EHRs Improving Care Coordination with Local Referral Network

To use electronic health records (EHR) to improve care coordination with the local referral network.

Aquideck is a member of the Rhode Island Regional Extension Center (RI REC) and the Rhode Island Beacon Community Program, an ONC initiative to support Rhode Island's transition to the PCMH model for delivering health care, and to provide foundational capabilities in quality reporting. "Because they are a very advanced practice, they were dedicated to learning all the Meaningful Use measures. Our role was to serve as a resource. Jean would bring her tough questions to me, and we would research ONC FAQs and other sources to find the answers," said Andrea Levesque, one of the RI REC's relationship managers.

As early EHR adopters and pioneers using their EHR to improve patient care and care coordination, Gorelick and Sanders participated in educational events sponsored by the RI REC, including three Health IT Expos. At the May 2011 Expo, they participated in a panel discussion on how to purchase an EHR and work towards MU.

Aquidneck Medical Associates, Inc. is a primary care practice in Newport and Portsmouth, Rhode Island (RI) that sees approximately 4,500 patients a month. The practice currently has 12 primary care physicians and a surgeon, and 37 non-physician employees with clinical and/or administrative roles. Aquidneck was recognized as an NCQA Level 3 Patient-Centered Medical Home (PCMH) in 2010 and attested to Stage 1 Meaningful Use (MU) in 2011. Going through the process of achieving PCMH and MU status requires the practice to implement procedures to improve its transition of care, including tracking referrals and tests, utilization of outside resources, and overall care coordination of the patient. Seven providers including internist David Gorelick, MD, have attested to MU and received incentive payments from Medicare. Gorelick is Aquidneck's physician champion in charge of EHR implementation, customization, physician training, and the lead physician on clinical projects. Jean Sanders is Aquidneck's clinical project manager dedicated to implementing, upgrading, and improving health information technology (IT).

“We implemented the EHR system to create efficiencies in workflow. We developed a system that provides flexibility for providers, yet preserves structured data that is integral to clinical decision making and provides the ability to generate population level reports for clinical use and quality reporting,” said Gorelick.

In August 2005, Aquidneck purchased eClinicalWorks after determining that it best met the needs of the multispecialty group. The practice went “live” in two stages in 2005:

• The practice management system was implemented in November, followed by the EHR system in December. Sanders was instrumental in customizing the EHR before implementation, establishing lab, imaging, and e-prescribing interfaces, testing data integrity, and working with eCW to develop their clinical reporting modules. Clinical reports help guide patient care, and satisfy requirements for pay-for-performance initiatives, care coordination and MU quality measures.
• Gorelick and Sanders analyzed and customized every section to provide a more intuitive system that fit with their clinical and administrative workflow in all aspects of running their practice.

“Dr. Gorelick created webinars and/or videos on how to use the system and for many workflow aspects. Since we know the system best, we train new hires rather than the vendor,” said Sanders. eCW trainers came twice – first during the training of the billing office and a second time for the training of clinical staff to prepare to “go live” by December 15, 2005. “As a result of the combined training, the transition was smooth and nondisruptive to patients. There was also no significant impact on revenue,” said Gorelick.

Aquidneck took out a loan in 2004 to establish an electronic intranet, preparing the practice for full EHR implementation shortly thereafter. Funding for the implementation of eCW was partially subsidized by the local Blue Cross Blue Shield (BCBS) of Rhode Island Quality Counts Project, which combined financial support for meaningful EHR implementation, quality reporting, and pay for performance. BCBS of RI was the first insurance company in the state to support primary care practice implementation of EHRs, and continues to be a strong advocate for primary care in the state.

Aquidneck was the first group practice in Rhode Island to attest to MU in June 2011. The practice was the second in the state to establish a Direct messaging account with the capacity to effectively exchange information in a secure HIPAA-compliant manner with practices and facilities, and to connect providers to current care, the state-wide health information exchange (HIE). Aquidneck worked with its staff and providers to develop internal workflow policies and procedures to ensure a smooth transition of care when patients transition between their practice and other providers/facilities.

