James D. Gamble, MD
LESSONS LEARNED FROM A MULTI-PRACTICE ELECTRONIC HEALTH RECORD IMPLEMENTATION
Colleen Woods and Mike Squires
HEALTH IT IN NEW JERSEY: A VIEW FROM THE NJ HEALTH IT COORDINATOR’S OFFICE
This publication is sponsored by MDAdvantage™ Insurance Company of New Jersey.
Commissioner Mary E. O’Dowd, MPH
THE IMPORTANCE OF THE NJ IMMUNIZATION INFORMATION SYSTEM IN IMPROVING PUBLIC HEALTH AND STREAMLINING PATIENT INFORMATION
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VOLUME 4 • ISSUE 4 • FALL 2011
HEALTHCARE INFORMATION TECHNOLOGY:
REVOLUTIONIZING THE HEALTHCARE INDUSTRY?
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TE N A OST C . A
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pr wi am , ch ed in a c o n s i s t e in e up y iPad, f y i k l l s o gy m my Iw hat eles nolo ged gs t n i n g e n t s o n live wir h n r n c i a o e n t r m ch ore m e to our f mo gy has dm This r docu s n m o a a s s e a re los wn t. low olo ices the ges l o n g that al chn e in tha dly kno ract n e n p e r t l l l , u lth a r a o er hea ape ll join m r is fon edic The ch sm tow c p e i m s n m y n o a o eti new man d v is gy o ystem. ectr you l r A o l e s o m “ re a l ” o e D f r o s u fM f an re chn a tion ms st o ue o ct of te ealthca nica and And I a o s u c s i e m a t h n, h s. com rb t rren the imp larger ro w f u o way B o s c l a ro hod ients? res the e ab The t met ctic xplo act on o r C r all of a a t e d r i p t e p d I r e. all fer ach yE mp d fo o issu its i es a sm ia a pre ty to re o l o g sue an t y l n i h d l a a is ed s u re ec do d l T m a o e w i b ro r l b c o m a u spe y. H lso, eo soci this ced s. A e d g for this man ? With use r l van o e w d h o w a t d n r u n n ack aisio reco how ca he a n how initi ar v e to ith t , o e l h k s i w t c l u l e of hea uld ting rticl ng a r is I wo vidi blic dina wd’s a r u o viso r o p d p o o c A r g , fo MD O ’ D p ro v i n k in er, P h D rd w o r m ner b to i o i m e s a h ing is ar me o m e s g r her m em nd Co r by syst y. A registe visor. e re a d a t i o n s r Je Ad an rm ou c com/MD info in New Y . ine s line. tive ble onl eon g a t a il van ava DAd M . w ww y, erel Sinc EO ey &C Jers n w a ™ e irm fN ge Cha ny o anta a v p d m A MD nce Co a r u Ins
MDADVISOR
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MDADVISOR
Dear Readers:
A Journal for the New Jersey Medical Community PUBLISHER
Carol V. Brown, MBA, PhD Distinguished Professor, Stevens Institute of Technology Technology Editor, MDAdvisor
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MDADVISOR | FALL 2011
PATRICIA A. COSTANTE, FACHE Chairman & CEO MDAdvantage™ Insurance Company of New Jersey PUBLISHING & BUSINESS STAFF
ACKNOWLEDGMENTS
The healthcare information technology (HIT) landscape in the U.S. has dramatically changed within just a few years due to the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which was part of the American Recovery and Reinvestment Act (ARRA) signed by President Obama in February 2009. Similar to the Affordable Health Care Act of 2010, the potential impacts of the HITECH Act on healthcare delivery are far-reaching. The articles in this issue discuss a range of HIT application experiences. Authored by those in project leadership and other physician support roles, the articles provide first-hand accounts of how to successfully implement electronic health records (EHRs) in physician practices of different sizes, as well as how to effectively utilize Internet-based applications for communications between healthcare providers and patients outside the office. Also in this issue is a report from New Jersey’s first Health IT Coordinator, Colleen Woods, who provides a high-level description of the state’s current HIT goals and federallyfunded activities to coordinate the exchange of healthcare information across New Jersey providers and those in bordering states. Although several of the HIT examples in this issue were begun before the passage of the HITECH Act, they all address major national objectives for the utilization of HIT: to improve healthcare quality and safety, to increase the engagement of patients in their healthcare and to lower healthcare delivery costs. I hope that you will find them useful.
CATHERINE E. WILLIAMS Senior Vice President MDAdvantage™ Insurance Company of New Jersey JANET S. PURO Vice President MDAdvantage™ Insurance Company of New Jersey THERESA FOY DiGERONIMO Copy Editor MORBELLI RUSSO & PARTNERS ADVERTISING INC. EDITORIAL BOARD STEVE ADUBATO, PhD CAROL V. BROWN, PhD PETE CAMMARANO STUART D. COOK, MD VINCENT A. DeBARI, PhD GERALD N. GROB, PhD
JEREMY S. HIRSCH, MPAP PAUL J. HIRSCH, MD WILLIAM G. HYNCIK, ATC JOHN ZEN JACKSON, Esq. SIMON J. SAMAHA, MD HENRY H. SHERK, MD
PUBLISHED BY MDADVANTAGE™ INSURANCE COMPANY OF NEW JERSEY Two Princess Road, Suite Two, Lawrenceville, NJ 08648 www.MDAdvantageonline.com Phone: 888-355-5551 • Editor@MDAdvisorNJ.com INDEXED IN THE NATIONAL LIBRARY OF MEDICINE’S MEDLINE® DATABASE. Material published in MDAdvisor represents only the opinions of the authors and does not reflect those of the editors, MDAdvantage™ Holdings, Inc., MDAdvantage™ Insurance Company of New Jersey and any affiliated companies (all as “MDAdvantage™”), their directors, officers or employees or the institutions with which the author is affiliated. Furthermore, no express or implied warranty or any representation of suitability of this published material is made by the editors, MDAdvantage™, their directors, officers or employees or institutions affiliated with the authors. The appearance of advertising in MDAdvisor is not a guarantee or endorsement of the product or service of the advertiser by MDAdvantage™. If MDAdvantage™ ever endorses a product or program, that will be expressly noted. Letters to the editor are subject to editing and abridgment. MDAdvisor (ISSN: 1947-3613 (print); ISSN: 1937-0660 (online)) is published by MDAdvantage™ Insurance Company of New Jersey. Printed in the USA. Subscription price: $48 per year; $14 single copy. Copyright © 2011 by MDAdvantage™. POSTMASTER: Send address changes to MDAdvantage, Two Princess Road, Suite Two, Lawrenceville, NJ 08648. For advertising opportunities, please contact MDAdvantage™ at 888-355-5551.
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LETTER FROM MDADVANTAGE™ CHAIRMAN & CEO PATRICIA A. COSTANTE
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LESSONS LEARNED FROM A MULTI-PRACTICE ELECTRONIC HEALTH RECORD IMPLEMENTATION | By James D. Gamble, MD
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PHYSICIANS HELPING PHYSICIANS: DEVELOPING COMMUNITIES OF PRACTICE AMONG SMALL-PRACTICE PHYSICIANS TO SUPPORT ELECTRONIC HEALTH RECORD ADOPTION AND USE | By Elizabeth Davidson, PhD
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THE IMPORTANCE OF THE NJ IMMUNIZATION INFORMATION SYSTEM IN IMPROVING PUBLIC HEALTH AND STREAMLINING PATIENT INFORMATION | By Commissioner Mary E. O’Dowd, MPH
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HEALTH IT IN NEW JERSEY: A VIEW FROM THE NEW JERSEY HEALTH IT COORDINATOR’S OFFICE | By Colleen Woods and Mike Squires
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PATIENT-CENTERED MEDICAL HOME CARE MODEL: IT CONSIDERATIONS | By Cari Miller
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PATIENT TELEMONITORING: VALLEY HOME CARE’S JOURNEY | By Elaine Davis, RN
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HELPING PHYSICIANS ACHIEVE QUALITY GOALS AND METRICS: THE PCIP’S EXPERIENCES | By Mytri Singh, MPH, and Vicky Tiglias
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A MEDICAL GROUP’S JOURNEY INTO SOCIAL MEDIA, PART II | By Simon J. Samaha, MD
MDADVISOR
FALL 2011 – CONTENTS
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LESSONS LEARNED from a Multi-Practice Electronic Health Record Implementation By James D. Gamble, MD Virtua Medical Group (VMG) is a health Many large and small ambulatory practices across the U.S. are migrating system–owned medical group practice from paper-based patient records to electronic health record (EHR) with a total of 200 physicians, whose software, with aggressive timelines, to take advantage of the HITECH specialties are mostly primary care, but also include surgery, cardiology, neurolAct incentives. In this article, Dr. Gamble shares firsthand what the ogy, sports medicine, pain manageimplementation team at Virtua Medical Group has learned about how ment, orthopedics, podiatry, breast best to implement this type of software in ambulatory settings–including surgery, hospital medicine, neonatology and gynecology/oncology. In 2008, decisions about what, when and how to digitize data from paper files VMG decided to implement an elecand other actions that can increase the likelihood of success at the tronic health record (EHR) for all of its time of Go-Live. The learning points shared in this article will be ambulatory practices, which were locatvaluable to not only those physicians anticipating a future EHR ed at more than 25 sites throughout three counties in southern New Jersey. implementation, but also those now reflecting on how their organizations In this article, we share our “lessons could “do it better” next time. learned” from our experiences thus far Carol V. Brown, PhD in implementing an EHR across several different practices, with different Technology Editor specialties, within a very aggressive timeline. Because of the current Health Information Technology for Economic and Clinical Health an EHR did not include one that necessarily had a practice (HITECH) Act incentives, our expectation is that these lessons management system (PMS), as our intention was to build will also be of interest to many other physician practices. an interface from the EHR to the PMS. We also wanted a system in which Virtua would host the EHR and all of the THE EHR PROJECT practices would access it over a secure network. Each VMG practice was using the same practice manAfter we selected our EHR, we established an impleagement system for scheduling and billing, but was using mentation organization to govern the rollout. The oversight paper charts for medical records. Therefore, our search for committee, the Core Team, consisted of a physician lead
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THE LESSONS LEARNED We have categorized our “lessons learned” into eight themes that include activities prior to the Go-Live date, the initial days of Go-Live and longer-term issues. Pre-Go-Live: Entering Patient Data Through Abstraction
(the author), managers from Virtua’s Information Services (IS) department, practice administrators from VMG and consultants with experience in EHR implementation. The implementation project manager was an outside consultant with previous implementation experience with our EHR vendor. The project team, led by the Core Team, also included busi-
ness analysts from Virtua’s IS department, as well as outside consultants with experience with our vendor’s EHR. The Virtua business analysts received training from our EHR vendor. The first practice went live in August 2010, and one additional practice site has gone live each month since then. The Core Team is expected to complete the implementations across the 25 locations by the end of the second quarter of 2012.
