Children's Minnesota's EHR approach within the hospital campus-based primary care clinics had suffered from years of minor revisions to original workflows and systems that no longer were a model for use.

THE PROBLEM

As part of a larger health system, the ambulatory clinics were added to the EHR piece by piece following implementations within the inpatient setting. As each piece was added (computerized physician order entry, billing and coding, problem list management, and documentation), an overall system came into existence that was not as consistent as staff would have preferred.

"Over the years, parts of the process were refined and updated – dynamic documentation, mPage workflow management and others – but the entire process of ambulatory patient management wasn't cohesively reviewed," said Dr. Chase Shutak, a clinical informaticist and primary care pediatrician at Children's Minnesota.

"These changes and updates improved aspects of our ambulatory EHR but were not universally adopted and actually led to increased variation in practice," he continued. "Experienced clinicians who had worked through years of updates had singular workflows they had cultivated as a result of incomplete adoption of various updates."

The end result of these issues was an ambulatory primary care workflow that did not guide clinicians and other clinic employees through a standard workflow. Metrics across the two clinics demonstrated wide variations in practice with documentation time per patient and after-hours EHR times, ranging from efficient versus national averages to three times the national average.

Nursing intake varied widely between medical assistants and many aspects of nursing forms were either no longer in use or inappropriately left incomplete. Additionally, as a larger health system with community clinics using other EHRs, Children's Minnesota was not modeling best practice for the hospital system's EHR.

"Additionally, our clinics essentially offer three different clinical services," Shutak explained. "One is standard, scheduled primary care – ranging from well checks to chronic disease management to acute care. The second is a walk-in offering for acute care that Children's Minnesota calls 'Ready Care.'

"For care management within applicable visits, 59% of our clinicians demonstrated increased mental health screening compliance and 40% of our clinicians had increased asthma action plan completion."

Dr. Chase Shutak, Children's Minnesota

"The third is an interdisciplinary Complex Care Clinic in which our visits are longer and other team members (pharmacy and care coordination most commonly) are integrated into the visit," he continued. "These three services were all being offered via the same EHR process without clear differentiation. Managing the walk-in 'Ready Care' visits via a system built pre-scheduled patients was particularly difficult."

PROPOSAL

EHR vendor Cerner conducted on- and off-site reviews of Children's Minnesota's EHR and in-clinic workflows. Cerner then presented the health system with a blueprint to model for Pediatric Ambulatory Care. This evaluated the entire care process for the clinic from pre-visit planning to post-visit care coordination and compared processes to Cerner model standard.

"Using the blueprint, Cerner highlighted areas for improvement in our current processes and workflows," Shutak noted. "These areas were broken down into buckets consisting of clinic operations, patient check-in, rooming and intake, provider visit, and between-visit management.

"Before even addressing the technical issues, Cerner stressed the need for process standardization and uniform delivery of care," he added. "Efficient use of the EHR would require standard work in our operations ranging from check-in to clinical evaluation."

Within the technical realm, many different technologies were proposed. In order to standardize processes within different roles, Workflow mPages would be created for the medical assistants (who had previously not used mPages) and three separate Workflow mPages would be created for the clinicians for their three different clinical services (primary care, ready care and complex care).

As well, the intake power-forms and quick orders page would be reviewed and refined to eliminate unused options and simplify their appearance.

"In order to further standardize work, Cerner proposed expanding upon a method for completing all the components of a common visit (such as a well-child check or an acute visit for an upper-respiratory infection) called 'Quick Visits,'" Shutak explained. "This tool was already present but not uniformly used and missing some of the frequent visit issues (like urinary tract infections)."

Expanding upon the Quick Visits was thought likely to increase its adoption.

"In order to better standardize our well-child checks, Cerner proposed creating and implementing a method for better integrating the American Academy of Pediatrics' Bright Futures guidelines into the EHR," he said. "This would replace a homegrown system we had in place that had some known issues.

"Our internally designed system did not retain information – it allowed for efficient documentation but not the creation of a database for panel management or population health purposes," he continued. "Even when applicable, information from one visit could not be carried forward to the next."

As well, the internally designed well-check system required the time of local content experts and IT resources if the AAP updated the Bright Futures guidelines. The proposed Cerner-created and Cerner-managed service would retain discrete data outside of the note created for the visit while also being continually updated by Cerner staff.

"For our walk-in Ready Care, Cerner proposed implementing their LaunchPoint Tracking Board," Shutak explained. "LaunchPoint is a technology purposefully designed for walk-in settings like urgent cares and emergency departments.

"Being built for walk-in services, it would allow for easier check-in and registration as well as more efficient acute-care management," he continued. "Within LaunchPoint's functionality were specific metrics that we had been unable to efficiently measure previously – the most glaring of which were time to provider and duration of visit."

To better manage patient panels and think more concretely about population health management, Cerner proposed a service called Dynamic Worklists. Dynamic Worklists allow ambulatory clinicians to review and manage their patient panels based on specific problems, ages or health maintenance requirements.

"Our prior list creation options were designed around locations and services, which is more easily used in the inpatient rather than outpatient setting," Shutak said. "Dynamic Worklists would allow us to review the patients that are our primary panel for conditions like asthma and whether they had met certain health maintenance conditions – whether that was annual completion of an asthma action plan or annual visit within the clinic.

"Other standardization recommendations included an initial effort at referral management for our local birth-to-three early childhood intervention services (called Help Me Grow in Minnesota) and creation of a between visit mPage workflow for our Message Center management," he added.

The referral process had always been somewhat piecemeal and site-dependent. A deliberate follow-up process for referrals was not established. The creation of the Help Me Grow early childhood intervention referral was intended to be the first step toward standardizing referral management for all services.

