Transitioning to Electronic Medical Records in Student Health Services

STUDENT AFFAIRS LEADERSHIP COUNCIL Transitioning to Electronic Medical Records in Student Health Services Custom Research Brief June 13, 2011 RESEARCH ASSOCIATE David Bevevino RESEARCH MANAGER Sarah Moore I. Research Methodology II. III. IV. TABLE OF CONTENTS Executive Overview Benefits and Challenges of Employing Electronic Medical Records (EMR) Features of EMR Systems V. Transitioning to EMR THE ADVISORY BOARD COMPANY WASHINGTON, D.C. 2011 The Advisory Board Company

I. RESEARCH METHODOLOGY A member institution approached the Student Affairs Leadership Council with the following questions: How did other institutions decide to transition to electronic medical records (EMR), or to maintain paper-based student health records? How do other institutions convert their paper records to electronic records? How do institutions fund the initial costs of transitioning from paper to EMR? Which staff members are involved in the transition to EMR? What training do these staff members require before they can fully utilize the EMR system? What systems do other institutions use to manage student health records electronically? How were these systems selected? Is the system web-based, cloud-based, housed on a local server, or hosted in another manner? How do institutions provide technical support to EMR systems? Do health services and counseling services host student records on the same electronic records system? If not, what services or information are shared between the two entities? What are the potential benefits and challenges of using electronic medical records in student health services? Sources: Education Advisory Board internal research library www.educationadvisoryboard.com Electronic Medical Record Vendor websites: o Amazing Charts http://amazingcharts.com/ o eclinicalworks http://www.eclinicalworks.com/ o MediCat http://www.medicat.com/ o Point and Click http://www.pointnclick.com/ Institution websites: National Center for Education Statistics www.nces.ed.gov Titanium Schedule Counseling Software http://www.titaniumschedule.com/main/ 2011 The Advisory Board Company 2

I. RESEARCH METHODOLOGY Guide to the Institutions Profiled in this Brief Institution Region Type University A College B University C College D University E West Mid-Atlantic West Southeast Southeast Public (not-forprofit) Private (notfor-profit) Public (not-forprofit) Private (notfor-profit) Public (not-forprofit) Source: National Center for Education Statistics (www.nces.ed.gov) Carnegie Classification Master's Colleges and Universities (larger programs) Baccalaureate Colleges--Diverse Fields Research Universities (very high research activity) Baccalaureate Colleges--Arts & Sciences Research Universities (very high research activity) Approximate Enrollment 35,600 2,800 22,000 1,200 28,900 2011 The Advisory Board Company

I. RESEARCH METHODOLOGY Institution University A College B University C College D University E Guide to the EMR Vendors Purchased by Contact Institutions EMR System Reported Cost (if available) Server Host (Institution or Vendor) Point and Click N/A Institution Amazing Charts eclinicalworks MediCat eclinicalworks $1,500 Implementation Fee Product website indicates that the EMR and practice management package has two pricing options: 1) $10,000 for the first provider and $5,000 for each additional fulltime provider 2) $400 per month per provider $25,000 setup fee for health services $5,000 fee to add counseling services $3,800 annual support fee See cost information for University C Sources: Research Interviews and EMR Vendor Websites Institution Institution Institution Institution Additional Details In March 2011, University A transitioned from Clinics MD to Point and Click, an EMR system designed for colleges and universities, in order to reduce costs and for the ability to collect data for benchmarking. Contacts report that Amazing Charts allows the student health service to include specialists in the scheduling function without requiring the formal inclusion of additional providers within the system and thus saving costs. Contacts stress the importance of eclinicalworks ability to interface with Banner, the student information system used at University C, in selecting this product. College D health service and counseling service share MediCat, though contacts report that Medicat has difficulty serving the counseling service. Contacts report that the eclinicalworks record keeping system and practice management feature were two attractive offerings that led University E to select eclinicalworks 2011 The Advisory Board Company 2

