A West Virginia Health Center Discusses Implementing Electronic Health Records

The Shenandoah Community Health Center (SCHC) in Martinsburg, WV, is a federally qualified health center with about 30,000 patients that averages 129,000 visits per year, and has been working on implementing electronic health records and achieving meaningful use. It is also a Level 1 NCQA Certified Medical Home and Joint Commission Accredited. SCHC delivers care through internal medicine, family practice, pediatrics, obstetrics, gynecology, and midwifery services. SCHC began implementing an electronic health record (EHR) system, NextGen, in 2005, and has made several upgrades to the system.

Working with the West Virginia REC (WVRHITEC)

The West Virginia Medical Institute (WVMI), the statewide REC, has worked with SCHC to share its more than five years of experience in EHR implementation and utilization with other practices around the state. SCHC is considered by WVMI to be a “super-user” for NextGen EHR systems. WVMI has made arrangements so that SCHC staff can serve as consultants on NextGen systems for other practices around the state that may be considering implementing electronic health records from that vendor.

Why SCHC Implemented an EHR

SCHC focused on combining patients’ paper records into one electronic record. Prior to implementing electronic health records, the same patient at SCHC could have up to five separate medical records. The process to find a system that could combine these disparate records took the SCHC EHR development team several years.

EHR Implementation Highlights

• Selecting a focused, easy-to-implement EHR system that emphasized quality measurement, and creating business and workflow rules to ensure quality data input standards
• Selecting a physician to serve as the EHR champion
• Engaging a multidisciplinary implementation team comprised of both clinicians and dedicated IT staff
• Requiring SCHC-run EHR training for all staff
• Training lower-level staff and nurses on executing meaningful use tasks
• Assigning “scribes” to each provider to ensure quality data entry
• Engaging IT to customize EHR templates, workflow, and phrases to individual providers’ workflow and business processes.

A Focus on Quality Measurement in the Journey to Achieving Meaningful Use

Quality measurement was one of the considerations in selecting SCHC’s EHR system. The main concern was to have the capability to enter clinical data needed for quality measures into discrete data fields, and not into free text notes, so the quality measures could be easily calculated within the EHR. The team looked for a system that met three central needs:

• Allowed for the set-up of a range of data collection templates for each department (e.g., internal medicine, pediatrics) tailored to the needs of patient visits. The quality measure data are entered into the templates by the providers, nurses, or other department staff.

• Included check boxes for data entry and methods for entry of laboratory results in numeric fields. Check boxes helped to speed the data entry process for busy clinicians and staff, so they could just click on check boxes and did not have to type text or numbers into EHR data fields.

• Had a system that did not allow the providers or nurses to leave a particular page of the template when they were entering essential data until they entered the important information.

Record patient demographics

Patient demographic information is entered into the EHR as discrete data during the patient registration process.

• Quality measurement  
  SCHC already calculates a number of quality measures using its EHR for reporting to HRSA for the community health center minimum data set. It also calculates some quality measures for its own internal use.
  
  SCHC has not yet finalized the Clinical Quality measures (CQMs) it will report for meaningful use, but will likely select a range of CQMs that are similar to the quality measures it is already calculating for those other purposes.
   
• Maintain active medication list  
  The EHR records data on what prescriptions have been written for each patient from the EHR’s e-prescribing system, downloads from SureScripts, and faxes sent by pharmacies.
   
• Incorporate clinical laboratory test results into EHRs as structured data  
  SCHC developed interfaces with external laboratories, including LabCorp, Quest, and the local hospital, so results of laboratory tests can be entered in the EHR electronically.

The Critical Role of an EHR Champion

Dr. Dawn Jones served as the physician champion for implementing electronic health records at SCHC. She also chairs the SCHC quality assurance (QA) committee that monitors use of the EHR. Most recently the SCHC QA committee is considering ways to use the EHR to generate lists of patients needing reminder calls, and linking those data with an automated telephone calling system.

Engaging a Multidisciplinary Team

Dr. Jones worked with a multidisciplinary team of SCHC staff to implement the EHR. The team included Lori Goforth, EHR project manager; David Stuller, IT director; nursing staff; and others.

