Small Practice Monitors Clinical Quality through EHR System Templates

Middlebury Family Health (MFH), a practice with four primary care providers, is located in Middlebury, Vermont. The practice has about 4,500 active patients, with 20 percent enrolled in Medicaid, 20 percent in Medicare, 55 percent in private health insurance, and 5 percent uninsured. Dr. Eileen Doherty-Fuller is a primary care physician and pediatrician at the practice and she is also its electronic health record (EHR) physician champion. She has been working with two of the other three physicians in the practice, Dr. Dayle Klintzer and Dr. Linn Larson, both of whom specialize in women’s health and pediatrics, for nearly 20 years. Dr. Jean Andersson Swayze, a family practice physician, joined the practice more recently.

MFH began working with the Vermont Information Technology Leaders (VITL), Vermont’s Regional Extension Center (REC), in March 2010 and implemented its EHR, Medent, in January 2011. MFH is currently using Medent Version 19.5. Stacy Ladd is MFH’s practice manager and its dedicated information technology (IT) staff member. Michelle Clark, a medical assistant, is the practice’s Medent specialist. They, together with Dr. Doherty-Fuller, were instrumental in implementing the EHR and in attesting to Meaningful Use in June 2011. Throughout the implementation process, VITL provided MFH with various tools and resources to assist in the implementation process and the achievement of Meaningful Use.

MFH chose to switch from paper charts to an EHR because they were interested in creating a patient centered medical home (PCMH) and the EHR provided with the capabilities to streamline processes to eventually achieve an NCQA-PCMH Level III designation. To start the process, MFH staff members attended a number of Vermont EHR collaborative educational programs to help them prepare for their EHR implementation. These collaborative programs helped them understand the requirements of achieving both the PCMH designation and Meaningful Use, and thereby helped them to understand what they should be looking for in an EHR.

During their EHR selection process, MFH staff researched five different vendors and called other area medical practices to ask about their experiences with EHRs and if they were happy with the one they had chosen. MFH was looking for a system that would be relatively easy for medical providers to use and one that would also allow clinical information to be pre-loaded for patient visits. Dr. Doherty-Fuller also referred to the American Academy of Family Physicians (AAFP) Practice Management Journal, which consistently rated Medent among the most usable EHRs. In the end, MFH chose Medent because of the positive reviews they heard from other area medical practices, because they found it to be user friendly and easy to customize in their testing process, and it also had the charting and reporting capabilities that MFH sought.

Leading up to implementation, MFH staff worked with VITL and a State collaborative to create flow charts of their current practice workflows (for example: How do referrals happen? How are medications prescribed?). They also thought carefully about how the transition to the EHR would affect each member of the practice staff, from front desk staff, to billing staff, to clinicians. They noted that it was helpful to bring people from each of their departments in on the EHR decision and implementation process; all their voices and concerns could be heard and they all felt that they were part of the decision process. MFH began the EHR implementation process in January 2011. They chose that month because it is typically a month with lower patient visit volume and the practice could therefore more easily spend the time they needed for setting up and learning the EHR. At the start of the implementation process, MFH staff attended 100 hours of in-house training with Medent. Ms. Ladd and Ms. Clark noted that perhaps most important in the training process was setting up test patients for staff to practice; this also allowed everyone to better explore the EHR.

In describing their EHR implementation experience, they report that they lost productivity, saw fewer patients, had to hire additional staff, scheduled longer appointments, and often stayed late into the night during the first several months, but by October 2011, nine months after beginning the implementation process, they were getting close to the productivity levels they were at pre-implementation. Although MFH is still not quite back to their pre-implementation productivity levels, they are experiencing other improvements due to do the EHR, such as using EHR functions to better follow-up with patients regarding their care.

MFH also made use of the clinician templates provided in the Medent system. Dr. Doherty-Fuller began by focusing her efforts on creating templates for three of their most common chronic conditions: asthma, diabetes, and hyperlipidemia. She researched the information that would need to be collected for these conditions based on both quality measure criteria and evidence-based guidelines. When it comes to templates, Dr. Doherty-Fuller recommends using templates that the EHR provides and tweaking them to fit the needs of the practice – no need to “reinvent the wheel”. Now that these and other chronic condition templates have been developed at MFH, Dr. Doherty-Fuller and the other physicians are sharing the responsibility of creating the remaining templates that the practice staff is interested in using. As a result, when a patient with both diabetes and hypertension comes into MFH for a visit, the physician can simply merge the diabetes template and the hypertension template. This enables all of the information that needs to be collected for the patient (for all of the quality measures for which he or she qualifies) to be collected in one template.

MFH’s Medent software also came equipped with a “plan package”, which is essentially a checklist and ordering system for common diagnoses. The software allows MFH staff to order procedures, lab tests, referrals, etc. that are common to a particular diagnosis while they are working in a patient’s progress note. The diabetes plan package, for instance, includes items such as “order A1C lab test” or “refer to ophthalmologist for eye exam.” Medent’s plan packages are fully customizable and MFH dedicated a lot of time to customizing the checklists for the needs of the practice. The time spent in customizing was well worth it because it helped streamline processes and expedite future orders.

MFH staff has been very pleased with their working relationship with Medent. From the start, MFH staff were proactive about working with Medent to understand where the quality measure reports were pulling data from to calculate numerators and denominators. MFH pays a monthly fee to Medent for support, but MFH staff feel that this fee is well worth it, given how approachable Medent is and how willing they are to work with MFH to troubleshoot any EHR issues they might encounter. Medent also has a Meaningful Use department which is dedicated to helping practices such as MFH achieve Meaningful Use.

For Meaningful Use, MFH chose to submit clinical quality measures (CQMs) that they were already monitoring, which included the three Core CQMs as well as three Menu CQMs:

• Hypertension: Blood Pressure Measurement (NQF 0013)
• Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention (NQF 0013 0028)
• Adult Weight Screening and Follow-Up (NQF 0013 0421)
• Diabetes: Hemoglobin A1c Poor Control (NQF 0013 0059)
• Diabetes: Blood Pressure Management (NQF 0013 0061)
• Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD (NQF 0013 0067)

Knowing that entering discrete data is an essential part of calculating quality measures in an EHR, MFH utilized drop-down menus to allow providers to select discrete values instead of entering free text. The Porter Hospital, which is adjacent to MFH, does the majority of MFH’s laboratory testing, and its lab system has been electronically interfaced with MFH’s EHR. As a result, MFH is able to get all of its lab test results that come in from Porter Hospital automatically entered into their Medent EHR as structured, discrete data.

With this range of discrete clinical data on hand in its EHR, MFH staff can report on a number of clinical quality measures. Their report on Diabetes Hemoglobin A1c Poor Control, for instance, returns a list of patients whose A1c is greater than 8 percent and what actions have been taken to follow up with the patient (such as scheduling a follow up appointment or requesting additional laboratory tests). This also allows MFH to generate a list of patients for whom follow is needed.

• Be prepared for a loss of staff productivity and practice revenue during EHR implementation and in the months following implementation.
• Have a staff member on the clinical side be the EHR specialist full time during implementation, and informally or part-time thereafter.
• Expect to put in overtime and to hire additional staff to cover the responsibilities of the clinical staff who are dedicated to the EHR transition process during implementation.
• Have a good understanding of the practice’s needs when looking for an EHR.