II. EXECUTIVE OVERVIEW Key Observations: Contacts stress that the desire for a secure messaging feature with which student health staff can communicate confidential information to students served as a major factor in choosing to transition to EMR. The growing use of electronic communication methods such as e-mail and social networking inspired some contacts to consider transitioning to EMR. According to contacts, the process of adopting EMR requires the collaboration of various campus units such as enrollment or admissions, information technology services, and student health services administrative and medical staff. For example, contacts recommend the inclusion of technology services staff in the evaluation of EMR vendor proposals in order to ensure the EMR system s compatibility with the student information system used by the institution. Though no contact institutions share an EMR system with a local hospital or health provider, the ability to send health information to outside providers such as emergency personnel, pharmacies, and hospitals has reportedly improved patient care. During the admission of a student to a hospital, the transmission of information from the health service to the hospital in a professionally-formatted electronic record helps hospital staff provide timely and appropriate care. Among all contacts, only those at College D report that counseling and health services share the same EMR system. Differences in note-taking and practice management needs and preferences for confidentiality among both counseling and medical staff prevent sharing of electronic systems at other contact institutions. It remains unclear whether or not institutions realize cost savings from the transition to EMR; some contacts observe that health services staff costs shift from maintaining paper records to IT support staff and fees for EMR systems. The cost of EMR systems among contact institutions varies significantly as does the number of staff needed to support the EMR system. Contacts note that health services can realize some savings by reducing the staff needed to physically retrieve paper records. Appropriate hardware, such as high-quality laptop or tablet computers, can play a critical role in allowing health staff to realize the benefits of EMR while seeing a patient. Though staff at each contact institution employ different devices, contacts recommend purchasing devices that are affordable, compatible with an institution s wireless internet, and easy for a provider to use during an appointment. Training administrative and medical staff to use the EMR effectively typically involves practicing with the EMR in a variety of scenarios and requires support from both dedicated student health staff, IT staff, and vendor personnel. Contacts at some institutions report that they met frequently with EMR vendor staff to craft training and orientation programs and to resolve problems regarding compatibility with the institution s student information system. Contact institutions either selected a small population of student records or selected a limited amount of information from current student records to manually transfer from paper to EMR. Some contacts manually scanned all first-year students paper records into the EMR system and then scanned in other students records if those students made appointments with the health service. Another strategy among contact institutions involved selecting a limited amount of important health information to manually enter into the EMR system. 2011 The Advisory Board Company 3

III. BENEFITS AND CHALLENGES OF EMPLOYING EMR Overview of Reported Benefits of EMR Secure communication with students Contacts report that their EMR systems provide a secure messaging system through which medical providers can provide health information and lab results to students. Contacts at University A also cite Point and Click s automatic appointment reminder feature and secure lab result messaging as two useful features. Uniformity of billing and diagnosis coding EMR systems assist providers and health services staff by suggesting codes for diagnoses and billing within the system. Contacts report that these suggestions and the uniformity of codes has reduced errors in diagnoses and billing for insurance purposes. Simultaneous access by multiple staff and providers Paper records can only be viewed and manipulated by one individual at a time. Contacts report that EMR allows multiple staff members to view the same record simultaneously if necessary. Ease of communication with emergency personnel Though no contacts report using the same EMR system as a local hospital or medical practice, most contacts report that EMR facilitates communication with outside providers, especially in emergency situations when information must be transmitted quickly. Electronic prescription submission Providers can send prescriptions electronically to on-campus or local pharmacies with which the student health service has a relationship. This reduces the amount of time staff must spend processing paper prescriptions and improves service to patients. For example, College B student health service maintains an agreement with a local pharmacy that delivers to students, and the ability to send prescriptions electronically improves the efficiency of this process. Ease of appointment scheduling for staff and students Contacts report that electronic medical record systems typically include a scheduling feature that improves efficiency of communication with students and nursing or medical staff. For example, administrative and scheduling staff at University C can immediately provide a link to a student s health record to the attending nurse or physician. This requires no physical transport of materials, as paper records require. Reduction of necessary physical space and staff to store records As more students pass through an institution, student health services must securely store paper records within their facilities. EMR reduces the physical space needed to house medical records. Contacts at University E indicate that they reduced staff costs by eliminating positions dedicated to maintaining and recovering paper records. Reduction of paper usage and reduced impact on the environment The vast amount of paper required by a paper medical records system creates waste and consumes both natural and economic resources. The positive environmental impact of transitioning to EMR can contribute to sustainability efforts. 2011 The Advisory Board Company 4

