When Lawrence General Hospital (lawrencegeneral. org) set out to convince 36 providers within its Choice Plus Independent Physician Association (IPA) (choiceplusnetwork.com) network to jettison their paper charts and adopt electronic heath records (EHRs), a personal touch was a key part of the winning formula.
The multi-year effort, which began in 2010 through a collaboration between Lawrence General, the Choice Plus IPA – a subset of 18 small practices – and Beth Israel Deaconess Care Organization (BIDCO), looked to a local project manager already familiar with the practices and their divergent interests and needs, along with the very experienced BIDCO EHR project team, to help make the transitions happen. The decision proved critical in assuring providers that EHRs could work in their unique care environments without disrupting or diminishing the quality of care they are used to providing.
Tucked in the Merrimack Valley region of northeast Massachusetts, the IPA groups include 11 primary care provider practices, four specialty practices and three pediatric practices. Getting each to realize the full potential for EHRs would require a lot of shoe leather.
“The gap (in implementing an EHR) was that these solo independent practices really didn’t see the benefit of the investment that would be required in dollars, disruption and initial productivity loss in their practices,” said Andrea Sullivan, Director of Managed Care and PHO at Lawrence General.
“They did not have a clear value shown yet to them for making that investment, and many of them really could not afford to make that investment in making that transition [to an EHR]. We made it as easy as possible for them by providing the financing as well as the extra resources that were comprehensive enough so we would have successful implementations.”
Overall support for the project arrived in several channels. The financial backing came under the Stark Law, which allows hospitals to provide practices with 85 percent of EHR startup and implementation costs. Lawrence General Hospital and its Trustees made a significant commitment to enhance the adoption of electronic technologies in small physician practices in the community, for greater efficiency and quality of care as well as to support the hospital’s vision of a “regional health care” model that would serve to improve health care across the Merrimack Valley region. Lawrence General also collaborated with the Massachusetts eHealth Institute (MeHI), which is the Regional Extension Center (REC) for the Commonwealth. The REC is key for providing education and resources to help health care providers adopt EHRs.
BIDCO, with which the Choice Plus IPA’s physicians are also affiliated, provided a comprehensive project management team that included addressing technical buildups as well as workflow enhancements going from paper to electronic and the actual implementation and training. BIDCO had already successfully implemented 75 practices with many lessons learned from which the Lawrence physicians then benefited.
The ground support – and the piece that really helped to “seal the deal” and push the implementation forward – came by way of Caitlin Mundry, PHO Physician Integration Manager at Lawrence General. She already had existing relationships with the practices and their providers and focused on assisting them through the implementation process, including advocating on their behalf with the project team members to assist with workflows and other issues that arose once the EHRs were installed.
“I think that aside from good project management plans and aside from quality products being implemented, there becomes a whole other personal level in how you deal with the people and not just the computers,” said Mundry. “I think having a one-on-one project manager who was familiar to them from the beginning – to answer questions, reassure them and relate to them how they are currently functioning and how we can improve their functioning – gave the practices confidence throughout the process.”
The practices in the EHR project ranged from pediatricians, to surgeons to OBGYNs, so being familiar with the processes the offices employed prior to the EMRs helped to understand how they could benefit from an electronic system.
“I think the trust factor was huge because these physicians had only recently – within the prior six months – joined BIDCO,” added Sullivan. “So they really didn’t know the BIDCO staff that well and I think the fact that we were sanctioning and promoting this project and would be there as part of it made a big difference in getting the buy-in with the physicians and contributed to its success.”
One of the practices had been using an early electronic system, but all the others needed to transition completely from paper. The existing system – as is often a drawback with paper-based systems – provided significant challenges with making important patient information available exactly when it’s needed.
“In one case we had a specialty practice with four locations that were doing chart drops every night,” said Mundry. “Someone had to physically deliver information in this archaic model. Now you move to a model where a patient can show up at any of their four practices and have their information readily there. There’s the opportunity to see the whole picture of the patient wherever they may be.”
One primary care physician who recently brought up a bi-directional lab interface from the hospital is able to check lab orders and reference charts against lab results with a few easy clicks as opposed to having to ask a medical assistant to pull a chart. The real-time results can yield numerous benefits, such as getting a medication to a patient in a more timely manner.
“I think we’re seeing increased speed with knowledge and the ability to use that knowledge to benefit the patient,” said Mundry.
Sullivan echoed that sentiment.
“I think no matter how painful it was to go through the processand the slowdown in productivity as you learn to use the system, there’s definitely no going back. No one could ever think of possibly going back to paper once you have that information at your fingertips and readily available,” she said.
Multiple factors influence resistance from providers and practices to make the switch from a paper to an electronic system.
“We had some practices where it was a cost concern, and we have everything from brand new doctors to doctors nearing retirement age,” said Mundry. “It was many factors but having that local resource and understanding where the pitfalls were for each practice helped us avoid them.”
One doctor might not want to bring a computer in the exam room while treating the patient, while another doctor would want a pc or tablet device there at all times, so part of the team’s challenge was to determine each provider’s unique needs and interests and help them to develop a process that worked best.
Some of the larger practices were interested in the financial benefits, such as the funding that could be acquired from the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Program; others examined whether billing and coding could be done more efficiently with an electronic system. Specialty practices needed the system to fit within their specific needs. A “one-size-fits-all” approach would not work if all the providers in this group were to get on board with EHRs.
The practices and providers also had to contend with the trepidation of learning a new system and the logistical concerns that go along with it, such as loss of productivity during the training process.
“The financial barrier I think was the biggest one,” said Sullivan. “Once you took that away and made it more affordable for them they were more willing to even think about dealing with the rest of the barriers.” Our physicians and their staff really rose to the occasion, embraced the effort, and they and their patients are now deriving value and benefits from the use of electronic records.
With the EHRs in place, some of the new initiatives being worked on are electronic connectivity to lab orders and results, as well as electronic radiology results delivery and the difference from the previous faxing method is that these results can be released and flow right into the patient’s record.
The effort has also allowed all the providers involved to attest to Meaningful Use through the CMS EHR Incentive Program. The 36 providers between 2011-2012 earned a total of $642,000 Meaningful Use Stage 1 and AIU dollars. Fourteen providers are in the Medicaid program and 22 are in Medicare.
“100 percent of eligible providers in our project were able to achieve (Meaningful Use) with the help of the experienced BIDCO team and the local project manager,” said Mundry.
With Meaningful Use Stage 1 progressing, attention will soon turn to Stage 2.
“Again it goes to this one-on-one nuance of how this project operates and how we can make these Stage 2 requirements fit into their daily patient care versus something brand new,” said Mundry. “So knowing the practice, the staff, how they function and their typical work flows, helps improve their achievement of Meaningful Use as we can adapt it and make it relevant to their particular patient care practices.”