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Rural Physician EHR Adoption: a report from the trenches. Kim J. Horowitz, MD Agency for Healthcare Research and Quality September 26, 2007. Goals for Today. Who we are What did it take to get “us” to do this? What were the barriers along the way? Where we are today - PowerPoint PPT Presentation
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Rural Physician EHR Adoption: a report from the trenches
Kim J. Horowitz, MDAgency for Healthcare Research and QualitySeptember 26, 2007
Goals for Today• Who we are
• What did it take to get “us” to do this?
• What were the barriers along the way?
• Where we are today
• What I’d like you to know
In the beginning….. Agency for Healthcare Research and
Quality funded initiatives– October, 2004 – 1 year planning– October, 2005 – 3 year Implementation grant
Purpose is to “promote the use of health information technology (health IT) to”…..
“Increase our knowledge and understanding of the clinical, safety, quality, financial, and
organizational value and benefits of health IT”.
80% of land mass 14% (and growing) of population live in rural California
4.9 million residentsSource: 2000 census data
Rural Medical Service Study Areas
Frontier – less than 7 persons per square mile
Rural – less than 250 persons per square mile
Non-Rural
Status of IT in the Region - 2005• Approximately 17 primary care physicians and 7
midlevels in 17 sites in 4 towns• Various stages of IT adoptions
– Some with no computerized practice management systems
– Some without internet access– No customized databases
• One with an EHR– No data exchange occurring– System not being used for reporting
• Hospital with multiple systems at different levels of functionality and not interfaced
Providers Hospital and RHCs
Acquisition and
Dissemination of
information technology
Comm
unity Based Quality
Improvem
ent Programs and
Monitoring
Continuing Education
Research
Practice Management
Support
Evidence Based
Medicine
Workforce
Development
Before….no infrastructure to facilitate information technology, quality or disease Before….no infrastructure to facilitate information technology, quality or disease managementmanagement
Negotiation leverage
Return on Investment
X
Presence of consistent and coordinated community oriented approach ???
X X X X X X
Date Dx Tx
Date Dx Tx
Smith, Joe 123 Main St. Anytown, USA Tw2-5053DOB 12.1.17
6.3.52 FXR wrist cast
7.12.58 Luies PCN
3.24.62 Tonsilectomy
9.21.66 Obesity Dex Inj
10.15.68 CHF Digitalis
12.21.68 MVA ASA, letter to Atty
Tehachapi Hospital
98.7% outward migration for inpatient care
Hospital Discharges of Patients living in southeast Kern
47.0%
10.0%
9.5%
7.2%
1.3%TVHD0.7%
0.7%
0.8%1.9%
3.9%
1.8%2.3% 1.2%
9.7%
0.5%0.5%
What did it take to get “us” to do this?
Inertia“The tendency of an object to continue in motion at the same speed and in the same direction, unless acted upon by force”.
I’m not a magician Spock, just an old country doctor
Key Informant Interviews•Key informant interviews
–Listening and maintaining confidentiality
•Identifying a Common Passion and Vision to Save our Hospital
•Opportunity to improve Physician-Hospital and Physician-Physician Relations
Perceptions of the ability to“Remove ALL Barriers”
Dollar Cost Issues
Time Cost Issues
Personal Skill Set Inequality Issues
Issues of Culture Change
Breaking down the Barriers
Dollar Cost Issues• Dollar Cost Issues
– What will it cost me?– Hardware and software expense– Time lost from practice– Re-tasking of employees– New, recurring expensives (ie support,
connectivity, upgrades, maintenance)
Time Cost IssuesWill I lose even more family time?
