I have written about workflow, proper documentation, and clinical quality measures over and over, but my perspective has always been a little one-sided until recently.  Always writing from the clinical staffs’ viewpoint, I never really considered how the patient might perceive the implementation of our EHR and all of the workflow changes that have come about as a result of our EHR incentives programs, like Meaningful Use or PQRS.  However, with the recent illness of my middle daughter, I’ve gained a lot of valuable patient insight (albeit not from the best of circumstances), and I’m very appreciative of the learning opportunity.

So exactly what have I learned?

1. Computers can be glitchy, but they provide a lot of valuable information. While at the hospital and at follow-up appointments with Anna, there were a few times that the computers froze or caused a problem, but, honestly, not that often. And given the alternative —of not having Anna’s information readily available and having to wait on records to be faxed—I’ll take the occasional glitch. Anna has seen multiple providers during the past few months, and with all them having access to her electronic chart, it put my mind at ease.

2. Computers do get in between the provider and patient, but it isn’t all that bad. I have heard several clinicians say that they feel like the computer gets in between them and the patient. And I have also heard patients say the same thing. But from what I observed during Anna’s experience, it’s not really that intrusive. Sure, you have to spend some time entering information, but once the information was entered, all of her providers spent time examining her and talking to her directly. It definitely wasn’t any different than writing down the information on paper. I discovered that most everyone who saw her has developed a balance in using the computer and seeing the patient.

3. An EHR saves the patient money. As mentioned in #1 above, when providers share the same record, it’s time gained, but it’s also money saved. All of Anna’s orders (labs, imaging, etc.) were shared by all of her providers, and no duplicate tests were unnecessarily ordered, saving me money.

4. The Clinical Summary is nice. First of all, let me say that Crystal, one of the check-in staff at Pediatrics, does an awesome job. She never forgot to ask us if we wanted a clinical summary of our visit. Although I didn’t need her to print it for all of Anna’s visits, the document has come in handy at other times. With so many medications and orders and diagnoses, it’s difficult to keep track of all that information, especially during a stressful acute illness. Thank you, Crystal, for always asking, because there are times when this mom forgets things. 

5. Quillen ETSU Physicians are wonderful physicians. Although I’ve taken advantage of Anna’s illness for inspiration to write, I hope everyone will indulge me. The most valuable perspective I gained during this experience is how wonderful our physicians and staff are. Anna has received the best of care, and I can’t say enough how appreciative I am for everyone who has helped her. To everyone at ETSU Family Medicine in Johnson City, ETSU Pediatrics, and ETSU Surgery, thank you so much for providing the best of care. You rock (the EHR, too)! 

According to the TennCare website, the definition of Meaningful Use involves using certified EHR technology to

· Improve quality, safety, efficiency, and reduce health disparities,
· Engage patients and families in their healthcare,
· Improve care coordination,
· Improve population and public health, and
· Maintain privacy and security.

Remarkably, we have already seen first-hand examples of Quillen ETSU providers and clinical staff using our EHR to each of these ends. 

Addressing health disparities has been the primary  focus of the patient lists generated for each provider. Many of the family medicine and internal medicine providers now have access to a list of all their diabetic patients with records in the EHR. 

These lists help providers and clinics manage this patient population, who, in Tennessee, had a 19% higher risk of dying from diabetes than the national average.  The Tennessee diabetes death rate of 30.2 per 100,000 was ranked 10th highest in the nation in 2002. In 2004, the age-adjusted diabetes death rate for black Tennesseans (61.1 per 100,000) was over twice the rate for whites (27.8 per 100,000).* 

*Information from tn.gov. 

Each of the Quillen clinics has also been offering  Clinical Summaries to patients and/or their family members at check out.. While not every patient asks for the summary, some patients have found these summaries very beneficial, such as parents wanting the most up-to-date immunization record, or simply patients who are on multiple medications.  

As we look toward adding a patient portal, patients will gain even more access to their health records, and, hopefully, this will prompt many of them to become more engaged in their own healthcare.

Improving care coordination has been one of the biggest benefits of using the system. With multiple providers and specialties having quick access to the patient’s chart, duplicate labs and medications have significantly decreased, saving patients money and time.

The referral process to providers within ETSU clinics has also  been significantly improved. Faxing records is no longer necessary, and clinics can use tasking rather than phones and faxing to make the referral.

