The process to implement an electronic health records system at Yakima Valley Farm Workers Clinic (YVFWC), a multi-specialty community healthcare practice with 18 clinics throughout Washington and Oregon, began several years ago as an initiative to improve patient care.
Many patients alternate visits between three of YVFWC's largest clinics, and it became increasingly difficult for the clinic to update and maintain multiple patient records. Providers felt that in order to provide the best quality care, it was necessary to have an electronic health record (EHR) system with one database that could be accessed by all sites.
Other key implementation goals included:
Providing quick, accurate and real-time access to up-to-date clinical data, such as transcription, progress notes, test results, medical and family history, prescriptions and medications.
Aiding physicians and other clinicians by providing best-practice alerts.
Implementing in a modular fashion to minimize the amount of disruption for clinical staff.
Consolidating charts from multiple sites.
Improving the prescription refill process.
Eliminating duplicate entry into multiple systems.
In search of a solution
Searching for a solution to consolidate patient information, YVFWC needed a system that allowed for a centralized database. Since YVFWC is a multi-specialty practice, it also needed a flexible, customizable system that could conform to the data and functionality needs of all the specialties.
During its search, YVFWC learned that although EHR implementation attempts have failed for various reasons, one of the most common is the "big bang" approach, where changes were instituted too quickly. To avoid the problems and subsequent resistance this approach can create, YVFWC wanted an EHR system that allowed a phased-in implementation so users could become familiar with the applications at a comfortable pace.
After completing a comprehensive evaluation process, YVFWC chose the IC-Chart EHR solution from InteGreat (Scottsdale, Ariz.). YVFWC physicians, nurses and administrators, who were highly involved in the selection process, unanimously felt that InteGreat's IC-Chart was the easiest system to navigate and the most intuitive.
YVFWC phased in the EHR system one module at a time at each location. This approach allowed users to become familiar with the application gradually, instead of piling too much functionality on all at once. It also allowed YVFWC to make changes to their workflows in stages, beginning at the pilot site, to work through the difficulties, learn how to implement the module in a clinical setting and further develop documentation prior to rolling it out corporate wide.
Clinics are now connected with outside providers such as their reference labs and transcription services. The system also interfaces with YVFWC's practice management system.
YVFWC is now planning to implement document imaging, working on additional patient forms, talking with reference labs about an outbound lab orders interface and billing capture, and is considering a communications link with radiology groups for the future. Also on the horizon is an interface between IC-Chart and the State of Washington's immunization registry (ChildProfile). The implementation of a prenatal record module is being co-developed by InteGreat and YVFWC.
Today, more than 750 healthcare professionals at 15 YVFWC locations use InteGreat's IC-Chart EHR system, with two additional clinics scheduled to deploy shortly. Switching to an EHR system has met YVFWC's primary goal of improving patient care, and has also improved the bottom line by enhancing efficiency.
How has the EHR implementation benefited YVFWC? The answer is by providing streamlined access to patient information through a single patient chart that can be accessed at any YVFWC location. With IC-Chart, providers at various clinics can share much of the information online that they would have previously requested to be faxed, such as last progress notes, problem list, lab results, medication list, allergy list, diagnoses/procedures, and so on.
In addition, IC-Chart enables users to view transcription and lab results in real-time. Once in the patient chart, anyone with appropriate access can view information, whether or not it has been signed or reviewed by the dictating or ordering provider. The result: reduced occurrences of missing or bottle-necked patient information.
With EHR, it is no longer necessary to pull paper charts for medication refills, which had been a big drain on nursing resources. This also eliminated multiple calls to the clinic for refills as well as the need for nurses to return calls because the paper chart was being used by others. Other benefits include tracking past medications by usage dates, dose, frequency, duration and quantity; monitoring drug-interactions; tracking patient allergies and intolerances to medications; renewing all existing medications easily; and minimizing human error by tracking medications and their effectiveness.
The EHR system has reduced the number of medical records staff through attrition or reallocation. While YVFWC continues to pull charts for every patient visit, chart pulls have gone down because nursing requires fewer chart pulls for prescription refills. In the first nine months of 2005, monthly chart pulls were reduced by 6 percent from the monthly average in 2004. This trend should continue as IC-Chart becomes the legal record for additional chart elements.
YVFWC's EHR implementation timeline: April, July 2004 — Deployed EHR on fixed PCs with the CPU mounted on the wall in each exam room at a pilot site in Washington. Utilizing a fixed server for electronic prescribing, prescriptions were automatically faxed to the patient's pharmacy of choice.
August 2004 to June 2005 — Deployed IC-Chart using a Cisco wireless network on wireless Toshiba tablets at a Portland, Ore., location, allowing wireless access to information. Each physician received two tablets — one for their own use and one for the MA, CMA, CNA and/or nursing staff. Deployment of base IC-Chart and prescription writing on a wireless network continued through June 2005.
July 2005 — Rolled out patient forms across all clinics.
— J.S., D.T.
The software includes functionality to alert providers and/or other clinical staff when certain conditions need to be monitored — for example, a diabetic patient who has not had lab or other exams performed within a certain timeframe. IC-Chart will notify providers, nursing staff or others that the patient needs to schedule an appointment.
YVFWC is looking forward to reducing transcription cost by letting providers enter notes directly into the chart using the keyboard, voice recognition software or chart templates.
Security rights allow YVFWC to manage who has access to the medical chart and to define what that access encompasses, as well as to audit everything a user sees in the system. These are essential elements for complying with HIPAA privacy and security regulations.
Despite the cautious, phased approach YVFWC employed, the launch had its challenges. Providers in each of the locations wanted to retain their own way of handling certain tasks and they wanted the system to display data according to their preferences, which could sometimes be at odds with other locations. An implementation team, consisting of five employees, worked with the staff to sort out the kinks. Moreover, YVFWC needed to add equipment such as wireless access points and tablet PCs to spaces within each location in addition to shifting existing PCs to make space for the new equipment. All of this caused some disruption and necessitated extra training on new equipment.
While transitioning from a paper-based environment to a digital one, YVFWC had to coordinate closely with the Quality Assurance and Accreditation department to determine where legal documentation at each clinic resided. The location of the legal documentation varied from site to site, depending on how far each location had progressed in its implementation.
Training before, during and after implementation is crucial. Training and testing sessions are scheduled as new functions and added to the system, as existing employees take on new responsibilities and when new employees join the staff.
Jim Simmons, EHR supervisor/project manager, work at Yakima Valley Farm Workers Clinic.