Using Carrots to Make EMRs & Quality Initiatives Palatable
Developing an electronic medical record (EMR) that doctors will embrace requires an understanding of practitioners' motivations and habits, as well as quality assessment markers. Three doctors share their strategies for building and maintaining robust EMRs, from early stage to fully established — all while applying technologies to improve their workflow and patient outcomes.
As an early adopter, Holly, CEO and co-founder of the Southeast Texas Medical Associates (SETMA) in Beaumont, introduced EMRs to the multispecialty group with 23 physicians, 12 nurse practitioners in five clinics in southeast Texas that serves 170,000 patients a year. three years after its founding in 1995. What started as a method for documenting patient encounters soon evolved into a system to manage patient care. Not satisfied, Holly and his team have developed a suite of tools that distill complex medical conditions into an intuitive electronic interface that alerts doctors when they fail to adhere to evidence-based guidelines.
For instance, SETMA incorporated recommendations from the Centers for Disease Control and Prevention (CDC) that called for routine HIV screening for at-risk patients into a pre-visit/preventive screening tool for providers. A query shows those patients who fall within the at-risk profile asking if an HIV test was performed in the last year. If the answer is "no," the query will show in red. If "yes," it will be in black and include a test date.
"While all of our providers may not be deeply and personally committed to evidenced-based medicine, they all hate red," says Holly. "If they see red, they want to get rid of it."
When the caregiver sees that a test is needed, he or she simply needs to push a button, Holly explains. "That button sends a request to the lab, puts it in the chart, sends it to billing and prints a note so the patient will sign an agreement to commit to an HIV test." The provider is notified with test results and can arrange a follow-up consultation, if necessary.
"We made it easier to do it right," Holly says. The HIV program not only allows SETMA to identify and provide care to HIV-positive patients at an early stage, but also provides aggregate data for a Texas Department of State Health Services' program designed to prevent and control the spread of HIV.
Smirz, CMO at Indiana University Health North Hospital in Carmel, Ind., sees the use of electronic reporting as key to achieving quality standards, but processes play a role as well. The 6-year-old hospital, which is part of a 17-facility system with more than 3,700 physicians, is scheduled to be completely paperless sometime in 2012.
In 2010, Smirz worked to improve the hospital's operating room on-time starts from 21 percent of the cases to 68 percent within one month by clarifying that start time meant when the surgeon makes the first incision. The new measure forced the OR team of anesthesiologists and nurses to calibrate schedules to ensure their pre-incision duties were completed before the scheduled start time.
"Surgeons don't typically like anything to interrupt the flow of the day," Smirz says. "If a surgeon gets to the pre-op area [and it is not ready], he or she could start to get frustrated, which may lead to mistakes. To save time, he or she may try to cut corners, or won't want to complete the checklist, or won't give full attention to the procedure. He or she may try to move things along faster than is safe to do."
The success of the OR program has created political capital for instituting other quality initiatives using the EMR. Those initiatives include pre-operative checklists, post-operative procedures, medication tracking and patient monitoring through recovery. She estimates that 50 percent of the physicians already use computerized physician order entry for documentation, which has reduced potential errors like misreading a handwritten order. "We're building more and more on what we call knowledge-driven care where the EMR is there to help us deliver better care to the patient because we've built in the evidence-based tasks that need to be done," she says.
Spotts sees his role as CMIO at Evangelical Community Hospital as part liaison, part facilitator and perhaps a little bit of pioneer for the 200-physician hospital in Lewisburg, Pa. Spotts gave up his practice as a family physician in February to spearhead Evangelical's EMR efforts, one of 13 facilities in central and northeastern Pennsylvania participating in a $16.7 million federally funded Keystone Beacon Community program that is seeking to improve the consistency, quality and efficiency of care for patients with chronic diseases.
Spotts is helping get physician buy-in for the Beacon program, which is designed to use the Keystone Health Information Exchange to integrate health records from disparate sources such as hospitals, nursing homes and hospice facilities to ensure accurate and up-to-date patient records. His responsibilities include coordinating efforts within Evangelical with the larger Beacon community. At the same time, he is working internally with IT and administration to develop quality initiatives that address federal reporting requirements such as care measurements and meaningful use criteria.
"This is the dilemma where the clinical side needs to interface with the technology side," Spotts says. "We can't have the two pieces marching to the beat of their own drummer. We have to come together and understand each other. Evangelical chose a physician champion to help lead us through this process because there are so many moving pieces."
Initiatives on the horizon include the addition of a staff member who will observe workflow to identify gaps to help achieve meaningful use compliance and a coordinator to track care transitions as part of the Beacon program.
"We are hoping to prove that we can save patients money, we can save Medicare money, the hospital money and we can use that information to justify the continuation of the Beacon grant program for five more years," Spotts says.
The veteran Holly says the biggest impediment to building an EMR is inertia. "Get started," he says. "A lot of people get frustrated because they feel they are so behind, but they really aren't. And secondly, celebrate where you are. Solve a problem that is your problem and then the solution is yours."
