Los Angeles Practice Uses EHR Functions for Quality Improvement

AltaMed is both a Joint Commission-designated patient centered medical home and a federally qualified health center that sees approximately 150,000 patients per year. In addition to its 26 primary care sites, which include both medical and dental clinics, AltaMed has an HIV program, a youth clinic, and six sites that offer the Program for All-inclusive Care for the Elderly (PACE). An affiliated independent practice association counts approximately 100 primary care physicians in the community as members. Many specialty services, including cardiology, endocrinology, pediatrics, and obstetrics, are offered in AltaMed’s clinics. AltaMed began implementing its NextGen electronic health record (EHR) system in the clinics in 2009, and adoption in all sites was largely completed by April 2010. NextGen is used for both the EHR and the electronic practice management systems, although the dental clinics use a different management system. From the very beginning, AltaMed’s providers were involved in the planning and implementation process for the EHR system, and they invested heavily in EHR education and training for a broad range of staff.

• A ground-up approach to EHR implementation, including extensive provider involvement and staff training, is essential for smooth implementation.
• EHR training needs to be comprehensive and continuous to ensure that the benefits of the EHR for improving the quality of care are fully realized.
• EHRs can help all clinic staff to work at the top of their licenses by enabling improved communication between staff and physicians and giving access to data and quality-of-care alerts that enable non-physician staff to provide more care to patients.
• Expanding the EHR beyond the clinic’s walls can improve quality of care by enabling improved coordination with other providers in the community.

AltaMed is both a Joint Commission-designated patient centered medical home and a federally qualified health center that sees approximately 150,000 patients per year. In addition to its 26 primary care sites, which include both medical and dental clinics, AltaMed has an HIV program, a youth clinic, and six sites that offer the Program for All-inclusive Care for the Elderly (PACE). An affiliated independent practice association counts approximately 100 primary care physicians in the community as members. Many specialty services, including cardiology, endocrinology, pediatrics, and obstetrics, are offered in AltaMed’s clinics. AltaMed began implementing its NextGen electronic health record (EHR) system in the clinics in 2009, and adoption in all sites was largely completed by April 2010. NextGen is used for both the EHR and the electronic practice management systems, although the dental clinics use a different management system. From the very beginning, AltaMed’s providers were involved in the planning and implementation process for the EHR system, and they invested heavily in EHR education and training for a broad range of staff.

AltaMed initially implemented an EHR system in its HIV clinic in 2005 as part of a grant program. Dr. Felix Carpio led this effort, and as a result he was later asked to spearhead AltaMed’s clinic-wide EHR implementation effort. In 2008 AltaMed released a request for proposal to which 15 EHR vendors responded. Three vendors were selected for more detailed analysis and assessment. Ultimately NextGen was selected as AltaMed’s EHR vendor because of its single database, its 25 different provider specialty templates, and its ability to interface with AltaMed’s laboratory services provider, Quest Diagnostics.

In 2009, AltaMed had NextGen’s EHR system up and running in 22 of 23 practice sites in just 9 months, with one taking longer because of its collaboration with a local hospital. Implementation started at 2 large practice sites and 2 smaller ones, and then was followed by waves of EHR implementation at the other 19 clinical practice sites. Each wave included both larger and smaller practice sites, with the first wave lasting 2 months and the rest lasting just 1 month each until all 23 practice sites were live.

AltaMed attributes much of the EHR implementation’s success to the degree to which the providers were involved in the effort and the education provided to a variety of staff. A group of approximately 15 providers, including two from each medical specialty, created the plans for new workflows and the ongoing evaluations and feedback from providers to make the EHR implementation successful. Providers were educated about the advantages of EHRs, such as no more “lost” patient records, improved communication between all staff via online messages, improved coordination between staff when all have electronic access to a patient’s medical record, and better attention to quality-of-care issues with EHR tools for quality measurement and electronic alerts regarding needed care. EHR champions spoke at quarterly staff meetings during the year before implementation. During the implementation EHR trainers shadowed providers, including in the exam rooms, to provide more detailed guidance on how to adapt to the EHR system and how to use it to improve patient care. Dr. Carpio noted that shadowing is one of the most effective ways to train providers because it allows immediate feedback on how the EHR was used in a particular patient visit and how the EHR could be used more effectively for documentation of care and quality improvement in the future. The trainers included physicians, nurses, and medical assistants (MAs) who were familiar with the clinical processes. Nurse Practitioner Traci Vargas, who specializes in obstetrics and gynecology, recalled the attention and support provided by AltaMed and NextGen and noted that no complaints or concerns that she and other providers raised “fell on deaf ears” because everyone, including management, was actively involved in doing the detailed work of EHR implementation. For example, two common concerns were that the computer was sometimes slow in responding when providers were in the exam rooms with patients, and that many clicks were needed on the EHR screens to use the templates provided for each medical specialty. In response, AltaMed invested in hardware and software to ensure that templates would load more quickly. AltaMed also worked to modify the templates initially provided by NextGen to reduce the number of clicks needed by providers for most clinical processes needed during patient visits.

Throughout the implementation process, AltaMed worked with staff from their Regional Extension Center (REC), HITECH-LA. Dr. Carpio said that the REC provided “extremely useful” consultation on how to use EHR technology to improve care and assist clinical staff in using the EHR system effectively. REC staff also helped AltaMed achieve meaningful use (MU) of their EHR with ongoing assessments on readiness for MU. AltaMed had 94 providers achieve Stage 1 MU in 2012; they aim to increase that number to 112 by 2013.

