Dr. Anne Brooks in 2012 at the site of several Habitat for Humanity homes.
The American Osteopathic Foundation recently named Dr. Anne Brooks the 2012 physician of the year, for several reasons in which I have described here.
In a nutshell, she’s compassionate, caring and loving of all her patients, and as a nun, it probably helps that she relies on a little help from above.
But, even with her country doctor ways in which she still makes house calls, helps teach her patients to read and write, and building community centers and Habitat for Humanity homes with her own hands, she’s connected technologically – using an electronic health record in her practice – and is informed of many of the latest issues affecting healthcare and healthcare policy.
As a practicing physician, she also serves in the hospital setting, and she drives care for patients while in people’s homes, caring for them in their own environments. As such, she is considered a partner by those lives she’s touched, and she’s seen a great deal of change at the practice level.
The following are a few of her observations from 20 years of practice.
How has patient care changed since you became a physician in 1983?
There are mid-level providers on the scene who are not always appreciated by the patients, who seem to think they need a doctor or by their physician colleagues who often look down on them because it’s a less intense training.
There are RNs who get a doctorate in nursing, but what we need is bedside nurses who care physically and emotionally for and about patients.What I see happening is often the best nurses end up being paper pushers because of new and complicated regulations and disease tracking and length of stay requirements.
Are the patients getting more involved in their care or do they just not care?
I think we need a health blitz in our school curricula so that kids and parents/caregivers all know how to care for an illness or accidents and how to eat healthfully, and the manufacturers of all the fat food would make and sell something much more nourishing so that diabetes and obesity would not cause so much ill health and lower the mortality rate. Change has got to start in the home, but in our case, many parents didn’t go to school so what they don’t know and what they need to know and do are two different things.
Behavior needs to change, too. For example, too many patients have no teeth and eat soft starchy foods which only puts on weight; kids get soft drinks in their baby bottles way early on. So we teach and teach and review and teach some more and a few people get fired up because they learn they have power — which is a big deal at our office — to empower each patient is our major goal. And when we see people actually making lifestyle changes it is incredibly rewarding.
Why did you decide to implement an EHR?
Because of the benefits of speed in communication, ability to quickly access past clinical info and dealing with the handwriting deciphering issue (fewer mistakes related to bad handwriting) the desire not to have to lug a pile of charts home to finish them; urging from forward-looking trusted colleagues; the availability of a grant; articles in medical journals that piqued my curiosity; and the ability to invite salespeople in to speak to the administrative team and then the staff, and pepper them with questions.
Are you more efficient because of an EHR or has there been little or no change?
Technically, I’d probably have to get someone to actually do a time study, but I feel more efficient, which removes some levels of stress for me.
When your career is over, what one thing will you want to carry on in your absence?
Patient-centered care given generously without regard to ability to pay meaning that every patient will get the best care.
I also want our patients to be welcomed with concern, care and compassion, and I want the caregivers to educate and empower patients so they can assume responsibility for their own healthcare, change their lifestyles, and learn how to pass on the education and empowerment to their families and friends.
And, I want caregivers to follow the M*A*S*H* model:
Improve healthcare for patients. A lofty goal for many clinics; perhaps easier said than done for most practices, but not all.
But with the tools now available to practices and physicians, some believe it’s only a matter of time until the entire healthcare landscape changes.
This drive for change is one of the reasons why practices are increasingly bringing electronic health records into their practices.
Sure, the EHRs help practices save money, space and supplies, such as paper, but for Adrienne Laverdure, medical director of the Lac du Flambeau Indian Health Center – the Peter Christensen Health Center – in Wisconsin, implementing an EHR wasn’t a matter of less paper or creating more space in the clinic; it was the obvious choice for improving the quality of healthcare for all of the practice’s patients.
However, Laverdure had little idea that implementing an EHR would lead to a 35 percent jump in revenue, longer life expectancies for the patient population and allow clinic to add more providers, which in turn, means more patients are now being served than ever before.
For her, all of these benefits were the surprising part of adding an EHR.
