EHR 2.0: Pivoting from Implementation to Optimization

With the rate of EHR adoption hovering at about 70 percent of providers, has healthcare truly pivoted, as the Office for the National Coordinator for Health IT claims, from implementation to optimization? It seems the answer is a firm maybe.

Some organizations have made impressive progress with new care delivery models, thanks to health IT. Reliant Medical Group, for example,  is able to take on financial risk for 80 percent of its patients thanks to its cutting edge work to optimize its health IT, according to Lawrence Garber, MD, medical director for informatics for the multispecialty group based in Worcester, Mass. Garber shared his organization’s health IT strategy at recent conferences.

Reliant’s structure is built on a solid foundation of an EHR system, patient engagement tools, clinical decision support and health information exchange, he says. When the group rolled out its EHR in 2007, they had prepopulated the system with 15 years of data.

Meanwhile, Reliant uses current data to tailor future care needs. They extract data nightly from the data warehouse to run analytics reports to identify patients needing extra monitoring or care management. This information loads directly into the EHR and users receive it on the front end. 

Looking ahead

Reliant also uses the data warehouse to identify its highest risk patients. Reports identify who has the highest likelihood of hospitalization in the upcoming six months based on the prior year’s claims such as frequent ED visits in the preceding 12 months. “We review that list every two weeks with primary care nurses, care managers and, soon, a behavioral health nurse practitioner to talk about what treatments could be done to prevent problems that have existed or are about to happen and what other services might be beneficial.” Those decisions are updated to the care plan which is in the EHR all Reliant clinicians share.

The practice has established a connection with nearby St. Vincent Hospital that streamlines emergency department (ED) admission. When a Reliant patient is admitted, the system is triggered to send a summary document. “Thirty seconds after ED registration, Reliant’s CCD [continuity of care document] is automatically loaded into the ED’s EHR,” Garber says.

That kind of information flow is important to control, he adds. “It flows silently so I have access when I need it but the more important alerts come to my inbox. Routing is incredibly important.”

To fine-tune alerts, Reliant prioritizes how abnormal a lab result is so physicians are appropriately notified and not overloaded. The medical group loads its patients’ claims data directly back into the EHR weekly and prescription claims are loaded on a nightly basis to populate the medication list and for population health maintenance. Mammograms, colonoscopies, immunizations, diabetic eye exams and more show up in the record. “When I get an alert [the patient] truly is overdue for something so I can focus energy on making sure they are taken of.”

Overall, Garber said Reliant has spent $24 million over the past three years on a number of improvements.

At the junction

A more recent EHR implementation puts Piedmont Atlanta Hospital, part of the five-hospital Piedmont Healthcare in Atlanta, at the “junction of stabilization and optimization.” After rolling out its EHR system in November 2013, the facility is catching up on issues identified during the active rollout but the optimization team is in place, says Mark Cohen, MD, PhD, vice president of medical affairs and chief quality officer.

The process has been very painful, says Cohen. “Everyone was already working at 100 percent so bringing in a whole new paradigm for how you get your job done, particularly at first, slows everybody down.” During the implementation they put off elective procedures but “we don’t have a lot of control over our volume.” The timeline was driven by Meaningful Use deadlines and resulted in getting five hospitals live over a 10-month period. “It was rolling chaos. It would have been nice to do one hospital first, wait four months and then gather lessons learned, but that would have just prolonged the agony.”

Having been through it, however, Cohen says he doesn’t necessarily want to stop and catch his breath. “The things that need to be optimized really need to be done.” One priority is medical reconciliation. “We have a team attacking that. Improving our workflow and the user interface around med rec will dramatically improve patient care. As long as we don’t flood the organization with too much change too fast and we do a good job of communicating along the way, users will welcome it and adapt to the changes as they occur.”

Establishing an optimization team is part of the standard process recommended by the EHR vendor. The biggest challenge for that team is prioritizing, says Cohen. The team must establish the degree of urgency for each potential project because it’s all related to patient care. “In the minds of the users, it often appears that everything needs to get fixed or changed because, if you don’t, patients will die.” However, some changes really do have to be made right away. For example, when Piedmont receives emergency patients by helicopter, they haven’t been registered so the clinicians can’t place any orders right away or in advance. 

“The team has to balance the importance of the project, the resources it’s going to consume and the desire to get some quick wins so the organization is being rewarded for all the pain of the transition. We’re constantly juggling that.”

Focus on the team

Balancing and juggling fits into a triangle model for improvement in innovation with EHRs, says Lyle Berkowitz, MD, MBA, associate chief medical officer of innovation for Northwestern Memorial Hospital and the medical director of IT & innovation for Northwestern Memorial Physicians Group in Chicago, as well as a health IT entrepreneur and author.

Maintenance sits at the base of the triangle while optimization of the current system and new projects serve as the two sides, he explains. Many organizations get caught up in maintenance rather than allowing for optimization, he says. “Places that have done the best with their EHR have dedicated resources for exploring new tools.” A combination of people, processes and technology drive real value, he says.

For example, oftentimes someone other than the physician can address alerts or responses can be automated. “The problem we’ve had is not that technology was unable, it was that we just assumed it should all be done by the doctor. The future of medicine is team-based care but EMRs aren’t necessarily designed, and certainly not implemented, as a team-based tool.”

To change that, Berkowitz has been focused on making it easy to do the right thing for a combination of improved patient experience and quality of care delivered. The more users use the tools, the more an organization’s quality score improves. His facility has developed care pathways to manage certain events, such as a cancer diagnosis and blood in urine. A doctor can initiate the pathway which helps route orders together and ensures all the right next steps occur “instead of making the doctor try to remember every step on an electronic checklist.”

For example, using the pathway for patients with a finding of blood in their urine has resulted in the right follow-up occurring in an average of 35 days instead of the former 75 days. It also decreased the number of visits the patient has to make to the urologist. Overall, both the patients and the doctors have a better experience.

In many cases, he notes, “technology is the easy part. The important part is how to use the right people and figure out the right processes.”

A role for ONC

Going forward, organizations with more mature EHR systems “should be figuring out how to optimize their use and build on top,” says Berkowitz. To that end, he hopes to see the ONC “do what they can to help EMR vendors to open their systems up to creative innovative companies building tools on top.” Some companies are openly embracing this concept, he says, but “the more ONC can do to make it easier for everyone to work together, the better for everyone.”

Meanwhile, Cohen recommends good humor for anyone working on EHR implementation and optimization. When asked about specific goals for Piedmont’s optimization team, his first response: “To optimize the EHR.”