Summary: One of the first physicians in the country to be certified as a "meaningful" user of health information technology says the electronic health record system she implemented has significantly improved her performance on measures of clinical quality by providing immediate feedback on her adherence to evidence-based standards of care. The system has also reduced the administrative burden on physicians and staff, resulting in increased productivity and income for the practice.
By Sarah Klein
In May, the federal government awarded its first payments to physicians who successfully demonstrated that they are making meaningful use of electronic health record systems (EHR). To qualify for the payments, physicians had to prove that—among other things—their EHR systems were capable of capturing and exchanging health information on patients, including lists of medications, allergies, and test results. Physicians were also required to demonstrate that the EHR had the functionality for computerized physician order entry, electronic prescribing, and reporting of clinical quality measures to state and federal bodies. (For a complete list of the requirements, see Exhibits 1 and 2).
Two weeks after the government began allowing physicians and other providers to certify that they had such systems in place, 283 providers had qualified for the first payment of $18,000 (another 37 hospitals and/or health systems qualified for larger payments.) Over the next five years, those who meet additional and increasingly rigorous requirements will be eligible to receive a total of up to $63,750. To create an additional incentive to adopt an EHR, the government will begin penalizing those physicians who forgo EHRs with a 1 percent reduction in Medicare fees beginning in 2015. The penalties increase each year until they reach 5 percent.
The federal government hopes the financial incentives, the threat of penalties, and the regional training it is offering providers to facilitate the implementation of EHRs will encourage the participation of the nearly 50 percent of U.S. physicians who do not now use any form of an EHR.
To understand the obstacles these physicians may face in implementing an EHR that meets the government's meaningful use standard and how these systems enhance quality of care, Quality Matters asked Jen Brull, M.D., one of the very first physicians in the country to be certified as a meaningful user of an EHR, to describe her experience incorporating one into her medical practice.
Jen Brull, a family physician, treats patients in Plainville, Kan., a rural town within Rooks County, which has a population of 5,181 and one critical care hospital. In practice for 10 years, she shares office space and support staff with two other family medicine physicians. There are a total of 20 people (including the physicians, a nurse practitioner, a physician assistant, nurses, medical clerks and administrative staff) in the office.
In 2007, Brull and her colleagues jointly purchased an EHR system for approximately $90,000, selecting the system based on its price and its ability to integrate billing and medical records, a function that allowed the practice to avoid duplicative data entry.
Among other functions, the system they purchased has the capability of tracking progress notes, medical history, medication lists, and laboratory results. The system also notifies users of overdue laboratory and screening tests, provides best practice guidelines for specific conditions, and alerts providers to drug interactions and patient allergies. The EHR enables the practice to receive results from the laboratory at the local hospital electronically and it allows the physicians, all of whom use the same EHR, to share medical information with one another.
The product also has a number of features designed to improve office efficiency. It allows staff to scan the forms patients fill out and automatically transfers that data into designated fields within the medical record. It also allows providers to assign tasks to particular staff. For example, a physician in an exam room can notify a nurse of the need for a referral to a specialist and attach relevant medical records, visit notes, and images to the request. The information already contained in the chart populates the referral form.
Prior to having the system, "I used to have to finish the note, I had to fill out the consult form, and then I had to get the note and the consult form to my nurse. If I was on top of things, that took anywhere from five to 10 minutes. If it was the end of the day and I had to remember things, maybe 15," she says. "Now, I make the decision for the referral, send the request to the nurse, and sign off my note at the end of the office visit," Brull says.
The system also offers a portal for patients through which they can access current and past medication records, allergy lists, past medical history, and their appointment record, among other information. They also can request refills, ask for appointments, receive laboratory and x-ray results, and send a direct message to the provider or nurse. Brull estimates that 20 percent of her patients now use the patient portal, though it is available and free to all.
Process of Change
Practice leaders felt it was important to engage staff from the outset and thus included them in site visits to view the systems under consideration and discussions of the EHRs' strengths and weakness. Soon after the purchase the office set up a test database on the server, populated by data from a training database. All employees practiced on this system over several months leading up to the launch. After the initial training, staff began the process of incorporating information from paper records into the system by abstracting and scanning information into the electronic chart, a process that reinforced the training and helped them understand where to locate information in the electronic chart.
