Pediatric Clinic Uses EHR to Automatically Generate Clinical Quality Reports

The May Street Practice is located in Worcester, Massachusetts, and has four pediatricians and seven internal medicine doctors. Its parent organization, Fallon Clinic, is an independent nonprofit organization that includes 20 practice sites and 275 physicians. The May Street Practice and the other Fallon Clinic practice sites use the Epic electronic health record (EHR), which was implemented starting in 2006. With over four years of implementation experience, the Epic EHR systems now collect the data elements needed to calculate and report meaningful use clinical quality measures (CQMs).

Dr. Lloyd Fisher is a pediatrician at the May Street Practice and its EHR physician champion. Dr. Fisher spends 20 percent of his time working on EHR issues and 80 percent of his time on his clinical practice. He attributes this allocation of practicing physician time to EHR development and troubleshooting to aiding greatly in the implementation and acceptance of the EHR at the May Street Practice and Fallon Clinic.

• Incorporating clinical laboratory test results into their EHR as structured data
  The Epic EHR system is directly interfaced with four area hospitals for laboratory results. When doctors at one of the hospitals order laboratory tests, the results of these tests are entered automatically into discrete data fields in the Epic EHR. Results of tests ordered by May Street physicians are sent to the physician’s inbox and are also entered into the EHR.
• Selecting CQMs
  • The May Street Practice and the other Fallon practice sites chose an initial set of meaningful use clinical quality measures that reflect their twin focus on pediatric care and adult primary care. The CQMs chosen also utilize data elements already collected in their Epic EHR. The CQMs they chose include:
  • Childhood Immunization Status
  • Weight Assessment and Counseling for Children and Adolescents
  • Appropriate Testing for Children with Pharyngitis
  • Asthma Assessment; Asthma Pharmacologic Therapy
  • Preventive Care and Screening: Tobacco Use Assessment and Tobacco Cessation Intervention
  • Adult Weight Screening and Follow Up
  • Blood Pressure Measurement in Adult Hypertensives; Controlling High Blood Pressure
  • Diabetes: Blood Pressure Control
  • Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
  • Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older
  • Preventive Care and Screening: Colorectal Cancer Screening
• Calculating Meaningful Use Clinical Quality Measures
  The Epic EHR has been programmed with the required codes to calculate the numerators and denominators (including denominator exclusions) for each CQM. As a result, it is able to automatically generate performance reports on each of the CQMs for May Street Practice and other Fallon practice site physicians.

Working with the Massachusetts REC (MeHI)

The Massachusetts REC recognized that the Fallon Clinic’s years of experience with the Epic EHR would be valuable in assisting small and solo practices in meeting meaningful use clinical quality measures with their own EHRs. As a result, the REC certified the Fallon Clinic as an Implementation and Optimization Organization (IOO) in 2010. As an IOO, Fallon Clinic staff can work with independent small practices and implement their Epic EHR for them. In Epic’s eyes, the small practices would become an extension of the Fallon Clinic’s system, like the May Street Practice. The small practice can benefit from the EHR experience and knowledge of the Fallon Clinic’s physicians, nurses, and staff. The small practice can also benefit from the ongoing EHR upgrades, maintenance, local support, and refinements that are implemented by Fallon Clinic.

To encourage these types of collaborations, the REC provides funding to the Fallon Clinic to enable people like Dr. Fisher to work on EHR optimization within their own practice sites as well as with outside, independent small practices who may choose to join their Epic EHR. Dr. Fisher sees the REC as playing an important role in spreading EHR awareness across the state and in selecting IOOs that can help to bring EHRs to small, independent physician practices that otherwise might not be willing or able to implement one.

Until 2004, most physicians at May Street Practice and the other Fallon Clinic practice sites were using a “homegrown” EHR. However, they realized that they needed to purchase a more robust EHR to be able to meet the necessary meaningful use clinical quality measures. Their ultimate goal was a paperless system that would improve the quality and safety of medical care, as well as make physicians’ jobs easier and their work more efficient.

Creating an Advisory Council

An Advisory Council was created and comprised of physicians, nurses, medical assistants, and technicians to choose an EHR vendor that would meet their needs. They wanted an EHR that would allow them to:

• Customize the system to their likings,

• Convert records from their old EHR into discrete data, and

• Offer clinical decision support for physicians.

Dr. Fisher also stressed how important it was for staff to visit sites similar to theirs that had successfully implemented the EHR they were considering. In 2004, with these considerations in mind, the Advisory Council voted unanimously to purchase their EHR from Epic.

Transitioning to the Epic EHR System

Started in the spring of 2006, the May Street Practice and other Fallon Clinic practice sites transitioned to Epic in a three stage process:

• Scheduling system and view-only results and notes,

• Followed by paperless telephone messaging, and

• Culminated with the physician order entry and visit documentation within the exam room.

As the roll out began, staff were required to attend roughly 24 hours of job- and specialty-specific training sessions on the EHR functionalities. (Note: It is essential to understand that rolling out new EHR functionalities does not stop after the initial implementation period – it is an ongoing process that will need to continue following changes in medicine and in legislation that affect the practice of medicine.)

Identifying “Super-Users”

The strongest users, “super-users” were identified at each practice site. They participate in “super-user” webinars and presentations, and are ultimately responsible for disseminating EHR information at their practice site.

