Electronic Medical Records

Choosing the Right Technology Facilitates Better Care

“Health information technology (HIT) has the power to transport us to almost a dreamlike world of health care perfection in which the work of doctors and the care of patients proceed with barely imaginable quality and efficiency, “ David Blumenthal, MD, MPP, and John P. Glaser, PhD, wrote in their article “Information Technology Comes to Medicine,” which appeared in the June 14 issue of the New England Journal of Medicine.

Electronic health records (EHRs), or electronic medical records (EMRs), have been gaining popularity in general medicine and medical specialties—including the dialysis setting. They have the potential to streamline patient care in areas such as ordering care, ordering medications, running reports about one patient or the entire clinic.

They can eliminate the necessity of a paper chart. But some physicians or clinic owners may require a little convincing. Incorporating this novel technology can be as beneficial as it is frustrating. Although it can add great value, it can also be troublesome when physicians lack the “buyin” mentality that is so necessary to a successful implementation.

Why Implement?

“An EHR allows for an efficient and legible collection of clinical data,” said Brenda H. Lepley, chief operations officer for National Renal Alliance. “It is a resource that lets us easily retrieve information and provides accuracies. The information we collect in our EHR includes important factors that we use to improve the quality of care for our patients. We consider our EHR a vital component to our continuum of care.”

An EHR system can help team communication with retained documentation, which is easily searchable. It also helps trend complex lab data and keep a record of medication dosing, which may affect the lab outcomes, said Evan Norfolk, MD, an associate in nephrology for Geisinger Health System in Danville, Pa. “Specific to dialysis, it allows direct exportation of data from the dialysis machine (blood flow rate, dialysis flow rate, blood pressure, heart rate) into the electronic record, which nurses traditionally did manually. Finally, a physician does not need to be in the dialysis unit to access the complete shared documentation.”

The first step when considering an EHR, said John Hartman, MD, chief executive officer of Visonex LLC, is “to make a distinction between paperless and electronic record. It’s a misconception that a clinic can be paperless. I’ve never seen a clinic where paper consumption has gone down after they’ve adopted an EHR.

“When we talk paperless, what we mean is that all information is stored in electronic format. They don’t get rid of paper. One of the true benefits is it allows you to access data in different ways to create new information or new insights into old info. One of the biggest benefits that is often overlooked is the elimination of data silos, or data kept in multiple locations.”

Without an EHR, a physician might write an order to change a patient’s medication. The order can be changed on various forms, and may be copied for at least one or two treatments in advance. The order may need to be rewritten many times, for many locations, so staff can have access to the information. There is a great opportunity for error in this situation. Keeping all of the orders synchronized is a challenge. But an EHR eliminates this issue; with remote access for employees, they will all be able to see the same information in one place.

EHRs can provide specific benefits for a dialysis center, said James M. Cox, medical adviser for Health Informatics International. “EHRs can promote standardization of workflow to progressively optimize workflow and have data to support changes in workflow designs; make known documented knowledge available more quickly; make known documented knowledge available remotely, leading to better outcomes in a more efficient, less costly way; and increase collections per treatment and reduce days in accounts receivable.”

Speed is another crucial consideration, said Nick Nemmers, marketing manager for InteGreat Concepts. “You can speed up your daily work and see more patients in a smaller amount of time, which in turn produces more revenue for a clinic.”

Switching to an EHR can reduce the number of errors in the practice of medicine and can add convenience. “There is a lot of good information available through an EHR; with our package, you can customize links that come up when you’re in a visit, so if you want educational material right on the screen, you can show it to your patient, email it or print it out for them. If you use our patient portal, people can go online before the office visit and actually input their medical history, family history or previous illnesses. That gets everything out of the way and speeds up the process when they actually get to the clinic,” Nemmers said.

Nemmers pointed out that there are additional benefits to an EMR. These include the following:

Storage: You can get rid of all the paper files, which sometimes take up large amounts of space in a clinic and become old, unorganized, etc.

Security: Information is always backed up if something major happens (hurricanes, flooding, fires, etc).

