Part Three of our series on Reliant Medical Group’s EHR implementation delivers ten lessons and seven tips from Dr. Larry Garber, medical director for informatics, and the project team.
1. Get Started Early on a Thorough Data Conversion
The data conversion project took a full year, longer than expected due to the extensive mapping required for lab results originating from seven reference labs over the preceding 15 years and loading the records into Epic. “In retrospect, there was no doubt that it was worth the effort and worth the wait, but we should have started the conversion earlier,” Dr. Garber said.
When sites went live with Phase 4, physicians no longer needed the paper medical record and didn’t have to juggle paper and electronic records. “We continued to deliver the paper charts to the stations for up to a year in the event that something was needed urgently, but that was almost never the case,” Dr. Garber said. What was more remarkable, however, was that when a physician looked into the Epic EHR on the first day of Phase 4, they could see encounters from 15 years prior with visit notes, prescriptions, diagnoses, and test results.
2. Equip Your Team with a Good Project Management Tool
Managing an EHR implementation requires careful oversight, coordination, and prompt issue resolution. At Reliant Medical Group, the project was tracked using a 3,500-line project plan, as well as a Risks, Assumptions, Issues, Dependencies (RAID) spreadsheet which doubled as a decision-tracker—which proved valuable when resolved issues resurfaced. The project was run by a Physician Champion, a Nurse Champion, an IT Owner, and a talented Project Manager, all of whom understood both the technical aspects of the project and the clinical and operational aspects of Reliant Medical Group. The EHR vendor provided corresponding analysts to work with the project team.
3. Do the Work In-House to Retain the Knowledge
Reliant Medical Group used very few consultants because “we wanted to keep the knowledge and skillset in house, which has proven to be invaluable as we continue to enhance Epic long after the initial implementation phases,” Dr. Garber said. The Project Team reported to the Epic Steering Committee, comprised of the CIO, Physician Champion and Nurse Champion, along with representatives from Operations, Finance, and Revenue Operations. Meeting frequently, they monitored the status of the projects and were able to quickly resolve scope or resource issues. The Epic Steering Committee reported regularly to the “C-Level” Management Council to keep them informed and engaged throughout the project.
4. Frequently Employ All Manner of Communications
Targeted and clear communication permeated the entire implementation process, according to Dr. Garber. This kept users engaged in the rollout and allowed for timely feedback on how things were going. Following an all-employee kick-off meeting, numerous presentations at departmental and managerial meetings, software demonstrations, frequent memos, and newsletters kept everyone informed about what was coming and how to prepare. Direct feedback to the team and trainers, as well as calls to the “Help Desk” enabled rapid adjustments to EHR workflows and content. “This open and frequent two-way communication was crucial to the success of this project, and continues to this very day,” he said.
5. When Enthusiasm Wanes, Reignite it with Even More Communication
Despite efforts to keep physicians and staff engaged in the project, significant change is hard for everyone, and keeping up positive momentum is even harder over a several-year project. As a result, Dr. Garber’s team found it necessary to actively “re-market” the EHR, reminding everyone through presentations and newsletters of the numerous benefits that had been defined by such a broad group of Reliant Medical Group employees. In addition, CIO Ed Nazzaro held one-on-one meetings with every manager, department chair and site chief to remind them of the value of the EHR and their important role as leaders to champion the EHR and disseminate these values. These herculean efforts reinvigorated the EHR implementation and allowed it to proceed with positive attitudes as each person had a fresh vision of the future.
6. Training Trumps Vacations: Get the Calendar Out Early
Effective training and support were also crucial to the success of Reliant Medical Group’s implementation. Training at each phase was mandatory for all physicians and staff. Sites were given at least six months advance notice as to their go-live date for each phase. This gave them enough time to plan so that physicians and staff would not take vacation during this critical time. The team tried to avoid school vacation weeks and left a blank slot at the end of the Phases 3 and 4 in case something went wrong at a site, in which case that site could be rescheduled to the open time slot without disrupting the rollout. “We never needed to use those slot,” Dr. Garber said.
