Ouuch: Making Excellent Health Responses

OUUCH:

MAKING EXCELLENT HEALTH RESPONSES BETTER

CCHIT: The Certification Commission for Healthcare Information Technology (Bennett, 2009,

¶ 5).

EHR: Electronic Health Records (Amatayakul, 2009, ¶ 2).

EMR: Electronic Medical Record (Clemons, 2007, ¶ 3).

HHS: Health and Human Relations (Bennett, 2009, ¶ 5).

ACADEMIC ABSTRACT

OUUCH: Making Excellent Health Responses Better depicts a case study which examines a number of contemporary considerations relating to the influence of Electronic Health Records (EMR) in a healthcare organization. OUUCH, Orlando's Universal Urgent Care Home (fabricated walk-in clinic) began serving walk-in patients July 4, 2008. Six months later, Dr. William Stringent, the director of OUUCH, initiated the process of implementing EHR in the clinic. With EHRs, clinics, hospitals, pharmacies and physicians can share patient information in real time to better deliver timely, personalized and portable care.

EXECUTIVE SUMMARY

Proponents of Electronic Health Records (EHR) routinely outline a number of advantages the new technology proffers. With EHRs, clinics, hospitals, pharmacies and physicians can share patient information in real time to better deliver timely, personalized and portable care to locations throughout the world. OUUCH, Orlando's Universal Urgent Care Home (fabricated walk-in clinic) began serving walk-in patients July 4, 2008 and will celebrate two years of service on July 4, 2010. In January 2009, Dr. William Stringent initiated the process of implementing EHR in the clinic.

Walk-in clinics are making big strides in the industry, according to Laura Jane Pittman (2008) in the article, "Walk-in clinics are making big strides in the industry ." Generally, the walk-in clinic's medical staff treats non-life threatening accidents and illnesses. OUUCH, however, as an urgent care clinic, is in some ways similar, yet also dissimilar to the typical walk-in care clinic. OUUCH not only "offers limited services for common, nonacute medical conditions such as strep throat, ear infections and pink-eye," but because it is an urgent care clinic, it also treats "emergencies such as chest pain and broken bones" (Pittman, ¶ 5). Most urgent care clinics are often staffed by physicians, however, most nonacute walk-in clinics employ nurse practitioners and physicians' assistants. As OUUCH provides services to clients 16 hours a day, seven days a week, its network of practicing physicians, primary care physician assistants and nurse practitioners (NPs) work eight-hour shifts on a rotating schedule. Whether the patient needs treatment for an emergency, life-threatening situation which requires immediate attention or a nonacute condition, members of OUUCH's staff can provide the needed treatment.

Even though OUUCH faces multiple challenges as a novice international urgent medical care provider, it offers a much-needed service, particularly to individuals who may need urgent care but may not speak English. Due to EHR and OUUCH's subscribing to an international translation service, language does not present a barrier for staff to communicate with the patient -- no matter his/her language. Whether or not the individual securing treatment at OUUCH lives in a country that has implemented EHR of not, the electronic record of the medical treatment will be available if/when the patient needs it in the future to virtually any health care provider.

INTRODUCTION

"Make no mistake, & #8230;[EHRs] are the inevitable next step forward in healthcare, shortening patient wait times and lowering operating costs for physicians through improved efficiency and reduced malpractice risk"

(Electronic Medical Records, 2010, ¶ 4).

OUUCH's Business

When one thinks of Orlando, Florida, Mickey Mouse and Disneyland typically come to mind. At times, individuals who travel from all parts of the world to experience the manufactured "magic" Mickey Mouse and the myriad of other Disney characters present, experience medical problems perhaps serious enough to merit a trip to the emergency room (ER) if one were nearby, or perhaps only uncomfortable of painful enough to mandate minimal medical care. OUUCH, Orlando's Universal Urgent Care Home, directed by Dr. William Stringent, provides the "perfect" resolution for securing timely urgent major and not so urgent minor medical attention. During the case study, "OUUCH: Making Excellent Health Responses Better," the researcher examines a number of contemporary considerations relating to the influence of Electronic Health Records (EHR) in an urgent care clinic. With EHRs, clinics, hospitals, pharmacies and physicians can share patient information in real time to better deliver timely, personalized and portable care to locations throughout the world.

