Rural Health Clinic Exchanges Information with Hospitals and Physicians for Improved Coordination of Care

To use the EHR system to improve patient care coordination within the rural health IT setting’s local referral network.

Working with the Washington and Idaho Regional Extension Center (WIREC)

The Seattle-based REC has provided free technical assistance to the clinic since 2010. Michelle Glatt, a physician assistant and health IT consultant, visited the clinic last year to conduct a readiness assessment and gap analysis. Glatt reviewed each meaningful use care coordination objective to determine whether the workflows supported the data that needed to be collected, how the data will be reported and whether the software was capable of meeting each criterion.

When the gap analysis showed that workflows needed to be improved, the clinic’s team attended a WIREC workshop to learn how to analyze the clinic’s care coordination workflows critically, and lay the foundation for continuous practice improvement. “A best practice is to look at rural health IT from a systemic workflow perspective. Rural health IT projects are more than just software development projects. Reviewing how the flow of information, staff and patients intersects with the technology is critical to the success of a project like meaningful use,” said Glatt.

In 2005 the clinic chose DocLinks, a local proprietary Web-based EHR product. Its services include unlimited patient portal access, e-prescribing, and scanning and faxing documents. The EHR selection process involves several steps:

• Including staff in the decision making
• Identifying a physician champion
• Determining the most important features
• Requesting proposals and demonstrations from vendors
• Selecting finalists
• Negotiating a contract

The transitions from a paper chart system to an EHR system took about two years to complete and involved an interim step of maintaining paper records until the physicians felt confident that the EHR system was stable and consistently accessible. “Initially, the platform was not fast enough, or stable enough, and we had to hire a company to bring us high-speed Internet,” said office manager Pam Schlauderaff, R.N.

The clinic scans about 400 pages of paper a month including labs or consultant’s notes from providers using only paper records or a different EHR product without the software interface. “This requires about 40 FTEs [full-time equivalents] of staff time to assign the document to the patient’s EHR and label it appropriately,” said Pam.

• Clinical Information Exchange. 
  Olympic Physicians, a rural health IT setting in Washington state, exchanges key clinical information including patient histories, medication, and allergy lists with other providers. These include the local hospital and primary care and specialty clinics that use the same EHR product (DocLinks™) or a software interface that connects different EHR products. For providers using paper records or who lack the interface, Olympic Physicians exchanges key clinical information via fax or e-mail and clinical summaries via fax in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
• Clinical Summaries at Transitions of Case or Referrals. 
  The EHR system can generate a transition of care summary that includes progress notes, problem lists, orders, medication lists, and demographics and transmit the information electronically to the local hospital, primary care provider, or specialist. In addition, the provider can input orders into the EHR using programmed order sets while the patient is in the office and hand the patient a clinical summary before leaving. The workflow impact is that the provider no longer dictates clinical summaries after the patient has left, which had to be transcribed and added to the patient’s record, and then faxed to the referring provider.
• Medication Reconciliation. 
  When patients check in, the medical assistants review and update the medications in the EHR to provide an accurate list for the provider at the point of care. If there is a discrepancy, the patient is instructed to take the clinical summary home and verify the medications. The four hospitalists [doctors who specialize in the care of patients in the hospital] also use the EHR system to import medication lists from the office record into the hospital chart when they admit patients, and update the medications in the office chart when they discharge patients. Both the local hospital and Olympic Physicians use Surescripts, an e-prescribing service, which interfaces with DocLinks™.

"This is a vast improvement from trying to communicate through paper notes about medication changes in the nursing home." –Mark Schlauderaff, M.D

• Since purchasing the EHR system in 2005, the clinic has reduced the number of medical record personnel from 4 FTEs to 1.25 FTEs, which has off-set the monthly fees and other costs associated with the EHR system.
• The clinic’s EHR system generates dashboard reports that show monthly progress in meeting care coordination objectives. The reports are provider-specific and are used for quality improvement purposes.
• Anecdotally, the EHR system appears to have improved care coordination among local providers. Olympic Physicians has 24/7 access to Mason General’s Emergency Department (ED) reports, labs, x-rays, progress notes, histories, physicals, and discharge summaries.
• When Olympic Physicians refers patients to specialty practices that are licensed to use DocLinks™, the specialist can see the clinic’s records in the patient’s chart and the clinic can see the specialist’s notes and recommendations, enabling them to avoid ordering unnecessary and/or duplicative tests.
• Using a Web-based EHR product also enables physicians to access the clinic’s records from their laptops or other devices. Providers update the patient’s medication list when they see patients in other rural health IT settings, including the local nursing home.

"Electronic access to the cardiologist’s records enables us to know the most recent test results, and avoid ordering unnecessary and/or duplicative tests." –Mark Schlauderaff, M.D.

The clinic has experienced the following systemic barriers to using the EHR system for care coordination:

• Washington State is developing health information exchanges, but they are not operational yet. This limits the ability of different EHR systems that lack the software interface to connect to each other.
• Improving connectivity between the EHR systems in larger hospitals and the rural clinics costs money. For example, St. Peter’s hospital in Olympia would have to pay DocLinks™ a licensing fee so its ED doctors could access ambulatory office records.
• Medicare-certified rural health clinics, including Olympic Physicians, are ineligible for Medicare meaningful use incentives because they bill Medicare on a capitated rather than a fee-for-service basis.

Implementing an EHR system is a time-consuming and labor-intensive process. It’s critical to obtain buy-in from staff at every level of the organization because everyone has to adapt to the new system and way of doing things. “This change was also necessary to move forward and recruit and retain young physicians,” said Pam.

• Conduct Onsite Readiness Assessments. WIREC will conduct more onsite readiness assessments to determine how the upgraded EHR system affects their care coordination workflows, including a medication allergy checkbox.
• Payment Avenues. WIREC is also investigating other payment avenues, including Medicaid.