Training staff on how to use the EHR

After implementing electronic health records in 2005, training was mandatory for all SCHC staff. The training was job-specific, so staff working in similar jobs was trained together. Training was conducted for about three weeks before the EHR went live. SCHC chose to do its own training, using in-house staff, since it believed that it is important for staff to be trained by someone who is “speaking their own language.”

Partnering a “Scribe” to Each Provider After Implementing Electronic Health Records

While in the beginning, the SCHC staff was uncertain of the value implementing electronic health records might provide, providers are now seeing a range of benefits:

While in the beginning, the SCHC staff was uncertain of the value the EHR might provide, providers are now seeing a range of benefits:

• Instant access to anyone’s chart; no more waiting around or lost charts
• Off-site access to the EHR, such as from home when called by patients in the evenings
• Not worrying about possible loss of patient data if charts lose pages or are lost all together
• Continuity of information between SCHC and the hospital
• Ability to obtain information on the number of patients not having flu or pneumococcal vaccines
• Ability to track patients and visits by week for care management follow-up or for public health issues with infectious diseases

Challenges

Collecting data for quality measures requires that data is entered properly or consistently in the EHR, and SCHC ran into the following challenges in acquiring consistent, proper data:

1. SCHC had to ensure that doctors and other clinicians entered data into discrete data fields and not in free text comments, in order to calculate quality measures. Many doctors and clinicians were more familiar with writing progress notes, care plans, and other free text entries in paper charts, so at the outset, a number of them still entered data by typing free text entries into the EHR.
2. SCHC staff invested substantial training time to help clinicians learn to enter data more consistently in the discrete data fields, and to make the templates easier for them to use, so that they would find the discrete data fields useful in their clinical work with patients.
3. Quality measure data needs to be collected in all of the right templates in the EHR system. SCHC discovered that “smoking status” was in the internal medicine templates from the start of the system, but it was not initially in the pediatrics template. That data element had to be added to the pediatrics template, and the Pediatrics Department providers and staff were trained to ensure the data is entered correctly and consistently.
4. Concerns about the privacy of their patients with mental health and substance abuse conditions delayed the adoption of the EHR by the Behavioral Health Department, but now the department is in the process of implementing the EHR.

Lessons Learned

• When first implementing electronic health records, staff should agree on what information needs to be transferred from paper charts.
• While not always feasible, providers should be encouraged to complete all documentation in the EHR during the visit. Meaningful use will require practices to provide patients with a “summary” of the visit prior to their departure from the provider.
• Nurses should be trained to help physicians with health maintenance quality measure reminders (e.g., cardiac patients due for EKG, or any patient due for a flu shot).
• The EHR should be implemented with each provider’s “favorite phrases.” This will help the doctor by making it easier to fill those in automatically.
• Administrative staff should be trained to do as many meaningful use tasks as possible. It is unrealistic to think that doctors will be able to complete all of them. Identify which things that providers, nurses, or medical assistants should do. Think about who can check when a patient last had a mammogram – this should be a nurse, not a doctor.
• IT needs to be able to write in business rules in the backend of the EHR system to point all the same fields from the different templates to one place. This way, each department can have unique templates that work for their doctors and other clinical providers. At the same time, on the data capture and reporting end, IT can still easily pull the fields for quality measurement, because the same fields in the different templates are all pointing to the same single location in the backend of the system.
• Once committed to an EHR vendor, a practice needs to commit at least one-third of the original cost of the EHR per year for hardware and software upgrades.
• Using an EHR effectively for quality measurement and to improve population health outcomes can require a practice to invest consistent effort over a number of years for training staff, customizing the templates and reports to the needs of the practice, and refining the system so that it is actively used by staff for quality improvement. It has taken SCHC more than three years to get its EHR working effectively toward those quality improvement goals.

Next Steps

• SCHC wants to enhance its EHR system to be able to recognize providers’ practice patterns and automatically fill in information based on historical practice patterns. Clinicians dislike “too many clicks.”

• SCHC would also like to broaden the range of data captured in the EHR. The system has standardized clinical data captured now, but is still working on ways to enhance that information to better help providers improve an expanded range of “whole patient” outcomes and to use the EHR to share information across the different clinical departments when a patient is treated by more than one department.

• SCHC would also like to use information from the EHR to identify patients needing health education interventions, or to improve peer consultations and collaboration among physicians and other clinical providers, or to identify cases where providers could share success stories on how to better educate and motivate patients.