It took vision to imagine a 21st century EMR crossing a “frontier” state, but it took grit to implement it.
New Mexico Gov. Bill Richardson is nationally recognized for his strong support of information technology (IT) initiatives, particularly in the area of healthcare. Richardson maintains that the lack of automation information leads to inefficiencies and errors. To address this deficiency, in 2005 he created the New Mexico Telehealth Commission, which encourages a single, coordinated system statewide to advance telehealth.
It took vision to imagine a 21st century EMR crossing a “frontier” state, but it took grit to implement it.
Gov. Richardson’s vision included advancing technology within the state’s own operations, including public health facilities. As recently as 2006, New Mexico’s clinical health services relied on paper processes. Today, however, after careful planning and coordination, the clinics serve as exemplary models of efficient and fully digitized healthcare, with a Web-based electronic health record (EHR) and practice management (PM) system automating and connecting all 48 clinics with providers across the state.
The Public Health Division of New Mexico’s Department of Health (DOH) provides essential health services to approximately 43,000 low-income and indigent patients a year across 55 offices. Forty-eight of the clinics provide direct patient care, offering such services as family planning, immunizations, and sexually transmitted disease diagnosis and treatment. Individual public health facilities range in size from a single nurse and clerk to 20 or more providers and staff in the largest location.
A Paper House
Before Gov. Richardson’s initiatives, New Mexico’s public health clinical services relied on paper for virtually every clinical and administrative process: medical records were stored in hand-written patient charts; appointments were logged to traditional appointment scheduling books; insurance claims were printed on paper forms; and, none of the 55 statewide facilities could share patient data electronically.
Typically, staff was unaware when or if patients visited other public health clinics. Even when patients disclosed this information, staff had no simple way to share medical history between offices.
Standardizing care across the state was difficult. Offices cover the entire state — 121,593 square miles. Providing consistent quality oversight was an on-going challenge. Many facilities are in “frontier” counties populated with less than seven persons per square mile. With so many remote and isolated clinics, conducting routine chart audits or regulating administrative functions was often not feasible. Patient tracking was also problematic: Typically, staff was unaware when or if patients visited other public health clinics. Even when patients disclosed this information, staff had no simple way to share medical history between offices. They worried about compromising patient safety because they lacked ready access to patients’ complete medication and treatment records.
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Billing efforts were hampered as well. The processes were cumbersome and inefficient, so often times insurance companies and patients were under-billed for services, resulting in less revenue. Each remote office keyed demographic and charge data into the antiquated billing system. Since the outdated software was unable to transmit insurance claims electronically, all claims were printed and mailed. Likewise, patient statements were manually printed and mailed.
Creating reports was challenging. As a state-funded organization dependent on taxpayer dollars and private grants, staff must document the number and type of services performed at each facility. Details such as patient diagnoses, race and ethnicity, are essential as well. Roll-up reporting was difficult and imprecise without automation tools.
Once the DOH received approval for its clinic automation project, they initiated a typical government procurement process, including requests for information, requests for proposals and product demonstrations. The department’s requirements included a hosted solution from a CCHIT- (Certification Committee on Health Information Technology) certified vendor; master patient index capabilities; EHR templates to support the standard clinical functions; appointment scheduling; and, robust reporting and electronic billing. While price was also a consideration, any product selected had to meet these minimum requirements.
A committee of clinicians and information system specialists from across the department reviewed proposals from vendors and asked finalists to provide detailed product demonstrations. To ensure the proposed solutions would mirror their workflow requirements, the committee asked vendors to follow specific scripted scenarios.
In the end, the department contracted with Dallas-based MedNetwoRx to provide a hosted version of the Allscripts Enterprise Health Record and Practice Management solution. The product stood out for its ability to meet the unique needs of a public health facility, its flexibility and its price. In June 2007, the DOH finalized its agreement with MedNetwoRx to automate the 48 public health clinics. They then quickly initiated an aggressive implementation plan.
The project team to lead the implementation effort included a project manager, IT representatives, clinical staff, and the chief nurse for public health. The group traveled to Allscripts’ Dallas training facility for intense instruction on the new software. The team created a customized implementation plan and optimized the software setup. Finally, they organized regional training sessions for employees to learn the basic system operations.
Clinical workflow is markedly more efficient than in the old days. Now when an existing patient arrives at any DOH clinic, staff has ready access to the patient’s financial and clinical record.