Training on Meaningful Use Functionalities

Training on meaningful use (MU) functionalities for the EHR is done on an individual basis and often communicated through email.

• The Epic EHR allows the team to see each physician’s utilization of the MU functionalities, and to follow up with those that are under-utilizing one or more of them in order to understand why.

• Individual physicians can also receive real-time feedback from the EHR system on how much they use each MU function. The hope is that this instant feedback will drive physicians to increase their use of the MU functionalities, allowing them to meet the meaningful use clinical quality measures.

Three Physicians Dedicated to EHR Troubleshooting

Overall, there are three doctors at different practice sites who dedicate a portion of their time to EHR development and troubleshooting:

• Dr. Fisher (Pediatrics),

• Dr. Garber (Internal Medicine), and

• Dr. Trudel (Family Medicine), who dedicate a portion of their time to EHR issues. Dr. Garber is also the overall Medical Director of Informatics at Fallon Clinic.

These physicians serve as liaisons between doctors and information technology staff and give monthly presentations focused on physician workflow. They have found that their fellow physicians appreciate having other physicians available who understand their day-to-day experiences and needs and how they are affected by the EHR. Furthermore, because Dr. Fisher, Dr. Garber, and Dr. Trudel use the same Epic EHR system in their own clinical work, they are easily able to identify (and often fix) problems they come across throughout the day.

Easy Access to Patient Health Information

As physicians and the other May Street Practice staff interact with patients during either telephone calls or office visits, all of the necessary information is entered into the EHR on the spot. The central registration service gathers patient demographic information on all patients before they are able to make an appointment. The day-to-day activities of the front office staff, nurses, medical assistants, and doctors all involve using the EHR. From front office staff documenting patients’ telephone calls, to medical assistants recording vital signs and patient history, to nurses processing prescription refills and triaging laboratory values that come in from outside, the EHR allows the practice to function more smoothly while meeting the targets set by meaningful use clinical quality measures.

Sandy White, RN, is the nurse EHR lead at the May Street Practice. She took classes initially on how to use the Epic EHR system, and now attends webinars several times a year and dispenses information to her team of nurses. She emphasized the value of the EHR in being “very helpful in pulling reports on who is due of this immunization or this lab test.” She also likes the way their EHR “gives you information at your fingertips” – no more having to flip through a paper chart.

Patti Sedares is the administrative EHR lead at the May Street Practice. She noted how the EHR provides a great way to document all patient encounters, even telephone calls. She said, “You know when the patient called, who they spoke with, what they requested, and what actions were taken following the request.”

Brenda Guzman is the medical assistant EHR lead at the May Street Practice. She emphasized that the EHR makes it a lot easier to understand what is written in the charts; she no longer has to worry about misinterpreting doctors’ handwriting. She also noted that “patients like the after-visit summary.”

• Site chiefs: The May Street Practice and each of the other Fallon practice sites has a site chief at each site whose primary responsibility it is to report back to physicians on their CQM and other performance measures.

• Medical Director of Quality: The Fallon Clinic also has a Medical Director of Quality who is the overall champion for clinical quality measurement across the practice sites. The physician who holds this position monitors data and presents his findings on department performance and practice site performance to the site chiefs. It is their hope that providing feedback will help to drive behavioral changes in physicians at the May Street Practice and the other practice sites that will lead to improvements in quality measure performance.

Several lessons learned were emphasized by Dr. Fisher, Dr. Garber, and other May Street Practice staff, based on their over four years of working with the Epic EHR:

• Practices cannot expect simply to adapt their current clinical workflows to include the EHR and be done with the process. For instance, the role of the medical assistant changed significantly after implementing Epic at the May Street practice. The new EHR also meant that patients began receiving after-visit summaries, another task that needed to be integrated into the workflow. Even the way in which practice staff correspond with each other has changed; they now communicate via Epic’s online messaging system.

• The implementation team needs to involve clinicians in the EHR selection and decision-making processes, and in the process of building EHR clinical tools and quality measurement systems, in order to be successful in meeting meaningful use clinical quality measures.

• It is imperative to maintain a committee of physicians who are using the system daily and to endow them with the EHR computer user tools to fix any problems they come across in their end-user experience.

• It is important to explore the EHR system in order to fully grasp its potential. May Street Practice medical assistant Brenda Guzman indicated it was helpful for her to learn the system during the training classes, in which fictitious patients, doctors, and encounters were created and used as examples.

• Network with other Epic users. Dr. Fisher and Dr. Garber learned a lot by networking with other Epic users. They attend meetings twice per year in Wisconsin at Epic headquarters. Practice staff also attend smaller meetings by role, for physicians, nurses, and others.

In addition, Dr. Fisher and Dr. Garber believe that their dual roles as practicing physicians and part-time EHR specialists have helped a great deal to implement their Epic EHR by giving physicians in their practices confidence that someone who understands their work is also deeply involved in working with the EHR and improving and refining it wherever possible.

Consider acquiring an EHR through an Implementation Optimization Organization, like Fallon, to benefit from the experience and expertise of other practices. Also consider identifying physician(s) who are willing to take on an active role in EHR implementation and who can, through frequent use of the EHR, identify improvements that should be made following roll-out.