The between visit mPage workflow was intended to allow staff to manage patients from within the Message Center (when reviewing lab results or portal messages) more quickly by being able to review a patient's chart from within the Message Center.

Simultaneously, Children's Minnesota was rolling out the portable-device application Cerner offering Powerchart Touch. This would be released as well, allowing for easier between-visit follow-up of results or messages from a physician's phone or tablet.

MARKETPLACE

There is a wide variety of electronic health record vendors on the market today, including Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, Greenway Health, Medicomp Systems, Meditech, Medsphere Systems and NextGen Healthcare.

MEETING THE CHALLENGE

The creation of new mPage workflows and refinement of existing tools (Intake Powerforms, Quick Orders and Quick Visits) were used by both medical assistants and clinicians. This work helped to get both parts of the team collaborating within the same tool and thinking about the EHR in a similar manner.

The refinement of the existing tools helped standardize process and flow by removing unnecessary clutter and guiding along a standard process.

The implementation of the American Academy of Pediatrics' Bright Futures guidelines into Powerforms allowed for better data management and outsourcing of content management to Cerner's team.

Retaining patient answers in discrete data enabled the team to have medical assistants use an auto-text to share the information they collected with the clinician. Rather than having to look through other windows or forms, the clinician was able to see and review the information in real time as it would appear in their completed note.

LaunchPoint fundamentally improved walk-in Ready Care service. By being able to track patients rather than schedule them, registration and check-in by the patient service coordinators at the front desk was made considerably more efficient.

Further, the clinicians were finally able to monitor the status of and implement treatment of multiple patients easily. Other clinicians who may have availability (due to a scheduled patient missing their appointment, a late cancel, or finishing a scheduled appointment quickly) were also now able to review the available patients and sign-up to provide care.

"Dynamic Worklists have allowed our team to more easily manage their patient panels," Shutak noted. "For patients with certain medications (such as SSRIs for mood disorders or stimulants for ADHD), a clinician can now review their panel for a patient who is due for follow-up.

"For our patients with asthma, our asthma care coordinator can now more easily find patients due for care or other annual evaluations while simultaneously sharing her list and work with the rest of the clinical team."

The Between Visit mPage workflow used by the clinicians made message center management of results and portal messages quicker and more straightforward.

"The mobile application Powerchart Touch has significantly changed patient care outside of the clinic," Shutak said. "A result that returns after clinic hours can be checked from a clinician's phone or tablet rather than logging into their computer.

"Note addendums can also be accomplished via the application as well," he added. "While on call, chart review for a patient concern is easier and allows for the on-call physician to leave their laptop at home. One of our physicians has also used it to decrease the need for charting within the room – often dictating into his phone in between patient rooms."

RESULTS

Following the implementation, several notable metrics were achieved.

"There was an 18% reduction in after-hours work and an increase in same-day encounter closure of 12%," Shutak reported. "These two metrics communicate the same story: Charting and documentation were made more efficient from the primary care optimization.

"Given the number of processes we refined, it is difficult to say which single aspect contributed the most to these findings," he continued. "Whether it was a more standardized workflow designed toward our clinical services or a more refined quick orders page or better adoption of quick visits or less clicking to create a note that incorporated the Bright Futures guidelines, they had a cumulative effect on our clinical efficiency."

Ultimately, the clinician team was estimated to save more than 43 hours monthly in time spent within the EHR.

Within the walk-in Ready Care service, time per patient decreased approximately 10% while simultaneously seeing an increase in patient volume. The ability to monitor and track all the patients waiting for care and in the process of receiving care within LaunchPoint enabled the team to better triage and manage the walk-in population.

Rather than thinking through a list of patient charts on a schedule, the LaunchPoint tracking board presented an easily digested and acted upon panel of patients.

"For care management within applicable visits, 59% of our clinicians demonstrated increased mental health screening compliance and 40% of our clinicians had increased asthma action plan completion," Shutak stated. "By refining and standardizing our workflows, we were able to have the team better follow this standard work.

"With the many and variable requirements found within primary care, organizational priorities can often get lost in the accretion of tasks in an EHR," he added. "The systematic restructuring and retraining we underwent helped to clarify current care priorities."

ADVICE FOR OTHERS

"An organization hoping to complete a primary care optimization should prepare to think holistically regarding their entire care process," Shutak advised. "An electronic medical record and other associated technology solutions cannot by themselves overcome lack of standardization, standard work or clearly defined roles.

"An optimization of an organization's EHR needs clinic operations to be optimized in order to be successful," he continued. "Similarly, the importance of technological training and education must be emphasized. Often, optimizing an EHR means undoing bad habits learned from years of practice within an electronic medical record."

The time needed to train and retrain staff is an essential investment in the success of the technology, he added.

"Further, any EHR optimization within the ambulatory setting should consider the importance of mobile applications," he said. "While we should always strive to limit the amount of after-hours work performed, it is an inevitability of physician-call and primary care work that some tasks will happen from home or after the end of the formal workday.

"Given the level of communication expected by patients and patient families, being able to complete tasks like documenting on-call pages or messaging a patient regarding labs from one's phone should be a priority," he continued. "From the clinician's perspective, being able to leave their computers at the office while still feeling confident in one's ability to complete necessary after-hours patient care can be a liberating experience."

For any organization hoping to incorporate a walk-in model into their primary care clinics, having a technology that involves a tracking board should be a top priority, he further advised.

"Having operated within both settings (walk-in patients placed onto a provider's schedule and walk-in patients placed onto a tracking board), we have had foundational improvements in care after adopting a tracking board," he said. "A design maxim is that 'form follows function.'

"The difference between providing walk-in care and scheduled care is vast," he concluded. "Attempting to use the same tool to provide these fundamentally different services is unwise. The electronic medical record you employ within a clinic has to be able to flex between the two services from within a single application."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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