Readiness
There is so much hype about electronic health records (EHRs) that a rational and pragmatic approach is required. Many organizations have jumped in, only to waste time and money figuring it all out. A practical model for engaging in the EHR journey is the survey, align, launch (SAL) model, which describes how an organization or community implements EHR (see Figure 1).
Take Stock
The first step in computerizing health records at the community level is to take inventory of computer systems that are in place. Many physicians offices, public health clinics, hospitals and payers have existing computerized patient records (hospitals), electronic medical records (physician practices and clinics) and e-prescribing automation. However, these systems are not typically well- connected and in many cases are not capable of being connected. This is where the EHR initiative comes into play. In this age, we cant waste a nickel. It is very important to truly look at what needs to be accomplished from the community and organization perspective, and take advantage of the assets that exist, says Zan Calhoun, CIO for HealthCare Partners, a large healthcare organization in Southern California.
Part of this inventory step involves looking at what other groups have accomplished in converting electronic records. This includes early collaboration with payers, providers and government entities within a town, state, county and national framework however a community is defined. For example, the National Health Information Network and regional health information organizations are getting established in many areas. Before beginning an EHR initiative, organizations must determine what has been accomplished and how to link to these initiatives and infrastructures efficiently.
Organizations must also evaluate current internal standards and architectures by taking stock of in-house platforms and whether those platforms are interoperable with other systems in their community.
Agree on Standards
Health Level 7 (HL7) is the leading, ANSI-accredited, international standard for data exchange between computer systems in healthcare. It enables interoperability between healthcare information systems, such as electronic patient administration and management systems, laboratory information systems, dietary, pharmacy and billing systems as well as EHR systems. SNOMED and LOINC have also been endorsed nationally for laboratory data exchange. Building upon established standards is wise, and will reduce future headaches.
At a minimum, determining if an organization will be compatible with these standards sets the stage for evaluating interoperability issues down the road. Subsequently the community of organizations will also have to standardize their definitions of processes and events within the community that trigger the sharing of clinical information.
Leverage What Is Already Going On
HIPAA forced substantial standardization. Some organizations are using HIPAA reforms as a springboard to share information and standardization practices at the transaction level. This is an excellent example of collaboration that has already occurred around sharing health information.
Another example of collaboration already in process is the work being performed around e-prescribing, which leverages demands in the Medicare Modernization Act that physicians and pharmacies work on together to dramatically streamline the prescribing process. By sharing some of the interoperability and standardization issues that have already been accomplished through e-prescribing, payers, providers, physicians and patients can apply lessons learned toward EHR initiatives.
Appoint an EHR Czar
A logical strategy is to designate a leader to be the EHR czar in an organization. All eyes usually go to the CIO for this role, but in a lot of situations, this role is probably better served by someone who is in the fray of relationships between physicians, hospitals, clinics, employers and payers, says Tom Martin, CIO for UW Medicine, a large academic and community-based health organization serving the Seattle area. An EHR czar can help establish a business case for community efforts and prioritize among competing sets of initiatives that might otherwise diffuse provider efforts. This person acts as a lightning rod for EHR issues and tracks the efforts of their organizations strategic vendors.
There are many strategic and tactical options a healthcare organization can implement to begin electronic recordkeeping. However, these applications must be compatible with an organizations overall EHR system strategy. By picking one accountable person to be the expert, payers and providers reduce the risk of purchasing multiple systems that are incompatible with future EHR initiatives.
Develop an Organizational Strategy
After appointing an EHR czar, organizations must develop a strategy around community EHR implementation. Although this may seem like an organizations IT systems strategy, it is not. According to Larry Lotenero, CIO for the University of California San Francisco Medical Center, It is all about how the electronic health record benefits the community and how each constituent views their role in that community. Return on investment is critical, but so is improving the health status of a population. A community EHR organizational strategy must encompass initiatives within communities and the state and national healthcare arenas.
A solid community EHR strategy requires careful research both within an organizations four walls and out in the community. Payers and providers must define the value for all players, including patients. From this research, a business plan must be developed to put facts and figures around the proposed EHR investments. This solidifies buy-in and creates a clear road map for implementation.
Engage Physicians
The consumer is central to the EHR. Aside from the patient/consumer, physicians are the most important cog in the EHR wheel because they are most directly involved with using data in an EHR. For example, a physician admits patients to more than one hospital and typically participates in more than one health plan. Because the patient population is not oriented toward any one hospital, it becomes necessary to standardize information at the point of entry with physicians.