EHR

Healthcare professionals throughout the world are more readily dealing with two acronyms relating to health care records, electronic health records (EHR) and electronic medical records (EHR). Margret Amatayakul, RHIA, FHIMSS, (2009), author of Electronic Health Records: A Practical Guide for Professionals and Organizations, AHIMA, Chicago, Fourth Edition, reports in the journal article, "EHR vs. EHR: What's in a name?," that the institute of Medicine in 1991 and again in 2003 defined an EHR as "a patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids" (¶ 2). In 2008, the National Alliance for Health Information Technology (NAHIT) developed the following definitions for EHR and EHR:

EHR: An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.

EHR: An electronic record of health-related information on an individual that conforms to nationally recognized interopcrability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. (Amatayakul, 2009, ¶ 4-5).

Amatayakul (2009) explains that the ability to exchange information interoperably depicts the primary difference between an EMR and an EHR. As the medical moves toward electronic records that adhere to national standards for inter-operability, the term, EHR, will eventually dissipate.

Currently, a number of vendors offer EHR systems to medical offices, with the smaller companies perhaps offering a system at a lower price. These systems, however, may experience problems obtaining proper certification. David Bennett (2009), a senior editor in Advanstar Communications' Centralized Content Group, explains in the journal article, the EHR "market includes small and large system vendors," that because of federal incentive programs, some medical care providers rush to install EHR systems. Bennett stresses that "choosing the right vendor and EHR system is a high-risk gamble for healthcare providers with profitability, efficiency, staff morale and even patient safety at stake" (¶ 3). In 2009, 139 vendors offered EHR systems to medical care providers, with more currently working to achieve certification. Some medical care providers require that the vendor they choose will not only install an EHR system, but also guarantee that the medical facility will receive a reimbursement for its investment in the system.

Researchers predict that EHR applications could reach as high as $1.6 billion dollars by 2013. Bennett (2009) expresses that "a growing number of small vendors, as well as technology giants such as Intel, General Electric, Microsoft and Qualcomm, are vying for the business" (¶ 4). The Health and Human Relations (HHS) contracts the Certification Commission for Healthcare Information Technology (CCHIT) to certify EHR vendors. By law, Medicare and Medicaid Services only receive grants if the doctors and hospitals implementing EHR purchase certified EHR systems.

OUUCH's Background

OUUCH, Orlando's Universal Urgent Care Home (fabricated walk-in clinic) began serving walk-in patients July 4, 2008 and will celebrate two years of service on July 4, 2010. In January 2009, Dr. William Stringent initiated the process of implementing EHR in the clinic. Walk-in clinics are making big strides in the industry, according to Laura Jane Pittman (2008) in the article, "Walk-in clinics are making big strides in the industry ." Generally, the walk-in clinic's medical staff treats non-life threatening accidents and illnesses. OUUCH, however, as an urgent care clinic, is in some ways similar, yet also dissimilar to the typical walk-in care clinic. OUUCH not only "offers limited services for common, nonacute medical conditions such as strep throat, ear infections and pink-eye," but because it is an urgent care clinic, it also treats "emergencies such as chest pain and broken bones" (Pittman, ¶ 5). Most urgent care clinics are often staffed by physicians, however, most nonacute walk-in clinics employ nurse practitioners and physicians' assistants. As OUUCH provides services to clients 16 hours a day, seven days a week, its network of practicing physicians, primary care physician assistants and nurse practitioners (NPs) work eight-hour shifts on a rotating schedule. Whether the patient needs treatment for an emergency, life-threatening situation which requires immediate attention or a nonacute condition, members of OUUCH's staff can provide the needed treatment.

Even though OUUCH faces multiple challenges as a novice international urgent medical care provider, it offers a much-needed service, particularly to individuals who may need urgent care but may not speak English. Due to EHR and OUUCH's subscribing to an international translation service, language does not present a barrier for staff to communicate with the patient -- no matter his/her language. Whether or not the individual securing treatment at OUUCH lives in a country that has implemented EHR of not, the electronic record of the medical treatment will be available if/when the patient needs it in the future to virtually any health care provider.