At the time of a patient’s first office visit after the EHR is implemented, practitioners would like to have as much historical information as possible available in the EHR. One approach to this is to electronically scan information from the paper chart into the EHR; the disadvantages of doing this prior to Go-Live are discussed below. An alternative approach to the transfer of paper to electronic documentation is to manually enter specific information into the EHR prior to Go-Live, a process we refer to as abstraction of data. The advantage of abstraction is that the data is stored in a discrete, machine-understandable form. Certainly, there is a trade-off between the benefit of having as much data as possible in the EHR prior to Go-Live and the time constraints involved in trying to get as many charts abstracted as possible. We decided, therefore, that a minimum data set would be entered into the EHR for each former patient prior to the patient’s first visit after the implementation of the EHR. Although we allowed each practice to decide how much data to abstract, we required at minimum that problems, medications and allergies be abstracted. Several months before the first practice Go-Live, we provided all the practices with an abstraction form to add to each chart. This form was used as a guide for abstraction, and physicians were asked to enter data legibly on the form in order to make the actual data entry easier. This form served two purposes: 1) it encouraged physicians to update each active patient’s problems, medications and allergies, and 2) it provided a daily reminder to the practices that the EHR was “on the way.” Using this approach, the data abstraction could begin with charts of patients several months before the Go-Live launch. The Core Team instructed each practice to have patient charts abstracted prior to Go-Live for all patients scheduled for office visits for the two-month period from the
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“All personnel at each practice received 12 hours of training over a six-week period prior to Go-Live. The training was given on-site by members of the implementation team. Office staff members were trained in a group classroom setting, while the majority of physicians received one-on-one training.”
planned Go-Live date forward. Each practice printed its schedule, the corresponding charts were pulled and these charts were then abstracted by a variety of individuals: office personnel–including office staff, medical assistants, nurses and physicians–as well as by assigned members of the implementation project team. This ensured that, at the time of Go-Live, any patient who was pre-scheduled for an appointment would have at least a minimum data set available in the EHR. In this process, we learned that providing the physicians with the ability to dictate their abstraction data was cost-effective. Two of the practices had been using a transcription service for their notes in the paper chart, and in preparation for the EHR, these practices utilized this service to dictate their abstraction data. We did a cost analysis of this process and found that a non-clinician was able to enter the data into the EHR from about twice as many charts if the data had been dictated, compared to charts that had data handwritten, due to the better organization and legibility of the dictated data. This approach was expanded to practices that had not had previous experience dictating, and the benefits were similar. At this rate, the transcription service costs were well worth it, and we highly recommend giving physicians the option of dictating their abstraction data. Pre-Go-Live: Preparation and Training
Prior to the Go-Live date, each VMG office was visited by members of the implementation team to study the office workflow. These visits provided an opportunity to explain to all members of the practice how the EHR would change workflow, to answer questions, to assure them that ade-
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quate support would be provided and to allay any concerns about the coming EHR. All personnel at each practice received 12 hours of training over a six-week period prior to Go-Live. The training was given on-site by members of the implementation team. Office staff members were trained in a group classroom setting, while the majority of physicians received one-on-one training. One or two days prior to Go-Live, each practice closed the office for a few hours to have a mock Go-Live, in which simulated patients were managed through the visit process using the EHR. This was a valuable way to improve confidence in the readiness level of all members of the practice. Pre-Go-Live: Ensuring Technical Readiness
Go-Live at busy practices is always a very stressful time. Even if the users are well trained and well supported at Go-Live, the implementation will fail if there are technical problems. Personnel from Virtua’s IS department, who were skilled in computer hardware and both wired and wireless networking, performed an analysis of each practice’s technical resources months before Go-Live. Based on their recommendations, the project team provided the practices with the technical resources necessary for success. By doing so, we had only one practice that experienced technical problems during the Go-Live period. In this case, the problem was related to the network bandwidth that was available at the practice, which was intermittently overwhelmed during busy times when multiple users were online. With an increase in bandwidth, the problem was solved.
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“Since manually entering all of the data from the paper chart is not feasible for most offices, another approach to making historical data accessible from an EHR is to scan the documents from the paper chart.”
It is important to study the technical needs of a practice carefully to ensure that each is adequately configured. The resources needed to do this may be provided by the EHR vendor or can be obtained from a consultant recommended by the vendor. Following the first glitch with bandwidth, we investigated and resolved bandwidth issues in all practices before implementation and had no further problems of this type. Initial Days of Go-Live: Reducing Appointment Schedule
At VMG, each practice was instructed to decrease the frequency of appointments during the Go-Live period. While there could certainly be individual practice variation in the particular schedule chosen, we recommended some form of abbreviated schedule for the first two to four weeks of implementation. This allowed users adequate time to become proficient at using the EHR, and it gave the project team time to provide the necessary support for all users. Our recommended model was a 50 percent–reduced schedule for the first two weeks, a 25 percent–reduced schedule for the third week and then a full schedule thereafter. Initial Days of Go-Live: Providing Support
It is important to have adequate support staff on-site during all office hours, for at least the first two weeks of Go-Live. At VMG, we did this from the outset and can attest
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that it is invaluable. Our support personnel came from our project team, all of whom either had prior experience with our vendor’s EHR or had received training from the vendor. The number of support personnel needed depends on the size of the practice, but it is important to have support personnel specifically dedicated to assist front-office staff, medical assistants, nurses and physicians. Our staffing ratio was one person for every three physicians, as well as one to support the front desk, one to support personnel taking telephone calls, one to two to support nurses and medical assistants, one to support scanning personnel and one “float” to help anywhere needed. Limiting the Scanning of Historical Medical Records
Since manually entering all of the data from the paper chart is not feasible for most offices, another approach to making historical data accessible from an EHR is to scan the documents from the paper chart. During the planning phase of our EHR project, we considered several options for document scanning. However, scanning provides only a “picture” of the information: the individual data elements are not stored in a structured form that can be identified, queried and maintained by the EHR. Additionally, at VMG, scanning all charts for all practices would have cost millions of dollars, so this option was never seriously entertained. Instead, we
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“...the need for and the amount of scanning vary greatly, we learned from our implementations that extensive scanning of documents from old charts may not be necessary, which could result in significant cost savings...�
initially decided on the following approach: Scan all new incoming paper documents for all patients, both existing and new Scan any historical data that is flagged by physicians for patients seen in the office after Go-Live However, we quickly discovered that, on average, our physicians flagged 20 to 25 pages per chart to be scanned, and this amount of scanning placed a significant burden on the personnel in the practices. Based on the experience of the first few practices to Go-Live, we also learned that if the paper chart was still available at the time of the patient’s first and second visits after the EHR implementation, scanning historical data from the chart was often not necessary. Many practices, therefore, abandoned scanning historical documents altogether. Although opinions on the need for and the amount of scanning vary greatly, we learned from our implementations that extensive scanning of documents from old charts may not be necessary, which could result in significant cost savings for an implementation that involves migrating from paper charts to an EHR. Delaying Electronic Charge Capture
One of the often-cited benefits of implementation of an EHR is improved billing coding and charge cap-
ture. Our implementation required an interface between our practice management system and our EHR. At Go-Live, the interface for demographic and scheduling data was in place, but for implementations at our initial practices, our charge interface was not completed, and those practices continued to use a paper process for reporting charges. After the fact, we concluded that this delay was beneficial. There is a significant initial learning curve in using the EHR, and we think it is better to ask the clinicians to focus on capturing the clinical data and providing optimal care for the patient without the additional burden of ensuring that charges are captured correctly in the EHR. Therefore, we initially used a dual process: The clinicians were trained on charge capture in the EHR, but they also recorded the charges on paper. This gave the project team the opportunity to compare charges in the EHR with those on paper and to validate the accuracy of the charge capture in the EHR for that practice. Once a practice was comfortable using the EHR, and the computer-generated charges were proven to be accurate, the project team went back to the practice and implemented the charge interface, typically two to three months later. We recommend considering this kind of approach for practices in which clinicians are not capturing charges electronically prior to the EHR implementation.
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Ongoing Support to Maximize EHR Benefits
“While it certainly is important to have a well-conceived implementation plan for your EHR system, it is equally important that the plan remain open to change as new lessons are learned along the way.”
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After practices had used the EHR for a period of weeks, we found that going back to the practices and interacting with users for post-Go-Live support was very important. The visits allowed us to help users correct some inefficiencies in their use of the EHR, which subsequently helped them improve their workflows. We strongly recommend including a plan for revisiting practices several weeks after Go-Live to provide this kind of support. We also established a “User Group,” which consisted of formal meetings of individuals from each practice representing front-office staff, medical assistants, nurses and clinicians. The group currently meets monthly and provides a forum for further continuing education, reporting of problems and sharing of experiences in using the EHR.*
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CONCLUDING RECOMMENDATION In addition to the advice gleaned from these eight lessons learned, our overall recommendation is this: While it certainly is important to have a well-conceived implementation plan for your EHR system, it is equally important that the plan remain open to change as new lessons are learned along the way. Different practices have different cultures, and some of these differences can be accommodated during the implementation planning phase for that practice. An example of this from our own experience is the different approaches to the clinician’s review of incoming patient information. Some of our practices elected to have all incoming documentation for existing and new patients (i.e., paper lab and imaging results, letters, etc.) scanned immediately into the EHR, so that clinicians could review the documents electronically. Other practices chose to have the clinicians review the paper documents prior to scanning.
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This kind of flexibility allows each practice to employ processes that best fit its workflow, without compromising the overall implementation plan. James D. Gamble, MD, is Medical Director of Informatics for Virtua. He is a primary care internal medicine physician, and for the past 19 years has been a member of the faculty of the Virtua Family Medicine Residency. Dr. Gamble has a master’s degree in computer/information science. Dr. Gamble would like to thank Al Campanella, Maureen Owens and Dave Malick for their editorial help with the article. * Editor’s Note: See “Physicians Helping Physicians: Developing Communities of Practice Among Small-Practice Physicians to Support Electronic Health Record Adoption and Use” by Elizabeth Davidson, PhD, in this issue of MDAdvisor (page 12) for more information on this type of community-of-practice.
