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Realizing the Promise of EMRs

July 20, 2010
by Karen van Wagner and Michael R. Solomon
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How a Group of Physicians in Texas Moved Forward on EMR and HIE at the Same Time


North Texas Specialty Physicians (NTSP), an independent practice association based in Forth Worth, has been working with healthcare organizations across North Texas to build an HIE known as SandlotConnect. NTSP Executive Director Karen Van Wagner, Ph.D. lays out four key strategies that appear to have been successful in winning broad and sustained acceptance by clinicians.

The unspoken truth about electronic medical records (EMRs) has finally been exposed. A recent study by the Washington, D.C.-based Center for Studying Health System Change concludes that implementing an EMR system within a medical group is inherently limited in enabling quality improvement through better coordination of care. This research, sponsored by the New York-based Commonwealth Fund, determined a vital need for clinicians to redesign their practices to streamline the exchange of health information across organizations involved in the patient care continuum.

Recognizing and resolving the limitations of EMR systems is critical to successfully achieving improved care coordination, a core priority of the criteria for the “meaningful use” of electronic health records (EHRs) recently published by the federal government. Three years ago, a physicians' group of EMR early adopters facing this reality embarked to find a practical solution.

The leadership of North Texas Specialty Physicians (NTSP), an independent practice association (IPA) headquartered in Fort Worth, decided to add the “missing link” as part of their efforts to automate the IPA's clinical practices. NTSP set out to expand the percentage of their 600 physicians using EMRs, while connecting those systems to each other and local hospitals and labs, to form a comprehensive record of a patient's healthcare that could be viewed at the point of care-regardless of where the patient was seen within the community's health system.

While many communities across the U.S. have experienced false starts and short-lived ventures in attempted rollouts of health information exchanges (HIEs), NTSP has been working with healthcare organizations across North Texas to quietly build a robust, self-sustaining health information network known as SandlotConnect. Currently, 1,400 office-based clinicians and staff in seven hospitals have access to 1.4 million comprehensive health records, which span patients' visits across the healthcare delivery system. Each day, 50,000 clinical transactions are added to SandlotConnect. Telly Shackelford, SandlotConnect's executive director, provides a simple explanation of the value of the HIE: “SandlotConnect's goal is to offer physicians access to information that they wouldn't normally have. Our care model is designed to give physicians the information they need to make informed clinical decisions at the point of care.”

Getting physicians to embrace the combination of EMR systems and SandlotConnect has been challenging. According to Shackelford, “People don't like change much. If they've followed a particular workflow for years, adopting a new system slows them down.” The broad and sustained adoption achieved by NTSP can be attributed to four key strategies:

  • Encourage adoption of EMRs by providing incentives for the physicians to license and install EMR products, which have to meet stringent interoperability requirements as defined by SandlotConnect.

  • NTSP physicians working alongside of the system's engineers design the information flow in and out of SandlotConnect and the various EMR systems. This is critical to incorporate the information originating from other sources seamlessly into the clinician's view of the patient's electronic chart in a way that physicians embrace.

  • For NTSP physicians not quite ready for an EMR, a secure Internet portal enables view-only access to SandlotConnect's rendition of the patient's electronic health records. Once physicians become comfortable with the portal and experience the benefits of electronic access to their patients' health information, they are eager to have access to more system capabilities. If still hesitant, physicians can take an incremental step by using the system initially to electronically prescribe medications.

  • NTSP has firsthand experience with the challenges physician practices face in having the resources to successfully implement information technologies in their offices. A team of specialists knowledgeable in physician practice operations and experienced in getting physicians and their staff to use EMRs provides “high-touch” (i.e., in-the-field, personalized) support, before, during, and after the initial activation of the system. The technology itself is just a small part of what is needed to successfully integrate HIE into the medical practice.


“The more doctors you have using the health information exchange, the more valuable it becomes,” observes Tom Deas, M.D., a gastroenterologist who was one of the first physicians to integrate SandlotConnect into his practice and who now also serves as SandlotConnect's chief medical officer. As the size of the network grows, many of the tangible benefits of being connected, once envisioned by the IPA, are now being realized with evidence of improved quality and efficiency of care.

Most importantly, instances of more informed clinical decisions abound. In one case, SandlotConnect's report about a patient's recent surgery provided staff with critical information that explained the patient's anemic condition. In another situation, the staff was able to quickly stabilize a patient through access to information about co-morbidities and polypharmacy, which were not in the clinic's chart. These examples highlight probable benefits of EMR integration in multiple practices.

Although NTSP's financial analysts are just starting to collect data to measure the impact of SandlotConnect and the EMR systems on healthcare costs, qualitative findings are promising. Ordering of duplicate procedures has been avoided with access to patients' test results across the continuum of care. Saving money is important and Shackelford admits that cost is always a concern and can be a barrier to EMR adoption.

As NTSP's leaders look ahead, they are making investments in SandlotConnect with the objective of enhancing the value of the HIE to current and potential physician users, expanding EMR choices, and developing applications to fill the gaps in care management that the standalone EMR systems cannot support. An example of the latter is a new clinical decision support application that is slated to go live later this year. Using the 90 proposed quality measures in the federal meaningful use criteria under the federal Health Information Technology for Economic and Clinical Health (HITECH) Act, care guidelines will be embedded in the various point-of-care applications that clinicians use to write prescriptions, order tests, and make referrals. Physicians involved in the project anticipate the guidelines triggered for a given patient situation will be more accurate (and therefore more useful) to clinicians due to the systemwide EMRs for patients maintained by SandlotConnect.

The HIE currently in operation in North Texas has not only changed the way physicians make clinical decisions, but has started to transform the model for care in the region. With the combination of SandlotConnect and large-scope adoption of connected EMRs, NTSP has made great progress in reaching their goal-physicians meaningfully using a true EHR that makes a difference in the quality of care that is delivered.

Karen Van Wagner, Ph.D., is executive director of the Fort Worth-based North Texas Specialty Physicians. Michael R. Solomon is a consultant with the Washington, D.C.-based Gorman Health Group. Healthcare Informatics 2010 August;27(8):19-20

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