Prior to Launching Technology Initiatives

Over the past seven years, many healthcare organizations, like OUUCH, have begun to transition from the traditional paper-based systems to EHR systems. Research has shown that over a period of time. EHR systems can improve quality of care for patients, provide more accurate information, and overall improve safety issues relating to reducing mistakes with patients. In the exploratory study, "Change factors affecting the transition to an… [EHR] system in a private physicians' practice: An exploratory study," Aaron D. Spratt, Social Security Administration and Kevin E. Dickson (2008), Southeast Missouri State University, report that the U.S. health care industry reportedly ranks among the world's leading inefficient information enterprises. Although the system needs major changes, the transition process however, creates a high change in the business aspect of an organization. Spratt and Dickson (2008) explain that for an EHR system to be successful, doctors must be involved from the very beginning of the process. Mary Ellen Schneider (2006), Senior Writer, also asserts in the journal article, "Customization, involvement key to & #8230;[EHR] success," that doctors need to be involved in the process in order to customize their system to fit their specific needs. Prior to OUUCH launching it technology initiatives, it implemented the business model that replicated the model most walk-in clinics without HER capabilities use. OUUCH secretarial/accounting staff routinely completed the following duties. In the book, Implementing an Electronic Health Record System, James M. Walker, Eric J. Bieber, and Frank Richards (2006) note the following typical workflow in a medical facility.

1. Pull charts, enter information into the computer and re-file charts.

2. Complete service sheets

3. Prepare paper medical records

4. Prepare test results for signature of physician or other medical personnel

5. Filing of test results in the paper medical record

6. Billing charge entry

7. Documentation of office visits and resulting on-site testing (Walker, Bieber, & Richards, 2006, p. 26).

Prior to implementing the use of EHR at OUUCH, Dr. Stringent met with the technical team to discuss which of the above workflows EHR could support. Dr. Henry Plummer, who began his medical career at the Mayo Clinic in Rochester New York, and worked there from 1900 until his death in 1936, created and developed one of the first medical records, which he called the "unit record." The unit record later evolved into the company business the researcher examines in the case study, the influence of EHR or technology in a healthcare organization. Kateri Clemons (2007), project manager at Nelson Publishing Company, asserts in the article, "Capturing medical data in the & #8230; that [EHR]," that "[Plummer's] theory was that all of a patient's records should reside in a single file that travels with the patient and is stored in a central repository. Plummer's record-keeping system replaced an inefficient ledger system" (¶ 1). On a patient's first visit, one of the Mayo clinic's medical personnel would enter the patient's demographics into a ledger book. Later, when the patient returned for another visit, doctors would have to locate and update the original record, which proved to be an inconvenient, time-consuming practice.

By 1907, Plummer and an assistant created and implemented Mayo's medical record system. Clemons (2007) explains that Plummer's single-unit record brought together a patient's clinical visits, hospital stays, laboratory tests, and doctor's notes, quickly becoming the standard for around the world" (¶ 2). After further research observing factories and how they managed information, the Mayo Clinic built a series of conveyers and tubes to transport patient's medical records throughout the clinic.

In 2005, more than 6.2 million patient records, dating back to 1907, became electronic at the Mayo Clinic. Clemons (2007) asserts that the Mayo Clinic staff may instantly access all information relating to a patient's care, "from physician notes, lab reports, and surgical dictations, to copies of correspondence and appointment schedules, to X-rays, ultrasounds, CT and MRI scans, and echocardiograms," (¶ 3) by more than 16,000 computers on all three of the Mayo Clinic campuses, including Jacksonville, Rochester and Scottsdale. As more than 3,000 doctors and 47,000 other healthcare professionals practice/work at the Mayo clinic, its electronic medical record (EHR) may comprise one of the largest medical systems in the world.

During the study the Centers for Disease Control and Prevention's National Ambulatory Care Survey conducted, researchers collected data from 2,500 physician offices between 2003 and 2004 and found that physicians who used paper-based systems outperformed physicians using EHR systems. Bill Gillette (2007), Staff Correspondent argues in the article, "EMR users may not have an edge, study suggests," that physicians using paper-based systems are reportedly 14% points more likely to properly prescribe statins (drugs that can lower individual's cholesterol) for patients experiencing problems with high cholesterol. On the other hand, the study found that doctors who used EHR systems were not as likely to order unnecessary urinalyses or inappropriately prescribe depression medications.

Dr. Stringent disagrees with Gilette (2007) and notes that Gillette also reports, that Dr. Christopher Zachary, with the University of California, argues that the 2003-2004 Centers for Disease Control and Prevention's National Ambulatory Care Survey study proved to be flawed. Zachary expressed that the study generically examined older EMR systems and did not ask appropriate questions like those regarding the billing efficiency, the collection of the demographics, direct pharmacy interface, and whether or not interactive drug alerts transpired.

