Care Coordination Improved through Health Information Exchange

Coastal Women’s Healthcare offers gynecologic and obstetric care, mammography, bone density, and minimally invasive surgery to women in Scarborough, ME. The independent practice of eight physicians, two nurse practitioners, a midwife, and a support staff, saw 22,705 patients in 2011.

The providers attested to Stage 1 Meaningful Use (MU) for Medicare in 2011. At a May 2012 ceremony, Coastal Women’s Healthcare was recognized for this achievement and for being the first independent women’s health practice to be connected to Maine’s HIE, operated by HealthInfoNet. Representatives of the Centers for Medicare and Medicaid Services (CMS), Maine’s congressional delegation, and the Maine Medical Association, as well as other Maine health care leaders, attended the ceremony and made congratulatory remarks.

Quality Improvement Goal: To use the Health Information Exchange (HIE) connection to better coordinate patient care with other providers.

The practice formed a MU team in February of 2011 consisting of nurses, lab technicians, and secretaries to review and implement MU and HIE workflows, according to executive director Bev Neugebauer. “Since teamwork is embedded in our practice culture, we sent a team of experienced electronic health record (EHR) users—two physicians, a nurse, and an administrator—to the MU conference that our vendor, Greenway, sponsored in January 2011 to learn about EHR capabilities for MU and then share what they learned with the MU team.” Greenway also provided technical assistance to assist the practice in establishing workflows that would allow them to meet the MU objectives. The EHR dashboard feature allowed the practice to monitor and see their progress toward achieving the objectives on a daily basis. Achieving Meaningful Use and the HIE connection has improved Coastal’s ability to coordinate

“By measuring and reporting on care coordination measures, we have been able to improve our processes. The data gathered by the EHR dashboard also enable us to know, for example, which providers have updated their notes in the system and to share that information with other providers,”
- Bev Neugebauer

The practice demonstrated for attestation that their EHR system could exchange key clinical information by migrating a new patient diagnosis or problem such as dysfunctional bleeding, to a patient’s current problem list.

“We have since maintained patients’ current problem lists about 98 percent of the time compared to the average of 88 percent of the time,”
- Dr. Barbara Slager

As with all their measures, Coastal took a team approach.

1. First, the team learned how the system would record that a practitioner had updated the “face sheet” that provides a quick overview of the patient’s medical and surgical history, medications, medication allergies, and previous treating physicians.
2. Then, the team mapped a new process in which practitioners and nurses would perform additional recordkeeping steps to enhance the quality or meaningful use of their EHR system. Specifically, when a patient’s diagnosis is recorded in the visit record, the software has the ability to attach free text details to the data field.
3. Once appropriate details about the diagnosis or problem are recorded, such as quality, duration, timing, and complicating factors, the provider clicks a box marked “add to the problem list.”

This allows the details and the diagnosis to be maintained on the first page of the patient’s electronic chart. Having pertinent details of active patient problems without having to search through individual patient notes, improves patient care and illustrates how the EHR can be used meaningfully.

Medication reconciliation was performed by the practice for more than 50 percent of patients transitioned into their care. Prior to attempting to meet MU, a patient would be asked if they have any new medications and their answer would be recorded. With the focus on improving patient care and achieving MU, the practice refined this process. Now the nurses access the patient’s medication list using the e-prescribing software that connects them to the pharmacy database. The nurses review the medication lists with patients and record any changes in their medications, doses, or frequencies in the patient’s electronic record, which ensures that the information is complete and accurate. The EHR tracks the maintenance of the medication list and sends daily updates to a dashboard report.

The practice providers who transitioned or referred their patients to other care providers or care settings provided summaries of care more than 50 percent of the time. For example, the practice provides clinical summaries to primary care physicians who refer patients with abnormal pap smears, as well as to patients. A typical procedure is a colposcopy that involves a biopsy of the abnormal cells of the cervix. “When HealthInfoNet has the capacity to connect primary care physicians with specialists, the patient’s primary care physician will be able to access the patient’s EHR with the specialist’s care summary and recommendations,” said Dr. Slager. This allows for better care coordination and information flow.

At Coastal Women’s Healthcare, providers must first complete and sign their entries in the medical records before the care summary is available to patients on their secure portals. The care summary may include normal test results and problem lists. Patients can log into their accounts and see the updated information and print out their summaries, complete forms, make appointment requests, and ask billing questions. Patients without online portals can ask the practice to download the care summary onto a CD or a flash drive.

HealthInfoNet operates both the Maine Regional Extension Center (REC) and the HIE, which are funded by the Office of the National Coordinator for Health Information Technology. Below is a summary of the process undertaken by Coastal Women’s Healthcare to connect with the HIE with help from HealthInfoNet.