Accessibility: Medical records and information can be pulled up from anywhere you can access our system.

Terry Daly, RN, vice president of clinical services for InteGreat, added, “Physicians can access patients’ charts from the dialysis facility. They can see the patient’s current medications and allergies and lab results helping them to monitor their kidney function. They also can enter their visit note directly into the EMR and send charges from the EMR to the billing system.”

Those are not the only reasons why dialysis clinics need EHRs, said Jonathan Lorch, MD, FACP, associate professor of clinical medicine; director of medical informatics; and director of nocturnal dialysis at The Rogosin Institute, at New York Presbyterian Hospital-Weill Medical College of Cornell University. “One of the reasons is financial, one is clinical and the other reason is quality. If you take an average dialysis patient, for example, they have somewhere between six and 10 different diseases going on at the same time. Once they get to end-stage renal disease (ESRD), the kidneys aren’t the problem anymore; it’s everything else in their body that is the problem. Keeping track of such things is really quite difficult, especially because patients may be on dialysis for 10 to 20 years, or come back after having a transplant and then you have to start again. Having some way to track their diagnoses over time is very important.”

The second issue has to do with chronic disease and how healthcare providers follow the mountain of information, he added. “In a study, we looked at how much information a dialysis patient generates in a year, and they probably generate somewhere between 12,000 and 19,000 data points in a year—similar to congestive heart failure patients, who may generate 4,000 or 5,000 data points. Consider all the data you have to keep track of— weekly and monthly lab tests, information from the dialysis machine, notes that have to be done.”

“The problem with a paper-based system is you can’t read it; it becomes unintelligible,” Lorch added. “Second, paper-based systems are a snapshot of time, and you can never rearrange the information in the piece of paper if you want to have a different view of the patient. If you have a good medical information system, you can go back in time and re-run what happened to the patient by looking at any combination of data they had at that point of time. The EHR is a particular kind of medical information system designed to report data so you can, over a long period of time, see what happened to the patient and what you did to them, and how that affected them.”

There is, he said, a point-of-care feedback loop. “Let’s take the patient who is getting ever-increasing amounts of Epogen, and the hemoglobin starts to fall. If you deal with paper, you will never know what happened in the past, but if you deal with a system that can atomize data, you can go back and see when the person last got iron, what the last iron saturation was. Have they been hospitalized? Have they ever had a GI bleed?”

Nowadays, most clinics are not using paper—they are using medical information systems. The problem is, some of those systems are mainly administrative in nature—they are not good for point of care, or for treating the patient. They are not designed for quality assurance. “That’s part of the problem when people speak of EMRs—you have to know what kind of EMR it is, if you want to begin to say whether it will help or not,” Lorch pointed out. “You can’t just say that having an EMR will be helpful. EMRs, to be useful, have to allow users on the ground to be able to extract data for a given problem they may be facing, without going to a programmer who won’t have a report for eight months.”

Drawbacks to Implementing EHRS

Not all EHR vendors can install and implement a new record system successfully, and there are other drawbacks associated with the disruption to regular service inherent in a switch to an EHR. There is also the issue of users who are not computer-savvy, who are not comfortable with the technology associated with the EHR. “One of the biggest hurdles to overcome is physician and upper level workforce resistance,” Hartman said. However, he added, “Physicians have gotten a bad rap about being bad with technology, but physicians are some of the fastest adopters of technology. They were the first industry to achieve 85 percent to 90 percent use of the Web or email when all other professions were in the 60 percent range. They’re smart consumers of technology, which should make life faster, easier, less complicated, more convenient.”

At first, it may take them longer to perform certain tasks, because they must sign in and out of the data management system, and they may not find a tablet PC as convenient to carry as a paper chart. “Some may think, ‘Why spend $300,000 on something that slows down work and is a big headache?’” Hartman said. “Physicians need to change and adapt to technology; we really have to come up with smarter technology that offers better physician workflow, allowing them to do jobs faster and in a more convenient matter.”