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Physicians Helping Physicians: Developing Communities of Practice Among Small-Practice Physicians to Support Electronic Health Record Adoption and Use By Elizabeth Davidson, PhD
User groups for sharing experiences with computer technology are common in the business world, but bringing together physicians to share their practice’s experiences with healthcare information technology is relatively new. In this article, Professor Davidson describes some of the benefits that emerged over a two-year period as a group of physicians in small practices in Hawaii regularly met to share their experiences with the same electronic health record (EHR) software–the problems encountered and their own discoveries about how to more effectively use the software’s features. I hope that the information in this article will be a catalyst for more such “communities” of small physician practices to be sponsored, not only during the initial chaotic years of ‘Meaningful Use’ incentives but also on a long-term basis. Carol V. Brown, PhD, Technology Editor
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Many physicians are considering investing in an electronic health record (EHR) system for their private practice or clinics. Although financial incentives from the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) program (and from hospitals and local insurers) can help defray the high costs of pur1 chase, implementation and initial training, few physicians have been willing to take the leap–with EHR adoption rates historically lowest within small practices.2,3,4 Those who have braved the leap have found that the acute pain of EHR implementation typically lessens within six months, but reaching and maintaining effective EHR use becomes a chronic condition for the practice.4,5 Practices typically remain stuck between paper and electronic records for some time.6 The physician and practice staff must become adept at diagnosing EHR computer and network problems to know who to contact if electronic interfaces with laboratories or pharmacies malfunction (and they do!). Staff turnover and retraining for a software upgrade or process change require ongoing time and attention. Today’s physicians are also faced with digesting the evolving regulations for “Meaningful Use” of EHRs to qualify for financial incentives.1 And eventually, physicians will also be asked to interface their EHRs into local or regional health information exchanges (HIEs) for data sharing among physicians, hospitals and perhaps even patients, insurers and other stakeholders. Effective EHR use is not a destination, but a continuing journey. Physicians in large-group or hospital-based practices typically have full-time IT or other support staff to help them through this journey, but physicians in small practices (i.e., five or fewer physicians, which is about 60 percent of all U.S. physicians2) run very lean, with few in-house staff resources to devote to EHR adoption.5,7 EHR vendors are typically contracted to help with initial workflow setup and training but then move on to the next new customer. The cost of ongoing support from EHR vendors or from IT and practice management consultants is steep for the small practice, and experienced help may not be readily available in all locations (especially rural communities). With few resources to help them prior to the Go-Live stage, physician owners of small practices have typically needed to devote time on an ongoing basis to absorb, adjust and master the EHR. Physicians who have experienced the chronic challenges of using EHRs in day-to-day practices are important sources of expertise and innovation. Bringing together
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physicians in small practices to share their experiences and to help each other would help promote EHR adoption and effective use. A current grant-funded research project for physician users, called Bridging the IT Adoption Gap (IT Gap, for short), is based on a community-of-practice (CoP) model to offer this type of support structure. PHYSICIANS HELPING PHYSICIANS THROUGH COPS The Bridging the IT Adoption Gap project was initiated in Honolulu, Hawaii, to help physicians in small practices 5 adopt health IT, in order to improve patient management. This multiyear research project is funded by the Physicians’ Foundation and operated by the Hawaii Medical Foundation. The project provides services at no cost to physicians and includes modest stipends for their time as part of this research project. The cost of project staff and EHR trainers is covered by the grant. As an academic researcher interested in health IT and in the organizational challenges to successful adoption, I designed this project based on theories of learning and 6, 8 innovation through communities-of-practice.5, A CoP is a group of people who share a concern or a passion for something they do and who learn how to do it better by sharing experiences, sharing solutions and supporting each other’s efforts.9 Clinicians are typically trained in community-based apprenticeship programs, as well as through formal education. Applying the CoP approach to learning about effective EHR use was a logical extension for the Bridging the IT Adoption Gap project. Ten community physicians (four obstetrician/gynecologists, five general/family practice physicians and one specialist) in solo and small practices were recruited in 2009 as a pilot group for the IT Gap project. Each had adopted an EHR 4 to 24 months before joining the CoP. The research project team was small, and all members were part-time. In addition to the physicians, the team included an education professor as Co-research Director, a part-time certified EHR trainer, a parttime physician representative to coordinate schedules with doctors, an administrative support person and me as Project and Research Director. Team members worked collaboratively, researching topics and preparing information for CoP meetings.
“Bringing together physicians in small practices to share their experiences and to help each other would help promote EHR adoption and effective use. A current grant-funded research project for physician users, called Bridging the IT Adoption Gap (IT Gap, for short), is based on a community-of-practice (CoP) model to offer this type of support structure.”
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For practical reasons, the CoP was limited to physicians using the same EHR software package. The physicians in the pilot CoP were primarily interested in learning how to use their own EHRs more effectively, and so relating experiences with the common software was one way to facilitate their interactions. The project’s ability to provide an experienced trainer for the group’s common EHR software package was also important, as the group discussions ranged from the general (Is “Meaningful Use” meaningful?) to the specific (How do I use this feature and function?). Through grant funding, we are able to provide post-Go-Live training and hands-on support to encourage physicians to explore and expand their use of the EHR system’s feature set; it was most cost-effective to provide in-depth support for one software package. (With adequate funding for trainers and sufficient CoP participation, multivendor CoPs would likely work as well.)
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cating with the staff,” highlighting how various systems features (telephone encounters, memos and alerts) might be used for different purposes. Most importantly, physicians discussed their own techniques for using the EHR software and shared with each other their issues, questions and solutions for incorporating the EHR into their practices. The usefulness of the CoP to its members is evident in their ongoing involvement with the project for two years, their animated discussions that typically ran past scheduled meeting times (despite long days and busy schedules) and their subtle but continuing journey towards more effective EHR use. In its two years of operation, the research team has observed several ways in which the CoP has helped participating physicians achieve effective use of EHR systems. A few of these examples are as follows. Becoming self-aware of practice patterns. To incorporate EHR use into
HOW PARTICIPATING PHYSICIANS ACHIEVED EFFECTIVE USE OF EHR SYSTEMS In the first months of the project, research team members interviewed physicians and their staff to identify common EHR practice issues. An EHR trainer (who was also a research team member) visited practices bi-monthly to answer questions and assist the physician and staff with EHR-related workflow changes. The research team organized monthly CoP meetings for participating physicians. At CoP meetings, the project staff presented developments in the physicians’ software systems and EHRrelated developments (such as Meaningful Use guidelines). For example, one such meeting focused on “communi-
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workflows, physicians must be highly self-aware of their own practice patterns and understand how their habits and preferences relate to the EHR’s design. As IT Gap participants discussed with each other and with the research team how they used the system (for example, when and how extensively they used templates), assumptions surfaced about what could be done or what might be done differently. The research team’s observations and feedback helped direct discussions about use of existing or new software features. Through sharing “tips and tricks” with each other, CoP members learned to modify some of their habitual EHR practices (and those of their staff), and they continued to innovate with EHR use.
Learning about uses and technical limitations of EHRs. The technical
nuances of EHRs are not obvious to many physicians. Even those practices using the EHR extensively use it in some ways that can limit its future technical capabilities. For example, in one CoP meeting, physicians were surprised to learn that computer faxing of prescriptions was not the same as “e-prescribing.” It was also revealed that the physicians and their staff relied (to various degrees) on “e-paper”–a digitally scanned image of paper such as computer faxes from other physicians, scanned lab results and scanned paper charts and documents. However, because not all test results are electronic and transmissions are not 100 percent reliable, physicians and their staff adjusted workflows with extra steps, such as scanning printed lab reports. Some physicians dictated lab orders into the narrative note or scanned, rather than fully integrated, lab orders and results into the EHR as structured data. In the CoP meetings, the research project staff had an opportunity to explain that e-paper documents are not readily searchable, limiting the EHR’s utility for database searches. The group discussed the technical limitations of such uses of the EHR and the ease-of-use tradeoffs for the physician. They also explored the future capabilities of the EHR system, which include the ability to search data for reporting on preventative care or chronic-care goals and to meet Meaningful Use criteria. Moving beyond the first plateau of EHR use. The CoP members had all
passed the acute pain phase of EHR
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“Ongoing involvement in
RX
a CoP can be a source of information, encouragement
@
and recognition for physicians’ efforts to achieve the maximum value from EHR use for their practices and their patients.”
implementation by the time they joined the group. They had made decisions about how to incorporate the EHR into workflows during or shortly after training, before they fully grasped the software’s potential, and most had settled into habitual ways of using their EHR. For example, all had developed their own style of charting. Few physicians in the group consistently utilized EHR features such as problem lists, templates or structured data, due to personal preference and interface limitations. In the CoP meetings, physicians discussed moving to the next level of EHR use. In some cases, more recent users challenged experienced users to rethink their habitual practices. A new CoP member’s success with e-prescribing, for
instance, encouraged others to move beyond computer faxing of prescriptions to pharmacies. During the two years of the CoP meetings, some of the practices upgraded to new versions of the software, which incorporated new features (e.g., order sets). In CoP meetings, these physicians discussed how and why they adopted the new features, generating interest among others. Physicians have helped each other apply new features, and the EHR trainer also provided help in the meetings or in follow-up office visits. EXTENDING THE EHR-FOCUSED COP MODEL The experiences to date of the IT Gap project members suggest that EHR-focused CoPs of physicians in solo and small practices can help promote
learning about effective EHR use. Although innovations with EHR use can (and will) occur in some small practices without this type of ongoing support after implementation, many small practices will achieve a less-than-optimal plateau of EHR use. Ongoing involvement in a CoP can be a source of information, encouragement and recognition for physicians’ efforts to achieve the maximum value from EHR use for their practices and their patients. With the federal government’s push toward widespread EHR “Meaningful Use,” the need for ongoing support and engagement of physicians is very important. Although the IT Gap project’s CoP physicians were experienced EHR users, none would qualify for Meaningful Use incentives without a significant investment of time, personnel, effort and
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“Establishing and maintaining a CoP requires some modest resources of time, attention and expertise. With physicians’ busy schedules, it is questionable whether CoPs can form and operate without intervention and planning by a funded support team.”
