Dr. Russell Kohl, Green Country Family Medicine
Some residents of Vinita, Oklahoma, a small town of 7,500 outside of Tulsa, have remarked with disbelief to the town’s doctors about visits to physician practices in other cities that don’t use electronic health records (EHRs).
The residents’ comfort with the secure electronic capture of their health data is thanks to the tireless and creative efforts of one of their doctors who embarked on a journey to implement health IT.
Dr. Russell Kohl is one half of a two person medical practice, Green Country Family Medicine. Kohl is an Air Force veteran of Operation Iraqi Freedom. During his deployment in the Middle East he grew accustomed to the efficiencies and overall benefits that the Air Force’s Global Expeditionary Medical System (GEMS) provided for his practice with respect to the handling of medical data and patient information. He relocated to Vinita through Oklahoma’s program to recruit physicians into rural areas.
Prior to Dr. Kohl’s arrival, the practice, the employees, and the patients were perfectly happy with the traditional paper method of tracking medical care. Dr. Kohl was not comfortable reverting to paper records, so he immediately began to effect change. After discussions and some convincing, the practice partners decided the adoption of electronic health records (EHR) was viable.
The financial outlay necessary to adopt health IT would be substantial for the small town practice. To surmount the fiscal challenge, Dr. Kohl decided that he would work with the state’s rural physician placement program to reallocate the money that would be his personal bonus for becoming a rural physician, and use it to fund the adoption of EHRs at Green Country. The Oklahoma Foundation for Medical Quality (OFMQ) was supportive of Dr. Kohl’s effort because this was the first rural practice to adopt in the state. With a deal in place for funding, Dr. Kohl had secured an interest free loan for an EHR system.
The next challenge was to find a vendor. Dr. Kohl requested information and cost quotes from several. One vendor responded that Green Country’s practice was too small, and they were not interested in an implementation. Another company replied that they were too busy to come to the small rural practice in northeastern Oklahoma to do the work. A third vendor proposed the use of their proprietary database to store patient information. Dr. Kohl was concerned that if the company went out of business there was no way to extract the patient data from the proprietary system for use in another system for continued patient care. He finally decided on an EHR system that uses a more universally known database technology that could be easily extracted if needed.
Having made an EHR selection, Dr. Kohl now needed to implement. Fortunately there were only 1,100 medical records on file at Green Country, so he hired a company to bulk scan the records and save them in a .pdf format in the chart file. However, the implementation of the EHR itself was more challenging. The initial subcontractor that was sent to install the system turned out to be disastrous. Kohl was completely dissatisfied with the technical abilities of the installer, and could not continue with corrupted databases and a non-working system. He notified the EHR vendor, and the company promptly sent their best installers to complete the job properly. There were long hours over a one month period to get the EHR up and running, but with diligence the system went live.
To build patient support, Dr. Kohl engaged in some grass roots efforts to introduce them to the system. He set up demonstrations of the EHRs in their workplaces, at the rotary club, and the university women’s society. That hands-on exposure for the patients allowed them to interact with the system, ask questions and actually see the answers to their questions and concerns. Next, the practice introduced the use of an electronic tablet for health data entry during patient appointments. Patients were very receptive to the tablets because eye contact with the patient could be maintained. Additionally, electronic tablets mimicked the interaction the patients had with their doctors when they were using paper charts. Eventually the doctors moved away from the electronic tablets as health IT was truly accepted in the day-to-day practice and patient interaction.
The staff’s reaction to the changes was surprisingly mixed for such a small crew. The nurses were completely accepting of the adoption of health IT in their work flow. Dr. Kohl’s partner initially said, “this isn’t as easy as paper.” To accommodate his discomfort with the electronic system, they redesigned some process to suit the disparate needs of the two doctors. On the opposite end of the spectrum from the nurse’s acceptance, the office manager was completely against the use of EHRs and quit because she didn’t want to use the system.
Beyond acceptance of EHRs, there has been a clear culture shift at Green Country. Patients and doctors have a true appreciation for conveniences like graphical representation of historical blood pressure measures. When the system is down for any reason, the practice has to revert to paper records, frustrating the physicians and the patients. But while patient satisfaction with the efficiency of the system is important, the actual outcomes of an implementation effort are paramount to its perceived success. Green Country has been electronically prescribing for more than a year now, an immeasurable process improvement gain. The practice is no longer experiencing the frustrations involved in faxing prescriptions, receiving phone calls about the prescriptions, or patient disgruntlement with inefficiencies in the process. Similarly the lab interface has expedited the practice’s lab interactions dramatically.
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Many parts of America are plagued with drug abuse. Some addicts use prescription drugs for recreational purposes, called drug diversion. Addicts are creatively seeking ways to visit multiple doctors for the same prescription drugs to satisfy their needs. The adoption of health IT and the implementation of health information exchange across multiple care settings in Oklahoma is preventing drug diversion in the state, as doctors are able to easily see if a patient has visited another physician recently to obtain prescription drugs.
Looking toward the future, telemedicine is on the horizon. Telemedicine is the transfer of medical information over audiovisual media for the purpose of consulting, analyzing medical data, or conducting remote examinations. Dr. Kohl will be involved in the implementation of telemedicine projects that will allow for cardiac monitoring of ambulance patient transfers to determine situational severity in real time. Similarly, patients in their bed in a rural clinic that are connected to cardiac monitoring apparatus can be monitored by technicians at a hospital many miles away.
Dr. Kohl encourages small practices that are unsure if their challenges to adopting are surmountable. He believes that smaller areas have the ability to move rapidly to make changes toward adopting EHRs. To begin the journey, Dr. Kohl makes these recommendations:
- Find others that are already adopting in order to have support and establish contacts.
- “You can’t implement unless you’re 100% committed”; “cross the bridge and burn it…there is no retreat”. If the approach you take is ‘if this fails we’ll go back to paper’, it will fail.
- The money IS available for the hardware and the implementation.
- Recognize that more efficiently tracking patient care will result in an increase in practice income.