7. Hire New Grads as Cost-Effective EHR Trainers; Reward Staff with Food and Credits
Training for each phase involved hands-on classroom training using a combination of PowerPoint presentations and live scenarios. Reliant Medical Group hired several recent college graduates who were interested in working in the healthcare field and trained them to become EHR trainers. “As a result, we were able to afford a greater number of these high-quality trainers than would otherwise have been possible,” said Dr. Garber. Just-in-time training of physicians and staff was done the week prior to each go-live and was customized to both the specialty and the category of user (provider, nurse, medical assistant, etc…). While attending training was a job requirement for all physicians and staff, CME/CEU credits as well as food were also provided as rewards.
8. Model Behavior for Physician Use of Technology in the Exam Room
As part of Phase 4 and new-hire training, Reliant Medical required each user to watch a 10-minute video that teaches exam room etiquette for using the computer in front of the patient. Using the “LEVEL” tool developed by Kaiser Permanente, actors demonstrated the wrong way and right way to Let the patient look on, use Eye contact with the patient, Value the computer as a tool, Explain what you are doing, and Logoff and say you are doing so. While these humorous vignettes were well received, LEVEL also dramatically changed how patients are engaged in the exam room. Historically, the paper medical record would be a secretive document on the physician’s lap where notes were scribbled that the patient could never read. In contrast, using LEVEL, the computer monitor is strategically located between the physician and patient to form a triangle so that both can view the screen simultaneously. The computer is the proverbial “elephant in the room,” and by acknowledging its presence and demonstrating its value to the physician and the patient, everyone wins.
9. Be Prepared with a Disaster Recovery Scenario
Reliant Medical Group adheres to an electronic protected health information risk management program (see Appendix D) that is comprised of both a vulnerability analysis as well as disaster plan. Two data centers are set up in an active-active mode that allows for almost immediate failover and recovery from most common disasters. All information contained in the Epic EHR is logged between production and Disaster Recovery (DR) data centers.
“We also split our Active Citrix environment that hosts our EHR system between these two data centers and have the capacity at each to host all clinical users,” Dr. Garber said. “These systems are tested monthly when we go to a downtime “Read-Only” state using our DR data center during off hours in order to apply production updates and patches.”
Reliant Medical also performs a complete system restore and validation every few months when rebuilding development and quality assurance environments. The Group also evaluates its DR process and downtime procedures each year to incorporate any changes in systems or workflows that would affect the Clinic. “These processes proved to be effective on 1/16/2009 when we had a catastrophic hardware failure with database corruption,” Dr. Garber said. “Read-Only access to our EHR from the DR site was available within 1 hour and system restore/validation was complete 35 hours after the initial failure.”
10. Institute a Collaborative Vendor Selection Process
Just as there was a participatory environment determining the need for an EHR, a diverse team selected the vendor. The “Advisory Council for the EHR” (ACE) was created with over 70 multidisciplinary physicians as well as clinical, business, and IT staff. They reviewed the RFP responses from the three EHR vendor finalists. The implementation team then drafted a demo script about the medical journey of a fake patient, Wanda Getbedder. This script laid out the functional requirements to be demonstrated at each moment, along with scoring.
The script/score cards were given to the RFP finalists as well as the ACEs who then sat through and rated 12 hours of vendor demos. The vendor demo score cards revealed two clear leaders, which prompted further investigation. Multidisciplinary teams performed site visits, reference checks, and attended User Group meetings for these top vendors. KLAS survey results were reviewed and financial due-diligence was performed to evaluate the long-term health of the vendors. Finally, a detailed and sophisticated financial 10-Year Total Cost of Ownership and Benefits (ROI) analysis was performed with the help of a spreadsheet developed by our consultant.
The results of this exhaustive evaluation pointed to one EHR vendor being most likely to meet the 140 functional requirements necessary to achieve the 100+ benefits aimed at solving the 127 problems identified several years earlier, and to lead the clinic towards a healthy future.