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expense to upgrade software, conduct data exchange tests and security audits, and, importantly, to change their own and their staff members’ ineffective EHR-use habits. Understandably, physicians’ attention and energy may lag as they consider how “Meaningful Use” may cause even more disruption to their practices. With mutual support and learning through the CoP, achieving Meaningful Use is more feasible for these practices. Establishing and maintaining a CoP requires some modest resources of time, attention and expertise. With physicians’ busy schedules, it is questionable whether CoPs can form and operate without intervention and planning by a funded support team. The Bridging the IT Adoption Gap project (and similar ventures) is grantfunded and of limited duration. Regional Extension Centers (RECs), funded through the HITECH program, are developing services to help small physician practices adopt an EHR system and learn about Mean1 ingful Use criteria. Perhaps RECs might organize and sponsor CoPs among physicians participating in their programs to supplement and extend REC staff efforts. Or, local professional organizations, such as the state or county medical association, might sponsor local EHR-focused CoPs. Additionally, EHR IT vendors might provide support for local user groups, which would extend their efforts with national user group conferences and online user exchanges. Such EHR-focused CoPs could support not only those physicians who directly participate but could also develop a critical mass of EHR users
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among small physician practices. This would engage an extensive group of experienced physicians who are interested in promoting and fostering effective EHR practices among their colleagues and who could help diffuse EHR experiences and expertise to other physicians. Elizabeth Davidson, PhD, is a Professor and Chair at Shidler College of Business, University of Hawaii at Manoa. 1
Squires, M., & Brown, C. (2010). Healthcare information technology and meaningful use: The journey begins. MDAdvisor Supplement, 3(2), 1–5.
2
DesRoches, C. M., Campbell, E. C., Rao, S. R., Donelan, K., Ferris, T. G., Jha, A., et al. (2008). EHRs in ambulatory care: A national survey of physicians. New England Journal of Medicine, 359, 50–60.
3
Ford, E. W., Menachemi, N., Phillips, M. T., & Mshi, M. (2006). Predicting the adoption of electronic health records by physicians: When will health care be paperless? Journal of the American Medical Informatics Association, 13(1), 106–112.
4
Gans, D., Kralewski, J., Hammons, T., & Dowd, B. (2005). Medical groups’ adoption of electronic health records and information systems. Health Affairs, 24, 1323–1333.
5
Davidson, E., & Heslinga, D. (2007). Bridging the IT adoption gap for small physician practices: An action research study on electronic health records. Information Systems Management, 12(1), 15–28.
6
Davidson, E., & Kim, K. (2010, November). Bridging the IT Adoption Gap with a community of practice (CoP). Paper poster session presented at the American Medical Informatics Association Conference, Washington, DC.
7
Reardon, J., & Davidson, E. (2007). An organizational learning perspective on the assimilation of electronic medical records among small physician practices. European Journal of Information Systems, 16(6), 681–694.
8
Wenger, E., McDermott, R., & Snyder, W. (2002). Cultivating communities of practice: A guide to managing knowledge. Boston: Harvard Business.
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Wenger, E. (1998). Communities of practice: Learning, meaning, and identity. Cambridge, England: Cambridge University Press.
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The Importance of the NJ Immunization Information System in Improving Public Health and Streamlining Patient Information By Commissioner Mary E. O’Dowd, MPH
The benefits of health information technology have been well documented and include improving the quality of healthcare delivery, decreasing medical errors and strengthening the interaction between patients and healthcare practitioners. The New Jersey Department of Health and Senior Services (DHSS) is committed to helping the state’s providers make significant progress in using health information technology to improve patient care and public health. As part of the state’s effort to move patient information from paper to electronic records, New Jersey uses the New Jersey Immunization Information System (NJIIS, also referred to as “the registry”), a free, confidential, population-based online system to collect and consolidate vaccination data for all New Jersey’s residents. In New Jersey, currently more than 2,300 medical providers participate in the registry. However, many more providers could be using the registry. In fact, by the end of 2011, practitioners who immunize children seven years of age and younger are required by law to become authorized users of the registry and to report vaccinations. The DHSS strongly encourages all providers to use the registry, regardless of patient age. The Department’s goal is to enhance the usefulness of NJIIS by increasing the number of providers using the registry and by ensuring all vaccinations given to residents from birth through adulthood are captured. Healthcare providers who use NJIIS will realize many benefits in caring for patients. Having access to a patient’s complete and accurate immunization history reduces paperwork and staff time spent obtaining records and responding to record requests and reduces redundant vaccination of new patients. Participating healthcare practitioners can input and retrieve immunization information 24 hours a day, 7 days a week. The registry is
also connected to the Electronic Birth Registry and newborn hearing screening and lead screening–so providers have access to preventive child health screening information on their patients. The registry can also assist practitioners in managing office supply and operations such as maintaining vaccine inventory, ensuring proper reimbursement by tracking administered vaccines and generating reminders and recall notices. Utilization of the registry would also qualify as a Meaningful Use measure for Medicare and Medicaid’s Electronic Health Records (EHR) Incentive Program, which provides incentive payments to eligible healthcare providers as they adopt, implement, upgrade or demonstrate Meaningful Use of certified electronic health record (EHR) technology. In order to facilitate entry of data, NJIIS offers an electronic interface option with EHRs. Many practices are already using EHRs that interface with the NJIIS to report immunization data. This registry also provides the DHSS, local public health agencies and providers with the ability to assess their immunization coverage and to identify pockets of need. This information helps public health and medical providers target vulnerable populations and respond quickly during outbreaks of vaccine-preventable diseases. The NJIIS, like all electronic health records, is an important tool that can be enhanced by greater participation among healthcare professionals. By sharing information through a robust registry, we can improve care and public health in our state. To learn more about the registry, please visit the NJIIS website at www.njiis.nj.gov and click on “Forms.” Then complete the “Enrollment Request for New NJIIS Site” form and fax or mail it to the regional trainer for your county. Mary E. O’Dowd, MPH, is the Commissioner of the New Jersey Department of Health and Senior Services.
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Health
IT
IN NEW JERSEY:
A View from the New Jersey Health IT Coordinator’s Office By Colleen Woods and Mike Squires
Less than two years ago, New Jersey was clearly behind in adopting and utilizing health information technology when compared to East Coast leaders such as New York and Massachusetts. Today, however, the situation has greatly improved: New Jersey hospitals, physicians and local IT leaders are collaboratively engaged in statewide, regional and organization-level initiatives to leverage federal grants and incentive programs under the HITECH Act. The first author of this article, Colleen Woods, is playing a key role in this new collaborative environment as the first Health IT Coordinator in a new office, reporting to New Jersey Governor Chris Christie. For New Jersey readers not actively following statewide initiatives, this is a “must read.” The article provides information about the six health information organizations (HIOs), formerly called health information exchanges (HIEs), in the state, the current opt-out approach to electronic health information sharing across providers and working groups looking at HIT-related economic, consumer and technology issues. Carol V. Brown, PhD, Technology Editor Providing all New Jerseyans with electronic health records (EHRs) is the core mission of the statewide program for health information technology. With physicians, hospitals and clinics communicating with each other, a
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patient’s medical record will contain more complete medical information. Up-to-date, digitized health data will help physicians make better clinical decisions with better patient outcomes. Today, such information may be stored on paper, in different locations, and may not be accessible in a timely manner or when needed. Ultimately, the patient’s information in the electronic record is envisioned to include physician notes, lab results and medication history based on information from all physicians and hospitals involved in a patient’s care. The patient is, of course, a key beneficiary but so too are other stakeholders. Access to current information in electronic form should also help physicians contain costs and help insurers (including the government) produce cost savings by avoiding redundant tests and enabling better coordination of care. To help achieve the state’s health IT vision and to ensure the cooperation and coordination of statewide health IT programs, in July 2010, New Jersey Governor Chris Christie established the Office of Health Information Technology Coordinator within the Governor’s office and appointed the first coordinator, Colleen Woods. One of the major duties of this new office is to coordinate the development of regional groups of hospitals and physicians organized into health information organizations (HIOs),
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formerly referred to as health information exchanges (HIEs), and establish the foundation for the New Jersey Health Information Network (NJHIN), which will facilitate data exchanges among the HIOs operating in the state, as well as connecting to other states via the Nationwide Health Information Network (NwHIN). Dubbed a “network of networks” approach, the system for exchanging health data in the state will enable a patient’s health information to be gathered confidentially and securely from all of the patient’s providers. HIOs in New Jersey will use national standards to overcome the technical obstacles to information sharing that have been of concern in the past.
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The federal funds for these four HIOs awarded by the Office of the National Coordinator (ONC) for Health IT within the U.S. Department of Health and Human Services (HHS), will be channeled through the state’s Health IT Coordinator’s office. The two nonfederally funded HIOs are the following: • Trenton Health Team HIO in Trenton • MOHIE in Monmouth and Ocean counties In addition to hospitals and physician offices, regional HIOs include nursing homes, emergency medical services, home health services and health systems. New Jersey also
NEW JERSEY’S HIOS As shown in Figure 1, the six regional HIOs already planned will cover hospitals, their affiliated physicians and their patients in almost all of the counties in New Jersey. By the summer of 2011, 43 of the 73 hospitals in New Jersey and many of their affiliated physicians were already participating. Four of these HIOs are slated to receive federal funds for initial startup and operations to exchange information: • Health-e-cITi-NJ in Essex, Passaic and Hudson counties (In May 2011, this HIO was the first in New Jersey to receive federal funds.) • Jersey Health Connect in north and central New Jersey • Camden HIO in the city of Camden • South Jersey HIO
Figure 1
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“
The state health IT program seeks to provide everyone with electronic health records and exchange of health information to improve the health of and healthcare for all New Jerseyans.
