Overview

A rural physician practice successfully adopted electronic health records in 1993 as part of its strategy to improve clinical quality of care and reduce overhead costs. The system has supported the Colorado group's recent move toward population health management and provided a positive return on investment within two years of implementation.

Issue: Policymakers are promoting electronic health records (EHRs) as a tool to improve the efficiency and quality of American health care, but physicians have been slow to embrace EHRs because of financial, organizational, and logistical barriers.[1] Many U.S. physicians practice in small groups that face unique challenges both in adopting EHR systems and using them for quality improvement. The experience of small physician practices that have successfully implemented EHRs and, as a result, improved their quality of care, can provide useful insights to other groups working to overcome these obstacles.

Objective and Intervention: The Western Colorado Physician Group (WCPG) adopted EHRs to increase their office efficiency, gain fast access to information, and optimize their patients' quality of care.

Organization and Champion: WCPG is a seven-provider family practice. The group is a division of Primary Care Partners, P.C., a 38-provider primary care practice serving 50,000 patients in rural Grand Junction, Colo., and surrounding Mesa County (population 120,000). Gregg Omura, M.D., a family practitioner at WCPG, led the EHR system adoption effort.

 Implementation Timeline: WCPG established its EHR system in 1993. At that time, the group was an independent, four-physician practice. WCPG later merged with two other physician groups, forming Primary Care Partners in 1999. The EHR system was expanded to the entire Primary Care Partners practice in 2002.

Key performance measures: WCPG initially focused on the use of EHRs to reduce cardiovascular risk, targeting the following parameters:

1. hemoglobin A1c
2. blood pressure at goal;
3. on aspirin if indicated;
4. on ACE inhibitor if diagnosed with congestive heart failure;
5. lipids at National Cholesterol Education Program goals; and
6. tobacco free (nonsmoker or ceased smoking).

The group also assessed other preventive care interventions, such as increasing childhood immunizations.

Process of Change: Growth in WCPG's practice in the early 1990s left the group facing an overflowing chart room and growing demands on front-office staff. Rather than invest in bricks and mortar, WCPG physicians opted to purchase an EHR system on the assumption that it would reduce overhead costs and thus provide a better return on investment. The team evaluated EHRs from several vendors, selecting a system primarily based on its potential to improve efficiency. Terminals and printers were installed in every room to ensure ready information access. The practice also made quality a priority. At the heart of its EHR program are customizable templates linked to treatment guidelines. As physicians record a patient visit, the EHR prompts them for critical diagnosis-related data and provides information about a patient's care, for instance, by flagging records when blood pressure and laboratory results do not meet treatment goals. By organizing a patient's treatment history and making it easy to find information, the EHR system facilitates comprehensive care.

"When a patient is being seen for an acute condition, say an ear infection, you can review other chronic disease parameters and make adjustments in those areas as well," Omura says. "The EHR makes it very simple to do that; you don't have to search through the chart." And, because the information is already in the record, it doesn't require "a lot of extra time" to document the discussion. Although some clinical templates are shared, most WCPG physicians customize them for direct data entry to suit their particular practice style. "If you have a good template, you're not doing a lot of typing," Omura says. Instead, "you're selecting information." Those doctors who continue to dictate patient notes to be transcribed into EHRs do not realize the full benefits of such systems. "In that case, you're not really utilizing a lot of the potential value of the EHR to act as the monitor and prompt for chronic diseases," he notes.

Electronic records also make it easy to spot patterns that facilitate patient education. "I'm frequently showing the patient their results graphed over time and will print [the graph] for the patient to take home," Omura says. "It's quite dramatic to see how much weight you've gained or lost, or how much your cholesterol has improved or worsened over the last five years. It helps to motivate patients." WCPG physicians are using EHRs to support a practice redesign effort, called the renaissance program, which they have modeled on the Institute for Healthcare Improvement's Idealized Design of the Clinical Office Practice principles.[2] EHRs help to promote patient safety and quality improvement at WCPG in several ways:

• Medication lists, derived from electronic prescribing, are always up-to-date and accurate, which is not always the case in a paper system. Physicians can review a patient's medication history at a glance, and the system alerts them to drug allergies and potential drug interactions as prescriptions are written. "It's better to do this up front, as opposed to relying on the pharmacy to call and tell you there's a problem," says Omura. Pharmacists also might not have complete information for patients who shop at more than one pharmacy.
• Disease registries can be compiled to identify patients who fail to obtain scheduled preventive services or follow-up visits, prompting offices to send reminder letters or make phone calls to encourage patients to keep their appointments. Likewise, the EHR system links laboratory results to patients' health records and generates customized patient communications, thus ensuring timely follow-up and helping to educate patients about their results.
• Performance data are easily extracted for internal monitoring and external reporting. "We sat down and came up with shared goals for cardiovascular disease prevention, and then we started monitoring results among the doctors within our group and sharing that information on a regular basis," Omura explains. Rocky Mountain Health Plans, a local HMO, collaborated with the Mesa County Physicians IPA (independent practice association) to create financial incentives that reward WCPG physicians for better diabetes care and outcomes. "In the old days, with a paper chart, you didn't have a way of monitoring that," Omura says.

