In 1999, when the Cleveland, Ohio-based MetroHealth system went live on its electronic health record (EHR) with its first ambulatory site, the underlying mission of the organization was to implement health IT across the system—not for the sake of health IT, but instead to use it as an enabler to provide better healthcare at a lower cost, says David Kaelber, M.D., Ph.D., CMIO at MetroHealth. “At that time, we said that if we really wanted to be a healthcare system of the future, it needs to be technology-enabled,” Kaelber says.
The culmination of that 15-year journey was recognition from HIMSS Analytics, the research arm of the Chicago-based Healthcare Information and Management Systems Society (HIMSS), which earlier this month designated the MetroHealth System as a Stage 7 ambulatory center for the sophistication of its EHRs. All 16 of MetroHealth’s community health centers, along with the Cancer Care Center and the Women & Children’s Pavilion, have attained “the pinnacle achievement” on HIMSS’ ambulatory electronic medical record adoption model (A-EMRAM).
Developed in 2011, the EMR Ambulatory Adoption Model provides a methodology for evaluating the progress and impact of EMR systems for ambulatory facilities owned by hospitals in the HIMSS Analytics database. Stage 7 represents the highest level of EMR adoption and indicates a health system’s advanced electronic patient record environment. During the first quarter of 2014, only 4.54 percent of the more than 24,000 U.S. ambulatory clinics in the HIMSS Analytics database received the Stage 7 Ambulatory Award.
MetroHealth is among the first safety-net health systems in the country to reach Stage 7 status, and the first to do so using the Verona, Wis.-based Epic Systems. It is also the first Stage 7 ambulatory health system in northeast Ohio, its officials say. It was a 15-year journey that required sustained commitment, Kaelber says. “For anyone that has gotten to Stage 6 or Stage 7, either on the ambulatory or hospital side, it’s not something you decide in a day or complete in a year. It’s really something that takes years to do.”
As such, it isn’t just the quick payoff to focus on, but instead the long-term payoff, Kaelber says. “With an EHR, it’s not about how can you get more patients in the door or how you can provide more cost-effective care this month or next quarter. [On the contrary], it’s about how we can do this over the next five to 10 years so the infrastructure will be in place to do all sorts of amazing things that lets us accomplish all of our goals. It’s an infrastructure investment,” Kaelber says.
Leveraging the EHR
According to Kaelber, one way MetroHealth’s EHRs have ensured better care is by providing raw data on how many patients are suffering from undiagnosed pediatric hypertension and alerting medical caregivers when a patient’s blood pressure merits follow through. “In 2007, we were the first system to show that pediatric hypertension is only diagnosed about a quarter of the time, even though the data in the EHR needed to make the diagnosis is sort of just sitting there,” he says. That revelation, says Kaelber, was considered a top-10 breakthrough in cardiovascular medicine by the American Heart Association. “Since then, we have actually put in mechanisms to improve the diagnosis, and with the EHR, you can study the care that is being provided to patients in ways that are impossible to do without it. And then you can identify opportunities to improve the care as well.”
David Kaelber, M.D., Ph.D.
Another way the health system has leveraged the EHR has been by reminding patients when they are due for an immunization. “We leveraged the idea that most of the patients in the MetroHealth system get their care exclusively in that system, so we used the infrastructure that we had in place to see who was behind on immunizations,” Kaelber explains. “About two years ago, we used our medical records to proactively message people to find out who was behind on a vaccine, and we found a significant improvement in our vaccination rates as a result. We’re going beyond our four walls to tell patients that we are still thinking about you and concerned about your care. Everything surrounding population health and patient engagement would be impossible without this EHR infrastructure,” Kaelber says.
The technology infrastructure in place additionally helped the organization with referrals, notes Kaelber. Being an integrated healthcare delivery network, MetroHealth has primary care and specialty care physicians, and the majority of specialty care comes from referrals from the primary care doctors, explains Kaelber. As such, with new generation medicine, the idea is that the system can track if the referral actually happens and if the visit occurs, which is different than old generation medicine.
“And we will reach out to the patient if that doesn’t happen in a given time period,” Kaelber says. “We use one month from the date the referral was placed as our metric, and previously, only 48 percent of the time was the referral completed or scheduled to be completed in a month. Now since we’re tracking the metric, we’re at a 60 percent rate. That is only possible because of the EHR infrastructure,” says Kaelber.
And lastly, the health system has tracked incidental findings, or unrelated medical issues that pop up in treatment, ensuring that they’re addressed in a timely matter, says Kaelber. Being a trauma center, people will come in on a routine basis because they had some sort of trauma, he notes. And a lot of the time, the patient ends up getting a CT scan or something similar from head to toe. As a result of that, it’s not super infrequent that even though the imaging test is ordered for something else, the radiologist will find something that is not an emergency but really needs to be followed up on, Kaelber says.
The classic example, he explains, is if someone is in a car accident and suffers a chest injury. At that point, the patient will get a CT scan of his or her chest, and from a trauma standpoint the patient might be fine, but the radiologist could see a little nodule in the lung, which could be early lung cancer. And it just so happens that the patient got the scan for something else, notes Kaelber.
“Someone has to follow up on that,” he says. “We did not have a system in the older world to follow up. Now, in our fully-integrated EHR world, these findings are flagged, they come across to our EHR, and then we can have systems in place to track it. We have automated messages to primary care physicians and letters that go to patients, so there are multiple levels of enabling both doctors and patients themselves to make sure the findings are followed up on. And when we track it, we see a substantial decrease in time between when the finding is found and the follow up,” Kaelber says.
More Than Just Technology
While MetroHealth has had plenty of success in developing and leveraging its EHR infrastructure, Kaelber says that the organization’s mission is not health IT, but rather accomplishing the organization’s goals by enabling health IT. And in addition to technology, there is a strong need for senior leadership in an industry where high level executives are constantly in flux. “Leadership changes, and has changed for us over our 15-year journey,” he says. “CIOs, CMIOS, and CEOs all changed over that time. So how do we continue to push the roadmap? When we started in 1999, the concept of a personal health record didn’t exist, nor did the concept of health information exchange (HIE). You need to be a fast follower of what technology can enable, and have to have a pulse of what has come out as well as what is coming,” he says.
Kaelber says that a lack of senior leadership, focus, and commitment are why many organizations have not yet gotten to a Stage 6 or Stage 7 level. “Ultimately, to do something big such as an advanced EHR infrastructure, you have to understand what the value is to you and your organization,” he says. Kaelber feels that healthcare reform is helping because there is more emphasis financially placed on population health management. “Are you interested in providing cost-effective, efficient, high-quality care? You have to answer if an EHR infrastructure will help you do the things you want to do,” he says. But what’s nice, he continues, is that now there are specific examples of technology helping healthcare systems that people in the ‘laggard’ category can point to.”
However, the key is patience, as reaching the level of a paperless environment takes years and years, albeit maybe not 15 years like it took MetroHealth since technology is much more robust, Kaelber notes. “I do think that many places are somewhere along that journey and in that process right now. I would expect that in next three to five years there will be significantly more places that reach the Stage 7 level on both the hospital and ambulatory side.”