont, Ohio Fred Rachman, MD Alliance of Chicago Community Health Services Chicago, Illinois Doug Smith Community Partners HealthNet Snow Hill, North Carolina Greg Wolverton White Rive Health Systems Batesville, Arkansas

4 Page 4 Strategies for adopting electronic health records in community health centers Preparation (continued) strategic and tactical viewpoints. Every champion and stakeholder needs to understand EHR capabilities and limitations in order to set realistic expectations and contribute to the process of setting meaningful goals. On a tactical level, readiness involves documenting workflow and determining what can be streamlined or automated. You will need to identify and analyze all processes, including office management and administration, patient/visit-related tasks, and integration with other practices, labs, hospitals, etc. You will need to interview clinicians to determine how they do their job and the information tools they need to do it. And you will need to identify barriers to EHR adoption related to workflow, data entry, integration/interfacing, and personnel. At this point with a clear sense of purpose and self-assessment in hand you will be ready to formalize a strategic plan. Make sure it includes technology planning, business and financial planning, and a plan to manage organizational change. Decide if you need a consultant to augment existing expertise. Give special attention to estimating the total cost of the project and how you intend to pay for it, including a cash reserve for unexpected costs. Lack of money is the number-one barrier to starting an EHR project and a frequent cause of failure. Critical Milestones Conduct a rigorous readiness assessment Identify partners and champions Decide network vs. single-center installation Secure key stakeholder involvement Identify a timeline and budget for preparation Educate key stakeholders on EHR capabilities Establish vision, goals, and desired outcomes With an EHR, learning together is strength. Identify adequate and sustainable funding Formalize a plan Complete these steps before contacting a vendor Resources Healthcare Technology Resource Guide, California Community Clinics Initiative The Electronic Medical Records System Planning Requirements, Bureau of Primary Health Care ftp://ftp.hrsa.gov/bphc/pdf/chc/emrprojectplanningreqs.pdf EHR Readiness Assessment and EHR Starter Assessment, California Community Clinics Initiative

5 Strategies for adopting electronic health records in community health centers Page 5 Step Two: Selection Key Questions: How long does the selection phase take and what does it cost? Who needs to be involved in the selection process? What criteria should the evaluation team use to narrow the list of potential products and vendors? What are the best clinical and administrative scenarios to test EHR functionality? What is the best way to test drive a product before buying it? Who should negotiate the vendor contract? What needs to be included in the contract? Can existing staff handle product selection and contract negotiation or do we need help? The Issues The selection phase should start only after the preparation phase is complete. It is a mistake to think you can identify the best product or best vendor before you have a clear understanding of how the technology will be used, the implementation process, and the real cost to your organization. Taking these steps out of order increases the risk you will purchase a system that does not meet your needs or that you are unprepared to use. Don t just rely on price. Make the vendor prove they can do the job and put it in the contract. Do your homework and don t rely on vendors to identify required and desired functionality. A good starting point is the Bureau of Primary Health Care s Functional Requirements for EMR Systems and the Institutes of Medicine s Key Capabilities of an EHR System. In addition to minimum technical requirements, list the functions that are crucial to your center. Translate what you want into a detailed request for proposals and distribute the RFP to vendors (there is a checklist of EHR vendors and a model RFP available at: Develop a plan for product assessment and create a budget to support the process, which can take up to one year. Convene an evaluation team to narrow the list of potential products. Make sure the evaluation team researches the vendors as well as the products under consideration. Look at financial data, including stock performance is the company financially sound? Consider the size and longevity of the company, customer service reputation, and planning and training methods. Think twice before selecting an untested product or a small company that may or may not be around in a few years. And don t let your existing practice management system drive EHR decisions choose the best possible EHR product and integrate (or replace) the PM system. Involve key stakeholders to narrow the list of products to two or three. Ask interested vendors for a list of potential sites to visit, and make the contacts yourself to arrange visits without the vendor present. Visit at least two installations of the exact product you are considering and go during busy business hours to get a good sense of functionality. Develop test scenarios that fit the special circumstances of your center. And conduct intensive demonstration sessions with clinicians and staff to help provide input into vendor selection.