Prior to implementing EHR, staff at OUUCH completed a Site Characteristic Questionnaire. A data analyst later completed a workflow study to customize the EHR system for OUUCH. Figure 1 depicts the four phases of the iterative

1. Development

2. Assessment

3. Implementation

4. Modification (Walker, Bieber, & Richards, 2006, p. 37).

Figure 1: Workflow Redesign Process Phases (Walker, Bieber, & Richards, 2006, p. 37).

OUUCH staff attended16 hours of a training curriculum to become familiar with the software configuration of EHR as well as with its workflow and analysis, redesign factors and user training and support. Staff training also included "three weeks of self-directed learning, an online medical terminology class, and a comprehensive test…" (Walker, Bieber, & Richards, 2006, p. 42). To reinforce the staff's application training and expose them to typical questions regarding the use of the EHR, staff also had to work as teaching assistants in the HR training classes.

Implementing an EHS

Table 1 portrays a number of benefits of EHR for particular process types Dr. Stringent stressed to the OUUCH staff.

Table 1: Benefits of Particular Process Types (Walker, Bieber, & Richards, 2006, p. 174).

Process Type

Benefits

Patient Safety

Automatic, real-time drug-drug and drug-allergy checking

Care Quality

Automatic, patient-specific reminders in real time; Documentation standardized, searchable, readable

Patient Access

Standardize scheduling system integrated with the EHR

Patient Information Access

Any time secure access to the E. HR and practices

Clinic Workflows

Simple, standardize workflows

Information Reporting

Automated reports on aggregated clinical data

Remote Access

The clinical and administrative information

Digital Radiology

Remote, real-time access to most images

Outpatient Quality Management

Automated tracking of pharmacy and ER use of patient access

Clinician linkage of orders with diagnoses

Billing

Automatic medical necessity checking

With the clinic's operation implementation completed, the inpatient implementation began. OUUCH was well on its way to transform the way it provides healthcare. Some of the steps taken included:

1. Explicit Goals and Measures: As individuals in the clinic started to become more familiar with assessing needs and defining goals, a trait needed to ensure congruence between the EHR projects and organizational strategies. Medical personnel regularly checks progress toward the goals and as the clinic reaches its goals, defines new goals to initiate the next improvement phase. When the clinic misses a goal, medical personnel analyze the reason for the "failure" as well as the missed goal. Medical personnel then implements changes needed to be made to meet the original or revised goal. Even reportedly simple changes, like decreasing a chart requires management to actively participate.

2. Operational Leadership: The clinic's clinical leaders along with the administrative leaders increase their protests oppression in transitioning to EHR. Those with roles on oversight and feedback committees assume responsibility to identify new business initiatives the EHR can maintain. Streamlined document distribution, for instance, depicts one specific, affective example. When OUUCH's task force identified the need for one of the clinic's physicians to more rapidly communicate with referring physician, the EHR team customized the EHR to meet this particular need.

3. Integrated Workflows: EHR possesses the potential to support seamless care across the patient's spectrum of care from his/her home to outpatient as well as inpatient and long-term care. Achieving this potential, albeit, requires that the EHR team thoroughly analyses and processes redesigned by all CDOs and that the EHR vendors invest concentrated efforts to fill even basic needs like thoroughly accounting for changes in the patient's medicines during the transitional time from outpatient inpatient care and back

4. Standardize implementation: For the EHR to be effectively and thoroughly implemented, the clinic needs to develop standardized implementation methodologies, efficient enough for not only community hospitals and physician practices to realize benefits but also for patients to benefit. The clinic is in the process of developing methodologies to develop and maintain a high performance E. HR, capable of providing order entry and a real time decision support; accompanied by appropriate workflows, which communications capabilities support. The clinic is investing additional credible, critical research to identify challenges to the broad implementation of EHR as well as projected ways to overcome potential challenges.

5. EHR Tool Development: The development of high efficiency, validated, shareable EHR tools depicts one enabler that will promote the implementation of widespread EHR. These tools which will need their construction assessment and maintenance standardized will include, for example, note templates and order sets. The tools will also need to be set in "the context of proven change methodologies" (Walker, Bieber, & Richards, p. 175).

6. Use of the patient E. HR for patient interview in education: As patients have access to secure e-messaging, this gives the medical profession the potential opportunity to address a number of critical concerns/gaps in providing Health Care. Use of e-messaging in conjunction with EHR could help address ameliorable adverse event resulting from prescribed medicines or symptoms the patient may experience after a medical treatment.