”
contains some Integrated Delivery Networks (IDNs) that exchange health information within their hospital systems (including Barnabas Health and Virtua Health). The drive to improve patient care and lower healthcare costs in New Jersey has, therefore, already brought groups of hospitals and physicians together in HIOs to eventually enable a physician to see a patient’s complete and up-todate medical records with medication history and lab reports in one place and to share that information with the patient. USE CASES Under the direction of the New Jersey Health IT Coordinator, the HIOs are developing the technical details needed to exchange these five types of health data, referred to as use cases: 1—Medication history, which will be available when a patient appears in an emergency room. Medication data will be drawn from New Jersey Medicaid records, electronic health records in different physician offices and hospitals and from the Surescripts E-Prescription Network database of prescriptions purchased from retail and major mail-order pharmacies nationally. This will give emergency room clinicians in New Jersey a better basis for understanding a patient’s medication history. Access to medication history in the emergency room is the first use case being developed 2—Immunization records, which will be transmitted and accessed directly with a physician EHR 3—Lab and radiology reports, which will be delivered to a hospital or physician EHR 4—Transfer patient information after an emergency room visit or hospital discharge, which will be sent to a patient’s primary care or specialist physicians 5—Transition of care information, which will be shared between a primary care physician and specialist EHRs
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PRIVACY AND SECURITY The state health IT leaders recognize the importance of safeguarding the confidentiality of patient health information. The Privacy and Security Rules established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) ensure that physicians and hospitals protect the electronic personal health information in their own electronic health records. The HITECH Act, passed in 2009, also applies these rules to business partners that may be involved in hosting or supporting IT for providers or using personal health information in other services to providers. In order to bring these federal and state privacy and security rules in line with the operation of regional HIOs and NJHIN, the Health IT Commission of New Jersey, comprised of a range of stakeholders, appointed by the Governor, and those state officials designated in legislation, has made a series of recommendations. (For a fuller description of the Commission, see the section “Governance” later in this article.) The Health IT Commission has made the important recommendation that a patient’s health information may be exchanged with other authorized health providers, unless the patient specifically chooses not to share the information beyond the specific provider organization that maintains that record. That is, patients must opt-out if they choose not to participate in the secure exchange of their health information across providers. According to experience reported by HIOs in other states, the vast majority of people allow their information to be appropriately exchanged because of the value patients see in ensuring that their primary care physician and specialists provide care that is based on complete, up-todate information. An exception to this recommendation would be the exchange of certain sensitive health information already protected by law, such as behavioral health, HIV/AIDS, alcohol and chemical dependency and genetic counseling. For these types of data to be exchanged, patients may be specifically required to opt-in. Recent federal legislation also has increased the monetary penalties for breaches of unsecured protected health information, and state attorneys general have been given a new role in monitoring for such breaches. The HHS website is required to list breaches affecting 500 or more individuals. In addition, eligible providers seeking federal incentive payments for implementing Meaningful
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Use requirements with certified electronic health record systems must perform an annual security risk analysis and document the correction of any problems identified. GOVERNANCE The New Jersey Health IT Commission, established by state law, started meeting monthly in December 2009. The Commission recommends to the Health IT Coordinator strategic direction and provides advice and recommendations for operational design and implementation of various health IT initiatives. Its membership includes 14 public members appointed by the Governor from the private sector and 5 members representing the following New Jersey state departments: Commissioners of Health and Senior Services, Banking and Insurance, Children and Families, Human Services and the State Treasurer. The Commission’s founding chair was Kennedy Ganti, MD, a practicing family physician and medical director for primary care research at Virtua Medical Group, who remains a Commission member. The current chair is Alfred Campanella, Vice President and Chief Information Officer of Virtua Health. Five other physicians serve on the Commission, as well as a registered nurse and a pharmacist working in New Jersey. In addition, in 2010, the Health IT Coordinator set up the Health IT Steering Committee to guide the final development and implementation of the New Jersey operational health IT plan in cooperation with the federal ONC. The committee includes some members of the Commission and representatives of the regional HIOs. Additional subcommittee workgroups within the Governor’s office, which include members of the Commission, state employees and subject-matter experts, are engaged in activities such as the following: • Consumer Advocacy and Quality Care. Recommend a dashboard to measure the number of HIO and NJHIN transactions and related health outcomes in several categories, and recommend a comprehensive communications plan to reach New Jerseyans • Technical and Data Standards. Develop technical specifications under which prioritized sets of data will be exchanged by HIOs and NJHIN • Privacy and Security. Recommend the privacy and security framework and legislative changes that may be necessary for exchanging information
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within federal and state law • Financial Sustainability. Estimate costs for building and maintaining the health IT infrastructure for the state and evaluating the value, cost savings and potential revenue streams for NJHIN and regional HIOs • Personal Health Records. Review current PHR environment and recommendations for best practices • Economic Development. Review and develop forecasts of economic and workforce development impacts of statewide health IT programs In addition, a Health IT Action Team (HAT) Committee, composed of state officials and the federally funded New Jersey Regional Extension Center supporting physician adoption of EHRs (NJ-HITEC), meets every Friday in the Health IT Coordinator’s office to synchronize the health IT initiatives they are involved in across the state. LOOKING AHEAD The state health IT program seeks to provide everyone with electronic health records and exchange of health information to improve the health of and healthcare for all New Jerseyans. By 2012, the New Jersey Health Information Network (NJHIN) is expected to be set up as a 501(c)(3) not-for-profit to purchase and manage the technology infrastructure to connect all the regional HIOs, New Jersey Medicaid and other statewide resources. The long-range plan foresees that NJHIN, along with other state-level HIOs, will eventually connect to a Nationwide Health Information Network (NwHIN). For more information on the state’s health IT program, see the New Jersey Health IT website at www.nj.gov/njhit. Colleen Woods was appointed by Governor Chris Christie as New Jersey Health IT Coordinator in July 2010 and works in the Governor’s Office. Previously Woods served as the Chief Information Officer for the New Jersey Department of Human Services. Mike Squires serves as Communications, Outreach and Policy Lead for the New Jersey Health IT Coordinator’s Office. He is Vice President, Strategic Development and Public Policy for BluePrint Healthcare IT.
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Reports received from Specialist
Medication Allergy Alert E-prescribing
Referral Status Lab results in, call patient
PATIENT: John Kurt
By Cari Miller
Patient-Centered Medical Home Care Model: IT Considerations The medical home concept is being heralded today as a healthcare delivery reform with many potential benefits for healthcare providers and their patients, and recent surveys suggest that transformation to this care coordination model is a major goal of many primary care and multi-specialty practices. Based on her experiences with physician practices in New Jersey and other states, Cari Miller highlights in this article some of the ways that health information technology can enable primary care practices to meet the patient-centered medical home (PCMH) qualification standards developed by the National Committee for Quality Assurance (NCQA). Although the medical home concept was first envisioned several decades ago before we had microcomputers, primary care practices implementing EHR software for the first time should find this article especially useful. Carol V. Brown, PhD Technology Editor
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The patient-centered medical home (PCMH) is a model of care provided in primary care practices that seeks to strengthen the physician-patient relationship by replacing acute, episodic care with coordinated care and a long-term healing relationship. The American Academy of Family Physicians and other primary care associations have jointly defined the medical home as a model of care in which each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. The patient-centered model is high-touch, based on the personal relationships and enhanced communications that are developed between the patient and his or her personal physician and multidisciplinary care team. The strong PCMH model is also high-tech, infused with the ability to use electronic information to efficiently and effectively address the patient’s healthcare needs, be it for chronic conditions or for wellness and prevention services. Information technology is critical to the operation and success of a PCMH practice–technology supports workflows, assists with quality improvement activities and is key to being able to collect data and use that information in meaningful ways to enhance patient care and patient experiences. High-touch and high-tech are mutually important, and when used together enhance the quality of care and the relationship between patient, physician and healthcare team. Certainly, implementing IT or working within the
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patient-centered model of care is not an easy task or one without costs. Quite the opposite. Oftentimes, practices believe they are already operating in a patient-centric model, but when the layers of operation begin to peel away, similar to the layers of an onion, more times than not, the practice learns that there are opportunities for improvement and needed changes that can greatly enhance and foster the practice’s patient-centric approach. In addition, at times, system upgrades, staff training and possibly additional staff can make the process a costly one. A recent status and needs assessment study was conducted by the Medical Group Management Association (MGMA). The study, which collected data from March and April 2011 from 341 medical organizations, including approximately 5,800 primary care physicians, indicated that while medical practices are interested in operating as a PCMH, making changes to operate as a PCMH poses challenges relating to work flow redesign and costs associated with practice 1 transformation. While recognizing that such challenges do exist, it is important to highlight the role health IT can serve when venturing into the PCMH implementation arena. The focus of this article is on answering this question: What are some of the critical information technology features a primary care practice must consider when implementing and operating as a PCMH?
“
Information technology has many other roles within the PCMH environment, including creating patient portals; enabling advanced electronic communications; assisting with care transitions; monitoring care across settings; collecting, monitoring and reporting quality data; increasing use of and adherence to evidence-based care guidelines and more.
”
Access Code: Patient’s Date of Birth:
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Month
Day
Year
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EFFECTIVELY BLENDING THE PCMH MODEL WITH TECHNOLOGY Care delivered in the PCMH model is often facilitated and enhanced through the use of electronic health records, registries, tracking and monitoring systems and e-prescribing capabilities. In addition, having information technology within the practice setting allows for the possibility of health information exchange between a patient’s healthcare providers and healthcare systems, such as the patient’s primary care physician and consulting specialist, hospital or laboratory. Access to information technology in the office is a first step. Being able to use that technology and use it effectively is the next and critically important step. Through the use of health IT, physicians and the healthcare team can more easily identify services, tests, screenings, referrals and education that the patient may need and provide these when and where needed, in a culturally and linguistically appropriate manner. Four helpful features included in the PCMH model that are high-touch and high-tech include the following. Identification of patients in need of tests. Utilizing electronic systems to identify patients in need of services or tests or those who may need extra attention to help manage specific conditions is critical to the care coordination and population management tasks that are necessary in the PCMH model of care. In order to accomplish this kind of patient identification, the clinical data systems (electronic health record systems and disease registry programs) should be capable of storing clinical data within searchable data fields. This means that the system is capable of searching through selected data fields to identify patients who meet the search criteria. This capability is invaluable in many situations. For example, a birth year can be searched to identify all patients born in a specific year; this would assist when trying to identify all patients over the age of 65 who are due for a pneumococcal vaccination. Searchable data fields can also generate a list of patients with chronic conditions, which can help identify patients who need tests to help manage their conditions or patients who may not have had recent visits to monitor their conditions. In the past, this kind of patient identification
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was almost impossible with paper charts. Now, physicians and medical staff who utilize information technology can automate the process and implement procedures to ensure patient lists are generated and that staff is proactively reaching out and educating patients. While one would think that all electronic health record systems can do this, many times the systems are not capable of generating lists from searchable data fields; a registry based on data from the electronic health record system is needed. This kind of registry is becoming even more important within the practice setting as health plans, larger employers and others begin to provide payment incentives to practices that are better able to identify, communicate and work with patients to manage their conditions, as well as practices that are able to achieve or exceed quality and utilization metrics. Having the capability to utilize information technology to identify and manage patient populations within the practice is key to positively positioning a practice to receive potential incentive payments. Test and laboratory tracking. Practices can use electronic capabilities to order and receive test and laboratory results. Utilizing the system to track which results were received and which are still outstanding helps practices “close the loop” on patient care. Staff that is assigned to monitor tests and lab work being ordered electronically can quickly see which results have not been received and then follow up with the patient or service provider to help ensure the patient test results are received. Specialist referral tracking. The ability to track referrals to specialists is also enhanced through information technology. Important referral information regarding the patient’s status and need for referral can be transmitted electronically, and reports and recommendations regarding the patient’s condition from the specialist can be received electronically–thus expediting care planning to best address the patient’s healthcare needs. In addition, tracking referrals electronically helps ensure that a patient with a critical referral does not fall through the cracks. It enables a practice to see if the results are received, and if not, provides a monitoring tool for the practice to follow up with the specialist to get the reports or to contact the patient to encourage follow-through on the referral to the specialist. E-prescribing. Another key feature of electronic systems that is critically important in a PCMH practice environment is e-prescribing. Electronic systems include features that
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can conduct safety checks that provide alerts for medication allergies or drug interactions. These systems can also provide cost checks, indicating availability of generic alternatives or a list of medications that are on a specific health plan formulary. These systems can also be used to generate lists of patients on a specific medication during times of medication recalls, allowing practices to expediently identify patients and take any necessary actions to mitigate risk to the patient on the recalled medication. Information technology has many other roles within the PCMH environment, including creating patient portals; enabling advanced electronic communications; assisting with care transitions; monitoring care across settings; collecting, monitoring and reporting quality data; increasing use of and adherence to evidence-based care guidelines and more. PCMH practices that have implemented information technology have reported many positive benefits for patients, physicians and healthcare staff.
