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?