III. BENEFITS AND CHALLENGES OF EMPLOYING EMR Overview of Reported Challenges Associated with EMR Long and potentially difficult research and implementation period Contacts at University A and College D describe the implementation of EMR as a long process that involves feedback and participation from many stakeholders. The identification of a suitable vendor and the education of student health and IT staff takes considerable time and attention away from other important duties such as patient care. High implementation costs Some contacts report that the high initial financial costs and staff time required to transition to EMR makes a transition a difficult choice, especially in a challenging financial environment. Difficulty providing adequate IT support during and after the transition Contacts at College B report that the lack of IT staff within student health services forced the health services staff to be dependent on the college IT unit s timeline when implementing EMR. Student health services staff now control the updating and security of the Amazing Charts EMR system. Acquisition of appropriate EMR hardware Effective use of EMR systems requires appropriate and user-friendly hardware such as laptops or tablet-style devices, according to contacts at College B and University E. Failure to select the appropriate hardware for providers can prevent full utilization of the EMR system due to lack of wireless capability, difficulty of maneuvering the device in the appointment room, and the lack of adequate processing speed. Potentially less-intuitive system According to some contacts, medical staff may not always find the EMR system s format and templates to be organized in the same manner as the provider would organize a paper medical record. To combat this challenge, contacts recommend extensive training and incorporation of medical staff feedback prior to the selection of an EMR system. 2011 The Advisory Board Company 5

IV. FEATURES OF EMR SYSTEMS Secure Messaging with Students Contacts at University C, University A, and University E express their desire to communicate with students more effectively as students increase their use of electronic communication methods such as e- mail and social networking. The EMR systems at these institutions allow health staff and administrative staff to send confidential information such as lab test results, x-ray results, and information about diagnoses in a secure manner. EMR systems can also send reminders to students about upcoming appointments or other interactions with the student health service. Coding for Billing and Insurance Purposes Though contact institutions bill students and insurance providers in a variety of ways, all contacts observe improvements in their coding and billing practices with EMR. For example, contacts at College D report that the institution s student health service has received fewer returned insurance claims due to errors in coding. Contacts at University C and University A observe improved input of diagnosis codes by providers. Some EMR systems, such as Point and Click used at University A, recommend a diagnosis code to a physician or nurse as they enter information into the EMR. Tracking Immunization Records Few contacts describe formal electronic processes for incorporating student immunization records into an EMR system, as most contact institutions receive immunization records from enrollment or admissions offices. College B student health staff, using Amazing Charts, currently scan immunization record sheets into the system. Students at College B also complete an electronic health form prior to enrollment that imports into the EMR. Contacts at University C connect the ability to securely communicate with students with the ability to track immunization records by sending notifications to students if they are not compliant with the institution s immunizations requirements. The student health service receives information about a student s immunization record from Banner, the student information system at University C. Communication with External Health Care Providers No contacts indicate that their institution s student health service shares an EMR system with a local hospital or medical center. However, the EMR system at University E provides the university hospital with a student s record in a professional format that assists hospital staff as they care for the patient during a referral or admission. University A student health staff do not electronically send records to local providers, but EMR allows student health staff to generate referral forms for ambulance personnel in emergency situations. Several contacts cite improved communication with pharmacies since the introduction of EMR. At University E, student health staff and psychiatrists can use the EMR system to send prescriptions to the on-campus pharmacy. This electronic submission reduces paper recordkeeping and reportedly improves service to students. College B student health staff can submit prescriptions to a local pharmacy with which the student health service has an agreement; contacts report that the pharmacy delivers prescriptions to students at no cost, and the electronic submission of prescriptions decreases the time between prescription submission and delivery of the medication to the student. 2011 The Advisory Board Company 6