On the day of the launch, the practice closed the office and a vendor representative came to oversee the process. Three office representatives—a physician, a nurse, and a member of the administrative staff who had attended a two-and-a-half day training program with the vendor—were on standby to answer questions from their colleagues as needed.
Once the system was up and running, Brull says staff began to notice its benefits. One of the most immediate was the time savings that accrued from not having to retrieve and return charts for patient visits and phone calls. "For one person, 50 percent of her job was chasing charts," Brull says. Not having to search for paper charts also reduced the time patients had to wait for a response to a phone call. And because the nursing staff was less occupied with managing paperwork, the nurses had time to provide additional services to patients, including a foot clinic for patients with diabetes and arthritis. While that service provides the practice with additional revenue, "it's also just better care," Brull says.
The EHR, which replaced a simple electronic registry the practice had used to track patients with diabetes and hypertension, broadly expanded Brull's ability to monitor quality measures. In addition to monitoring patients with those conditions, the system tracks how many of her patients have had cancer screenings. Using it, she discovered that only 43 percent of patients who needed colorectal cancer screenings had received them, and only 68 percent of women who needed mammograms had obtained them. "I was horrified," she says. "I thought I was this wonderful women's health care provider. But people were falling through the cracks and it's not until you have an EHR to show you those people's names, that you can do something about it," she says.
Once these problems were identified, the providers and staff developed strategies for increasing the rates. For colorectal cancer screening, Brull created a form that was handed to patients when they arrived. It explained in laymen's terms the importance of colon cancer screening and outlined screening options. When the patients reached the exam room, Brull asked them which approach they'd like to pursue. As a prompt to ensure Brull did so, the nurse placed a hemoccult kit in the exam room and added a reminder in the medical record, which Brull would see when she opened the electronic chart. With the use of the letter, the chart reminder, and the visual cue, the rate of colorectal cancer screening went up to 85 percent after 21 months. "Am I happy with 85 percent? No, but it's better than 43 percent," Brull says.
For mammograms, the practice began sending orders for mammograms to the local hospital, which contacted patients with appointment times. With that, the percentage of women between the ages of 40 and 80 getting mammograms at appropriate intervals rose to nearly 99 percent over 18 months.
Brull says her practice was able to act upon the data the EHR provided because it had always been geared toward process improvement. Staff were regularly meeting to brainstorm new ways of improving care. One recent session focused on how to increase the number of patients who have height information in their medical chart, a meaningful use requirement. When the staff examined why these rates were low, they discovered that some staff members had difficultly operating the stadiometer and that it was placed in an inconvenient spot. Once an easier-to-use stadiometer was placed in a new location, the number of patients with heights in their charts rose by 25 percent.
The EHR has engaged even more employees in process improvement. The staff member who is in charge of removing expired medications from the sample cabinet asked for help building a spreadsheet to track when medications in supply cabinet would expire so she could remove them in an efficient manner. She then asked for a list of patients who are taking those medications. Two months before the medications expire, "she sends them a little note or calls them or sends it by the patient portal to let them know we have samples if they would like them," Brull says. This employee "was not that computer savvy and now she's building lots of spreadsheets," Brull says.
The EHR has also enabled more efficient medical billing because the physician no longer manually relays that information to the billing clerk. And with less data entry, the billing clerk has more time to follow up on accounts receivable. "We can pay attention to all points along the line much more consistently than when we were doing the work by hand," Brull says.
Qualifying for Meaningful Use
The fact that Brull's practice had been using an EHR since early 2008 made it easier for her to meet the meaningful use criteria, but some requirements were still difficult. Brull found it frustrating to meet the criteria that require physicians to document that patients have been screened for and counseled against smoking, not because she didn't have data on smoking status, but because it was contained in a text box in the history section of the chart, rather a new template section as required. That meant that it needed to be moved. "We had to remember to check this each time," Brull says.
The requirement that practices collect smoking information at the time of the visit or within the previous 23 months was also a challenge because the practice had not marked the date at which the information was previously collected. Since the practice couldn't confirm that it met that standard, it had to repeat the advice, log the date, and enter a code for tobacco cessation counseling. That irritated patients whose insurance carriers did not cover the cost.
