A Solo Practitioner Uses EHR to Assess Quality of Care
Leland, NC - Fall, 2012
Carolinas Coastal Health is a small practice located in Leland, North Carolina, a town of around two thousand people located near Wilmington, NC. The practice is made up of three people: J. Wellington Adams, MD; Heather Britt, RN; and Toni Carovahllo, who runs the front office. The practice has about 900 patients, most over the age of 45, with 30 percent having Medicare coverage, while the rest are commercially insured. Carolinas Coastal Health adopted their electronic health record (EHR) in May 2009 and are currently using eClinicalWorks Version 9, which they used to attest to Meaningful Use in August 2011. They are part of the North Carolina Regional Extension Center (REC) for Health Information Technology.
Dr. Adams and Heather worked together in an emergency department with few EHR capabilities before opening a practice together in 2009. They implemented an EHR as they started their practice, so their adoption did not involve transitioning from paper to electronic patient records. Dr. Adams made the decision to adopt an EHR because he believed in the benefits of electronic health records and that it would make the practice more efficient. Specifically, it would allow them to see roughly 20 patients a day with just three practice staff, something that they believed would be impossible with paper records. Moreover, as Dr. Adams commented light-heartedly, “using their EHR internally and with their patients has allowed the practice to save money by not buying endless reams of paper!”
- Research. Dr. Adams spent a considerable amount of time and effort researching EHRs before settling on one. He reviewed the American Academy of Family Physicians (AAFP) survey of EHRs, to narrow the field down to 10 EHRs and ultimately tested and viewed demonstrations on 5 or 6.
- Demonstrations. To prepare for the demonstrations, Dr. Adams created a script for vendors to run through during the demonstration. This way, he could ensure that the EHRs could indeed perform the functions he prioritized. Dr. Adams also notes that it was important to him, given that he is a solo practitioner, to be able to have multiple people in the office accessing a particular record at the same time, a feature not all EHRs support. This way, the front desk staff can be loading information while Dr. Adams or Heather prepare for the visit – all viewing the same patient in different locations. Dr. Adams also made sure to ask vendors about any add-ons that might be necessary and the associated cost.
- Adoption. Carolinas Coastal Health initially adopted a widely-used product, but within the first month realized that it was not the right fit for their practice. Dr. Adams and Heather decided to “cut their losses”, despite having already expended some resources in the first system. However, instead of giving up on EHR technologies altogether, and going the paper chart route, Dr. Adams continued to research EHR systems and finally purchased eClinicalWorks. To date, the practice has only required about 16 hours of live technical support from eClinicalWorks, but has been pleased with the technical support received. In looking back on this experience, Dr. Adams commented that it is important for practices to realize that no EHR is going to be the perfect fit for every practice. He also noted the importance and need to tweak the application to best suit the needs of the practice and to receive the full benefits of electronic health records.
Benefits of Electronic Health Records
- Data and Efficiency. Dr. Adams and Heather noted many ways that having an EHR has increased the efficiency of the practice. The practice receives laboratory results over an electronic interface, and this data is automatically entered into the EHR as discrete data. With paper records, Dr. Adams expects that they would have needed to hire another staff member just to enter this data as laboratory results came in. Heather also uses the practice’s vital signs machine, which takes vital signs and automatically enters them into the EHR as discrete data. These functions help to ensure that the data required for clinical quality measures is structured data and can easily be extracted and analyzed for quality reports.
- Better care. Dr. Adams runs monthly reports on quality measures and discusses any trends with Heather. As a follow-up to these discussions, the practice staff then develop and implement any necessary corrective actions to improve the results. Dr. Adams, as part of the North Carolina REC, also participates in Improving Performance in Practice (IPIP), which is a quality improvement program for primary care practices in a number of states, including North Carolina. Participation in this program allows him to compare his results on a variety of quality measures to those of others participating in the program. Although Dr. Adams believes that he provides high quality care to his patients, with an EHR he can compare the care he provides to his patients with the care received by patients treated at other practices and thereby quantify the quality of care that he provides.