Community clinic meets community need
Located on the 400-square-mile Lac du Flambeau reservation in northern Wisconsin, the Peter Christensen Health Center provides approximately 16,000 patient visits annually. Until recently, the clinic served only Native Americans on the reservation, but now provides healthcare for employees and non-native patients.
Many of the members of this community and surrounding areas are medically underserved, said Michael Popp, director of information technology for the clinic, and the number of under or uninsured of people who are unable to afford the expense of paying out of pocket for a visit with the doctor or a trip to the emergency room continues to grow.
“We have a mission, and it’s to provide healthcare to all members of the community,” said Popp. “Care isn’t discriminatory, and we’ve found that when people don’t have proper coverage, they don’t know where to turn for healthcare. We’re in the position to help. We decided not providing care to everyone who needed it creates even more problems, so we opened to doors to everyone in the community that needs care.”
That decision meant the clinic went from being a Native American health center to a community health center, and for the patients that are under or uninsured, the clinic’s billing and finance specialists work to find them coverage, such as Medicaid.
To that end, the clinic recently moved from its 5,000-square-foot building into a newly built 26,000-square-foot facility. The clinic was able to accommodate more patients because of the practice management and enhanced patient care that was facilitated by the clinic’s EHR.
There was one problem with the move, though, said Popp. Architects blueprinted a chart room for paper records. A staple for most practices, the EHR changed that, he said, but the solution was simple: “We took that 400 square feet meant for the patient chart room created additional space for offices. By shifting around office space, we had more room for providers to see patients.” said Popp.
Without the room dedicated to storing paper, additional patient visits were accommodated resulting in additional revenues. With increased revenue, tangible gains beyond that of the savings created from the lack of paper ordered by staff each week, began to pile up.
Improving patient healthcare outcomes
Peter Christensen Health Center is considered an early adopter of electronic records, having implemented its system more than five years ago. There isn’t a paper record in the clinic, said Popp, adding that clinic staff uses the EHR to streamline billing and claims processing, increase appointment setting and scheduling efficiency.
Streamlined billing means more cash, and with the EHR, most claims are paid within 14 days. Improved scheduling means there’s time for more patients, which means more people can be seen. Along with three M.D.s, an advanced practice nurse practitioner and a physicians assistant, the clinic provides podiatry, oral surgery, mental health and dentistry services. Each exam room has a computer with access to the EHR, which helps with patient education, Laverdure said.
“There are so many facets to how the EHR has been able to help us,” said Laverdure. “It has created so many efficiencies and it allows more time for our providers to spend time with our patients.”
The results don’t end there, she added.
Revenue increases aside, the EHR allows the clinic to track patient health data and providers can see health trends across the population. “We can see trends in the health of the people we’re seeing and we can really dig deep into the data,” she said. “With the data, we’re able to provide preventive care, and we’re much better equipped to handle state and federal reporting requirements.
“The EHR provides a phenomenal record for us to help us help our patients get the healthcare they need; I like to think that we’re improving each of our patient’s quality of life.”
Diabetes strikes much of the patient population in Lac du Flambeau, as well as other chronic conditions, but by using the EHR, physicians are able to track patient health outcomes, risk indicators and condition variations. This information better enables clinic staff help control and manage patient chronic conditions.
Because the patient’s care is now managed so thoroughly across the entire practice, Popp said the life expectancy of patients has actually increased by more than three-and-a-half years since the EHR was implemented.
Return on investment
The health center returned its EHR investment within six months, having paid it off in less than half a year, but the returns – far exceeding financial gains — keep coming, said Popp.
Other than saving supply costs, increasing revenues and improving patient care, the clinic has become a model of how an Indian health center can operate as a viable business.
During the last five years years, Peter Christensen has drawn the envy of other clinics, and at least two other Indian health centers are following suit and implementing an EHR similar to that of Peter Christensen.
“Other tribes have purchased their EHR based on what we’ve been able to accomplish,” Popp said. “Perhaps we can be advocates for more than our patients, but for the healthcare system.”
But hurdles still remain, the biggest of which is often faced by Peter Christensen, like most clinics, is that it is underfunded, Laverdure said. But now there are ways to fix the healthcare system and control the practice’s costs, she added.