IV. FEATURES OF EMR SYSTEMS Sharing Electronic Systems between Medical and Counseling Services Most medical and counseling services at contact institutions do not share an electronic records or notetaking system. Contacts at College B, University A, and University C explain that counseling services purchased a software called Titanium for their own recordkeeping. Different requirements for record formats and a desire to keep psychological therapist notes private prevent sharing of systems, according to contacts. Despite using different records systems, contacts at University E and University A note that the two staffs share prescription information so that psychiatrists and medical staff have the necessary information prior to prescribing additional medication. Psychiatrists, though employed by the counseling service, can use the EMR to submit prescriptions to the on-campus pharmacy at University E. In especially sensitive cases, counseling and student health services can generate a report to send to other staff. Contacts at College B stress the ease with which reports can be generated and information can be shared as a benefit, even if counseling and medical services do not share the same system. Records from one office or the other can be copied and pasted into documents and then sent to the necessary staff member. Sharing a Health Records System at College D Contacts report that sharing the system has been more difficult for counseling than for medical services because MediCat staff did not have extensive experience with counseling records prior to its work with College D. The counseling feature in MediCat is, however, separate from the medical records system; the current access settings within MediCat do not allow medical and counseling providers to see each other s records for individual students the system requires all records to be shared between the two or no records to be shared. One of the primary benefits of the electronic records system for College D arises from communication with other providers. Contacts report that maintaining both counseling records and health records in the same electronic system facilitates communication with a local hospital during the admission of a student for psychological reasons. The attending physician or mental health professional is better prepared to fully understand a student s situation and determine if the student s self-reported health information is consistent. 2011 The Advisory Board Company 7

V. TRANSITIONING TO ELECTRONIC MEDICAL RECORDS Involving Campus Stakeholders in the Research and Implementation Process University A charged a task force, led by a member of the medical staff, to research EMR vendors and collect feedback from campus stakeholders. Though not all contact institutions charged a formal committee to implement EMR, each contact reports that the transition to EMR required outreach to and the participation of staff in a variety of campus units, especially student health service staff, enrollment management, and information technology services (IT). 1 2 3 Student Health Service Medical and Administrative Staff IT Student Health Staff Enrollment Contacts report that incorporating medical and administrative staff in the EMR implementation process creates a more positive working environment and prevents unnecessary frustration among those who work most closely with the EMR system. Contacts at University E and University C report that their medical staff productivity dropped immediately following the implementation of EMR due to lack of familiarity with the system prior to the launch date. In order to reduce the impact of this loss of productivity, contacts at University A recommend launching an EMR system at a student health service s least busy time of year so that staff may increase their familiarity and confidence with the EMR system. Enrollment Management or Admissions Department Student health services and enrollment or admissions departments collaborate frequently throughout the academic year, especially as students submit their legally-required medical information prior to enrollment. Without the participation and cooperation of the enrollment management unit, student health services may experience difficulty incorporating student health information into the EMR system, as contacts at University A and College B report. Contacts at College B indicate that they have begun discussions with their admissions office to determine the most effective method by which student health services can incorporate immunization records and self-reported student health information from applications and admissions forms. According to contacts, the incorporation of immunization records into the EMR system at College D has helped providers more completely understand a student s health history during appointments. IT Services Regardless of an institution s size, the IT support that an EMR system requires can present a challenge to student health administrators and to the IT services unit. Inclusion of IT staff early in the research and implementation process assists student health services and IT understand the timeline for EMR implementation and the technical support required by student health staff. Student health services at larger contact institutions, such as University A, University C, and University E, typically employ dedicated IT staff. Smaller institutions such as College D typically rely on the campuswide IT services unit to provide security, maintenance, and software updates for their EMR system. Contacts at College B note the helpfulness of a nurse practitioner who has volunteered to serve as the student health service s technical support expert; according to contacts, this individual assists with training, troubleshooting, and software updates. 2011 The Advisory Board Company 8