Omura cites the ability to delegate routine recording of patient histories as one of the greatest benefits of EHRs. Nurses work through a battery of about 60 questions to elicit the patient's health needs and medication experience. "If it's all laid out in front of me when I walk into" the exam room, then "I'm more productive and focused on the big issues," he says. The time saved on history-taking and dictation allows the team to care for an additional three to four patients per day, recouping the cost of staff time in additional patient revenue. WCPG physicians have high-speed access to EHRs from terminals located in the area's two hospitals. Mesa County is working toward establishing a community health information network, known as the Quality Health Network, for data-sharing among local health care providers, according to Dick Thompson, the network's executive director. Modeled after an initiative in Santa Cruz, Calif., the effort involves reaching agreement on interoperability standards to power electronic messaging services as a first step toward realizing the benefits of an interlinked EHR system.[3] A regional quality oversight committee is working to establish common infrastructure, such as disease registry tools that would support regional quality improvement for diabetes, cardiovascular disease, and preventive care.

Results: One year after WCPG began monitoring cardiovascular risk reduction performance, the proportion of eligible patients meeting goals increased to 74 percent from 61 percent previously, representing a 21 percent improvement. Also, an earlier survey conducted by the state of Colorado and Rocky Mountain Health Plans reported a 97 percent overall immunization rate for two-year-old patients of WCPG, compared with 63 percent for all two-year-old Mesa County children. In addition to its impact on quality, the adoption of EHRs led to administrative and operational efficiencies. WCPG administrative staff decreased from 7.5 full-time equivalent front-office employees and 1.75 transcription front-office employees serving four physicians before instituting EHRs to five front-office employees and a half-time transcriber serving seven providers today. This yields a conservative cost-savings estimate of $60,000 per year, meaning that WCPG recouped the $125,000 purchase price of the EHR system in a little more than two years. Considering that staffing levels likely would have increased in the absence of EHRs, the cost-savings are conceivably higher.

Lessons Learned: EHRs can be used as a tool for population health improvement. "This approach looks at the population of all your patients and tries to improve the quality of their care—both the people that see you [regularly] and the people that don't come in as consistently as they should," Omura says. Although "some people might get a little upset that you're giving them a call and bothering them, most patients think positively of it. If they can't afford to do what you want them to do, at least they know that you're thinking about them and trying to help them. On the other hand, someone might say, 'Gee, the doctor called again, maybe I better go in there, maybe it is important.'" Would every practice see these kinds of returns? "It depends on how aggressively each group of doctors wants to use the technology," Omura says. "If you want to optimize your practice but don't have the technology, it is very laborious and difficult. On the other hand, if you have the technology but aren't utilizing it [to its full potential], you won't get as optimal an outcome as you might have liked." What makes the difference is "a combination of your approach to patient care plus the technology to get the best outcomes."

Implications: "The best [users of EHRs] make efficiency improvements at the same time they're making quality improvements," says Robert Miller, Ph.D., a professor of health economics at the University of California, San Francisco, who has studied EHRs in physician practices.[4] Although EHRs bring about some basic improvements, such as improved legibility and information flow, "real improvement requires much more work," he says. This includes creating disease registries, generating preventive care reminders, and reorganizing workflow so that someone follows up with patients. Two things that can help promote EHR adoption among physician practices, says Miller, are: 1) pay-for-performance incentives, and 2) physicians with extraordinary skills, that is, leadership and commitment to quality as well as managerial and entrepreneurial skills. In the absence of homegrown skills, physicians will need external technical assistance to make the changes necessary to reap the rewards of EHRs. For example, Miller notes that the Medicare program has tasked Quality Improvement Organizations to support physicians in adopting EHRs.[5] Omura agrees that performance incentives are important if EHRs are to realize their role in quality improvement. "To some extent, you're getting paid for that extra time and effort to monitor patients and you're getting better results," he says. However, he doesn't foresee pay-for-performance "resulting in a wholesale rush toward EHRs, it's just one more factor to move in that direction."

David Herr, M.D., associate medical director at Rocky Mountain Health Plans (RMHP) in Grand Junction, Colo., says that EHRs can make data gathering for pay-for-performance easier and less obtrusive. Yet, he notes, some EHR systems were not designed to support population health management, so physicians should choose their EHR vendor carefully. RMHP is providing simple electronic registry tools to help physicians perform chronic care management. Seeing the value of electronic databases also could encourage physicians to transition toward EHRs. Regional health information networks can leverage EHRs' potential to improve quality by allowing physicians to share information about patients as they move through the health care system. Thompson at Quality Health Networks points to three factors that are facilitating the formation of a health information network in Grand Junction: 1) a history of collaboration between otherwise competing providers in an area, 2) start-up funding and a plan for sustainability, and 3) leaders with vision. "If the CEOs don't get behind it and put their money where their vision is, then it doesn't happen," he says.

 For Further Information: Read a transcript of Gregg Omura's recent testimony before the Medicare Payment Advisory Commission, download his presentation to the Colorado Medical Society, or e-mail him at gomura@pcpgj.com.

References
[1] P.D. Clayton (2005) Obstacles to the Implementation and Acceptance of Electronic Medical Record Systems. In Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington, D.C.: Institute of Medicine.
[2] C. M. Kilo and S. Endsley (2000) As Good As It Could Get: Remaking the Medical Practice. Family Practice Management 7, 48–52.
[3] R. Keets (1998) Pace Yourself! A Step-Wise Approach to Full Clinical Automation. Healthcare Informatics, 15, 103–104, 106–108.
[4] R. Miller (2005) Grantee Spotlight: Entering the Era of Electronic Medical Records. New York: The Commonwealth Fund; R. Miller et al. (2003) Electronic Medical Records: Lessons from Small Physician Practices. Oakland: California HealthCare Foundation; R. H. Miller et al. (2005) The Value Of Electronic Health Records In Solo Or Small Group Practices. Health Affairs 24, 1127-1137.
[5] Centers for Medicare and Medicaid Services (2005) Quality Improvement Roadmap.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.