This is an excellent example of why orchestration of an interconnected community EHR absolutely requires collaboration from the very beginning between physicians, between physicians and health systems and between physicians and payers. Collaboration among physicians creates an excellent forum for sharing best practices.
Begin a Community Dialogue
The EHR czar must initiate a community dialogue as early as possible. This brings different groups together to clearly identify collaboration partners who will share knowledge around electronic patient recordkeeping and establish common objectives.
Although EHR initiatives can be technically challenging, the greatest difficulty is to align the objectives of players with radically different perspectives. For this reason, all community EHR objectives should revolve around consumer and community health. Because a community EHR initiative cannot possibly deliver the same ROI for each participant, setting the goal of improving community health is a logical strategy to move everyone forward.
For example, patient safety is increased by computerized physician order entry (CPOE) in the inpatient setting and by use of an electronic medical record (EMR) system in the physician office/ clinic setting. CPOE systems and EMR systems are used by clinicians to order medications/prescriptions directly in computer systems. Such systems have been shown to help dramatically reduce medication errors and should be seamlessly integrated for physicians regardless of where in the community they are using a system. Therefore, EMR and CPOE initiatives are important building blocks in an EHR, but they must be linked at the patient, consumer and physician levels.
Develop a Business Case
After creating a community dialogue and establishing a framework for collaboration, the next step is developing a business case that outlines benefits by constituent. For example, a hospital might make a case for standardizing the interconnection of patient records to improve accuracy and reduce the rework that occurs when patient data are re-entered multiple times.
For a laboratory, the business case might be reducing the number of redundant tests ordered per patient by different physicians. For a payer, improvements in claim submissions due to electronic standardization could lead to fewer pended, rejected and resubmitted claims, resulting in reduced rework, lower processing costs and improved satisfaction.
In addition, overall benefits for a healthcare community must be part of the business case. Examples might include decreasing infant mortality or improving the rate of immunization in the community. By establishing micro- and macro-level benefits, all organizations involved in EHR implementation have a business case to support the necessary time and effort.
The business case must also outline overall cost projections and short-term and long-term sources of funding. This section of the business case is particularly important as it will carry the project forward.
Start Now
Many organizations are intimidated by beginning a community EHR initiative, perhaps because of the sheer magnitude of the project. Others are stalled by lack of funding or buy-in from members of their organizations. These, however, are short-term views. To reap the early benefits, organizations must take the following steps now to leverage a linked EHR system as it begins to deliver value:
- Build a community architecture plan. The best place to start is with infrastructure that already exists. Determine what exists on a regional, statewide and national basis so organizations can tie into these systems and follow established standards.
- Establish a delivery and support model. Payers, providers and other stakeholders must collaborate to decide how to deliver and support a community EHR before addressing individual systems. Questions that must be resolved include where the data will be housed, how the data will stay clean, who will address security concerns and how the network will be supported.
- Keep it simple. A community EHR is a massive undertaking, so health executives should carve up implementation into small, manageable projects. Unless participants see early wins it will be hard to gain momentum to tackle more difficult issues later.
- Integrate EHR standards and requirements into clinical design. Once all participants agree on how EHR will be implemented communitywide, introduce these standards and requirements for sharing information in-house and incorporate them into clinical design. An example can be seen in the way that HIPAA was addressed. Payers and providers communicated individual system needs and requirements through a HIPAA coordinator. From this information, standards and requirements were developed and incorporated into individual information systems to uphold HIPAA regulations.
- Monitor and communicate success. Establish metrics early on to measure the success of community and local EHR initiatives. This will hold all players accountable and will communicate early wins within each organization and within the healthcare community.
Summary
As payers and providers move toward a connected EHR, each must undergo a tremendous shift in culture, process and technology. Each must explore the current state of electronic recordkeeping within their individual organizations and within the healthcare community. Selecting a person within each organization to champion the community EHR movement will aid the development of an organizational strategy. This person must reach out to physicians to streamline efforts around a patient-centric system that aids physicians. Early steps also include taking an inventory of current technology and processes to provide stepping stones to early local and then community EHR implementation. Payers and providers must also initiate a community dialogue consistent both with individual and group strategies. As part of this collaboration, the group must establish community goals at the heart of the effort and communicate these goals through a business case. The business case must also provide overall cost projections and potential funding sources. The most important thing is to get started. By coming together now to establish proposed architecture, delivery, standards and requirements, all players will be ready to embrace an evolving community EHR model as it unfolds.