EHR implementation produced the following quality improvements and cost savings:

• Implementing an electronic Patient Portal connected to the EHR saved $5,000 per year in printing and postage to patients, and decreased patient wait time for appointments from about 2 weeks to 19 minutes (depending on clinical need)
• Replacing the Paper Charge Capture Form (superbill) saved $4,100 annually in printing and cut the insurance billing time from 19 days to 4 days
• Obtaining provider reports through HealthInfoNet reduced duplicate diagnostic testing such as ultrasounds. This saved an average of $100 per patient
• Using the EHR reminder module captured 334 missed appointments per year

Cost Savings from Staff Reductions:

• Reducing time spent on medical records management ($75,000 per year)
• Reducing time spent on billing ($140,000 per year)

Coastal Women’s Healthcare contacted HealthInfoNet in early 2011 for help with preparing for MU attestation.

HealthInfoNet sent the practice information about the CMS registration, attestation process, and meeting the MU measures. To help the practice meet the privacy and security measure, HealthInfoNet sent them a toolkit developed by the Privacy & Security Community of Practice (CoP) that is posted on the Health Information Technology Research Center (HITRC) web portal. The toolkit included sample templates for policies and procedures and a security risk assessment spreadsheet.

HealthInfoNet connected Coastal Women’s Healthcare to the state’s HIE in May 2012. This connection allows the practice to have access to patient medical records that have been pushed to the HIE by other providers, hospitals, and labs. Through a bidirectional interface, a provider will have access to the practice’s patient records.

The practice recently implemented a fully automated bidirectional laboratory interface with the HIE. This allows orders to flow from provider notes to their own lab or an outside lab. Results are returned directly to the ordering provider without any staff involvement. This increases safety and prepares the practice for MU Stage 2. This was a necessary first step toward implementing full bidirectional connectivity with the HIE.

HealthInfoNet sent an HIE implementation team to Coastal Women’s Healthcare comprised of communication specialists, a project coordinator, and information technology specialists to guide the practice through implementation.

“The first step was to create a communication plan to notify our patients of our purpose and intent to connect to the HIE,” said Ms. Neugebauer. Once Coastal’s board approved the communication plan, the HIE team trained practitioners and care teams on how to log in and obtain patient information. “Logging in and using the HIE was intuitive, simple, and required little training,” said Ms. Neugebauer.

The HIE implementation team held several training sessions onsite. “We conducted several "train-the-trainer" sessions with Dr. Slager and clinical support staff and then full sessions with their clinical and registration staff. The trainers attended our larger sessions as clinical champions to help us drive adoption,” said Amy Landry, communications manager of HealthInfoNet.

The training sessions provided an overview of HealthInfoNet, its history, how the HIE works, consent policies, and tips on talking with patients. The HIE team also provided a demonstration of the HIE and answered questions from the practice.

“We provided Coastal with a communications package that includes a communications plan, talking points and scripts, and sample letters to patients, community relations staff, and editors. The package also includes a press release, brochures, posters, and presentation templates. We set up a call to go over this with them and provide assistance in tailoring communications materials to their audiences,” said Landry.

The HIE team also trained all Coastal care team members on how to answer patient questions and concerns about information sharing with HIE. “In addition, they ensured that our Notice of Privacy Practices was updated with HIE information,” said Ms. Neugebauer. The practice notified 10,000 active patients by secure email on their patient portal or by standard mail. The patient calls following the communication “blast” were minimal and the HIE communication team was supportive and helpful to patients. “If our care teams could not answer questions about the HIE and connectivity, the HIE team was available by email and phone to talk to patients. Connectivity to the HIE was seamless and required little effort from our practice,” said Ms. Neugebauer.

“We have struggled with how to maintain our creativity and individual thought processes as we care for our patients amidst this new technology that requires us to follow standardized protocols and algorithms,” said Dr. Slager. “We were also concerned that the technology would interfere with our patient relationships.”

“We designed our exam rooms to allow the computer to feel secondary in the room – we use small laptops, never turn our backs on the patient to record, and try not to have the computer physically between us and the patient. We make many personal notations and use the patient’s photos to help us personalize the electronic medical record.” – Dr. Barbara Slager

“We learned that staff members have different levels of comfort with technology, different learning styles, and need to go at their own pace. People who needed more help were paired with ‘super-users.’ We changed our culture out of necessity and became more flexible and process driven,” said Dr. Slager

During the EHR integration process and preparation for MU attestation, the practice changed its management model from the traditional physician care manager to a collaborative care team. As a result, the front-line staff became less dependent on physicians to manage all aspects of clinical care and learned to solve problems creatively. This collaborative managerial style also made front-line staff feel valued for their ideas, according to Dr. Slager. The practice will continue to use this collaborative management approach as they prepare for MU Stage 2.

As Coastal Women’s Healthcare prepares to meet MU Stage 2, HealthInfoNet will continue to connect providers to the HIE, enabling the practice to have access to more patients’ records. The HIE database contains records on 80 percent of Maine’s population and has a 1 percent patient opt-out rate. As of July 2012, HealthInfoNet had connected 26 of Maine’s 39 hospitals and to about 200 physician practices to the HIE. HealthInfoNet expects to connect all Maine hospitals and the majority of the REC’s 1,000 primary care providers by 2014. Providers at Coastal Women's Healthcare currently access HealthInfoNet through a secure portal linked on their desktops and will soon be able to share their patient information with other providers through a bidirectional interface.