Dr. Amit R. Shah, MD
Medical Director Multnomah County Health Department
426 SW Stark St, Portland, OR 97204
Tel. (503) 988-3674
MCHD EHR team members Interviewed:
MCHD EHR team members interviewed: Amit R. Shah, MD, Medical Director Joy Allen, Clinical Systems Program Mgr Jennifer McClure, RN, EHR Optimization Coordinator Mindy Stadtlander, MPH - Quality Improvement Coordinator
Multnomah County Health Department is a federally qualified health center that serves up to 45,000 patients and averages 170,000 visits per year. MCHD delivers care through family practice, pediatrics, mental health, and internal medicine at eight clinic locations in the greater Portland, Oregon area. They first adopted their electronic health record (EHR) system, Epic, in 2005. They are currently using EpicCare, version Summer 2009.
To use the EHR to capture patient and clinical information for quality measurement and reporting.
MCHD, like other safety net providers nationwide, has a guiding vision: to improve the outcomes of their needy patients. Around 2001, they realized that in order to achieve this vision, they would need better data. They began a search for an EHR, but quickly realized that they would not be able to purchase a system that would meet their needs on their own. In 2002, they joined forces with other members of OCHIN, a non-profit provider of health information technology in Oregon, to purchase the Epic EHR.
In addition to support from senior leadership, MCHD benefitted from having a strong implementation team comprised of both clinicians and dedicated IT staff. Dr. Amit Shah, MCHD's medical director and EHR champion, was involved from the beginning to design and tailor the EHR to fit the health center's needs.
He stressed that having a physician who is involved in the practice's leadership, and partnering with a nurse champion are essential for provider buy-in and EHR adoption. The MCHD team also emphasized that it is important to have a clinical systems manager who understands the clinical system, but also speaks the language necessary to communicate with the IT department staff who are more computer oriented.
MCHD's implementation team worked to develop a "core" EHR that could then be adopted to fit in with the workflows of the individual clinics. To determine workflow requirements, the MCHD team first determined specific performance measurements and clinical improvement goals, and then determined what needed to be reported to support those objectives. At the same time, MCHD implemented team-based care in each of their clinics, with each team comprising of two primary care providers, one registered nurse, one panel/patient manager, two support staff, and one team clerical assistant. These multiple teams are supported by front office staff, administrators, and clinical medical assistants. Establishing these teams standardizes the roles and responsibilities of staff within and across all of the MCHD clinics. The EHR implementation team believes this standardization is crucial for EHR implementation and training. As new EHR functionalities continue to be rolled out, the EHR implementation team works with each clinic's practice management team to "train the trainer", who then disseminates the information on the new EHR functionalities to their teams. MCHD has not yet decided on which of the clinical quality measures (CQMs) they will report under Meaningful Use. However, they expect that reporting the CQMs will not significantly affect MCHD's workflow. MCHD already generates reports through Epic that provide clinic-specific and provider-specific quality performance data, to which providers have access. While MCHD has not yet seen clinical benefits of these process measures on patient outcomes, they have observed organizational improvements.
MCHD has a symbiotic relationship with their REC, the Oregon's Health Information Technology Extension Center (O-HITEC). O-HITECH helps MCHD staff understand the rules of meaningful use, and MCHD is providing the REC with first-hand experience in adopting and using their EHR for meaningful use, so that their lessons learned can be passed onto other practices and clinics. MCHD sees the REC as an important EHR partner because they can provide practices with an EHR "toolkit" that would include a readiness assessment, choices for EHRs that will best suit the needs of a particular practice, help for messaging and disseminating information on the value of EHR adoption to practice staff, strategies for leadership, and resources that practices will need in order to adopt.
One of the biggest challenges in quality measurement using an EHR is identifying which information to use for quality measurement and reporting. Because an EHR may be tailored to accommodate different clinic workflows, the same information may be entered in different places in the EHR interface. Second, the ICD-9 diagnosis codes recorded sometimes do not have the same clarity as clinical record data. Third, because there are no laboratory reporting standards, MCHD had lab results coming into its EHR from five separate entities, each having its own data structure and information.
To address these challenges, MCHD staff continue to create their own business and work flow rules to ensure that: (1) data are entered into the most appropriate fields, and in the most standardized manner (e.g., discrete data field that can be used for quality measure calculations instead of free form text); and (2) that data are abstracted from the most accurate field, sometimes choosing from multiple choices within the EHR. These efforts to ensure that the right information gets into and out of the EHR system are necessary to meet MCHD's internal and external reporting needs.
Next steps for MCHD include improving and expanding use of their HIT and EHR utilization for quality improvement purposes. Part of MCHD's strategy is to move toward a patient-centered medical home care delivery model. MCHD leadership believes that all of the MU objectives will be met if they focus on their efforts towards creating a medical home-based delivery model for their vulnerable patient populations. Another major focus is improving patient safety, and MCHD staff believe that they can discover medical errors more readily with an EHR. As Dr. Shah said, "We need to be proactive and not just reactive."
Consider developing and implementing business rules to streamline the data entry process and to make data retrieval for clinical quality measurement easier.
For more information about this and other aspects of Meaningful Use, contact Allen Traylor, Office of Provider Adoption Support Office of the National Coordinator for Health Information Technology U.S. Department of Health and Human Services e: firstname.lastname@example.org