- Efficient Care. In addition to running monthly reports, Carolinas Coastal Health has a number of other systems in place to ensure that their patients are receiving appropriate and timely care. First, they use the alerts within eClinicalWorks based upon prioritized diagnoses. For example, alerts can be set for patients with diabetes to ensure they obtain ordered lab work. The alerts will not turn off until an outstanding issue has been addressed, such as when a diabetic patient’s A1C lab result has been received. The practice team has found these alert functions helpful for monitoring the course of patient care.
- Patient Follow Ups. Dr. Adams also notes that with a paper record, the patient may sometimes need to remind the doctor that she is due for services such as a mammogram. This responsibility is now shifted to the EHR, which alerts Dr. Adams to follow-up with the patient. The practice also uses the EHR’s functionality for making phone calls to patients who are overdue for a physical, which helps them to ensure these patients are not neglected.
- Care Coordination. Another benefit of electronic health records is that it enables the practice staff to better coordinate care for their patients, both with the patients and with other physicians. When Dr. Adams refers a patient to a specialist, he receives a call or fax when the patient has scheduled an appointment and receives notes from the specialist soon after the visit. If the notes have not been received, Toni follows up with the specialist, a process which helps to ensure that patients are not getting lost in the referral system. Additionally, Heather estimates that about half of the practice’s patients are active users of the patient portal, which is an eClinicalWorks product that the practice chose to purchase and was installed along with the EHR in 2009. Patients can schedule appointments in the patient portal, request prescription refills, and view their lab results. In fact, instead of requesting that the practice send laboratory results over to a specialist in town, patients will often print their lab results from the portal and bring them to their appointment with a specialist. Patients can also fill out their pre-visit questionnaire online (which includes patient demographics, current medications, and the reason for the visit), which cuts down on the time patients need to spend filling out paperwork when they come into the office.
EHR Meaningful Use Quality Measurement Objectives Addressed
To attest to Meaningful Use, Dr. Adams reported on the three core clinical quality measures:
- Hypertension: Blood Pressure Management (NQF 0013)
- Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention (NQF 0028)
- Adult Weight Screening and Follow-up (NQF 0421)
He also reported on the following menu set measures:
- Diabetes: Hemoglobin A1c Poor Control (NQF 0059)
- Diabetes: Low Density Lipoprotein (LDL) Management and Control (NQF 0064)
- Diabetes: Blood Pressure Management (NQF 0061).
Although eClinicalWorks is currently certified for 10 clinical quality measures, the practice chose this subset of measures because they were already monitored as part of their internal and state quality measurement efforts. For instance, Dr. Adams extracts and submits data on hypertension and diabetes quality measures from his EHR to IPIP. To keep track of where Carolinas Coastal Health stands on these and other Meaningful Use measures, Dr. Adams uses the Meaningful Use dashboard that is part of eClinicalWorks, which shows him practice performance each month and over the course of 90 days (the Meaningful Use attestation period).
Dr. Adams views the Meaningful Use incentive payment as a bonus to offset some of the EHR implementation costs. However, the impetus to this practice’s EHR adoption was their belief that an EHR could help them achieve more efficient and higher quality patient care. Overall, implementing eClinicalWorks has allowed Carolinas Coastal Health to better communicate with patients, better track patient follow-ups, better track performance on process and outcome measures over time, and improve overall care.
- It takes time to implement an EHR and get to Meaningful Use. Purchasing an EHR does not automatically mean that Meaningful Use is just around the corner. The EHR requires customization to fit the practice and to collect complete and accurate data. It also takes time to load all of the information, such as local pharmacies and area providers into the EHR, which is necessary for prescription ordering and point-and-click referrals. However, the return on this time investment is highly positive, as these functions are useful and time-saving in the long-run.
- When possible, make use of templates and techniques that other EHR users have created (available on user forums and vendor websites) and customize from there.
- It is important to review CQM data with key clinical staff at the practice. Together, staff can develop and implement a plan to improve performance on measures of interest