6 Page 6 Strategies for adopting electronic health records in community health centers Selection (continued) Remember that cost is not the only criterion in the selection process. A vendor that underbids everyone is not necessarily the one that can provide the best product and support. Other important considerations include the vendor s role in customization, training and ongoing technical support, product updates, and response times. The contract you sign with an EHR vendor will define your relationship. The project will go more smoothly and there will be fewer misunderstandings if it is well defined, the scope is clear, and the roles and responsibilities of the vendor are spelled out. It should address contingencies such as insolvency, acquisition, and product abandonment. It needs to hold the vendor accountable to the promises made by the sales staff during the selection process. For example, if you selected a JCAHO-compliant system, then that functionality needs to be included. Finally, you need a strong contract negotiation team. Determine whether or not your existing staff can match the vendor s skill in contract negotiation and, if not, get help. The contract is the document you will rely on later to ensure that your expectations about vendor performance are met it is worth the investment to get it right. Critical Milestones Develop a plan for product assessment Involve key stakeholders Identify required and desired functionality Develop test scenarios Specify criteria for evaluation Technology is just a tool to help an organization realize its vision and mission. Convene an evaluation team Set a timeline and budget for the evaluation process Define the decision-making process Narrow the list of potential products Visit sites that use the products under consideration Create a contract negotiation team Contract with a vendor Resources Federally-Sanctioned Ambulatory EHR Products, Certification Commission for Health Information Technology Functional Requirements for EMR Systems, Bureau of Primary Health Care Key Capabilities of an Electronic Health Record System, Institutes of Medicine

7 Strategies for adopting electronic health records in community health centers Page 7 Step Three: Implementation Key Questions: How do I identify and secure adequate resources? Will the EHR implementation disrupt day-to-day administrative and clinical activities? What do I need to plan for at the site level? Center level? Network level? What are the readiness issues at the site level? Center level? Network level? When and how do I assign staff and other resources? Do I need a disaster recovery plan? The Issues Six to nine months after signing a contract with a vendor, most of the sites that were studied for this report were implementing an EHR. Some phased Implementing an EHR it in over time and others were more immediate, like flipping a switch. forces you to rethink every There is no clear evidence that one approach is better than the other. aspect of center operations. Realistic timelines and adequate funding are critically important to achieving a successful implementation. Break the project down into sub-projects or phases, and break each of those down into tasks. Developing and communicating a good rollout plan will help ensure that each task is supported by adequate staff and the entire team understands the goals and deadlines. Obtain financial support early. Projects often receive a mix of financial support from community partners, governmental contracts and grants, foundations, and private contributions. Show these funders how your project objectives match their priorities. Also, think ahead to sustainability projects that rely on grants with a limited time horizon or one-time private donations often face difficulties once those funds are no longer available. Leadership during implementation is critical. The most successful projects are led by project managers and directors who have strong leadership qualities and core project management skills. The project leader needs to be prepared and capable to manage organizational change of the scope required by an EHR. Virtually everyone s jobs and roles will change. Change management needs to be a deliberate and thoughtful process. The sites studied for this report approached the transition in various ways. One site became fully operational all at once but turned on functions over time to let providers adjust. They led with the functions that were most likely to reinforce provider buy-in, such as lab results and medical alerts. Another site started with a fully functional EHR but introduced staff to the system in groups. Another site flipped the switch in 20 sites over a couple of months with 100% of staff using the system in each site after a few days. It s a good idea to time your transition to coincide with a lower demand season.

