Electronic Health Records:

The Future for Silver City Providers and Patients

Electronic health records (EHRs) are a critical piece of the nation's health information technology infrastructure and are seen by many as a requirement for improving our health care system. They may also be a key for health care quality improvement in Silver City and southwest New Mexico. Having up-to-date and secure medical records for patients accessible to health care providers could do much to ensure safe and effective care transitions when patients are seen in different settings in the community. Properly implemented, EHR systems can provide significant efficiencies for medical practices.

The cost of implementing EHRs can be high and the risks of introducing computerized health records in an unprepared medical practice can worsen the conditions these systems are intended to improve. To lower the barriers and improve the chance of successfully adopting electronic health information technologies (HIT), the health care community in Silver City has formed a consortium to efficiently implement an EHR system in their community. This effort has involved the combined efforts of the Gila Multi-Specialty Independent Practice Association (GMIPA) and the Gila Regional Medical Center (GRMC), with the assistance of a number of local, regional and national resources, working with medical practices in the community. These resources include the Wellness Coalition and the New Mexico Medical Review Association (NMMRA) as part of its effort under the Doctors Office Quality - Information Technology (DOQ-IT) project supported by the Centers for Medicare & Medicaid Services (CMS).

In April 2006 a committee open to interested members of the community and chaired by GRMC's chief information officer began to meet monthly. The committee was charged by the GMIPA Board of Directors and membership to explore and recommend efficient and effective options for EHR implementation in GMIPA member practices. Early committee discussions evolved a vision of a centrally hosted EHR system that would keep patient and business (practice management) records securely accessible only by those with appropriate and designated access to them, but would also maintain a comprehensive and up-to-date abstract of patient health records available to other practitioners and health care providers with legitimate clinical needs for this information in providing direct patient care. The health information structure is designed to allow health care providers in the community to access electronic health information on their patients, regardless of where that information is stored. The governance structure, to oversee the implementation and operation of this system, has been dubbed the Gila Health Information Network (GHIN), an organization responsible to the GRMC's Board of Trustees.

In addition to facilitating the clinical and practice management IT needs of practices in the community, the committee's work focused on identifying appropriate products and services that could meet functionality and interoperability standards to support the local vision. This included consideration of HIT products currently in use in the community. The committee also monitored the progress of the Certification Commission on Health Information Technology (CCHIT) and its evolving standards for health records functionality, security and interoperability.

By November 2006 the EHR committee had explored numerous software products that could serve as a "preferred" community EHR system to fit into the GHIN's growing vision. After viewing demonstrations of seven EHR systems, and subsequent to development of a computing network model to support the community health records and information exchange, the committee produced and released a request for proposal (RFP) to software vendors for a community EHR system. Of the four vendors that received the RFP, two were determined to be of sufficient merit for broader community introduction. The two vendors made full-day presentations of their products in February 2007, and eClinicalWorks was selected as the preferred vendor for the community EHR system and the GHIN. This recommendation was approved by the GMIPA board on February 28, 2007.

Since March 2007, the GHIN has been working to bring this information structure to reality in GMIPA practices. By mid-2008, implementation planning at the participating practices representing 25 practitioners in the community became a reality. It is expected that these practices will begin using the system late in 2008.

What will all of this cost?

Even with cost efficiencies created by volume purchasing, judicious outsourcing, and central computer support for the community EHR, the system envisioned by the GHIN has been expensive and almost exceeded the $500 monthly cost limit per practitioner that was established by the GRMC Board of Directors, even with 50-percent cost sharing by GRMC. However, by making use of different strategies for hosting EHRs for different sized clinical practices in the area, monthly costs per practitioner for EHR software and local support from GHIN/GRMC should be kept below $350. The use of "software as a service" (SaaS) options for remote hosting from eClinicalWorks for smaller medical practices has made these cost efficiencies possible.

Community practices may need to upgrade their Internet connections and network hardware to connect to the system and to implement the EHR system in their practices. Many practitioners will find it most efficient to use tablet or laptop computers to document their patient encounters and access this EHR system. This need, coupled with the use of computers to support patient scheduling, prescription management, billing, and other activities, may require further upgrades to computing infrastructures in local medical practices. Efforts are planned to use the volume-purchasing network, of which GRMC is a member, to lower hardware costs for practices. A set of computer hardware requirements and recommendations of the types of computers a practice might choose will be provided by the GHIN and eClinicalWorks.

When will all of this happen?

Effective planning and training for the adoption of EHRs is a major factor in their success. When a practice changes the way it handles and documents patient care information, its very essence may change. This can be a change for the better, but it requires that the practice reconsider and adapt all aspects of practice operations to the new information management opportunities to be optimally successful.

Pre-implementation training from eClinicalWorks is expected to occur by fall 2008. In the meantime, planning, demonstration, learning and training opportunities for practices in the community are underway to prepare practices to get the most from this formal training process. The committee expects to receive support and assistance for these opportunities from the GMIPA, the GRMC, NMMRA, the Wellness Coalition and other community resources.

What is eClinicalWorks? Why did the EHR committee select this vendor?

There are some 80 electronic health record products that are currently certified as functionally appropriate by the CCHIT. Of the systems the EHR committee reviewed, eClinicalWorks was selected primarily because it demonstrated the most efficient solution for the community in terms of collecting, capturing and managing health information. Further, the committee believes this product will support the community's needs now and into the future. The committee's considerations ranged from reviewing the objective information ranking EHR products to considering the decisions being made by other practices and communities around the country as well as in New Mexico. eClinicalWorks is ranked at or near the top in customer service and user satisfaction in small- to medium-sized provider groups by the two independent rating services for EHR products. The committee communicated with and visited practices that have successfully implemented eClinicalWorks to make sure its were findings were supported by the real medical world.

More information on eClinicalWorks is available at http://www.eclinicalworks.com/.

Provisions for Early Adopters

The GHIN strongly supports efforts to assure that early adopters of e-health technology are able to integrate their systems into the health information exchange network or transition to the community EHR system. It is expected that these adaptations will involve technological, functional and economic considerations and that solutions will rationally conserve their core information investments. The solution to facilitate inter-EHR interfaces may involve technology developed for the interface engine used by GRMC.

The EHR System: A Central Resource for Quality Care

NMMRA is committed to providing tools and guidance for New Mexico's physician office practices to utilizing the capabilities of EHR systems for improved patient care. EHRs can help standardize the use of best medical practices by using EHR systems to:

• Generate and maintain patient medication lists
• Generate and maintain problem lists
• Manage laboratory tests and retrieve results
• Select medications, print prescriptions or transmit them, and conduct safety checks

In addition, EHRs can implement patient-centered care management activities by:

• Identifying specific patients by category (disease) who need to receive appropriate care and monitoring services - registry functionality
• Generating and distributing patient-appropriate reminders and prompts
• Managing, applying and updating patient-specific care plans (appropriate for patients' characteristics and conditions)
• Assisting patients in obtaining the appropriate information and gaining access to resources in their environment to support and sustain their self-care efforts to optimize their well-being

NMMRA is also committed to assisting practices, through the use of tools, guidance and other appropriate resources, to effectively participate in CMS' Physician Quality Reporting Initiative (PQRI), which offers providers the opportunity to receive a bonus payment of up to 1.5 percent of total Medicare billing as an incentive to participate in this care performance reporting effort. Information on PQRI is available at www.cms.gov/pqri/.

For more information on NMMRA's involvement with the Silver City community's activities surrounding GHIN, contact Mark Gottlieb, PhD, DOQ-IT project manager, at (505) 998-9742.