Optimizing EHR Implementation Through “Pre-Load Services”: Temple Physicians’ Experience

Sept. 4, 2013
Temple University Physicians, a 400-physician (salaried) academic faculty practice plan whose members are affiliated with Temple University Health System (TUHS), a four-hospital system in Philadelphia, has been moving forward on a number of fronts when it comes to EHR implementation. Frank Erdlen, the group’s CIO, has turned to the concept of pre-load services to make sure the implementation has gone well.

Temple University Physicians, a 400-physician (salaried) academic faculty practice plan whose members are faculty members of the Temple University School of Medicine, and affiliated with the Temple University Health System (TUHS), a four-hospital system in Philadelphia, has been moving forward on a number of fronts when it comes to electronic medical record/electronic health record (EMR/EHR) implementation. One of the areas in which Frank Erdlen, vice dean of information technology for Temple University School of Medicine and CIO of Temple University Physicians, felt the need for assistance, was in the area known as EMR pre-load services. He and his colleagues have been working with the Green Bay, Wis.-based IOD Incorporated to implement their services in the organization, in order to optimize EHR/EMR implementation.

Erdlen spoke recently withHCI Editor-in-Chief Mark Hagland regarding the need for pre-load services and what he and his colleagues at Temple have been doing recently. Below are excerpts from that interview.

What are EMR pre-load services?

Temple University is the organization that Temple University Physicians, the faculty practice plan, lives in. And most of the physicians are clinical faculty members with significant teaching responsibilities.

And we’ve been implementing the Epicare System from Epic [the Verona, Wis.-based Epic Systems Incorporated]. TUH and Episcopal Hospitals don’t have an EHR, but are beginning to implement Epic; and Jeanes Hospital and Fox Chase Hospital use Soarian [from the Malven, Pa.-based Siemens Healthcare].

We’ve been live since January 2012. So we brought up 100 practices in about 13 months.

So tell us about the need for pre-loading in situations like this?

Yes, we brought up over 100 practices in 12-13 months; and we have a staff of 38 people. And this is an important consideration, from a CIO perspective, since we had been using paper medical records. So we needed a way to be able to pull forward the key clinical information for established patients, and populate the EMR with clinical information; and that’s what IOD helped us do. So the high-level description, and we can drill down on any piece of this, is that we worked with our physicians and had them identify the information they felt was most important for them per patients, as we brought them up on Epic. And some of that involved scanning, taking certain kinds of reports and certain progress notes from the paper record, and scanning those into the Epic system to be available to the physicians.

And there was some other information they wanted in a discrete fashion, just as scanned documents. The discrete data—things like allergies, medication lists, problem lists, immunization lists, needed to be taken from the paper record and typed into Epic. You can use a medical record clerk to do the scanning work, because they understand what’s in a record and can be taught how to index that information in the record. For abstraction, you need a little more skill; and most organizations would go to medical coders for that purpose.

So it was really a two-part process: the first would be documents that would be required by our physician advisers… We had a group of physicians, champions…  Documents required by our physician advisers would be identified in the chart. So they would take the documents identified by the physician advisory group, find them in the chart, take them out of the paper chart, scan them into Epic, and would index them. It was people from IOD who were credentialed HIM [health information management] professionals and RNs. They go a bit beyond what a coder would be doing in terms of expertise: data integrity and increased efficiency, are very important.

So that happened first?

Yes, and then once the document scanning was done, these higher-level folks whom Dori described would go in and identify the discrete data—again, allergies, problem lists, diagnoses, immunization histories, medications, and would actually enter those into the appropriate place as a discrete data element in the Epic system.

How long did that whole double process take?

Our initial go-live for our first set of practices was November 9, 2010—that date is etched in my brain. After we did the haggling to get the contract terms executed, IOD was able to start their work three weeks before then, mid-October. The goal for us… we had an implementation cycle pretty much every month that included anywhere from four to six more practices, so we rolled this out over 13 months, so we had a schedule that had multiple practices scheduled to start using Epic each month. So we used the patient appointment scheduling system to let us know who was coming into that practice, so we knew what paper records to pull to let IOD do their thing.

