Community Clinics EHR Assessment and Readiness Project

1. Community ClinicsEHR Assessment and Readiness Project EHR: Pathway to Healthier Communities May 4th and 5th, 2005 Sponsored by the California HealthCare Foundation and Community Clinics Initiative Forum Highlights OBJECT HEALTH Julie V. Murchinson Timathie Leslie

2. What is an EHR? • Electronic, patient-centric clinical record of care encounters to support care processes • Longitudinal across providers, care settings and time • Enables clinical communication and patientcare planning • Accessible by authorized healthcare practitioners serving the patient • Enables continuing education and decision support • Documents specific services received by the patient for legal and reimbursement purposes • Source of data for clinical, health services, outcomes research, and public health Community Clinic EHR Project Source: Computer-based Patient Record Institute, 2002; HIMSS, Standard Insights, 2003.

3. Bush praised computerized records as a way to avoid medication errors, cut costs and improve care. Promises to have EHRs in 10 years Why EHR now? President Bush appoints David Brailer as the first Health IT Czar Hillary Clinton announces plan to introduce legislation to encourage development of a national health information infrastructure, including adopting electronic records.… IOM calls EHRs an “essential technology” to enable patient safety AHRQ grants awarded to demonstrate value of health care IT …unprecedented enthusiasm and commitment for changing the day-to-day world of health care with HIT from leadership across sectors. – David Brailer, National Coordinator for Health Care Information Technology Pay-for-performance programs are becoming more common and doctors are being asked to “demonstrate quality outcomes or consistent practices” - BTE Kennedy announces health care plan Source: iHealthBeat.org, Object Health research Community Clinic EHR Project

4. Health Care Delivery Landscape • Patient data unavailable in 81% of cases; average of 4 missing items per case • 18% of medical errors are due to inadequate availability of patient information • Patients receive only 55% of recommended care • 44,000 – 98,000 annual inpatient deaths due to a preventable medical error • Medication errors in 5 – 18% of ambulatory patients; resulting in 1 in 131 deaths • 17 years to translate medical research into medical practice • Physician Desk Reference more than doubled in 20 years to 3,075 pages • 5th consecutive year of double-digit growth in health care expenditures • 30% of health expenditures categorized as “unnecessary spending” = $7.4 trillion aggregate in US from 2004 - 2013 Incomplete knowledge of patients Patient safety & Medical errors Increasing complexity of clinical care Increasing cost of care Community Clinic EHR Project Source: iHealthBeat.org, Object Health research

5. EHR Value Proposition Savings Generated from EHR Clinical Automation • Increased operational efficiencies • Improved communication among providers Interoperability • Decrease administrative burden of manual data sharing (fax, courier, mail) • Decrease unnecessary utilization of ancillary tests Decision Support • Decreased medical errors and adverse drug events • Improved patient compliance Community Clinic EHR Project Source: Object Health Research, Gordian Project Analysis

6. Barriers to EHR Adoption Community Clinic EHR Project Source: Promoting Adoption of electronic Health Records: Incentives and Connectivity, September, 2004, Connecting for Health program.

7. Top 10 Reasons for EHR Adoption failure • No definition or measures for progress or success • No organized mechanism for communication and feedback • Lack of formal training plan • Lack of effective physician leadership * EHR does not meet core provider needs • Lack of alignment with business strategy • Weak executive-level sponsorship • Underestimating impact on organization • No readiness assessment for change • Unrealistic expectations • Lack of an effective, cross-functional implementation team Community Clinic EHR Project Source: Health Choice Network presentation, September 19 – 21, NACHC Convention, San Francisco.

8. Physician Leadership Executive Leadership Technical Leadership Lessons Learned from EHR Adoption Successful EHR implementation requires: • Effective change management • An EHR that meets defined needs Source: NACHC presentations, 2004, Robert Miller, UCSF, 2004 Health Affairs publication Community Clinic EHR Project

9. Heard at the Forum • “Training is forever…” – Ken Bernstein, Darin Camerena Health Center • “Move slowly pre-EHR, to go faster post-EHR; understand effective EHR use BEFORE implementation” – Robert Miller, PhD, UCSF • “Best practice definition is key” –Kwame Kitson, Institute for Urban Family • “Lengthy pilots don’t work; Super User Groups do work!” –Vija Sehgal, MD, MPH, PhD, WCCHC Community Clinic EHR Project

10. More Forum Advice… • Lessons Learned • Must be proactive in looking for opportunity (fix REAL problems) • Requires high level of organizational awareness & support • Know your capabilities (Design wide; Implement skinny) • Local engagement leads to commitments (People really matter in getting IT done) • Elements of Success • Clarity of goal; organizational alignment • Clinician participation • Key decision makers engaged • Situation must evolve to meet requirements - Jeremy Noble, MD, MPH, Harvard School of Public Health Community Clinic EHR Project

11. Clinic Readiness EHR Demonstration EHR product offerings Product Readiness Vendor Assessment Project Goal: Create a Community Pathway for EHR for CA Clinics EHR Self Assessment EHR barriers to adoption EHR Educational Forum Community Clinic EHR Project

12. Why is Readiness so important? 50% of EHR implementations have FAILED or produced suboptimal results Community Clinic EHR Project Source: Department of Health and Human Services, 2005.