And that means something to the folks in northern Wisconsin, where until now healthcare seemed to have been rationed. “Now there’s money for preventive care. Now there’s money for care,” said Laverdure, “and we’ve been able to use the system to get out of that hole.”
In continuing a series based on HealthIT.gov’s “How to Implement an EHR,” now seems like an appropriate time to seek additional insight into how to prioritize your implementation plan and identify critical tasks to perform when putting your system in place.
As the HIT world continues to reel from continuous change – meaningful use stage 2, ICD-10 postponement and mobile health among the biggies – like any commercial market, there’s bound to be some constant ebbs and flows.
Selecting, and changing, an EHR are bound to happen no matter what else is going on in the market. So, though much of the market may be focused on regulation and reform related to EHRs, there are still practices who haven’t yet implemented, and there are practices that are looking to get out of their current solutions.
According to the Office of the National Coordinator (ONC), “Building an EHR implementation plan becomes critical for identifying the right tasks to perform, the order of those tasks and clear communication of tasks to the entire team involved with the change process.”
Implementing an EHR is really about implementing a change management process: new rules, new ways of doing things and new things to learn. That’s an oversimplification, but it essentially hits the mark.
Setting up an implementation plan (the plan should be in place before the implementation begins) first starts with segmenting tasks into three categories, according to ONC:
What new work tasks/process are you going to start doing?
What work tasks/process are you going to stop doing?
What work tasks/process are you going to sustain?
The three categories help determine the future work environment of the practice; how things will work after the change.
Obviously, if you are moving from an existing EHR, you’re probably going to be more familiar with how things will work once the system is in place, with a few exceptions. However, moving from paper to electronic records means there are going to be a great number of changes that, if not accounted for, may cause some initial hurdles along the way.
Your next steps should include:
Mapping your current workflow and analyzing how you get things done
Mapping how the EHR will affect your workflow, and how you hope it will enable you to perform certain tasks or functions like how you plan for them to create more efficiencies and reduce duplicate processes?
Creating a backup plan to address issues that arise during implementation. This is crucial as issues beyond your control will come up and if you’re not prepared for them, they could derail your process and set you back. Think of worst case scenarios and plan for them to happen then hope for the best. No implementation is ever the same as another; each are there own experiences.
Building a project plan to blueprint the transition then appoint a team member to manage the plan.
Identifying data that must be transferred to the EHR either from paper or from the previous EHR (charts are the most obvious example here)
Finally, find out what can be transferred to the new system like patient demographics and schedules.
Once this point has been reached, you can bring other parties into your plan, like consultants and vendors, to get the plan rolling and potentially start the implementation.
In what appears to be an extension of yesterday’s post, today I want to examine some questions posed by Success EHS, which asks, “Should you replace your EHR?”
As you most likely know, most large enterprise ambulatory practices and hospital systems have well-established EHR systems in place. They are clearly recognized as among the early adopters of electronic health records, and, compared to their small counterparts, are also the most likely healthcare facilities to currently be in the market for an alternative EHR.
In the age of meaningful use, in a time where healthcare technology is also known as the electronic health record, the systems are being replaced with great frequency. The why and what fors are pretty simple to figure out if you’re familiar with the technology and the marketplace.
There are several prevailing reasons practices are jumping systems, though. They include (and I’m citing Success EHS here):
• Lack of strong vendor support
• Lagging product development
• Consolidation of disparate solutions
• Systems fail to live up to vendors claims
• EHR hinders efficiency and productivity
Given these hurdles – there may be others, of course – there are several questions practice administration must ask to determine whether it’s time to move.
Some of these questions include (feel free to grab a pen and paper and add to the list):
• Are issues able to be solved through remediation? No? Might be time to hit the road.
• Can the vendor’s technical improvements resolve any issues? If so, you need to ask that fixes be made in a reasonable timeframe. Obviously, telling said vendor that fixes need to be made “ASAP” won’t do; you must be reasonable. Consider negotiating a term of three to six months and get final terms in writing. Anything more than six months and it might be time to pack up and leave.