In site visits, our #2 vendor was not able to show us a practice as large as ours, and the smaller practice that we visited continued to deliver and use paper charts well over a year following implementation. By contrast, when we visited the Palo Alto Medical Foundation and Harvard Vanguard Medical Group, they were larger than Reliant Medical Group and were using their Epic EHR in exactly the way that we had envisioned using it.
Seven Tips for Making the Most of Your EHR
1. Use the EHR to Reduce Patient No-Shows
Reliant’s staff uses the EHR’s back-end database to make sure that patients show up for tests scheduled appointments. A few days prior, patients’ names and phone numbers are automatically extracted and sent securely to the ELIZA Interactive Voice Response (IVR) system to remind patients of their upcoming appointment. Through this system, they can also cancel the appointment, which sends data back into Epic to cancel their appointment and let the staff know about it. If a patient still doesn’t show for a scheduled lab test and it’s not subsequently completed by another order, then a letter is automatically generated and mailed to the patient to remind them of how important it is to get this test completed.
2. Discover Which Patients are Most Delinquent and in Need of Help
The EHR allows Reliant to more close monitor patients who may be falling through the cracks between visits. Using internally developed software integrated with Epic, health coaches in the clinic’s Patient Centered Medical Homes (PCMH) can identify patients with “actionable delinquencies.” If they are overdue for a monitoring test, for example, that is considered actionable and the patient is contacted to get the test performed. If they are merely overweight, that is less actionable. Thus, Reliant came up with a relative score known as the “Barometer of Actionable Delinquencies” (BAD). Patients who have the highest BAD score sort to the top of the registry so that the health coaches know who to call first. The EHR also automatically mails out letters to patients on their birthday telling them of any health maintenance or disease management tests or procedures that they are due for.
3. Simplify Fields for Ordering Tests
To help physicians use evidence-based medicine in make clinical decisions, the physicians on the Epic implementation team built guidance into the names of the orders so that it’s easy to order the correct test. For example, they created “1-click” orders that contain the relevant diagnosis/history (e.g. Hematuria), timeframe (e.g. within 2 weeks), and correct study (e.g. CT Abdomen and Pelvis with and without contrast). “We were also one of the first Epic customers to integrate the UpToDate medical reference into Epic so that it’s readily accessible at the point of care and accrues CME credits,” Dr. Garber said.
4. Allow Patients to Access their Records
Besides making computer monitors easily visible in the exam rooms, Reliant Medical implemented Epic’s tethered personal health record (PHR). This allows patients to view almost everything in their record online, including using their iPhone. They receive test results, can ask questions, request prescription renewals, download CCD summaries of their record, or do “e-Visits” for specific problems such as cough or back pain. Children of elderly parents as well as parents of young children can obtain “proxy access” to the patient records. Adolescents have uniquely secure access so that their parents only have limited proxy access to their records. This way, adolescents can be more honest with their physicians when using the PHR or when in the office.
5. Turn on the CDS Alerts to See Incremental Benefits
The team at Reliant also discovered that it wasn’t enough to just implement an EHR – they also had to turn on the clinical decision support (CDS) alerts in order to see incremental benefits. The group’s diabetic and breast cancer screening quality measures reveal that when they turned on CDS two years after the EHR go-live, they were able to achieve significant improvements, exceeding the National 90th Percentile in most cases. They were also able to show improvements in patient safety.
6. Consistency is the Key to Meaningful Use
Although Reliant implemented our EHR before “Meaningful Use” (MU) was defined by CMS, “we did find that MU had an impact on our organization,” Garber said. While prior to MU, they were using 100% of the HER functionality, MU ensured its consistent use.
7. Mine and Share the Benefits of HIE
Connecting to other components of the healthcare community not only facilitates the rate at which EHR users see value, but also improves the quality, safety and care delivered throughout the entire healthcare community. Reliant Medical Group has been a leader in the novel use of interfaces and Health Information Exchange (HIE). They have worked with the Massachusetts Medical Society to interface the EHR with Massachusetts eHealth Collaborative’s Quality Data Center to compare our quality metrics with those of other organizations in the region.