Approach to quality
James L. Holly, MD, Lynda Ann Smirz, MD, MBA, and Douglas A. Spotts, MD, might not describe themselves as motivators. But their ability to identify incentives—or disincentives—that nudge their medical colleagues into using EMRs is helping their respective institutions improve patient care. In the process, their hospitals and practices are edging closer to meeting quality initiatives and meaningful use criteria.As an early adopter, Holly, CEO and co-founder of the Southeast Texas Medical Associates (SETMA) in Beaumont, introduced EMRs to the multispecialty group with 23 physicians, 12 nurse practitioners in five clinics in southeast Texas that serves 170,000 patients a year. three years after its founding in 1995. What started as a method for documenting patient encounters soon evolved into a system to manage patient care. Not satisfied, Holly and his team have developed a suite of tools that distill complex medical conditions into an intuitive electronic interface that alerts doctors when they fail to adhere to evidence-based guidelines.
For instance, SETMA incorporated recommendations from the Centers for Disease Control and Prevention (CDC) that called for routine HIV screening for at-risk patients into a pre-visit/preventive screening tool for providers. A query shows those patients who fall within the at-risk profile asking if an HIV test was performed in the last year. If the answer is "no," the query will show in red. If "yes," it will be in black and include a test date.
"While all of our providers may not be deeply and personally committed to evidenced-based medicine, they all hate red," says Holly. "If they see red, they want to get rid of it."
When the caregiver sees that a test is needed, he or she simply needs to push a button, Holly explains. "That button sends a request to the lab, puts it in the chart, sends it to billing and prints a note so the patient will sign an agreement to commit to an HIV test." The provider is notified with test results and can arrange a follow-up consultation, if necessary.
"We made it easier to do it right," Holly says. The HIV program not only allows SETMA to identify and provide care to HIV-positive patients at an early stage, but also provides aggregate data for a Texas Department of State Health Services' program designed to prevent and control the spread of HIV.
Smirz, CMO at Indiana University Health North Hospital in Carmel, Ind., sees the use of electronic reporting as key to achieving quality standards, but processes play a role as well. The 6-year-old hospital, which is part of a 17-facility system with more than 3,700 physicians, is scheduled to be completely paperless sometime in 2012.
In 2010, Smirz worked to improve the hospital's operating room on-time starts from 21 percent of the cases to 68 percent within one month by clarifying that start time meant when the surgeon makes the first incision. The new measure forced the OR team of anesthesiologists and nurses to calibrate schedules to ensure their pre-incision duties were completed before the scheduled start time.
"Surgeons don't typically like anything to interrupt the flow of the day," Smirz says. "If a surgeon gets to the pre-op area [and it is not ready], he or she could start to get frustrated, which may lead to mistakes. To save time, he or she may try to cut corners, or won't want to complete the checklist, or won't give full attention to the procedure. He or she may try to move things along faster than is safe to do."
Organizational improvements
Indiana University Health North Hospital has used its successful on-time rate to recruit surgeons and improve its bottom line. The hospital added 24 new surgeons to its OR schedule in 2011, and by June had reached its projected revenues for the year. "In reality, the OR is the economic engine of the hospital," Smirz says. "We made money with this particular quality initiative because we made the surgeons happy."The success of the OR program has created political capital for instituting other quality initiatives using the EMR. Those initiatives include pre-operative checklists, post-operative procedures, medication tracking and patient monitoring through recovery. She estimates that 50 percent of the physicians already use computerized physician order entry for documentation, which has reduced potential errors like misreading a handwritten order. "We're building more and more on what we call knowledge-driven care where the EMR is there to help us deliver better care to the patient because we've built in the evidence-based tasks that need to be done," she says.
Spotts sees his role as CMIO at Evangelical Community Hospital as part liaison, part facilitator and perhaps a little bit of pioneer for the 200-physician hospital in Lewisburg, Pa. Spotts gave up his practice as a family physician in February to spearhead Evangelical's EMR efforts, one of 13 facilities in central and northeastern Pennsylvania participating in a $16.7 million federally funded Keystone Beacon Community program that is seeking to improve the consistency, quality and efficiency of care for patients with chronic diseases.
Spotts is helping get physician buy-in for the Beacon program, which is designed to use the Keystone Health Information Exchange to integrate health records from disparate sources such as hospitals, nursing homes and hospice facilities to ensure accurate and up-to-date patient records. His responsibilities include coordinating efforts within Evangelical with the larger Beacon community. At the same time, he is working internally with IT and administration to develop quality initiatives that address federal reporting requirements such as care measurements and meaningful use criteria.
"This is the dilemma where the clinical side needs to interface with the technology side," Spotts says. "We can't have the two pieces marching to the beat of their own drummer. We have to come together and understand each other. Evangelical chose a physician champion to help lead us through this process because there are so many moving pieces."
Active participation
As a physician, Spotts can help identify and deflect what might be impediments to participation. For instance, he recognized that a password system designed to meet federal rules for protecting patient-identified information might be perceived as cumbersome for physicians. He worked with IT, administration and physicians to find a balance that was compliant with regulations but did not place unnecessary burden on users. Spotts says they achieved a short-term need without jeopardizing physician participation.Initiatives on the horizon include the addition of a staff member who will observe workflow to identify gaps to help achieve meaningful use compliance and a coordinator to track care transitions as part of the Beacon program.
"We are hoping to prove that we can save patients money, we can save Medicare money, the hospital money and we can use that information to justify the continuation of the Beacon grant program for five more years," Spotts says.
The veteran Holly says the biggest impediment to building an EMR is inertia. "Get started," he says. "A lot of people get frustrated because they feel they are so behind, but they really aren't. And secondly, celebrate where you are. Solve a problem that is your problem and then the solution is yours."