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Note: For more information regarding health IT and
the PCMH model of care, the Patient-Centered Primary Care Collaborative has compiled a compendium of resources in an article entitled “Transforming Patient Engagement: Health IT in the Patient Centered Medical Home.” This article is available online through the PCPCC at www.pcpcc.net. Cari Miller is Director of Advocacy and Program Operations for the New Jersey Academy of Family Physicians. She has worked with more than 250 physicians in approximately 400 locations locally and nationally on patient-centered medical home (PCMH) recognition and practice transformation projects. 1
Flores, L. (2011). The patient-centered medical home: 2011 status and needs study. (Report from Medical Group Management Association’s Innovation and Research Team.) Englewood, CO: MGMA.
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PATIENT TELEMONITORING: Valley Home Care’s Journey
By Elaine Davis, RN “The Well@Home monitor is lightweight, portable and equipped with devices that the patient (or caregiver) uses to record blood pressure, blood oxygen levels, pulse, blood glucose levels and weight.” “The monitor is connected to a telephone jack… [or] to a modem…”
The cost, quality and patient access benefits of telehealth solutions have received increased national government attention in recent months as concerns about the impacts of an aging population have grown. In this article, Elaine Davis, RN, describes the multi-year journey at Valley Home Care as this organization successfully expanded its 24/7 home monitoring program for patients with heart failure diagnoses. For readers not familiar with today’s easy-to-use devices that enable patients to capture their own vital signs and transmit them via regular telephone lines from their own homes, this article provides a great deal of food-for-thought about how telehealth solutions can effectively supplement in-person healthcare delivery by multiple providers. Carol V. Brown, PhD Technology Editor
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At Valley Home Care (VHC) in Paramus, New Jersey, telehealth has become an important part of the nursing plan of care for patients. After a multi-year pilot funded by the Robert Woods Johnson Foundation several years earlier, in 2005 VHC decided to initiate a remote telemonitoring program. Providing quality care to VHC’s patient population is the primary focus of the telehealth program, but there are also cost-saving objectives: lower hospital readmission rates and lower emergent care visits. With this in mind, the program’s focus was narrowed to target the following patients with diagnoses that could reap the highest benefits from the telemonitoring service: • Primary population: primary heart failure diagnosis • Secondary populations: postoperative cardiac surgery, other cardiac diagnoses (hypertension, myocardial infarction), diabetes and chronic obstructive pulmonary disease (COPD) A vendor was selected that offered a telemonitor and hosted software that integrated with the VHC nurse documentation system. The Well@Home monitor is lightweight, portable and equipped with devices that the patient (or caregiver) uses to record blood pressure, blood oxygen levels, pulse, blood glucose levels and weight. There is an additional, optional capability for a Lead II ECG strip via thumb sensors if required. The monitor’s displays can also be customized according to the patient’s diagnosis to provide relevant educational vignettes about the disease process, interventions and medications. Specific questions for symptom checks and medication reminders can also be programmed. The monitor is connected to a telephone jack–”piggybacked” to an existing phone line–in the patient’s home. The monitor can also be attached to a modem if the patient’s service provider is a cable company. Any information that the patient records is immediately uploaded to the vendor’s Health Information Portability and Accountability Act (HIPAA) compliant website and then immediately downloaded into the patient’s electronic health record (EHR). On a daily basis, a nurse retrieves each patient’s readings for review. A secure link via the web of the patient’s daily telemonitor readings is also available to the patient’s primary physician and to the patient’s caregivers. Having patient information available to all care providers at any time always makes for improved patient care management.
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“After careful review of all of the information, the nurse will contact a cardiologist as needed, and the nurse or the physician will contact Mrs. K if any new or changed action is required.”
At the time of installation, the monitor is also set up to send an alert to the nursing staff when there is any deviation from the patient’s normal readings or there is a report of a symptom via the monitor. There is also an additional safeguard: The monitor will instruct the patient or the caregiver to call the nursing staff when there is a significant discrepancy in the readings. This allows the nurse to address these more urgent alerts in the patient’s daily telemonitor readings in real time. To ensure success in the telehealth program, selected patients are required to have adequate vision and the ability to use the equipment themselves or have a caregiver capable of performing the necessary tasks.
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The benefits of the telemonitoring program can be seen most easily by taking a look at a day in the life of a typical telemanagement patient and nurse. Mrs. K is an 89-year-old woman who needs careful monitoring for her congestive heart failure. She wishes to continue to live independently in the home where she raised her children. She also wants to take birdwatching trips and visit the library. First thing in the morning, she sits at her table in her breakfast nook and records her blood pressure, weight, blood oxygen levels and pulse with her easy-to-use, notebook-sized portable monitor. An up-to-datereminder of the names, dosages and schedule of Mrs. K’s cardiac medications pops up on the display screen so that she can easily and effortlessly keep to this schedule. Recently, Mrs. K has had difficulty remembering her nighttime medication, so an audible reminder has also been programmed to alert her when it is time to take the medication. Across town, every morning, Mrs. K’s VHC nurse retrieves the data for her patients from the secure vendor website. After careful review of all of the information, the nurse will contact a cardiologist as needed, and the nurse or the physician will contact Mrs. K if any new or changed action is required.
The telemonitor increases the amount of interaction the patient has with a medical professional throughout the telehealth episode. The patient’s primary visiting nurse makes
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on-site visits, one to two times per week, to assess the patient for physical signs and symptoms of disease. Meanwhile, on a daily basis, the patient’s telehealth nurse remotely assesses the data recorded by the monitoring device for signs and symptoms. Any deviation from the patient’s normal readings or a report of a symptom activates a call to the patient or the caregiver. This becomes a teaching session for the patient and caregiver with the telehealth nurse instructing them in the patient’s diet, medications and adherence to the medication schedule. Any symptoms or readings that require an intervention, especially if a medication change is anticipated, will also generate a call to the patient’s physician. Telehealth nurses routinely make follow-up calls the day after a patient has an office visit with a physician or after there have been any medication changes. In addition, calls are made to reinforce positive behaviors; if, for example, a patient shows improved medication adherence or weight loss after a dietary adjustment, that patient will receive a call acknowledging that positive effect. These types of personal interactions with the patient are one of the objectives of telemonitoring. This telehealth program is not just about recording numbers; it is all about increasing patient/nurse encounters and building relationships that enhance learning about disease management and result in successful outcomes for the patients.
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VHC’S TELEHEALTH JOURNEY The telehealth journey at VHC began in 1995 when VHC purchased 10 video monitors with a three-year Robert Woods Johnson Foundation grant to implement a pilot program in monitoring heart failure patients with their cardiac clinician team. Important goals were met with this program, including decreased emergent care visits and decreased rehospitalization rates. However, because the video telemonitoring occurred in real time and the nurse made a virtual visit with the patient, only a limited number of patients were involved. During the pilot, the on-site nursing visits were also not fully optimized. This pilot experience, therefore, led VHC to look for a remote telemonitoring system without video that would enhance the ability to deliver nursing care when the patient required it the most, and to maximize the benefits from the visiting nurse visits. When VHC began the new program with 25 telemonitors, a telehealth manager was appointed to establish the program, educate the staff and implement the program as efficiently and seamlessly as possible. Buy-in to the benefits of telemonitoring by the visiting nurse staff was key, as the program depended on patient referrals to the telehealth program; without the full participation of staff members, the program would have stalled. The plan was to deploy the monitors with minimal disruption. The only change on the part of the nursing field staff was to identify the patients who met the selection criteria and send a nurse referral to the telemanager. This allowed the nurses to discover for themselves, through improved management and outcomes, the benefits of the telemonitoring program to their nursing practice and to their patients. In 2005, the program initially did not focus on patients with any one diagnosis. Instead, the initial objectives were to keep the monitors in use and allow time for the staff members to acclimate to the change. As staff buy-in to the benefits of telemonitoring became evident, the focus of the program was narrowed to diagnoses that were most troublesome and that afforded the opportunity for the largest impact. Heart failure patients stood out as an obvious choice: These patients are typically fragile, repeatedly readmitted to the hospital and have a need for ongoing education. We also found that cardiac surgery patients significantly benefited from short-term, postacute care monitoring, as exacerbations of fluid overload, irregular heartbeats and blood pressure issues often arise during the
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early postoperative period. Over the next five years, the remote monitoring program continued to grow–to 50, 60, 90 and now 110 monitors. Initially, staffing was quite limited. One nurse deployed monitors, reviewed the data and discharged patients from the program. On-call staff was also needed to cover the 24/7 “alerts” feature of the program. When the program grew to include 60 monitors, additional staff was added. Over the next five years, as the number of monitors increased to 110, with a patient case load primarily of heart failure patients, more staff was added to assist in these tasks, as well as in weekend and holiday alert management. Today, the program is staffed by two full-time registered nurses, per diem nurses for the alerts on weekends and holidays and additional tech support to pick up monitors and troubleshoot technical problems in the home. Reimbursement by insurers for telemonitoring services continues to elude home healthcare. Instead, cost savings are garnered via more efficient nursing visits and decreased rehospitalizations. Within the past calendar year, VHC has provided a remote telemonitoring service to more than 700 patients, typically between 30 and 50 heart failure patient referrals a month, with a length of stay in the telemonitoring program between 10 and 60 days. For this population of heart failure patients, the 30-day hospital readmission rates have been below the national average for heart failure patients; in 2010 the readmission rate of VHC telemonitoring patients was 18 percent (readmitted for all causes). The national average 1 for this population is 24 to 25 percent. Over the past year, VHC incorporated a disease management program as part of the telemanagement system for heart failure patients. Nurses now have a prescribed care map to follow that was developed in collaboration with a local cardiologist and a nurse practitioner who specializes in heart failure patient management. In addition to the telemonitor in the home, patients now also receive an automatic dietician referral, physical therapy and specialty cardiac nurse evaluation and education sessions. The educational directives were developed according to Heart Failure Society of America comprehensive heart failure guidelines and the American Heart Association’s Get with the Guidelines program. VHC also offers a private-pay remote monitoring model in which patients are provided long-term monitoring
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without in-person nursing visits. This option provides timely interventions and peace of mind to caregivers and patients alike. For the future, VHC is considering using video monitors as an adjunct to the basic telemonitoring for heart failure patients on IV medications. This will allow nurses to make more frequent televisits that provide the physical assessment that a video monitor offers and the routine telemonitor does not. For the patients, this enhanced program could mean the difference between staying at home or being rehospitalized with an exacerbation. Other models being considered include using video monitors for ongoing instruction to family and caregivers for other types of patients with IV pumps or with hospice patients with high levels of anxiety and the need for frequent contact.
