Electronic Health Reporter

Collaboration has proven to be key when moving to a meaningful use certified electronic health record, time and time again. The same can be said about upgrading to a MU certified EHR.

From a single site opened in 1996, Santa Rosa Community Health Centers (SRCHC) has become a major provider of healthcare services in Sonoma County with more than 102 participating providers serving a patient population of 40,000 through eight facilities.

Services include family planning and reproductive health, HIV, mental health, obstetrics, outreach and education, pediatrics, primary care, senior and older care and teen services. SRCHC is a federally qualified health center, and provides more than 183,000 medical visits each year.

SRCHC went live on eClinicalWorks in May 2009.

$2.5 million in incentive payments devoted largely to upgrading existing EHR

Because SRCHC was on an existing EHR, a significant investment of time and money was required to upgrade it to a MU-certified system. “2.5 million is a lot of money, and it has been extremely important to us,” acknowledges Chief Operating Officer Kai Nissley. “Much of it was required for additional IT staff, upgrades, tools, and data reporting staff required to get useful information out of the system. We already had an EHR, but it wasn’t being used optimally. At the time we undertook the upgrade, many clinicians were wondering if the EHR effort was worth it, much less the effort to meet meaningful use standards. There’s no question that the fact that we were able to invest in more robust, redundant hardware was critical.”

Nissley notes that some of the incentive money was spent on eClinicalWorks clinician consulting to modify screens to make them more user-friendly for providers, and that they also used incentive money to fund their own in-house “answer person” who is dedicated to troubleshooting system problems.

MU attestation challenges

For an organization as large as SRCHC — with over more than providers at multiple facilities struggling to use an existing EHR that was in the process of being upgraded — the barriers to MU attestation were many and challenging. Among them:

•System reliability: “For starters, there was the whole question of system reliability and downtime,” recalls Nissley. “We had lots of complaints about the system. The system went down so often we actually developed a procedure for responding.”

•Little confidence in data: Clinicians had little or no confidence in the data, so SRCHC built reports with their input. “It required a significant investment of time, but I highly recommend it,” says Nissley. “Working this way, we got physicians to buy-in and own the process. Now when we introduce new reports there is less provider resistance. Collaboration with them on building reports has been hugely important.”

•Identifying and enrolling eligible providers: An early problem was identifying eligible providers, along with the actual mechanics of signing them up. “The system for signing up for MU was not intuitive for providers,” says Nissley. “We reassigned an existing staff member to provide administrative support enrolling providers. We tried to be very customer focused, offering lots of flexibility so that providers could find times that fit their schedules to work on this. We also provided lots of Granola bars.”

•Extracting useful data and improving input screens:

Extracting useful data —“The EHR seemed designed to put data in, but wasn’t good at helping us take useful information out,” says Nissley. “To resolve this we identified the data gaps, and assigned one staff person to help extract data, and make it useable. This has greatly helped to make our EHR functional, but this critical area is still a problem we are working on.”

Improving input screens: According to Nissley, because eClinicalWorks is customizable, it is easy to enter data into the wrong field. “It is really difficult to learn what fields you’re pulling data from,” she notes. “Early on we formed a Data Validation Committee that worked with us every step of the way to make sure we correctly understood the data we were entering. Learning how the EMR collects the data for specific fields continues to be a problem with the reliability of reports coming out.”

•Training staff and clinicians: Training is critical, but it also creates stress on routine workflow and productivity. Building training time into staff routines, and finding ways to release them from their duties for training has been a continuing scheduling and staffing challenge. The diversity of SRCHC staff also created the need for some tailored training. To manage this big job, a trainer was dedicated exclusively to working with staff and with their LEC. 

The time required for clinicians to participate in EHR improvements (including efforts to improve input screens), help build reports, and train in the use of the EHR directly affects productivity. Schedule changes can also be problematic for the clinician’s patients. “When we first started with an EHR we lost some providers who just couldn’t adapt to computers,” recalls Nissley.  “However, the majority stayed but lost some productivity.  It really took the investment this year in better input screens and workflows for entering data before I could say that we were back at the productivity levels we were at before the EHR.”

•Communication and oversight challenges: Because SRCHC is a multi-site, multi-specialty organization with a large lay and provider staff, keeping everyone on the same page, and updated regularly requires an ongoing comprehensive communication effort. “It has been a continuous challenge to make sure clinicians and staff are moving through the evolving EHR process together,” says Nissley. “A lot of our communication requires going to each site and talking one-on-one with providers. The fact that MU screens are individual for each provider, required some real creativity with respect to our communication with, and oversight of, clinicians in supporting them to use the system optimally.”

Nissley notes that, in order to standardize progress in effective use of the EHR, they started by focusing on a number of specific measures, including: timely completion of notes in charts, updating problem lists, updating medication lists, and adherence to allergy care protocols.

SRCHC has realized numerous benefits from its EHR upgrade and subsequent continuous improvement activities. Among them:

•The ability to generate accurate specialized and general reports that assist providers in improving care

•Population health information can now be shared with providers and outreach targeted to those most in need by support staff

•With better, more accessible data, patient care teams are able to generate reports and share information in a timely manner. Bottom line: better continuity of care.

•Front office efficiency has improved greatly. With better analytics-based software solutions, SRCHC is able not only to capture essential demographic information, including race, ethnicity and income, but is also able to give specific feedback to those who aren’t meeting goals for entry. Next step will be to share the upfront collections report for each medical receptionist.

•Compliance with HIPAA confidentiality requirements has been improved. To insure compliance, SRCHC used MU funds to commission an external HIPAA audit that provided a gap analysis, and identify priorities.

•An array of performance improvement projects are now supported by the EHR. Among areas addressed: referrals (standards, benchmarks); peer review (closing notes, standards, follow up, consequences); OB results reporting and documentation; and improvement of financial performance and insurance capabilities that help ensure SRCHC is using its operations to find those needing insurance.

When asked if SRCHC would undertake the whole EHR upgrade/MU journey again, Nissley responds, “Yes, 100 percent. Throughout the process we’ve tried to make it clear to clinicians and staff that this isn’t just about dealing with government requirements — in the long run it’s about helping us improve healthcare delivery. I think everyone would agree that, while there’s always room for improvement, we’re doing a much better job now.” 

Content provided by CalHIPSO, the largest of 62 federally designated Regional Extension Centers, and the largest in California, serving 56 of California’s 58 counties.