But not everyone is willing to change. “The greater the change, the greater the disruption,” Hartman pointed out. “Implementing an EMR changes work flow, and when doing that, they have to redesign or re-engineer the way they do their tasks, and putting in a full blown electronic record or trying to go ‘paperless’ or converting all data simultaneously to electronic format is a big disruption for a clinic—especially performing day-to-day activities while designing new business flows.”

One other challenge might be converting old paper records to an electronic version. That depends on the level of technology in the clinic beforehand, and also on the vendors. It is helpful if the information is not only electronic, but also searchable—so a scanned chart might not be helpful. Progress notes that are handwritten would take a great deal of effort to enter.

And then there is the sense of “buy-in.” “Sometimes we find that the willingness to go to an EMR is not there; sometimes you’ll find that a clinic will be divided—some will be all for it, but some others are stuck in their ways,” Nemmers added. “They see their paper process as something that works and don’t see the benefits right away. If some people get into it and don’t see benefits from day one, that turns them off. But once you get past the implementation and everybody is trained on it, people love it.”

Finally, there is the cost of the system itself. “The drawback of implementing an EHR system is the cost associated with the implementation and ongoing maintenance of the system,” Lepley said. “There can be significant costs for the hardware and software. In addition, there are costs associated with the initial wiring, ongoing support, training, ongoing maintenance and updating hardware/software.”

Cost of Installation and Implementation

Actually installing the technology can be costly or relatively affordable, depending on the system, the degree of automation, and how much information needs to be converted. “There is the cost of purchasing software or application to view EMR, and depending on the level of automation, there can be a lot of hardware costs—bedside charting needs might require computers that are easily accessible, such as computer or laptops on carts or fixed computers near stations, and varied solutions for connectivity, whether they be wireless or wired,” Hartman added. “And soft costs are often not taken into consideration—the disruption during deployment.”

It’s possible that the implementation could cause disruption to the clinic for months, if it is poorly planned. If disruption is longer than expected, it can result in staff turnover and disillusionment among employees. That can raise the cost of the implementation, Hartman said—adding political capital and staff turnover to the costs. Not only that, but there is also downtime during staff training before the new technology is launched—extra staff must be brought in just to cover for those in training with the new EHR.

But EHRs can dramatically benefit dialysis clinics. “One of the biggest things that is different about dialysis compared to other ambulatory care encounters is that dialysis is about delivering therapy or treatment for a diagnosis that is already known,” Hartman said. “A lot of times in an ambulatory care clinic, the doctor is still trying to figure out what is going on. The work flow is entirely different. The primary goal of a dialysis clinic is to deliver therapy, and ensure it goes well, and monitor patients for consequences. If those fall outside specific parameters, then the dialysis providers switch from therapy mode to diagnostic mode—such as if a patient comes in with a fever. But the primary goal is to deliver a specific therapy.”

When a facility is delivering standard repeated therapy over and over, that lends itself toward automation—which in turn lends itself to computerization, because it allows the physician to automate processes and know what’s going on inside the clinic. There is also a reduction in data “silos”—which can lead to a reduction in errors.

The EMR can demonstrate savings for the clinic quickly; in fact, said Nemmers, “You can see large return on investments fairly quickly. When everything is right there, you don’t have to spend 15 minutes searching through thousands of folders. You are cutting back on staff time and the amount of staff required.”

What’s Necessary? What’s Extra?

The “necessary” components of an EHR—compared to the “bells and whistles”—will differ from clinic to clinic. One necessary piece will be a good medication system to track prescriptions and treatments. But beyond that, it really depends on how fancy the clinic wants to get—whether the computer will be used as a primary source for getting data, or will be used to run many paper reports to weave into the workflow process. “A lot of people like to go to the computer for everything,” Hartman said. “The ability to use slideable bars on a graph that shows hemoglobin trends, and make them smaller or larger, might be considered bells and whistles for some, while others would really find that useful. It depends how the application is going to be used, and the technical sophistication of the people using it, and what they hope to get out of it. It’s in the eye of the buyer.”