With the system’s ability to track and report data, we are now able to run reports on various population and public health initiatives. In the Department of Pediatrics, data has been requested to track abnormal labs, the Read N Play initiative, and reflux diagnoses. In the Department of Family Medicine, various information is being tracked for improvement of their Patient-Centered Medical Home designation, as well as monthly reports on Controlled Substance prescriptions.

The system is also designed to generate reminders based on either input from individual providers or as system-generated reminders based on recommended screening and diagnostic guidelines, such as colorectal cancer and mammography screenings. Recently, reminders have been set up for CSMD checking  for patients on controlled substance prescriptions.

Maintaining privacy and security has always been a top concern for EHR users, no matter what the system. With retail electronic security breaches being reported regularly, many healthcare providers questioned the security of electronic health records when EHR systems were first introduced into practices. However, with quickly evolving technologies, and the stringent requirements on systems in order to be certified for Stage 1 of Meaningful Use, EHR systems are exceptionally secure. Eligible providers need to “attest” that they have met certain measures or requirements regarding the use of the EHR for patient care. 

EHRs are more secure than most paper charts ever were, especially within organizations where chart audits are frequently performed. In the paper world,  if an employee wanted to access a health record without reason, most likely, no one would ever know if he or she  had been in the record. With electronic records, anyone who accesses a chart is trackable, resulting in a more secure health record.

As we all become better users, the possibilities for how the system can be used in more meaningful ways will be illuminated.

"We have to do what?" This is the response we have heard quite often over the past few months when our team has updated our clinics on Meaningful Use Core Set #13: "Provide clinical summaries for patients for each office visit within 3 business days." The responses of disbelief are understandable. For clinics that have never had to provide patients with an after-visit summary of care, the concept is daunting. Not only is the cost associated with paper, printing, and postage a burden, but the completion of charting before the patient leaves the office is also overwhelming.
To help alleviate some of the unknown surrounding this requirement, here are some tips on developing an office workflow for providing clinical summaries:

1. Keep in mind, paper clinical summaries will not have to be provided forever. Eventually, patients will be able to view their clinical summaries from a patient portal (in which they are provided log-in information and can have access to much of their healthcare record).

2. Until the patient portal is ready, paper summaries are the only option. Although clinics have three business days to provide the summary, to curb postage costs, we recommend offering the clinical summary when a patient checks out. The check-out staff can ask the patient if he/she would like a summary of  the day's visit, and if he/she indicates 'yes', then the summary can be printed from the Daily Schedule. If the patient does not want the summary, then the staff member can record in the electronic chart that the summary was declined by the patient (for Allscripts Enterprise users, click on the blue "i" icon in the patient banner).

3. Providers are often discouraged by the requirement, not because they are opposed to the patient receiving the summary, but they want to finish documenting the visit before the patient receives the summary. If the patient is offered the summary at check out, the provider feels rushed. Here's what we suggest: document the essentials, namely the Plan and Active Problems (diagnoses), and finish the details when time allows. Much of the Clinical Summary is populated by information that the staff and nurses input (Vitals; Medical, Family, Social Histories; Demographics), so if the provider can get the Plan completed (Orders for Meds, Labs, Imaging, Referrals, Follow Ups, etc.), then the patient will receive the required documentation. Typically, the Plan is necessary for completing despite the clinical summary requirement, so this workflow shouldn't be much of a stretch for most providers.

4. Some providers have asked about how the clinical summary is populated (what sections are pulled in from the note versus the chart). For Allscripts Enterprise 11.2 users, the following sections of the note populate the summary: Chief Complaint, Reason for Visit, and HPI.  From the chart, Active Problems, Medical Histories, Vitals, Immunizations, Allergies, and Orders populate the summary.

5. Keep in mind that for Stage One Meaningful Use reporting, the requirement for providing the clinical summary is only 50% of patient visits. This lenient percentage gives clinics a little wiggle room - time to adjust to the workflow, budget in the costs, and practice documenting differently, if needed. We recommend that clinic managers and administrators look over the Daily Schedule regularly, and if clinical summaries are not being produced (or documented as "denied"), the providers and staff are made aware of the issue. 

Remember, change can be tough, but often, change can improve patient care. The ultimate goal of providing the clinical summary is to improve communication between provider and patient, which is good for everyone.