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Remote telemonitoring is a diverse IT-enabled technology that can be incorporated into many models of care. With current healthcare reforms focused on greater care coordination and increased adoption of electronic health records by physician practices, there is now an opportunity to even better utilize this type of proven technology. Elaine Davis, RN, is the Manager of the Telemanagement Program at Valley Home Care in Paramus, New Jersey. Relying on her expertise in the acute care and home care environment, Ms. Davis has spoken and written on incorporating telehealth into standard clinical practices and redesigning home care processes with the use of telemanagement. 1
Center for Medicare and Medicaid. (2011, April 11). Hospital 30 day rate of readmission. www.qualitycheck.org/QualityReport.aspx?hcoid=5503&x= mrtReadmission&program=Hospital
OTHER MEASURES OF SUCCESS Below are some comments that have been captured from telehealth patients. These are part of VHC’s success story, as well. 1 – When a telehealth nurse called a patient regarding an issue due to an adverse reading, the patient told her: “I knew you would call, and I think I know why my readings are off.” 2 – When a telehealth nurse discussed the cause and effect of a measurement change (gaining weight after eating a particular kind of food), a patient stated: “I never understood that before, but now I do. That’s why I can’t have that food!” 3 – When it came time to have their monitors removed, some patients have begged for “a few more days.” 4 – Other patients call weeks after the monitor is removed to maintain contact with their telehealth nurse and ask some questions. 5 – Some patients have even named the nurse icon on the monitor screen after the telehealth nurse, because of the strong bond that developed.
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Speak with Janet Puro to learn about advertising opportunities with MDAdvisor, or e-mail her at editor@mdadvisornj.com.
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EHR
Helping
Physicians Achieve Quality Goals and Metrics: The PCIP’s Experiences
By Mytri Singh, MPH, and Vicky Tiglias
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As part of the February 2009 American Recovery and Reinvestment Act (ARRA), the HITECH Act includes funding for regional and state support units–called Regional Extension Centers (RECs)–to help eligible physician practices achieve Meaningful Use with certified electronic health record software.* In this article, two managers within the Primary Care Information Project (PCIP) describe the support that this organization has been providing to physician practices in medically underserved areas in New York City even before the HITECH Act was passed. Since PCIP is now recognized as a national model for how government-funded RECs can help physician practices become “Meaningful Users,” there are several lessons here for physicians about the Quality Improvement benefits that can be achieved as part of the EHR implementation journey. Carol V. Brown, PhD, Technology Editor The Primary Care Information Project (PCIP) was founded in 2005 with a mission to improve the quality of care in medically underserved areas in New York City through health information technology (HIT). As of mid-year 2011, PCIP has implemented electronic health records (EHRs) for 2,673 providers across 570 practices within the five boroughs of New York City. The practices recruited for PCIP are small private physician practices and two types of large practices: community health centers (CHCs) and hospital outpatient departments (OPDs). The PCIP team began EHR implementations in 2007 with a single vendor, but in 2010 we began working with additional vendors for implementation services. A software development team within PCIP worked closely with the initial EHR vendor to develop population health measures and registry features in the EHR so providers could query databases to generate actionable reports. When appropriate, these features help doctors address the 10 health priorities outlined by the New York City Department of Health and Mental Hygiene’s Take Care New York (TCNY) program. (See “Take Care New York’s 10 Priority Areas for Intervention” box.) PCIP uses a “boots on the ground” model by providing on-site assistance to move from paper charts to electronic records. Providers in the program practice in underserved settings and might not have the resources to implement * For more information on New Jersey’s REC, which has been funded by the HITECH Act over the past year, see an interview with Executive Director William J. O’Byrne in the Winter 2011 issue of MDAdvisor.
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an EHR without PCIP’s support. The implementation team works with the practice and EHR vendor teams to assist with all aspects of implementation, as well as with post Go-Live support. Implementation specialists typically have a background in IT support, project management and relationship management; these specialists help practices understand their project plan, help advocate with vendors, as needed, on behalf of the providers and visit the practice for on-site support. Once the EHR is live, the implementation specialists also assist with managing version upgrades, add-ons (such as the patient portal), connectivity to a health information exchange, lab interfaces, etc. PCIP is also a designated Regional Extension Center (REC) with funding under the 2009 HITECH Act, helping physician practices to achieve the “Meaningful Use” criteria and to qualify for the current federal incentive funds.
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toward the ABCS: aspirin therapy, blood pressure control, cholesterol control and smoking cessation. PCIP’s small practice model gives providers and staff time to become comfortable with the EHR in the first few months after Go-Live. Immediately after going live on an EHR, many small practices are not ready to start working on quality improvement and need a few months to make the transition effectively. Additionally, practices may struggle with meeting their quality goals due to a lack of staffing resources. Therefore, during the initial three months, PCIP’s small practice QI specialists and EHR specialists (PCIP staff who know the in-depth functionality of the software) help address critical operational needs of the practices–billing and configuration needs. PCIP works with practices early on to fully detail expectations, including the potential for lost productivity. The typical Go-Live recommendation is to decrease providers’
Take Care New York’s 10 Priority Areas for Intervention 1. 2. 3. 4. 5.
Have a regular doctor Be tobacco-free Keep your heart healthy Know your HIV status Get help for depression
6. 7. 8. 9. 10.
Live free of dependence on alcohol and drugs Get checked for cancer Get the immunizations that you need Make your home safe and healthy Have a healthy baby
QUALITY IMPROVEMENT SERVICES The Quality Improvement (QI) services of PCIP follow two models: one for small, private physician practices (which are typically one- or two-provider practices) and one for large practices (CHCs and OPDs). Each practice is assigned a QI specialist. Although the support needs differ based on practice structure, in general, QI specialists provide guidance on clinical workflow redesign, planned care (reaching out to patients with chronic health conditions who have gaps in their care) and the use of data to track the quality of clinical care. Small Practice Model. Of the 570 practices in PCIP,
528 are small practices that receive significant oneon-one Quality Improvement assistance from PCIP. Small practices receive on-site QI visits geared
workloads by half for several weeks to allow sufficient time for instruction on and acclamation to the EHR features and workflows. Practices that have successfully followed this advice have found that revenue lost initially is recouped once office visits become more efficient. PCIP also helps practices prioritize their implementation with the understanding that full funding is not always initially available. For example, practices may not need to Go-Live on the EHR and a patient portal at once; they can implement the portal when more funding becomes available. Large Practice Model. The small practice model does not apply to PCIP’s larger organizations as they typically have existing QI infrastructure in place, perform routine QI activities, take part in regional and/or national QI programs
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and use some form of registry for chronic disease management. As a result, these practices are ready to begin QI work immediately, if not before Go-Live. Introductory QI activities that prepare large practices for the addition of the EHR include the following: • Assessment of the existing QI plan • Review and breakdown of reporting requirements and data elements • Review of QI measures and data elements, including numerators and denominators • Planning for manual clinical data preload into the EHR To date, 42 large practices at 135 sites with a total of 1,690 providers receive support from PCIP. Before working with a large practice, the QI staff consults with the implementation team to understand the setup and specific needs of each practice. This is very important, given the unique operation and reporting requirements for the practices. These consultations also allow the QI staff to understand any issues that practices may have struggled with during EHR adoption and how those issues could potentially affect successful use of the EHR. Before QI staff members begin working with a practice, implementation staff identify “as-is” workflows on the paper system and map out “to-be” workflows using the EHR; therefore, the QI staff can more easily assess how effectively the staff has transitioned to their new workflows. Understanding existing goals and what, if any, QI processes are already in place helps PCIP customize a plan for individual large practices. Through these QI assessments, it was found that many large practices struggled with documenting clinical information in a structured and consistent manner in the EHR as required for QI reporting. Often this difficulty could be attributed to lack of staff availability during vendor training and/or staff turnover. To address these issues, PCIP created a learning collaborative to bring organizations together to learn how to use the EHR meaningfully and how to share best practices with one another. Because the launch of this learning collaborative coincided with the Center for Medicare and Medicaid Services’ release of the final rule for Meaningful Use (MU) Stage 1, the program was called the Community Health Center Meaningful Use Program. PCIP partnered with a local community health center, Urban Health Plan, Inc., an early EHR adopter that could share its successes and challenges as a large, multisite CHC.