The DOH selected the San Miguel County Public Health Office as the initial pilot site. The project team and the vendors’ representatives conducted the first two-day classroom training session for the clinic staff. Next, the team worked onsite with employees as they entered patient data and scanned old charts. Their pre-live process included a review of upcoming appointments and the entry of patient demographics for the upcoming clients.
Just 61 days after signing the contract, the San Miguel County Public Health Office joined the digital world. By the end of the first week, all clinical information became electronically captured during the patient exam. Clinicians utilized the software’s automatic code calculator, which recommends the proper CPT code based on the documentation. The billing data was forwarded automatically to the practice management (PM) application. As staff continued to scan old medical charts for incoming patients, their reliance on paper dwindled.
Every week for the next year this process repeated, to add additional offices to the system. They provided regional classroom training for between one and three practices a time. The implementation team then worked with staff at their individual facilities. By August 2008, more than 340 DOH staff members were trained and all 48 patient care clinics were completely electronic.
As a result of New Mexico’s digital transformation, they’ve enhanced patient care routines and advanced administrative functions. For example, clinical workflow is markedly more efficient than in the old days. Now when an existing patient arrives at any DOH clinic, staff has ready access to the patient’s financial and clinical record. Public health employees enter patient information directly into the computer. They no longer require clients to manually complete paper questionnaires each visit.
Clinicians retrieve electronic medical charts during exams and document the complete encounter at the point of care. As soon as the medical record is updated, the clinician enters charges to the account. By the time the patient checks out, all the data required to hand the patient a receipt detailing the specifics of that day’s services is available. The central billing office also has all the necessary information to file a claim electronically or produce a patient statement.
The software’s clinical impact is considerable, including the increased safety benefits of the systemwide EHR. Providers have ready access to medication and treatment histories, increasing their confidence when prescribing new medication or treatment therapies. In addition, automatic warnings alert clinicians to potential drug interactions that might conflict with a patient’s existing medications. At every clinic they visit, patients are receiving more comprehensive care than ever before.
From an administrative standpoint, the system helps improve clinic oversight: The EHR allows access to records remotely; and chart audits, which ensure that all providers are following “best practices” and adhering to recommended care guidelines, are possible without having to travel to individual clinics to review paper charts.
Productivity gains from a number of providers can be attributed to the EHR-created efficiencies. For example, one of the nurse practitioners increased her daily average of 12 well-women exams to 22. In addition, she is completing all her chart documentation during the patient encounter. Other providers are improving their productivity by between 5 percent and 10 percent. As user familiarity with the system and workflow changes increases, we anticipate additional productivity gains across all clinics.
Though the overall revenue impact is still being evaluated, between productivity increases and the system’s sophisticated coding tools, New Mexico anticipates a boost in overall revenues. Patient financial data is more accurate now that each office has user-friendly tools to verify and update their information at every encounter. In addition, charges are posted to each patient’s account automatically and in real time. The state anticipates revenue gains as a result of the numerous clinical and administrative enhancements.
Feedback from New Mexico providers is predominately positive. Winona Stolzfus, M.D., a regional health officer for the DOH in Roswell, finds that the software is increasing patient throughput. “The system is very easy to use, and after the transition, we were able to shorten the time our patients waited for appointments,” she says.
Ramsey Allen, a nurse practitioner who rotates between three different offices, says, “The quality of care has risen because we’ve been able to standardize the questions we ask. We are doing a more extensive work up which helps us get a better picture of how the patients is doing. Our work is more consistent and charting is more concise and in order.”
The EHR software has created an incredibly rich source of data. The PM and EHR have the capacity to provide detailed reports on clinical services by diagnosis, location and patient demographics. In addition, the system can help monitor provider productivity. This data can be used to determine if the limited resources are efficiently apportioned between clinics, or if a different allocation would better serve the needs of the people of New Mexico.
The next step in New Mexico’s public health technology initiative is to implement automation at all state private practices and community health centers. Their success proves that it’s possible for all of New Mexico’s medical clinics to successfully incorporate technology into their facilities, without sacrificing productivity.
On behalf of physicians statewide, they have negotiated with MedNetWorRx and Allscripts to extend reduced pricing for the same proven EHR and PM solution they have successfully implemented.
In just one year, the New Mexico team successfully transitioned 48 clinics to an all digital environment and turned Gov. Richardson’s technology vision into reality.