IV. TRANSITIONING TO ELECTRONIC MEDICAL RECORDS College D IT Services Assists with Evaluation of EMR Vendors Contacts at College D suggest incorporating IT services personnel into the EMR implementation process as early as possible. During their transition to EMR in 2010, College D IT services assisted student health services by determining which EMR software would be most suitable for the institution s student information system. The IT services staff had the expertise to identify potential problems even if the EMR vendor claimed that the EMR and the student information system would be compatible. By selecting a compatible EMR system (MediCat), College D staff have had fewer technical difficulties sharing information stored on the student information system, including immunization records and student health information submitted prior to enrollment. Strategies for Training Student Health Services Staff to Use an EMR System Provide Joint Training by Institution Staff and EMR Vendor Personnel Most contact institutions collaborate with the EMR vendor staff to provide training to student health services medical and administrative staff. For example, training staff from eclinicalworks remained on campus for the entire first week of EMR use at University C. At College B, a nurse practitioner volunteered to collaborate with Amazing Charts to create an online training demonstration led by both the nurse and Amazing Charts staff. Encourage Staff to Practice Using the EMR System University A student health administrators did not conduct as much joint training as other institutions profiled in this brief. Instead, contacts at University A met with Point and Click staff weekly to generate ideas for trainings and scenarios during which student health staff could practice using the system. These scenarios included routine appointments, scheduling an appointment, ordering lab work, discharging a patient, and referring a patient to an outside provider, among others. Create Templates for Routine and Emergency Situations Contacts at University E created templates for medical and nursing staff to prepare for patients who had symptoms of H1N1 during the 2009-2010 academic year. The implementation of these templates improved providers ability to recognize the illness and provide appropriate care in a timely fashion. 2011 The Advisory Board Company 9

IV. TRANSITIONING TO ELECTRONIC MEDICAL RECORDS Transferring Information in Paper Records to Electronic Medical Records One of the major challenges that arises when an institution decides to begin using EMR involves the transfer of existing health records from paper to electronic systems. However, the transfer of this information provides a benefit often cited by contacts: the reduction of physical space dedicated to storing paper records. Due to the difficulty of maintaining two systems simultaneously and to the desire to make a fast transition to EMR, all contacts report that they ceased recording student health information in paper health records entirely upon full implementation of the EMR system. The table below presents two strategies that contacts suggest from their experiences. Two Approaches to the Transfer of Student Health Information from Paper to Electronic Formats prior to the Implementation of EMR Transfer a Limited Number of Complete Student Records Contacts at University C explain that student health services scanned all paper records from the past year into the EMR system, eclinicalworks. If a student came in who had not visited student health services within the past year, the student health staff scanned that student s record into eclinicalworks at that time. College B approached the transfer of information in a multistage process that first involved transferring all first-year student records from paper to EMR over a three-month period. Contacts report that they plan to hire a part-time staff assistant to transition all other currentlyenrolled student records in the near future. Transfer a Limited Amount of Information from Currently-Enrolled Students Records Contacts at University E report that they spent significant time determining which information to manually incorporate into the EMR system eclinicalworks. The student health staff entered information such as diabetes information, pap smear results, asthma records, and more in the form of a scanned document. This strategy required providers to simultaneously look at a patient s paper record and electronic record during an appointment. University E continued this practice until most students had complete records within the EMR system. 2011 The Advisory Board Company 10

PROFESSIONAL SERVICES NOTE The Advisory Board has worked to ensure the accuracy of the information it provides to its members. This project relies on data obtained from many sources, however, and The Advisory Board cannot guarantee the accuracy of the information or its analysis in all cases. Further, The Advisory Board is not engaged in rendering clinical, legal, accounting, or other professional services. Its projects should not be construed as professional advice on any particular set of facts or circumstances. Members are advised to consult with their staff and senior management, or other appropriate professionals, prior to implementing any changes based on this project. Neither The Advisory Board Company nor its programs are responsible for any claims or losses that may arise from any errors or omissions in their projects, whether caused by the Advisory Board Company or its sources. 2011 The Advisory Board Company, 2445 M Street, N.W., Washington, DC 20037. Any reproduction or retransmission, in whole or in part, is a violation of federal law and is strictly prohibited without the consent of the Advisory Board Company. This prohibition extends to sharing this publication with clients and/or affiliate companies. All rights reserved. 2011 The Advisory Board Company 11