Achieving Efficiency in the Health System Utilization of Electronic Health Records Experience at Fort Defiance Indian Hospital National Indian Health Board Phoenix, Arizona October 19, 2005

Is Our EHR Efficient? Efficiency = The ratio of the effective or useful output to the total input in any system.

Efficiency = Output/Input Input Output Dedication of Clinical and Technical manpower to the project. Cost of Hardware and Software. Time away from clinical work to learn new System. Decreased production during times of change and transition. Better Clinical Documentation Better Access to medical records New flexibility in work flow design New Coding Process. ?Changes in Collections?

Background IHS Hospital Service Unit of Navajo Area Using RPMS database for many years ‘behind the scenes’ for billing, data collection. IHS EHR brings computerized database into the foreground for clinical users.

Area and History of Fort Defiance Moved to 270 K square foot facility several years ago. Patient population served and patient visits rising.

IHS- EHR The IHS took a version of the VA’s CPRS- VISTA software and customized it for use by IHS. Main changes made were to facilitate billing, public health efforts, follow health care maintenance, screening and educational activities better.

EHR Milestones June 2002 – EHR prototype installed at Crow Hospital in Montana March 2003 – Development begins October 2003 – Deployment and training planning begin March-December 2004 – Alpha/Beta testing January 2005 – EHR GUI v1.0 certified Now in use at 16 facilities 11 additional planned for remainder of FY’05 Target is 40 sites per year thereafter Mandate is all Federal sites and as many Tribal sites who want it by 2008

IHS EHR Requirements- The IHS EHR software is loaded on top of an updated RPMS system that has all required packages and patches. Hospital databases, especially in lab and pharmacy require extensive ‘cleaning up’ before the EHR can be used.

IHS EHR Set Up Software Hardware End User Set Up Workflow Design Patient and Staff Education

Software Essentially free for IHS and Tribal Service units. VA software customized for use by IHS facilities centrally and distributed by OIT. Consistency across corporate platform.

Hardware FDIH was well prepared having just moved into a new facility. Computer access present in most clinical areas. Some upgrades were necessary to the wireless system and servers because of increased workload.

End User Set Up Extensive End-User Set-Up is necessary. Drug and lab lists, menus, and orders; super bills and Pick-lists must all be designed ‘on site’. Note Templates can be used from other facilities- FDIH found it necessary to create over 100 of these de novo since we were one of the first large IHS facilities to use it.

Workflow Design Work flow needed to be extensively examined when transitioning to EHR. This was taken as the opportunity to institute a lot of changes in clinic workflow. Providers now enter ICD and E&M codes into the computer and Coders review and perfect them.

Patient and Staff Education Health Care professionals got 1-2 hours of introductory teaching, 1-2 hours of intensive hands on teaching and then were allowed to use the EHR with close assistance from the CAC. More extensive teaching programs have been developed for nursing and other users. Teaching documents, CD’s etc have been created.

In House Training Define users, and keys needed. Train super-users/end users. 12/4 hours Super-users go live 2 weeks End users go live once super users up to speed (and able to help others). Clinically totally live after 4 weeks.

Full-time Clinics Pediatrics Well Child OB/Gyn AC NUC Ortho Surgery

Part-time Clinics GI ENT Audiology Opthalmology

Our Ambulatory Clinic’s caseload has steadily increase over the past 2 years.

Most of this growth is concentrated in our largest / busiest clinics- hitting record high volumes on EHR.

EHR

What Happens to Clinics When They Get On the EHR ??? It appears that clinics experience a drop in productivity for 1-3 months and then experience a rebound in productivity. Usually the clinics return to volumes above pre-EHR volumes.

Optometry, Pediatrics and Physical Therapy seeing more patients on EHR. Podiatry experiencing decreased demand. Internal Medicine just starting on EHR- experiencing a drop in productivity. OB/Gyn seeing about 10% fewer patients per provider on EHR.

Efficiency There appears to be an ‘acclimation period’ of several months in each clinic. After that period it appears that the performance of clinics can exceed previous levels – if there is the demand.

Changes in Documentation The average documentation on a patient encounter has vastly improved with use of EHR templates. Some of these Templates are quite comprehensive and allow documentation to follow certain standards. Notes have become more extensive, yet also more standardized. Of course legibility is an issue of the past!

Changes In Medication Ordering Medications are ordered off of Preset Menus, thus Providers order directly off of the Formulary. Providers get notices about restricted uses, required lab work, possible interactions and allergies before the medication order is completed. Medication Menus are Clinic/Problem oriented.

Healthcare Maintenance The Electronic Health Record tracks Immunizations, Health Risk-Factors and Sentinel Exams. Needed tests and exams are recommended by the software – prompting providers to keep their patients HCM up to date.

Billing and Collections When we look at clinic performance from the Billing and Collections view, we get a different picture. Discrepancies between clinic volume data and collections and billings are being looked into. ?

Podiatry Clinic shows decreased number of visits – likely secondary to the arrival of 5 more podiatrists in surrounding hospitals. It appears that more visits are now going unbilled. ?

Over Past year there is a decrease in total amounts billed and paid and an increase unpaid amount. ?

Information from our billing department shows a decrease in visits and an increase in unbilled visits. ?

Billing information shows decreased billing, an insignificant change in collections and an increase in unpaid amount. ?

Affect of EHR on Billing Information from our billing department reflects the following: –Fewer visits –Decreased Billing –Increase in Unbilled Visits. ?

Harder to Quantify at this Point: Patient Safety – medications errors expected to go down once providers used to new system. Better Health Care Maintenance with improved tracking tools. Increased provider productivity with better access to patient care records. Better standardization of care across IHS.

Questions?