Providers continue to stay involved in EHR training, as it is an ongoing process. Provider retreats were established to inform providers of upcoming changes in the EHR system and provide a forum to discuss concerns. New staff receive three 4-hour blocks of EHR training, with additional one-on-one time for follow-up. Each month an EHR expert comes on site to consult with staff. AltaMed is also creating a new technical training department with seven staff trainers to make sure that EHR training needs continue to be met. “Super-users” and “provider champions” have been identified to give staff access to peer resources within their specific clinics should they have questions, concerns, or suggestions. Dr. Carpio noted that staff is “trained on things they should already know.” This helps to create a culture of accountability where no one can claim ignorance to the expectations, and ensures that AltaMed lives up to its motto of “Quality Care Without Exception.”

AltaMed is looking forward to expanding the capabilities of its EHR in the future. A point-of-care dashboard was pilot tested in 2012 to provide more immediate feedback to providers on quality measures. The dashboard is intended to complement the current retrospective quality measures reports. Another new initiative is to begin exchanging patient data with other providers through a health information exchange to improve care within the AltaMed system. A related goal is to use the EHR to also improve care throughout the local community. A new EHR function, AltaMed Netet, was implemented in 2012 to simplify and speed up the process of arranging patient referrals to specialist physicians outside AltaMed and to enable the specialists to view the primary care record of an AltaMed patient. By the end of 2013 AltaMed staff aim to implement a method of exchanging patient data between AltaMed and external specialists and community hospitals and clinics using continuity of care document technology to further improve the coordination of care among the different providers treating a patient. AltaMed is also seeking to launch an EHR patient portal that will enable patients to communicate online with their providers, make requests for medication refills, make appointments, and view portions of their medical records. With the space the El Monte clinic has gained by not having to store all of those paper medical records, they are adding additional chairs to an expanding dental clinic space.

Dr. Carpio said that reaching quality improvement goals would not be possible without an EHR, and many AltaMed staff concurred. Quality measurement included provider involvement, with each specialty choosing metrics it wanted to report on to track improvements in quality.

• Continuity of Care - The EHR system has been used to improve communication among AltaMed staff. Instead of a paper note that can get misplaced, staff members can send an electronic “task” to their colleagues. Medical records can be accessed anywhere, anytime, in real time. Physicians know that if a test is not in the medical record, then it was not completed. AltaMed has also taken precautions to ensure that remote access to the EHR is secure and not abused: it monitors after-hours use of the EHRs and modifications made to key areas of patients’ records. Estella Garcia, a referral coordinator at AltaMed, discussed the ease with which the EHR system allowed her to access all the information she needed to coordinate with specialist physicians’ offices and with health insurance companies. Electronic physician notes make the work go faster, and electronic tracking closes the loop to ensure that ordered care or tests are provided. Ms. Garcia stated that the electronic system was better for the patient because nothing gets lost and there are no resulting delays in patient care.  Nurse Vargas noted that she now has the ability to select the specific parts of a chart she wants to share with a specialist. This capacity also improves care coordination.
• Providing Quality Care - AltaMed has a goal that everyone “works at the top of their license,” including physicians, nurses, and MAs. According to Michelle Hernandez Valencia, Nursing Supervisor at the El Monte clinic, this goal engendered a shift from reactive care, with the physician being the driving force, to more team-based proactive care. MAs in particular have an expanded role. MAs can provide more care using standing orders, such as orders for giving vaccinations, ordering mammograms, and ordering diabetic laboratory tests, according to specific protocols that conform to evidence-based guidelines. MAs also record patient demographic information, vital signs, and other relevant patient information in the EHR before the visit. After the provider sees the patient, the MA completes the visit with the patient by ensuring that future appointments are booked, performing tests ordered by the provider during the visit, and providing follow-up instructions and educational materials to the patient as needed. MAs also do more patient outreach, such as searching the system for patients needing cervical cancer screening and calling them to set up appointments. Providers were initially nervous about MAs taking on more clinical care, but they have gradually learned to trust the MAs as they have demonstrated their expertise. Yolanda Raygoz, an MA and EHR super-user, reported that processes are faster and easier with the EHR system, and the extensive training allays fears that MAs may have of “messing up.” Nurses provided training and coaching to MAs on their new clinical roles for giving injections, documenting care, handling emergencies, practicing infection control, and performing other clinical processes.  Nurse Vargas mentioned many features of the system that enable her to improve the care provided to her patients. She can verify patient information quickly, review quality-of-care reports on her patients, use protocols to see what care needs to be done for a patient, and quickly see if anything looks “off” to catch mistakes— for example, the EHR will not let her prescribe birth control to someone who is pregnant. She can also immediately see in the EHR if patients are smokers before prescribing them birth control (since smoking is contraindicated), and if they do smoke she can send the patients directly to the health education staff. She is forced to better document the care provided. She also notes that reminders help to improve quality of care—for example, by reminding physicians that a patient is allergic to penicillin if it is prescribed.
• Assessing Quality - Quality of care is continually measured at AltaMed using the EHR. Physicians are provided with reports and scorecards that show the highest and lowest quality measure scores for all of the AltaMed providers, with providers’ names intentionally included. This helps foster personal responsibility and friendly competition among providers, while also illustrating that improvement is possible where their peers have achieved better quality scores. The staff also recognizes that the quality score reports do not reflect only the work of a provider, but the work of the entire team that supports a provider, such as office staff and MAs. If any quality scores are found to be low, whether for productivity, quality measurement, or MU measurement, trainers are deployed to help find ways to improve and to reinforce quality improvement messages. Roberto DeLeon, Clinic Administrator at AltaMed’s El Monte Clinic, monitors clinic level reports on HEDIS measures using trends, benchmarks, payer type, no-show rates, and other methods. This illustrates how the staff at each AltaMed clinic has resources at their disposal to identify and monitor areas for quality improvement.