Phoenix Children's Health Project
This unique mobile program began tracking the care of children in the local areas through the use of conventional paper charts. The chart tracking system consisted of a box of files that were color-coded for each of the regular weekly service locations. In the beginning there were about four care sites, so the file system had four colors. The color coding worked well during the first year of the program. For example, when the mobile unit went to the Mill Avenue clinic location, the blue charts were pulled and transported to the site. Similarly, each set of colored charts would be packed in a box for transport to its designated location. In time, strong relationships developed with each of the sites; but, the patients being served were also very mobile and unpredictable, as they would visit several different sites for care. For example, if the patient didn’t reveal that they had been seen at Mill Avenue (with the blue charts), then when they went to the Sojourner Center location a new chart was created with a different colored folder. The repetition of chart creation for the same patient resulted in a rainbow of duplicate charts that multiplied clinical and administrative difficulties for the staff. At one point, it was thought that perhaps all charts should be taken to every location, but soon the precious little space available in the mobile exam room was overtaken by boxes of paper charts. It became clear that the color-coded process used by PCHP and its partners would not work for very long, as it was taking a long time to locate the charts and keep everything organized. PCHP staff soon realized that an electronic health record (EHR) was their best option, but the cost was prohibitively high for such a unique program. As a back up plan, PCHP began pricing a trailer that they could pull behind the van that would have file cabinets storing medical records. It was then that Children’s Health Fund stepped in to provide an EHR solution.
Initially there were some problems as EHR implementation was phased in over many months. Only the physicians focusing on chronic diseases moved to the EHR system completely, but the vast majority of volunteer staff and even some of the covering doctors never learned to use the system. The resultant problems from having only part of the staff trained on the EHR system, and other issues related to implementation frequently led PCHP to revert back to paper charting. PCHP noted they never properly embraced nor prioritized the use of the first EHR system. The second EHR system was intended to be vastly different form the outset, as PCHP was truly committed to a focused implementation spanning only one week. From that point forward, all charting efforts were to be done completely using the new EHR system.
The revamped approach to implementation and usage of PCHP’s new EHR system resulted in an entirely different outcome. Now in their second foray, PCHP is truly exploring the capabilities of the new system and they’re realizing many advantages of the system’s active use in patient care. When contrasting the first implementation attempt against the second, Randy Christensen, M.D., M.P.H., PCHP medical director says, “Never before have I seen a group more in love with an electronic record, including the families.” Some of the noted results of the EHR system implementation include:
- Clear and concise follow up instructions for the families through appropriate medicine discharge sheets, as required by hospital, accrediting agency
- Contact number for families to call the triage
- Clearly communicated diagnoses and concrete instructions for patients’ families
- Enhanced communication to other medical providers.
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The enhancements to provider communications were brought to light in January 2010, during the treatment of a patient with malignant hypertension (very high blood pressure). The child was to be admitted directly to the pediatric intensive care unit (ICU) and, before the ambulance arrived to transport the child, PCHP was able to print the child’s entire chart (including data rolled over from the first EHR system). At the hospital, the nephrologists were impressed with the comprehensive data provided by the EHR system including blood pressure measurement history, height/weight charts, medication sheets, and diagnosis codes for the previous two years. The pediatric ICU appreciated the access to such valuable data, stating how important that level of provider communication efficiency is for making a diagnosis earlier in the child’s care process.
Prior to the more focused EHR implementation, the PCHP staff was writing out scripts for medications, and filling out medication reconciliation notes on paper. Using the updated EHR system, PCHP is able to process those items electronically while working in collaboration with a local pharmacy that delivers medications to their patients. As a result of the interface between the mobile clinic unit and the pharmacy, PCHP staff has reported that by the end of a clinic, when the mobile unit is packing up and preparing to leave, they have occasionally witnessed the pharmacy delivery vehicle arriving to deliver all of the medications that were just prescribed during that clinic.
Physician experiences with the second EHR implementation have been overwhelmingly positive. Recently, the program had to shut down the new EHR to change the system’s Internet protocol addresses because of a recent facilities’ move. The outage forced the program to revert to paper charting, creating angst and dismay among the staff. Having to revert to the old system, the program fell two weeks behind in billing and filling out referrals, and once again data was lost. For future planned outages, clinic services may be cancelled to avoid such chaotic processing and poor outcomes.
- Before the second implementation, patients were known to throw away any informational handouts they were given regarding their care. The handouts that PCHP used were too impersonal for the patients to really feel like it directly pertained to their own care. Recently, PCHP has been able to offer more and clearer communication discharge instructions and specific information that patients can use in participating in their own care. The PCHP staff has noticed that families and patients are keeping the notes generated by the new EHR system, and are actively referring back to the information. It’s not unusual to see patients pull out a patient care information sheet several weeks after a prior visit to show what they’ve done towards their own care and what medications they were instructed to take.
Based on PCHP’s experience successfully implementing health IT, Dr. Christensen offers these recommendations to other organizations implementing health IT:
- Do the system implementation all at once in a period no longer than one week.
- Schedule the patient load lighter for only a short time after implementation then resume your normal patient load to push proficiency with using the EHR system.
- Schedule short bi-weekly meetings with providers to discuss lessons learned from the week as a means to share information, making everyone’s learning curve less steep.
- After implementation, schedule a six month visit from your trainers to review larger process, or system use questions
- Play around with your EHR as much as possible to familiarize yourself and discover new possibilities
- Designate a “super user” who buys into the adoption process and has the time to be the advocate the EHR system needs.
- Don’t let your providers get away with writing notes and then transfer them to the EHR chart later—they will never get used to using the EHR system if they’re permitted to circumvent its use.
- Practice over and over how to enter data into the EHR while continually engaging the patient. Where you place the computer is very important; give it lots of thought.
- Explore wireless capabilities, because they provide flexibility allowing your staff to move with patients as they move through your care system.