"I don't mind talking to my patients about smoking and it has made me more conscientious, but I have to remember how to document it to get it to count. That is a pain," she says. Having a supportive vendor—one willing to adjust the system to make these sorts of tasks easier—is critically important, she says.
The reception staff also had difficulty with the requirement that the practice collect demographic information, such as race, ethnicity, and preferred language. They "were worried about offending someone and they were getting questions about why we wanted the information. We did some cultural sensitivity training and talked about why we wanted the information (to reduce health disparities) and that answered the concern," Brull says.
Brull says working with the local Health Information Technology Regional Extension Centers (REC), which offers technical assistance and guidance to accelerate provider adoption of EHRs, has also helped her meet the meaningful use criteria. One of the ways the REC helped was by identifying security gaps. In her practice, the problem was not having a manual outlining security policies. "They had templates we could cut and paste. That probably saved me 100 hours," she says.
In addition to improving the quality of cancer screening, the EHR has dramatically increased staff productivity and enabled the practice to add two additional providers without increasing support staff. Brull's productivity has increased as well. She estimates she sees 2 to 4 additional patients per day. With that increase in productivity and concurrent cost savings related to EHR use, her annual income has increased by 40 percent. Brull believes the increase has little to do with better billing, but rather the increased efficiency she achieves by spending less time on paperwork and having more immediate communication with supporting staff via an electronic system. "I am not spending time on the back end. I finish all of my notes at the point of care. When the patient leaves, I am done and that includes things like writing a referral to a specialist," Brull says.
Though the financial gain was substantial, it was not immediate. Her income rose slowly over a period of three years, but that increase, together with her first incentive payment of $18,000, amounts to more than three times her share of the purchase: $30,000. "Everyone talks about this being a big hit financially, but none of us have seen that," Brull says. "The financial performance of our individual practices' is better," she says.
Lessons and Implications
Brull is confident the EHR program will have a dramatic impact on the quality, safety, and efficiency of her practice and this motivates her to continue discovering its potential. While she considers this work exciting, she has found many local physicians are not looking forward to the prospect of using an EHR. Some say "it's awful. The federal government is making us do stuff. They are looking over my shoulder," she says.
Brull tries to persuade them by arguing the benefit of EHRs to physicians and patients. "If you look at the [meaningful use criteria], it's to improve the quality of care, improve safety, collaborate with patients and others, improve security and coordination statewide," she says.
Part of the way this is accomplished is by making physicians aware of their performance, which can be hard, she says. "You think you are doing a great job and you pull up your colorectal cancer screening rates and you're hitting 43 percent. That's embarrassing and it's a real number," she says. But that's where she sees the incentive program's greatest benefit. "Physicians are driven and competitive and they will fix it," she says.
For physicians considering it, she recommends seeking help from the local REC. "They have amazing resources to help you pick an EHR and implement it. They will show up in your practice. My REC representative was here four times and I'm in the middle of nowhere Kansas," she says.
Once a physician selects the system, she recommends staying in touch with the vendor as the vendor can help revise the software when needed. "Letting your vendor know you are working toward meaningful use also helps. They would like to be able to claim a large number of users who have made it to that milestone," she says.
It doesn't hurt to have a highly driven physician like Brull at the helm. Brull was the 34th physician in the country to be certified. She believes she would have been one of the very first if she hadn't lost her password to the Office of the National Coordinator of Health Information Technology Web site that morning. She had to wait an hour and by that time she was 34th. "I really wanted to be first," she says.
Exhibit 1: Core Measures of Meaningful Use
Physicians Must Meet All 15 of the Following Criteria to Qualify for Stage 1 Incentives
Source: Centers for Medicare and Medicaid Services. See: https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp
Exhibit 2: Menu of Non-Core Measures
Physicians Must Meet 5 of 10 to Qualify for Stage 1 Incentives
Source: Centers for Medicare and Medicaid Services. See: https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp
1Physicians who qualify under the Medicare program are eligible to receive $44,000. Those participating in the Medicaid program can receive up to $63,750.
2 C. Hsiao, E. Hing, T.C. Sosey et al., "Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates," Dec. 2010. The preliminary results of a survey by the Centers for Disease Control and Prevention found only 50.7 percent of physicians reported using all or partial electronic medical record systems, while just 10.1 percent reported having systems that met the CDC's criteria for a fully functional system.