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Through the learning collaborative, PCIP assists large practices with the following: • Clinical workflow redesign • Customization of the EHR for documentation efficiencies • Optimization of EHR use • Quality measure improvement through shared provider dashboards (a snapshot of the provider’s performance in quality measures, syndromic surveillance and utilization data run against PCIP benchmarks as well as MU thresholds) • Forums for discussions and sharing materials among different provider types • An understanding of MU Stage 1 criteria and how to meet the EHR targets TRACKING QI GOAL ACHIEVEMENTS During on-site practice visits, PCIP staff members help practices create reports to examine and analyze the data collected. They also set up Plan Do Study Act (PDSA) cycles to identify barriers and implement improved workflows. Since PCIP receives monthly, automated, aggregated de-identified data transmissions from all practices, at the provider and practice levels, QI staff can track improvement to goals over time and can proactively reach out to practices that appear to be struggling with a specific measure or area of care. PCIP additionally uses this data to generate provider dashboards that are sent to providers electronically, showing how they are performing on specific measures in relation to all other PCIP providers. Not only has PCIP seen tremendous improvement in provider QI measure performance, but the program has also helped practice staff members work to the highest level of their licensure, freeing up time for providers to spend on other health priorities with their patients. For example, when addressing a patient’s smoking status, the provider does not need to assess and document in the EHR whether or not a patient is a current smoker; a medical assistant or nurse can incorporate that information into the vital sign assessment. PCIP has seen improvement in MU measures such as smoking assessment when practices adopt these methods. Similarly, practices have improved their use of electronic prescribing following a workflow redesign process. Armed with materials from
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PCIP, practices are making changes in the community and improving the health of their patients. PATIENT-CENTERED MEDICAL HOME RECOGNITION All PCIP practices receive assistance from QI staff to achieve the National Committee for Quality Assurance’s Patient-Centered Medical Home (PCMH) recognition. As early as 2008, PCIP recognized the quality of care benefits that its practices could achieve as part of the PCMH goals and dedicated resources to train QI staff on the 2008 standards and application submission process. Because practices could achieve Level 1 PCMH recognition by using basic functionality of the EHR (such as test tracking and flagging abnormal lab results), gaining Level 1 recognition for PCIP providers became a priority of the QI staff. As of May 2011, PCIP has 150 practice sites that have
PCMH recognition. Many practices achieved a higher level of recognition (Level 2 or 3) through additional support from the QI staff. This support included assistance with developing policies and procedures, standardizing documentation of care among providers in a practice and coordinating continuity of care and patient access. The impact of this QI initiative is evidenced in the National Committee for Quality Assurance’s report “The New PCMH 2011 Overview.” This report identified New York as the state having the highest number of medical homes (200+) of any of the 50 states as of the 1 end of 2010.
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Act incentives have been a great way to encourage practice leaders, providers and supporting staff to make adopting EHRs and achieving MU a priority. By including MU measures as baseline goals, PCIP assists the practices not only in meeting and demonstrating the achievement of the current requirements for the HITECH incentives but also in preparing their practices for future MU stages. As a designated Regional Extension Center, PCIP also continues to work collaboratively with other RECs to share “best practices” for EHR adoption and achieve QI above and beyond MU. Vicky Tiglias is the Senior Quality Improvement Manager at the Primary Care Information Project (PCIP) at the NYC Department of Health and Mental Hygiene. Mytri Pritam Singh, MPH, is currently the Executive Director of Implementation at the Primary Care Information
Project (PCIP), a Bureau within the New York City Department of Health and Mental Hygiene (DOHMH). 1
National Committee for Quality Assurance. (2011, January 31). The new PCMH 2011 overview. NCQA’s Patient-Centered Medical Home (PCMH) 2011. www.ncqa.org/tabid/ 631/Default.aspx.
LEVERAGING THE HITECH ACT INCENTIVES Over the past year, the MU criteria for the HITECH
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A MEDICAL GROUP’S JOURNEY INTO
,
Part II* By Simon J. Samaha, MD
In 2010, Summit Medical Group (SMG), a group of more than 250 practitioners supporting 70 medical specialties in Berkeley Heights, New Jersey, took a major step forward and embraced social media. After researching popular social networking sites, establishing objectives and assessing the risks, SMG began its journey. Designated members of the marketing
* See MDAdvisor Summer 2010 for Part I of this series.
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“
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…every communication and every touch-point is an opportunity to engage with our community. Starting with the SMG website, the marketing team displayed links to Facebook, Twitter and YouTube.
department first allocated the necessary resources, obtained support from within our organization and developed a process to monitor progress. Then, instead of taking “the big plunge” immediately, we tested the plan internally by creating a management blog and then externally by creating a presence on Twitter. Shortly after, we added Facebook and YouTube accounts. Overall, the goal in using social media was to reach out to the local community at large. This included current and prospective patients and families, employees and likeminded organizations with an emphasis on health, nonprofit and family-focused groups. In this way, SMG would be able to provide valuable education and other important information to our followers and fans. This included discussing current health topics and timely health and safety information from the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC), etc. This core group was also given regular updates on our new physicians and all the med-
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”
ical services SMG has to offer. Through these media platforms, our audience received relevant medical tips as well as health, fitness and nutrition articles. Additionally, because sifting through all the information available can be a job in itself, the marketing team created a video series called Medical Mondays, which links to videos about group services and specialties, physician interviews and patient stories. SMG also hired a full-time person dedicated exclusively to social media. This person observed and detailed favorite Facebook pages and noted how frequently our Twitter tweets were either retweeted or mentioned by others. We also tracked physician ratings sites, including HealthGrades, Vitals, RateMDs, Citysearch, Angie’s List and more. OPENING THE DOORS TO SOCIAL MEDIA SMG continued the journey with an understanding that every communication and every touch-point is an
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opportunity to engage with our community. Starting with the SMG website, the marketing team displayed links to Facebook, Twitter and YouTube. We did the same with our internal intranet site. And we added social media links to all SMG employees’ e-mail signature templates. In addition, we found opportunities to cobrand with relevant healthcare partners on Facebook and Twitter. Such partners include the Red Cross, mom groups and the YMCA, to name a few. To demonstrate an openness to new thinking and ideas, SMG found popular tweeters in the healthcare world and provided them with a forum by mentioning them in our own tweets and retweeting their messages when appropriate. And whenever we found like-minded healthcare Facebook pages, we posted our message with theirs. SMG has also made it a policy to add social media URLs and icons to all print communications–from patient newsletters, brochures, promotional posters and table tents to business letterhead and business cards. Additionally, we’ve done everything possible to make the most out of our patient database. We’ve purchased Facebook ads, added social media information to our customer survey letters and used tags on all Internet posts where SMG is mentioned. ASK YOUR DOCTORS FOR HELP Right from the start, many of our physicians were uncomfortable with the idea of social media. Part of this discomfort was due to a lack of understanding. Another part was a reluctance to engage in “self-promotion.” The challenge was to gain their support. To begin, we identified and recruited physicians who were most willing to promote ideas that would represent the best that SMG has to offer. These physicians, along with some of our other healthcare professionals, became visible advocates for some of SMG’s most successful online programs, including Kidz Corner–a weekly post of health tips, medical articles, kid-friendly recipes and events, all
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presented by our team of pediatricians. Our SMG allergist has also made regular updates on topics such as seasonal health information and timely alerts on current allergy news. From our audiology department, there have been weekly speech and hearing trivia contests, plus original content microblogs. And we’ve been diligent about posting and tagging lecture presentations, photos and videos from our physicians wherever and whenever appropriate. RATINGS SYSTEMS ARE GOOD; BERATING SYSTEMS ARE NOT Today, there’s a surfeit of information available to consumers who are interested in learning about how a physician measures up. From directories to ratings sites, these tools can be very valuable. But there’s also a lot of misinformation–and unfounded negative comments. Recognizing online rating sites were growing in popularity among consumers, the SMG marketing team researched the largest, most optimized sites and monitored the reviews. We were able to correct incorrect data and improve the presence of our doctors by adding detailed descriptions, photos and video links. Internally, we recommended that our doctors not ask patients to sign “gag orders” that would prevent them from making negative comments, as some physician practices are doing. It’s not transparent, not in the spirit of social media and it could backfire. Instead, SMG took a positive approach and provided our physicians with an educational overview of popular sites such as Google, Citysearch, HealthGrades, Vitals and Angie’s List. This overview included examples of physician results and overall SMG results, strategies for tracking and enhancing physicians’ online presence and strategies for managing negative comments. (Although there is no one correct way to address negative comments, we’ve found it best to correct wrong information, refrain from being defensive, resist engaging in online arguments and be as responsive as the situation allows.) We also developed a group-wide response strategy that made use of physician comment cards that showed patients how to share good comments on numerous sites. Cards were made available in all physician reception areas. The marketing team at SMG has continued to oversee
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“
…over the next year,
our goals are likely to change. However, whatever social media is and whatever it becomes, our goal
”
is to embrace it.
and share the reviews with our physicians, both positive and negative. Broadly speaking, it’s been a positive experience, but we keep an eye on negative comments, which do spring up occasionally. MEASURING SMG’S VITAL SIGNS The best way to gauge success in social media is by listening, observing and monitoring. The following are a few of the methods we have used at SMG: • FACEBOOK INSIGHTS. This Facebook feature has allowed us to know which posts are generating the most feedback and to assess if the hits are driving users to our website. It also tells us if fans are finding our Facebook page. • GOOGLE ALERTS AND ANALYTICS. This feature lets us observe and analyze web traffic in real time. It also allows us to determine how much traffic our social media vehicles are driving to our website and how often we appear in online Google search results. • OTHER TOOLS. HootSuite, YouTube Insights, Twitter retweets and @mentions are some of the measures we’ve used to analyze, learn and adjust our social media content.
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By effectively taking our own temperature and pulse, we’ve found that our audience is less engaged on weekends and that our highest online traffic days are Wednesday through Friday. We also see a spike in user interactions when we post questions, photos and videos. And the number of patient comments has increased exponentially–mostly praising our doctors. Recently, we surpassed our halfway goal for new followers and fans. THE ROAD AHEAD: SMG’S YEAR-TWO GOALS In 2011, SMG has become knowledgeable about the uses of social media. But to say “we’re there” would misrepresent the whole point of social media. One is never “there.” Social media is an emerging and constantly changing form of communication. In 2012, we hope to meet the following concrete goals: 1—Host live chat sessions with healthcare professionals 2—Increase employee and physician participation 3—Place more emphasis on our SMG LinkedIn page and use it as a recruitment tool for professional positions such medical assistants, office administrators, etc. 4—Use social media to mobilize our employees as brand ambassadors Of course, over the next year, our goals are likely to change. However, whatever social media is and whatever it becomes, our goal is to embrace it. Simon J. Samaha, MD, is President and Chief Executive Officer of Summit Medical Group, the largest privately held multispecialty medical practice in New Jersey, with a main campus in Berkeley Heights and area satellites in Berkeley Heights, Morristown, Shorts Hills, Summit, Warren and Westfield.
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