8 Page 8 Strategies for adopting electronic health records in community health centers Implementation (continued) Many of the EHR pioneers interviewed for this report emphasized the importance of training and most of them underestimated the time and resources required. They learned it is critical to train staff for at least one day prior to implementation and to provide coaching at least another two days or as long as needed. Many centers use a train the trainer model. In one example, an HIT team (comprised of a half-time physician, nurse, and clerk) conducted all training. The HIT provider trained providers, the nurse trained nurses, and the clerk trained clerks. Other training models include EHR users in one site helping staff in another site through the transition. Regardless of method, two to three weeks appears sufficient for most to gain competence using the EHR. There also are different ways to convert the paper chart into an EHR. Two sites pre-scanned the paper record and converted the most pertinent information from the chart. One site scanned everything first and hired data entry staff to input information from the paper record into the EHR. Another site warned against migrating old (and possibly erroneous) data from the paper record. They relied on providers and staff to verify and repopulate data from the chart, and then eliminated the chart after the provider determined it was no longer useful. The key to success in all of these cases was careful planning and forming realistic expectations to avoid surprises. Critical Milestones Identify and secure resources Develop a change management plan Develop site-level budgets Training...training...and more training. Conduct site-level readiness assessments Develop a detailed implementation workplan Site-specific details Network-level development Specify teams and resources Train, train, train Develop a business continuity/disaster recovery plan Implement Resources Implementation Tutorials, American Academy of Family Physicians An Opportunity to Improve Health Care in All Communities, California Community Clinics Initiative

9 Strategies for adopting electronic health records in community health centers Page 9 Step Four: Utilization Key Questions: What ongoing user and network support will the EHR require? How do I continuously improve interoperability with other systems and functionality for individual users? How can I improve patient care using the EHR? How can I maximize revenue using the EHR? How do I know if the system is functioning at its full potential? When can I expect a return on investment? When will I need to upgrade the system? The Issues Now you are ready to use your EHR. The critical issue at this stage of development is to establish ongoing processes to support system and user The only way to sustain an interface development, workflow redesign, report development and use, EHR is to share costs and data management and use, and evaluation and system performance. build expertise across a network of centers. System maintenance is a greater effort than most of the sites that were interviewed for this report anticipated. One network estimates that its members pay about 1.8% of their total budget to maintain the EHR. Another is certain that only by partnering can his center afford an EHR. We still have authority, he said, but the implementation and maintenance burdens are minimized. See page 2 for more about the benefits of networks versus single-site installations. Technology policies and procedures are a cornerstone of effective technology use. They translate the organization s values, resources, and priorities into a format that is clearly communicated and enforceable. Policies and procedures can begin with samples and templates (there is a good example at: but they must be customized and regularly updated to match changes in the clinic and technology environments. These policies and procedures also need to be used to ensure that basic responsibilities are clear and enforced, like securing personal health information for compliance with government rules. Providing support services to end users is critical to getting the most out of an EHR. An internal help desk can be used to document requests for technology support services, and track issues to their resolution and create valuable information that can be used to evaluate support resources and identify training opportunities. This is also the stage finally! when you should start to see a return on investment. Several of the experts interviewed for this report said that the financial benefits of an EHR like improved cash flow and the efficiency of going paperless were less meaningful than gains in patient care and safety. It is difficult to estimate...

10 Page 10 Strategies for adopting electronic health records in community health centers Utilization (continued) the value of eliminating a medical error for example, accurately reading a prescription that is otherwise illegible but there are evident gains, foremost for the patient, but also by eliminating liability for the center. Another significant outcome described by EHR pioneers is the ease of information retrieval, including the availability of standard, customized, and ad-hoc health center reports. One CIO said his system of centers used to run 36 separate databases. Now they have one EHR system that has the capability to run all reports. One site described its improvement in health care quality as a shift to a patient-centric model that facilitates patient self-management the patient can access lab results, communicate directly with their provider via , and even schedule their own appointments on the system. And the provider has built-in clinical decision support at the time of patient care, tools to initiate population-based interventions, and can establish baselines and monitor outcomes for quality improvement efforts. These are the returns that with careful preparation, product selection, and implementation can be realized by community health centers that embrace EHR technology. Critical Milestones Establish an ongoing help desk Establish ongoing processes to support... Determine when and how the system needs to be updated An EHR provides the right piece of information to right person at the right time. Contract management System interface development User interface development Workflow redesign Report development and use Data management and use Evaluation and system performance Resources Technology Management to Build Capacity and Create Sustainability, California Community Clinics Initiative Impact of Health Information Technology on Quality, Efficiency, and Costs, American College of Physicians