13. Readiness Attributes – Alignment Organizational Alignment • Culture: values; environment for achieving excellence; ability to manage change and maintain flexibility; team approach • Organization: infrastructure to support information flow, decision making, and problem resolution; role of the board and leadership team; vision for quality; ability to collaborate with external organizations • Leadership: the characteristics of leadership team: setting vision, commitment to quality; alignment across organization • Strategy: mission and vision and priorities documented in a strategic plan; internal and external communications Community Clinic EHR Project

14. Readiness Attributes – Capacity Management Capacity • Information Management: quality, accessibility, relevance and communication of data/information • Clinical and Administrative Staff: staff capacity; staff training and competence; consistent policies and procedures; methods to motivate and drive individuals/groups to achieve goals • Accountability: how results are achieved and mission/vision fulfilled; role and responsibility of patient in care process • Finance & Budget: extent of infrastructure and management of IT budget; capital and operational resources Community Clinic EHR Project

15. Readiness Attributes – Capacity Operational Capacity • Workflow Process: tools and methods for managing change, developing policies, procedures, protocols; Quality Improvement model; process for monitoring and communicating performance; analysis and actions taken to improve processes and performance • Patient Involvement: preventative and chronic care processes; patient follow-up and care continuum; comprehensive care • Training: Infrastructure and resources dedicated to initial and on-going IT training Technical Capacity • IT Management and Support: IT staff skill-set and capacity for IT management and support; consistent policies and procedures • IT Infrastructure: information systems environment and infrastructure Community Clinic EHR Project

16. In addition to ambulatory small office EHR functional priorities, community clinics desire: • Population management and quality initiatives including use of disease registries. • Desired sophistication of decision support features. • Reliance on multiple patient outreach, education, and communication. • Tracking of patient relationships other than genealogy • Collection of patient social status and other social characteristics. • Management of multiple payer types and program enrollment information. Clinic-specific Scenarios Clinic EHR functionality Community Clinic EHR Project

17. We are reminded that there is no “silver bullet”, and product gaps exist • Lack of Organized market for shared service and technology offerings (ASP) • Integrated population management and decision support programs are immature • Patient Health Record (PHR) modules are scheduled for future releases • Management of multiple payer types and program enrollment information require customization • Clinic specified data elements are not part of the standard data dictionary • Limited experience with regional, state and federal reporting • Standardized pricing does not account for clinic settings with concurrent and volunteer users Community Clinic EHR Project

18. Assessment (based on self reported data) Community Clinic EHR Project

19. When viewing demonstrations, evaluate functionality considering: • Ease of Use • Performed functionality with ease • Performed, but it was not intuitive • Workflow • How would this functionality be done? • By whom among clinic staff? • Does it fit within the current workflow? • Are there impacts to current workflow that represent a change? • If there is an impact to workflow, quantify the impact • Availability • Available in current release? • Requires code modification • Requires configuration • Pricing • Included in price quoted? • Requires hardware/third party software? • How is it maintained? Community Clinic EHR Project

20. Project Takeaways • Community Clinic Mission • Improve the quality of and access to care for communities • Clinic model has significant potential to achieve this mission through population health management • EHR • EHR is one information tool available to enable population health management, the successful use of which can result in improved quality of care and increased efficiencies • EHR momentum is increasing rapidly across the nation • Team leadership is critical for EHR success • EHR Forum • Goal: Provide information, resources and strategies; determine if there is interest and common need among community clinics that could be supported to accelerate adoption • Day 1 – Clinics assess their own readiness for change and adoption of health information technology to manage and improve clinical care • Day 2 – Clinics assess EHR product readiness to enable quality improvement goals Community Clinic EHR Project

21. Next Steps • Clinics • Use the Readiness Assessment tools to get a better understanding of your clinic’s readiness for EHR adoption • Take advantage of learning experiences from industry publications, vendors and other clinics • Communicate your needs and interests to CCI • Take your time to pursue the right path for your clinic! • CHCF and CCI • Continue work in this area: • Develop specific strategies to define models for adoption • Assist the field with determining readiness • Work closely with other funders to determine opportunities for collaboration Community Clinic EHR Project

22. Forum Materials Documents presented and distributed at the Forum are available in the Library section at http://www.communityclinics.org Community Clinic EHR Project