So we tried to maintain a two-week window, a two-week cushion, so IOD would be working on inputting data into the EHRs at least two weeks in advance. And we said we would do 12 months of this work for each practice, and we figured that would cover at least 80 percent or more of their established patients, based on estimating that people would come in at least once a year. So this process was completed by October 2011. And it was completed.

And basically, everything ran smoothly?

Relatively speaking, yes. When you implement an electronic medical record in a physician practice, particularly an academic medical practice, there are a lot of expectations that need to be managed or met, per hardware, software, support, maintenance, etc. This is kind of high-risk work for IOD, because you’re talking about trying to make sure all the physicians are satisfied, and of course you know that representing physicians, even when you’re a physician yourself, is not necessarily a homogenous thing to do. So you’re talking about summarizing data that the physician needed, so that when the physician was seeing a patient for the first time after implementing Epic. And we made the paper record available for the first few visits, because you needed to. And there’s a lot of variation in physician practice style; and we had to make sure the average presentation was workable for the docs. And the quality of the work was extremely important.

One of the fuzzy things in doing this work—and we love them dearly—but if you’ve ever thumbed through a paper record, they don’t always follow the rules of how to do things. And we were giving the IOD folks a general set of rules to work from, and then we were giving them every manner of paper chart to sort through and input. So there issues as we went along, but at IOD, they were aggressive about quality control, were responsive as we had issues; and as the physicians began using the record, they got comfortable with that, too.

And from an organizational or management perspective, we knew we were doing this quickly. We signed our contract with Epic in the early spring of 2010; we were bringing up our first practices about six months later; and after that, it was basically a forced march for all our physicians. And I have to commend our physicians, because they absorbed something that was almost like an assault. And any technology expert would tell you that you should do the process rapidly, because the longer you take, the more expensive and difficult it will become, and by the way, you don’t add more value. So that’s a good approach, but is difficult. Epic told us our rollout was something like twice as fast as average. But we needed to put ourselves in the position of optimizing the available meaningful use dollars; and everybody was concerned that the program might not last as long as it was designed to last. I’m thinking of the Cash for Clunkers program that ran out of money.

But we’ve collected so far about $10 million in incentives. We’ve attested for everybody for stage 1. The folks who have been on Epic for two years have attested for the first two years; we’ve got a large number in their third year. And next year, everybody’s on the 90-day cycle for stage 2.

When will that begin?

Fortunately, for us, if you want to get an incentive payment for calendar year 2014, it can occur anytime during the year. As you know, there are some specific requirements for electronic interchange between patients and doctors, and that’s going to be a little bit of a challenge, given our patient base, and their adoption of the patient portal tools we have. So one of our discussions right now is how to increase that communication between patients and their doctors. That will be what actually drives the specific timeframe for the attestation period for docs next year, hitting that 5 percent. It doesn’t sound like a lot, but it isn’t something you can manage directly.

What have the biggest lessons learned been in all this?

This part, the pre-loading of the EMR, is only one of many, many things that you do when you’re rolling out an electronic medical record, and for physician practices, it represents a significant investment in every aspect of training and support—both go-live support and ongoing support. And most physician practices don’t have large medical records/health information management support. Most don’t have large HIT staffs, either; and in our case, we had to grow rapidly to handle all this. But in most cases, you couldn’t expect to have a large enough HIM department to create this transition; so you’d need to identify a partner like IOD that would move forward in a specific timeframe, with the requisite quality, to help the physicians continue to provide quality patient care in an environment in which you’re learning to do everything all over again. So from my perspective, identifying the right partner, working closely with them, and having the requisite mechanics and processes in place, is important.

There’s a lot of basic blocking and tackling required, correct?

Yes, a lot of it. There’s a lot of potential for swirl. And when we have a good partner, as with IOD, you need to think about how to put them in a position to be successful; because if they’re working directly with 100 different practices, it’s very difficult to manage all those relationships, and make sure information is flowing correctly. And that’s why it was important to identify and work with the chief operating officers of all the organizations we work with.

Do you have any specific advice for CIOs, CMIOs, and other healthcare IT leaders around all of this?

I think that you’ve got to keep your eye on this kind of process; but I think any good manager would understand that implicitly as well. But it’s something that bears stressing because of the many different moving parts on a project like this that’s undertaken and completed on such a compressed timeframe.

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