Core items would include the ability to track treatments delivered and to capture all billable items, immunizations, medications, etc. There would need to be the potential for good auditing and insight into who’s capturing data.

There are really two main categories of information management in dialysis, Hartman said. “The traditional EMR is an information management system, an event log. I can ensure I can bill for it and protect myself from a medico-legal standpoint. But at Visonex, we look at information management and technology as a tool—giving insight into how a clinic operates, improving communication to ensure maximum productivity and workflow.”

Different clinics will have different levels of sophistication, so rather than giving an immature organization a complex system and making them figure out how to use it, they provide an application that is very flexible and can be delivered at the level of the maturity of the organization. “If the organization is more mature, we can turn on more functionality,” Hartman said.

One of the biggest problems in the industry, he said, is that most clinics will use only 20 percent of the record, while the remainder sits idle. “There is a difference between having it, and having it in use in the clinics. If you take complicated functionality and put it into a clinic that is less mature, or has poor leadership, that extends the disruptive period. But we really try to match the functionality to the organizational maturity level, so this gives them a quick return on investment for the least amount of pain.”

“I feel one of the most important aspects of an EHR is the collection of specific clinical and machine data” Lepley said. “For National Renal Alliance, it is important that other information such as laboratory data can easily be integrated into the system. Something else that is very important for National Renal Alliance is to have a system that provides patient demographic information and accurate reports. It is also vital for us that the system provide seamless electronic billing through the capture of patient demographic information.”

“The feature that is the most integral for National Renal Alliance is the collection of important clinical information including the patient’s vital signs, machine data, laboratory reports, individual modality modules including physician data, historical information, reports and integration with our billing software. In addition to that, I would say that the system needs to be easily used by all staff and designed to include as many failsafe information techniques as possible,” Lepley said.

Performing a Needs Assessment

“A needs assessment is a systematic process to develop an accurate understanding of the strengths and weaknesses of a business process in terms of efficiency and quality,” said Jean Adams, Geisinger’s director of information technology. “This understanding is used to set and prioritize goals, to develop a plan, and to allocate resources. A formal needs assessment requires that you understand: 1. The goals of the proposed project and future business plans and needs. 2. The current processes and workflows. 3. The gap between #1 and #2, and the gap analysis. 4. The capabilities and limitations of the software in addressing this gap. 5. The associated risks (technical and operational).”

A needs assessment defines a department’s priorities and lays out an organized approach for allocating resources, Adams said. “In addition, it helps to avoid many pitfalls, including missing stakeholder needs, scope creep (the gradual increase of the number of project deliverables), missed deadlines, unmet project goals and budget over-runs.

“To maximize the benefits realized, the EHR needs assessment should be completed prior to purchasing the EHR software or making process changes,” Adams said. “A needs assessment begins with a detailed walk-through of a practice site with the practice’s primary stakeholders (managers, clinicians and administrative staff). This walk-through is followed by a group meeting to determine a high-level understanding of the practice’s needs. This provides the basis for detailed questions in subsequent group meetings. The follow-up meetings include a team of managers, physician leaders, nurses and clinical technicians. An assigned interviewer documents the sessions; the full team reviews the documentation for accuracy and completeness. The team analyst then converts the interviews into process flow charts that are also reviewed by the team members.”

After the team documents and prioritizes the needs assessment and documents the current workflow and optimized workflow, the documents are shared with prospective EHR vendors, who are then given approximately two weeks to review this documentation. “They are then invited to demonstrate to us their ability to meet the stated needs, using scenarios provided by the needs assessment team,” she added.

“The next step is a point-by-point confirmation of the needs that the vendor’s current product meets. This review forms the starting point for the gap analysis, the identification of which needs the vendor’s product cannot meet. After the gap analysis is completed, the next step is to identify measures of success. Widely agreed explicit measures of success (short-term and long-term) are critical to the success of an implementation. They provide guidance to the implementation team and to the organization in making the myriad decisions an implementation requires,” Adams concluded. RBT

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