• Exchanging Key Clinical Information (Core Measure 14): Using Direct, Aquidneck performed the test for exchanging key clinical information. Currently, Aquidneck exchanges key clinical information seamlessly including patient problem lists, medications, allergy lists, and immunizations, with providers including the local hospital who use eCWand participate in the community-wide electronic health exchange (EHX). These include emergency department physicians, hospitalists, specialists, and radiologists. The EHXenables data sharing on a live basis that is structured and measurable.

  “This data helps providers make safe and appropriate management decisions, and is a big improvement over trying to remember a patient's medical history. The time and effort to get data before was prohibitive, and often resulted in duplicative and wasteful tests,” said Gorelick.

• Medication Reconciliation (Menu Measure 7): Aquidneck facilitates medication reconciliation using eCW, which is enhanced by having the EHX data integrated into the EHRdirectly and the provider's workflow. A staff nurse clicks on a tab and sees what diagnoses were added by other providers, or which medications have been prescribed or adjusted by other providers to incorporate information and prepare for the upcoming visit. At the point of care, Gorelick has immediate access to the data from other providers as well.

  “I can review the EHX data with the patients, confirm their medication history, and update the record at the same time. When patients are admitted, the hospital can also see our problem lists, medications, and allergies, which improves safety.”

  All of this information, including medications and allergies are pushed into the EHX and can be pulled into the EHR at the discretion of the care team.

• Clinical Summaries at Transitions of Care (Menu Measure 8): Aquidneck was the first practice in Rhode Island to test Direct's capacity to transmit a patient's continuity of care document (CCD) from an EHR system to the local hospital. Aquidneck transmitted the CCD when a patient needed an immediate referral to the local hospital's Emergency Department. After the patient was released from Newport Hospital, an Aquidneck nurse retrieved the patient's records, including the CCD and scheduled a follow-up appointment.

• MU Objectives: Aquidneck continues to use the eCW dashboard to continually monitor MU objectives, for clinical quality improvement, and to identify documentation issues.
• Changes in Staffing: As a result of implementing the EHRsystem in 2005, the practice reduced their billing office staff from six to five employees and their medical records staff from four employees to one employee. However, they added five new clinical positions between 2006 and 2011 including a nurse care manager, one registered nurse, and three medical assistants.

  “We reduced our staff when we first went live, but now we are hiring more clinical staff such as a nurse care manager, to provide better care, care coordination and services,” said Sanders.

Aquidneck physicians had to learn the new EHR system in addition to seeing a high volume of patients during flu season. The non-physician staff faced major adjustments since many had no computer skills, and they had to document every patient conversation in the EHR. “They continued to use their steno pads for a while but, no one uses them now,” said Sanders. The staff also had to adjust to everyone seeing their work. “Now, they love it. They are able to take more responsibility. Everything that they do is visible, and supervisors and physicians can work with them to solve problems,” said Sanders.

• When implementing an EHR, practices should try to cut back on patient volume to learn the system over a period of time. “The fact that our prior legacy product practice management software support was ending in March of 2006 pushed our hand. We made the decision to implement an EHR with an integrated practice management and clinical record system. Unfortunately, due to flu season and a high patient volume, there was no time during the day to get accustomed to the new computerized record system. Our doctors spent late nights and weekends learning the new system over the first several months,” said Gorelick.
• Another lesson learned is that “it is key for any group that runs a professional practice and uses an EHR system to have a staff person onsite or someone accessible to the community that is an expert on the system to avoid calling the EHR vendor all the time,” said Gorelick.

• Work with HIE's to ensure that the information provided remains accurate and relevant and that provider notification, and longitudinal health data are incorporated directly into the practice's EHR and workflow.
• Develop and implement a physician network for secure messaging and data exchange. “We are very excited to securely exchange clinical data to improve the process of care transitions, care coordination, patient safety, and overall clinical management, especially with instant notification in our EHR as the patient transitions between providers and facilities.”