Patient-Centered EHR Journey at the Community Health Level

April 22, 2014
Implementing an electronic health record is a major undertaking at any provider organization, but is especially challenging in an environment without any IT infrastructure or an information services (IS) department. Yet that’s the goal the Access Community Health Network (ACCESS) set for itself, and met in a short timeframe, to better serve patients in underserved areas of Chicago.

Implementing an electronic health record is a major undertaking at any provider organization, but is especially challenging in an environment without any IT infrastructure or an information services (IS) department. Yet that’s the goal the Access Community Health Network (ACCESS) set for itself, and met in a short timeframe, to better serve patients in underserved areas of Chicago. ACCESS, which is one of the nation’s largest networks of federally qualified health centers (FQHCs), provides ambulatory services to more than 200,000 patients at nearly 40 health centers across greater Chicago.

ACCESS met its goal in just four years, using an HIT strategy based on the patient-centered medical home (PCMH) model. According to Julie Bonello, CIO of ACCESS, who oversaw the implementation process, the PCMH model provided a simple and unifying vehicle that was understandable organization-wide. She recently spoke with Healthcare Informatics about the implementation process and how it has helped to transform patient care in the ambulatory setting.

PCMH as a Unifying Principle

Bonello explains that ACCESS has implemented a three-prong HIT strategy: first, an electronic health record (EHR) to document patient information and align it with PCMH patient population standards; second, a patient portal that aligns with the patient engagement standards in PCMH; and third, a community portal that aligns with PCMH care-coordination standards. That approach has allowed ACCESS to meet its patient-care goals, Bonello says. It aligns the patient record to chronic care conditions and also the normal preventative wellbeing of different age groups, she says.

To increase access for its patients, it also set up a call center and follow-up work queues for all of its patients who need appointments, based on preventative maintenance. It fully documents every patient in the electronic record, according to clinical guidelines for its most prevalent chronic care conditions, including diabetes, hypertension and asthma. To enable patient engagement, it implemented a patient portal. “We have utilized many different methods to assess a patient’s readiness to use a portal, and we have also built out the capabilities of our portal to align with the chronic conditions,” she says. This has allowed providers to speak with their diabetic patients to discuss their patient care goals, how to communicate with each other, based on their diabetic care plan, she says.

ACCESS clinics are ambulatory-only, so it has established partnership agreements with many area hospitals, Bonello says. The community portal is vitally important as a means of sharing data and communicating with the hospital partners, she says. “We see everything from an ambulatory perspective, and look to manage the emergency room and inpatient utilization through care coordination,” she says. She explains that ACCESS sees PCMH, the patient record, as residing with the primary care provider, who is at the center of the picture with the patient. Other providers are the spokes.

That explanation is in line with the organization’s hospital partners, she says. When ACCESS implements the community portal, which is called EpicCare Link (supplied by Epic Systems, Verona, Wis.),  it works out an operational service level agreement (SLA) between the operational departments of ACCESS and the hospital. If, for example, a patient is admitted to the ED, ACCESS will work with the hospital to schedule a follow-up appointment for mother and baby before they are discharged, or can request to see the discharge instructions through a continuity of care document, she explains. “We can all manage that patient’s care more completely,” she says. Bonello believes the migration to such clinical care workflows will improve care and decrease costs nationally.

Taking a Structured Approach

Bonello says her organization has taken an extremely structured approach to implementation. “For an organization that has gone from having no system to complete Stage 6 [in the HIMSS Analytics EMR Adoption Model], we have had to be really structured, we’ve had to be very clear in the way we communicated, and we have had complete and constant support from the CEO and all senior leaders,” she says. In addition, it has relied on the constant participation of its care providers, she adds.

Bonello, who says she had not yet joined ACCESS when the EHR vendor (Epic) was selected, stresses that it is crucial to establish a strong partnership with the vendor from the very beginning, based on structured planning. She notes that Epic offers a large toolkit to use during the implementation phase, but all implementation methodologies need to be adapted to the needs of the type of provider organization, she says. “We probably embellished the approach to include more change management, and perhaps more communication tools and more education, too,” she says.

Bonello describes ACCESS’ four-year project as an “incredible” journey. She notes that the group had to have an information systems (IS) department in place before it could begin work on the EHR implementation. The most important preliminary steps were to hire an IS team, get it certified, and establish an IS service department to support the infrastructure it was putting in place, she says. She describes the IS team as mature, passionate and mission-driven.