Training time
System Personalization
Personal Skill Set Inequality Issues• Computer literacy
• Physical limitations
Challenges with Vendors
Price Quote
1st Provider (Software)
Price Quote Additional Providers
Maintenance Fee Training FeeServer
Placement
Willingness to Partner /
Notes
AAFP Ranking Score
(n)
Encounter Pro $6,500/provider
$4,500/mid-level $1000/medical
assistants_practice
18%/year of Software license
~$100/hr/day In-house/ASP
Yes Additional
cost to interface--
depends on software
license/application
3.72 (10)
MedAppz Free Free <$450/mo $3000/doctor Hybrid Yes Not Ranked
e-MDs $15,000 $7,500
$3000 integration
fee per vendor & provider
4.32/4.30 (35/21)
All Scripts (Touchworks)
$10000 (depends on the # of providers in Practice…this is a
deposit)
$5,000 $567/mo$32550- IDX;
$49,000-Touchworks
ASP 2.98 (11)
eClinical Works $10,000 $5,000 18%/year of
Software license$750/day/office Hybrid 3.99 (40)
Mardon Free Free Hybrid Yes N/A
Amazing Charts
$995 $200 $500 (+$100 for
additional providers)
$1000/day/office
Hybrid (Offsite Back-up $250/year)
Yes 4.54 (24)
Vista n/a
Sun Seebeyond
$150,000 (Unlimited License)
18%/year of
Software license ASP Yes n/a
NextGen
Small Practice / Provider License (<5
providers) = $12,000 /product or
$18,000 for PM & EHR/provider
Practice License = $20,000 + individ.
Provider License Enterprise License = $150,000 + individ. Provider License
MidLevel Fees are ~1/2-2/3 less than
the Provider License
18% / year of Software License
ASP or In-
house server (Hybrid?)
~$6000 per interface
(prices vary)
2.94/2.37 (22/7)
It’s A lot of Work!!!!!
Interfacing
$25,000
$3,000
$ 500
XX
Vocabulary Test• CCR
• Granular
• Domain
• Network
• Secure
• HL7
• Use Case
CCR
Creedence Clearwater RevivalOR
Continuity Care Record
Granular?
Domain?
Real-a-noia
Issues of Culture Change• Fear
• Local politics
• Control issues
• Deep scars
• Hunkered down community
LAPTOPS
Happy!
Changing the Culture
LAPTOP
Workflow Analysis
So…Where are we today?
Providers Hospital and RHCs
Acquisition and
Dissemination of
information technology
Comm
unity Based Quality
Improvem
ent Programs and
Monitoring
Continuing Education
Research
Practice Management
Support
Evidence Based
Medicine
Workforce
Development
Before….no infrastructure to facilitate information technology, quality or disease Before….no infrastructure to facilitate information technology, quality or disease managementmanagement
Negotiation leverage
Return on Investment
X
Presence of consistent and coordinated community oriented approach ???
X X X X X X
EAST KERN COUNTY INTEGRATED TECHNOLOGYASSOCIATION
“EKCITA”(a 501(c)3 public benefit corporation)Providers in
SE KernHospital and RHCs
Acquisition and
Dissemination of
information technology
Provider leadership team
Governance
Comm
unity Based Quality
Improvem
ent Programs and
Monitoring
Continuing Education
Research
Practice Management
Support
Evidence Based
Medicine
Workforce
Development
Building infrastructure to address the quality chasm in Rural Communities Building infrastructure to address the quality chasm in Rural Communities
Consistent, Coordinated, Integrated, Community Approach to Health
Scope of our Project• Infrastructure
• Telemedicine
• EHRs and CHIE
• PHRs
• Diabetes Education
• Health professions training
What I’d like you to know• There is so much more to report,
and….
Need for custom solutions
• HIE implementation is NOT a One Size Fits All
• Plan for individualization that allows maximum participation opportunities in order to capture key data points – ie Full EHR vs. Scantron + Fax– ie Kiosks, Browser/Clinical messaging
Additional Challenges• Insurance
• Legal support is IMPERATIVE but expensive and time consuming
• HIE via Grant Dollars – sustainability model?– or “Helicopter Research”– Teach them to fish or leave no trace
What results in physician buy-in
•Relevance–How does EHR implementation help my patients or my practice or my community?–Is the data collection/time effort/culture change worth it?
•Fear Resolution–Big Brother–Unethical competitive Practices (data stealing)
•Security assurances (HIPAA, System Failure)•Unobtrusive Paced Implementation of EHR•Cost Mitigation
Who’s Your Buddy?!!
Funder?
Academia?
Community?
With whom have you built rapport?