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Weekly UpdatesWhen discussions began to establish a health information exchange (HIE) at the Kittitas Valley Community Health Information Network (KVCHIN), the HIE was little more than a pipe dream. Clinics in the region still maintained paper-based patient records, and individual provider investment in electronic health record (EHR) systems was anticipated to be prohibitively expensive.
Many clinicians and administrators, however, had a desire to see such automation touch their facilities--and their patients. They decided an answer lay in a standard EHR platform and shared community health network.
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KVCHIN is an electronic information-sharing partnership linking 30 providers--about 90 percent of all primary care providers in the county. These comprise family physicians, internists, pediatricians and obgyns, and include hospital-owned and independent medical clinics, as well as a federally qualified health center.
The network was founded by the Kittitas Valley Community Hospital five years ago to improve quality of care delivery as well as that of its related rural provider network. Objectives included implementing disease-management programs; integrating with other facilities such as nursing homes; advancing patient involvement through a Web portal; and, establishing an HIE that enables providers to share patient medical data.
An original group of seven clinics formed a steering committee to discuss what each provider needed in an EHR. With a $15,000 critical-access hospital grant, the committee was able to hire an outside consultant to write a request for proposals and guide them through a selection process based on functionality that would be mandatory if the project were to be successful.
Members of the group were concerned that each clinic's needs could not be entirely met and that they might eventually have to part ways. With that possibility in mind, the KVCHIN sent its request to EHR vendors and received nine proposals.
Strength in Numbers
The group built a comprehensive matrix that allowed participants to rank each feature from the various EHRs on a scale from one to five, based on how important each function was to the individual organization. Elements considered included automated-prescribing features, integration with practice-management (PM) systems and whether the networkwide EHR would be an interface or a fully integrated system.
The committee then weighted each evaluation based on the vendor's ability to meet a particular requirement, leading to a composite score representing vendor strength. With that number, the group was able to narrow the potential EHR vendors to three. It requested product demos from each, but only two obliged. The demos were open to every physician and office manager in the county, and once the presentations were made, all were invited to offer their input on which vendor they thought would best meet KVCHIN's requirements.
Topping the list of critical considerations was making sure the technology was in production in other communities. Also, while the clinics needed to share patient data seamlessly, they also wanted to remain independent entities. Finding the right balance between what information belonged to the network and what belonged to the individual providers was a challenge. This issue proved to be a significant distinguishing characteristic in the selection process.
The two-year evaluation culminated with the selection of the Community Health Solution (CHS) from NextGen Healthcare Information Systems. NextGen CHS is a central data repository and routing hub that enables users to exchange patient data securely in a community setting with other healthcare organizations, while still maintaining each clinic's individual integrity.
First, a central data repository was created, and referred to as "the cloud." Each clinic was afforded some control over the data it would or would not upload to the repository. When a patient is registered, a clinic's system automatically queries the repository to identify any pertinent data available, such as medications, allergies and chronic problem lists to prevent adverse events.
Common Format Required
Enabling the information flow is a master patient index (MPI) with one demographic file for each patient. Developing the MPI proved to be one of the project's more difficult tasks. All participants had to convert their records into a common format that could be exported to the cloud.
The company compiled all the records based on matching criteria and imported the final file into the system. Problems occurred when duplicate patient records appeared as a result of an individual visiting more than one clinic. KVCHIN worked with NextGen to merge the two records in an efficient manner.
KVCHIN initially thought it would host the platform with the hospital's existing infrastructure, but such an approach would require additional staffing with diverse skill sets. Recognizing that building the necessary infrastructure was not part of its core mission, the hospital and KVCHIN outsourced its server hosting to a third party that is responsible for all maintenance, data backups and technical support.
Wireless capabilities were already in place at most KVCHIN locations, and they were equipped with workstation or laptop computers so providers could access the network. Some providers found that they needed to augment their hardware with additional equipment, which was funded in part by a private grant.
Participating clinics have a secure tunnel to the server and have built a Web server that will be rolled out in the next development phase. The Web server will allow an emergency department (ED) physician, for example, to log onto a secure portal to see a patient's information. This application also could prove valuable in nursing homes. KVCHIN plans to have geriatric nurse practitioners document in the electronic patient chart, which will be uploaded to the CHS for other providers to see.
KVCHIN employed the "train the trainer" approach to user instruction. Staff members were trained first on the PM system that serves as a companion to the EHR. Since almost every practice already had a PM for billing, the group began this phase first, anticipating less resistance. PM rollout began in summer 2006 simultaneously at all clinics, and the system went live enterprisewide in February 2007.
Meanwhile, training began on the EHR's first phase in June of 2007, as the system was rolled out functionality by functionality at the various sites. Initial features included prescribing, tasking and telephone documentation. In August 2007, KVCHIN began the second phase of implementation with the system's remaining features, including all clinical documentation capabilities. Since rollout, select staff members have attended advanced training and serve as on-site resources.
Champions Discuss Benefits
To ready the staffs at the various provider groups for the conversion, KVCHIN launched an internal communications effort. Physician champions at each location discussed the benefits and worked with those who required more hand-holding throughout the transition.
The conversion was challenging and took longer than had been anticipated. Yet, users were able to reduce paperwork and associated supply costs substantially, while increased efficiency has allowed providers to see more patients each day.
Concerned initially about sharing specific data sets, providers are now seeing the value of a comprehensive medical record to view at the point of care. In particular, they have benefited when referring patients for services within the network--from primary care physician to obgyn, for example.
The telephone tag previously associated with making referral appointments also is no longer an issue. Too often, patients were unable to keep appointments arranged between the referring physician and specialist, and multiple calls were required to sync all parties' schedules. Now, physicians send a referral request to their colleagues electronically and the receiving practice calls the patients to set up an appointment.
The physician now has access to the patient's medical record and can immediately see what conditions need to be evaluated, what tests have been performed and results received, and what types of intervention may have already been tried. Information not currently available through the data repository can be sent as an attachment to the referral request.
This functionality saves significant amounts of time and virtually eliminates redundant diagnostic tests, since all relevant information is readily available at the point of care.
When responding to a patient call, KVCHIN providers are able to sign into the data center through a secure tunnel to view the current medical record, instead of driving into the office, as in the past. They can check for recent medications or care plans, and make an informed medical decision within minutes.
With Web access soon available to ED physicians and other providers in the community, KVCHIN anticipates the value of the network will increase. Potential drug interactions may be spotted and avoided, for instance, while network physicians will be able to consider other providers' care plans when making their own treatment decisions.
From the Catalog
According to www.nextgen.com: NextGen CHS is a central data repository and routing hub that enables users to exchange patient data securely in a community setting with other healthcare organizations. NextGen CHS promotes continuity of care by providing the medical community with consistent, up-to-date patient information at the point of care. A single-point connection for each participant to the CHS hub eliminates point-to-point interfaces, to share lab or test results, ER visits, referrals, medications and allergies. A Web-based provider portal allows practices without an EHR to exchange patient information and workflow, such as referrals, with the community. The solution also offers the ability to access only the patient information needed or new to the record, rather than having to pull down and weed through all data stored about the patient; and, emerging reporting and analytic tools to foster disease and wellness care-management monitoring.
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