In Bonello’s view, recruiting and retention is the biggest challenge for a community health center IT shop. She says that many HIT professionals are not familiar with community health centers. “We have to be clear as an IT shop about the people we want to recruit and what people work best in this type of environment,” she says. “We have a close team; it’s all about leadership and team building.”

In order to build an IT department in a short timeframe, it used Information Technology Infrastructure Library (ITIL) to create what Bonello describes as an “ITIL lite” framework.

Once the IS team was in place, the group moved ahead quickly, says Bonello, who arrived at ACCESS in March 2009. ACCESS had been awarded a grant by the Department of Health and Human Services (HHS) Health Resources and Services Administration (HSRA) to get its first 15 clinics live with the EHR by August 2010. It met that requirement, and devised a rollout schedule for the remaining clinics.

In addition to establishing an IT infrastructure, ACCESS also set about establishing standardized processes. To do that, Bonello says, it created 13 separate, integrated workgroups that were based on the different integrated processes across all health centers, and devised a standard best-practice workflow for every clinic. “It was a huge amount of work, because our organization, perhaps for the first time, had to make standard decisions on how we were going to manage all processes,” she says.

Physician Buy-In is a Critical Component to Success

Bonello says that from the beginning, physicians were included in every workgroup and were part of every decision, and that their role has evolved to the point where now they are active leaders in every decision. “We have integrated IT governance into the clinical operating governance of our organization,” she says. ACCESS has formed clinical quality workgroups for pediatrics, for women’s health, and for adults; and participants for each workgroup includes a cross section health center personnel such as providers, nurses and front desk people, as well as the health information management and the IT departments. 

Bonello says that all of the ACCESS physicians are using the system, as well as collaborative physicians. She adds that some partner hospitals are using ACCESS’ system to schedule appointments, and that ACCESS has designed templates for specialists to support their needs. Referring to the workgroups, she says that all of the right people are there to optimize the clinical guidelines and to figure out the best way to use the tools, whether it’s the patient record or patient or community portals.

As ACCESS adopts clinical guidelines, it is also aiming to enhance care based on its quality metrics, Bonello says. The quality metrics are on the physicians’ dashboards. Bonello says that many physicians have embraced the project as a powerful way to deliver great care. She notes that physicians who work in community health often do not have all of the tools they need to support efficient care delivery. As an organization, ACCESS has adopted all meaningful use quality metrics as a base, and educates its providers on their definitions. “We have a manual where we have defined all of the quality metrics,” she says.

Physicians see their own performance metrics, and can drill down by patient. Regional medical directors, who oversee multiple medical health centers, have access to performance of the providers they manage. Currently under discussion is how to show a complete picture of the performance measures for the entire organization.

As of March 2014, only about 5 percent of patients were using the patient portal. “We have initiatives to get the patients educated on the portal, but probably the baseline is assessing the readiness for them to use it—often that readiness is best assessed with the provider and the patient talking about their care,” she says. The patient portal allows patients to view their medications, medical record, schedule appointments and communicate with their provider.

ACCESS continues to take a structured approach as it optimizes its care strategy. Moving forward, Bonello sees clinical workgroups sharing how they use portals aligned to the needs of the patient. She says ACCESS has self-charting capabilities, but will not roll it out until it has a clinical protocol to support how it might be rolled out for a particular condition. Also under discussion is how ACCESS should adopt a home monitoring strategy. One requirement: triggers for abnormal results need to be easily identified for follow-up, and clinical protocols need to be in place for that to happen.

Again, Bonello notes, providers who are chairing the clinical quality workgroups are leading those initiatives. “They are talking about how clinical guidelines are changing and how we might need to adjust our record, how we might want to use our patient portal, and how we might want to talk to our hospital partners with our community portal, to support any new changes,” she says. They follow standard approaches to doing this, and all of their decisions go to the organization’s quality committee.

Bonello, who has previously served as CIO at the Cook County Health and Hospitals System, says the experience of implementing an EHR from scratch has been a great experience. “It takes different skills to build something than to maintain something,” she says. In her view ambulatory care will play an important role as the healthcare moves to a different reimbursement strategy using accountable care as a model. “To spend time thinking about managing a patient’s care across the continuum with an organization that talks about care all the time has been wonderful,” she says.

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