Optimizing Primary-care and Specialty Practices

Primary-care Practices

- Optimize an existing EHR for primary-care practices...[Geisinger’s experience]

• Understand the functions of EHR software
• identify useful and to optional ones;
• obtain info from peer via visit/phone;
• Analyze and document current workflow
• patient registration, phone calls, patient visits, patient check-out...
• verified by clinical leaders, managers
• decision: elimination, change, add, remain...
• design new steps/processes
• benefit al parties/ participants involved in the workflow
• maximize efficiency, more intuitive, less training, less effort, fewer errors,...
• benefits outweigh the effort required to put the changes into effect.
• allow feasibility to defer some workflow changes
• 3-6 months to make user comfortable with EHR
• 6-12 months to make users interested in EHR.
• a short lie of commonly used items (<20)>
• Dx, medications, orders, procedural codes etc.
• ICD-9, CPT-4
• cover 80% of patient visits
• Short enough for fast searching and selection
• new preference list request
• create synonym for missing or hard-to-find diagnosis/procedures
• challenge: easy for users to channel the requests support team
• request from: domain experts, super-users, practice managers, re-training sessions...
• Charting tools: (template notes) for documenting clinical observations directly to EHR
• fundamental to creating patient records
• complete, focused, timely, standardized, flexibility for free-text. Abstraction of relevant into from paper record and entering them into EHR.
• Skills at reading EHR screens and entering information
• Development
• Iterative, cyclic, continuing
• begin with most common problem and visit types
• build templates notes together with domain exerts
• to provide content and order sets from their practices

- training, EHR supports, tool-building workshop.

• Post implementation support
• Extensive post-go-live support is critical
• shadow training for 2 weeks after go-live
• Ongoing user training after shadow training
• Close coordination between shadow trainers and super-users
• Publish practical EHR tips
• User group meeting

-Go-live is the start of next phase

• Enhancement of EHR, and also user skills
• Usability needs, missing software functions, further EHR improvement to fit improved.
• Rooms for improvement, i.e. business opportunities, are found during post-go-live support.

• Workshop
• Training Review
• identify discrepancies, user confusion and dissatisfaction
• through interviews with clinica land admin staff
• schedule a few months after go-live (3,6,12 months), since it takes time to integrate basic EHR functions into workflows
• Allow notice for post-live training sessions, e.g. 1-2 months
• Allow time to prepare questions, suggest changes, e.g. add new diagnoses to preference lists.
• review under the joint leadership of practice management and IT director.
• Communication with EHR users
• to notify users and managers about system downtimes, upgrades, changes to EHR
• schedules
• short and free of IT jargons: tell extractly what users need to know
• what when alternative, whom
• unscheduled
• back-up communication channels
• phone call to practices, paging, automated reply, personal messages.

Specialty Practices

Specialty-Practice complexities

• Included:
• Collaborative care
• Ancillary services
• Outreach clinics

Collaborative care

• Multi-specialty clinics
• providers rotating to various sites, share support staff
• Integration problem: scheduling, patient registration, documentation, test ordering, result distribution, billing...
• Collaborative care between multi-specialty clinics and external physicians -> efficient communication
• Complex, changing schedules: inpatient round. supervising residents, outreach clinics.
• Participate in clinician trials: complicates order entry, documentation, billing...

Patient chart is important in specialty practices:

• Phased-implementation becomes complicated
• some use EHR; some use paper
• Use of paper medical record until every practice use EHR
• Notify clinicians that addition information are available from EHR
• It takes longer time to phase out patient chart.

Ancillary services

• Often the most complicated aspect of EHR implementation
• Ancillary services provided to both in/out patients
• various types of bills: physicians, technician, equipment,...
• Perform study using equipment & software that do not communicate with EHR [security reasons]
• Some scenarios
• cardiology: cardiac catheterization lab, EKG lab, Echo lab, cardiac rehab.
• Neurology: EEG lab, sleep lab

• To reduce complexities, practice leader can decide the level of EHR functions to be used by ancillary areas:
• result viewing, messaging, order entry, documentation
• for example,
• integrate EKG and echo lab results with EHR for their clinical significance
• audiology and speech lab personnel use all EHR functions in the ear/nose/throat practice.

Outreach clinics

• Specialists see patients in outreach clinics that are located in primary-care sites
• EHR did not support outreach clinics, from where order entry and documentation not permitted
• Include outreach clinics in the implementation planning of EHR of the specialty practice
• ensure EHR caters for the workflows of both home and outreach clinics
• shadowing support available at both locations
• EHR home practice go-live first, followed by that at specialist.

Special Purpose software

• Specialty practices use multiple special purpose clinical info system for
• equipment management: ultrasound, EKG
• Treatment: x-ray therapy, chemotherapy
• Handling data for regulatory and clinical trial report
• Special purpose software should be included in workflow analysis and design
• include their functions in the EHR
• link their function to EHR
• continue to use it as free standing software:
• enter into EHR the results from paper report produced by the software.

• Workflow Analysis
• In each practice, study patient movement from appointment scheduling to final checkout
• recognize the differences among the practices, e.g.
• the statement ‘a patient is placed in the exam room to await the physical examination’
• Urology: require complete urinalysis before being placed
• Orthopedics: require X-rays

- Checklist of analytic questions

• Communications & training
• Communicate with physicians during non-office hours
• training must focus on workflows and efficiency tools developed specially for their practice.
• short training sessions: to avoid productivity loss.
• Shadow training

Multi-specialty Clinics

• EHR should be redesigned to become integrated multi-specialty system
• Understand existing workflow, through the different perspectives of different contributing practices.
• Convince payers the single referral-multiple-providers system

Research patient

• must be identified as a research participant any time the EHR is accessed.
• Registries must be in list of patients participating in each study
• participant status entered into patient demographics; visible at front desk, scheduled appointment, check-in etc
• Appropriate EHR access for authorized clinical trial reviewers.
• Grant read-only access to the records of participants on the trial list
• Incorporate their workflows and customized security access agreement into the standard operating procedure
• the patient’s study-related medical history should be readily identifiable
• deactivate all identifiers at the end of the study.