11 Strategies for adopting electronic health records in community health centers Page 11 Federal trends moral support but no money In 2004, President Bush outlined a plan to ensure that most Americans have electronic health records within the next ten years. Since then, the White House, Congress, and private sector have acted to accelerate the development of a national health information technology system. Much of the federal activity has focused on developing an interoperable health information technology infrastructure to improve health care quality and efficiency, and the ability of consumers to manage their care and safety. These activities are coordinated by the Office of the National Coordinator for Health Information Technology. Two recent federal developments are likely to impact trends in EHR adoption. First, in July 2006, a Certification Commission for Health Information Technology released a list of 18 federally-sanctioned EHR products. Second, in August 2006, President Bush issued an Executive Order requiring federal agencies to utilize, where available, health information systems and products that meet recognized interoperability standards. The President s Executive Order is silent on whether or not Federally Qualified Health Centers are required to purchase interoperable health information systems (some federal agencies, like the Indian Health Service, are specifically included and some, like Medicaid, are excluded). The importance of being included in the Executive Order is that federal funds may flow to agencies that are required to purchase health information systems and products that meet federally-sanctioned interoperability standards. Several of the community health center leaders interviewed for this report doubt that a national health information system can be fully realized without additional federal funding for community health centers to purchase and sustain interoperable EHR systems. Federal agencies shall utilize But don t hold your breath for federal money to materialize, said one. health information systems and products that meet recognized With or without additional federal funding, community health centers need interoperability standards. to anticipate and plan for the likelihood that evolving federal policy will impact when and how they adopt EHR technology. Will interoperable health information technology become a condition of participation in federal grants and payment programs? or a condition of health insurance participation? or a condition of licensure? All of these outcomes are possible. Stay Connected Greg Wolverton, CEO of White River Health Systems in Batesville, Arkansas, is writing a white paper for the Bureau of Primary Health Care on financing EHRs in community health centers (October 2006). The federal Certification Commission for Health Information Technology will announce additional ambulatory EMR certifications on a quarterly basis beginning October The Bureau for Primary Health Care is in the process of updating Functional requirements for EMR systems on its website ( The National Association of Community Health Centers is expected to release findings from a national survey of health information use in community health centers (Harvard, GW and Yale, October 2006).

12 4150 Indianola Avenue Columbus, Ohio More information about strategies for adopting electronic health records in community health centers is available on-line at: The Ohio Association of Community Health Centers is a notfor-profit trade association representing Ohio s 30 community health centers at over 100 sites in both urban and rural areas throughout the state. OACHC is dedicated to the promotion of high-quality, cost effective health care with a special focus on Ohioans living in medically underserved areas. Ohio s community health centers employ 180 doctors, 42 dentists, and 300 nurses more than 1,700 staff positions overall to provide high-quality medical services to nearly 300,000 Ohioans during 1,000,000 patient visits every year. About this paper This paper translates lessons learned by electronic health record pioneers into strategies for adopting electronic health records in community health centers. It includes words of encouragement, but also caution. It provides information to help community health centers evaluate EHR readiness and build capacity to select, implement, and operate an EHR. Ultimately, it recommends thoughtful planning as the surest way to build an EHR system that delivers efficiency in service delivery, financial gains, and better clinical outcomes. Health Management Associates (HMA) prepared this paper for the Ohio Association of Community Health Centers based on interviews with community health center leaders who are nationally known for their highly functional EHR systems. HMA is a national research and consulting firm that provides leadership and technical expertise to local, state, and federal government agencies, foundations, health system organizations and singlesite health care providers, as well as employers and other purchasers in the public and private sectors. HEALTH MANAGEMENT ASSOCIATES 37 West Broad Street, Suite 1150 Columbus, Ohio