• Are you partially responsible for the EHR’s issues? If you’re partially or fully at fault for a botched EHR implementation or for poor usage, you owe it to yourself, your staff, your patients and, yes, to your vendor to work out a solution. If you’ve tried every solution and there’s no fix, you may be forced to move on. Some times it’s a matter of agreeing to disagree, let’s just agree on that.
• Do you have an opt-out clause? If so, you may wish to exercise it. If not, you’re going to pay, probably handsomely, to exit stage right.
• Are your current long-term goals going to be met using your current EHR? If not, you need to change your goals or change your system.
• Is your EHR negatively impacting practice efficiency? Success EMS says it best, “An EHR that hampers productivity now will only grow worse as the complexities of health reform initiatives increase in the future.”
If you decide it’s time to implement a new EHR system then it’s time to create an assessment plan. Assessments are designed to answer the “why” of implementing an EHR, and what is working and can be improved by installing one.
In taking a look around the HealthIT.gov site recently, I once again stumbled upon its series dedicated to offering practices insight into how to implement an EHR. A several part series, topics included cover what to look for when selecting a product, how to conduct training and, ultimately, how to reach meaningful use.
Given that nearly 50 percent of all practices currently have some sort of EHR, the process for setting up and implementing the systems are becoming more well known; however, having a clear plan and getting a little advice goes a long way.
So, without further ado, the following information is valuable and bears repeating, at least in part, even if you heard some of it before.
First steps
When starting an EHR implementation, a practice should assess its wants and needs. Keep in mind that no implementation is going to go completely smoothly (or at least as smoothly as imagined) so it helps to have a plan for what to expect and the plan should include room for error. Figure 10 to 15 percent in added time, resources and staff commitment over and above what you originally plan.
During the assessment, there will be some error and a few hurdles to jump. Don’t allow yourself to be told otherwise. If someone tries to tell you differently, that person does not have your best interest in mind.
If it’s a vendor, run. Do not purchase the product from the company because it’s only the beginning of what’s likely to be a long road of misinformation and false expectations. And no one appreciates being snowed, especially when you’re spending money on something.
Asking yourself questions
During the assessment phase, you also need to determine if you are even ready to implement a system, and if not, what more you need to accomplish. Assessments are designed to answer the “why” of implementing an EHR, and what is working and can be improved by installing one.
According to HealthIT.gov, “practice leadership and staff should consider the practice’s clinical goals, needs, financial and technical readiness as they transition.”
The site provides the following questions that practice leaders should consider during the process:
Are administrative processes organized, efficient and well documented?
Are clinical workflows efficient, clearly mapped out and understood by all staff?
Are data collection and reporting processes well established and documented?
Are staff members computer literate and comfortable with information technology?
Does the practice have access to high-speed Internet connectivity?
Does the practice have access to the financial capital required to purchase new or additional hardware?
Are there clinical priorities or needs that should be addressed?
Does the practice have specialty specific requirements?
What will the future look like?
Next up, it’s time to envision the future. Think about what you want to accomplish with an EHR, and write as part of your plan some things like: how are patients going to benefit, how can the care provided be better and how are providers’ lives going to change?
Finally, set some goals. According to HeathIT.gov, “goals and needs should be documented to help guide decision-making throughout the implementation process. And they may need to be re-assessed throughout the EHR implementation to ensure a smooth transition for the practice and all staff.”
Goals guide an EHR implementation, and are set once an assessment has been completed. As in life, goals provide an achievable end to an arduous task; the medal at the end of the race, if you will.
When developing goals for the implementation forgo conclusions like trying to determine what amount of savings will be created or how much of an increase in the number of patients or revenue will come into the practice. For now, these are intangible and often create a sense of failure if not immediately met after the EHR is “turned on.”
Keep the goals more process oriented and related to practice strategy and team building. For example, what goal do you have for the transition team? Do leaders emerge? Do advocates and coaches come to the forefront of the team that you had not expected? What practice visions are realized? Are you now more technologically savvy and able to attract better talent to the organization?
Perhaps you have business goals (other than the aforementioned money goals). Do you have a stronger business-planning process and clearer organization objectives now?
