Paperless: Showing EHR benefits in HIV care
Paperless: Showing EHR benefits in HIV care
Quality assurance easier, more efficient
The federal stimulus package with billions in health care and technology funding will help hospitals nationwide to transform paper-driven processes to electronic health records (EHRs).
A number of hospitals and health systems have already made this transformation, and experts say it hasn't been easy.
"Truthfully, it's a three-to-five year process in a large system with 17 facilities where we're trying to do this work," says Terry Hamilton, director of HIV services for New York City Health and Hospital Corp. (HHC) in New York, NY. HHC has 11 acute care hospitals and six very large community clinics, called diagnostic and treatment centers.
HHC uses electronic software from QuadraMed of Reston, VA, she says.
There are specific screens within the electronic system that were designed for HIV screening and care.
"All of our clinicians are trained on QuadraMed, the basic electronic record," Hamilton says. "In our area of HIV services, we have clinical visit screens."
It wasn't easy to implement the electronic documentation screen, she notes.
"It takes a lot of time and effort on the part of our clinical information systems staff, for example," Hamilton says. "It also took a lot of time and effort on the part of infectious diseases nurses and case management staff to refine what would be in those screens to make them more useful."
Training included small groups and some one-on-one sessions, and there was a test module that could be downloaded and used to help clinicians become familiar with the software.
"We took a very deliberate approach to this," Hamilton says. "No facility went live before there was an extensive amount of training."
Although considerable planning went into developing the screens and questions physicians would ask patients at each visit, this is an ongoing process, she adds.
"Frankly, once you have agreed to a set of documentation, you're always ready to refine it to make it better," Hamilton says. "You need to be ready to grapple with refinements that make these screens even more useful to staff."
Electronic health records often need to be tweaked with screens that are specific to a particular disease state or facility.
"HHC worked with the software company and their information technology (IT) department to build specific screens that would allow the provider to document all the things that were done and to serve as a reminder to the provider," says Judith Aberg, MD, associate professor of medicine at New York University (NYU) and director of virology at Bellevue Hospital Center in New York, NY. Aberg also is the director of AIDS clinical trials unit at NYU School of Medicine.
"As providers fill out [the electronic form] they might say, 'Oh yeah, did I address this issue?'" Aberg explains. "So it's a reminder to the physician, but also clearly documents what has been done."
Electronic documentation provides many quality assurance benefits because it makes it easy to track trends and performance, Aberg and Hamilton say.
For example, one issue that sometimes arises with HIV care is conducting tuberculin skin tests on HIV patients, Aberg notes.
"Physicians have to order it; the patient has to agree to have it done; the nurse has to administer it, and it requires patients to return in 48 to 72 hours to have it read," Aberg explains. "So we did a project to look at, one, were providers offering it; two, were patients accepting it; three, were nurses documenting it was done, and, four, were patients coming back?"
The electronic data showed there was a good rate of tuberculin skin tests being offered and accepted, but not such a good rate of patients returning, Aberg says.
"On the electronic health record we could see that almost 50% of patients weren't returning to have the tuberculin skin test read, or it was not being documented," Aberg says.
"Some of this had to do with the day of the week they were doing the skin test," she adds. "If you administer it on a Thursday, you don't have anyone who can read it until Monday, which is five days out when ideally you want it read in two to three days."
So armed with this information, HIV clinicians decided Thursdays were not the best days to do tuberculin skin tests, and the practice was changed.
Physicians follow the electronic screen prompters on offering the test, and they also provide more education to patients about what the procedure entails and why it needs to be done, Aberg says.
"Our rates have gone up with patients coming back," she adds.
One key to the electronic health record's successful implementation was obtaining physician buy-in initially.
Physicians were among the leaders who helped to develop specific screens for electronic documentation and clinical care.
"What the physicians agreed to was a relatively comprehensive approach, and within that certain fields were made mandatory," Hamilton says. "That includes treatment, physician, and billing-related services and, selectively, various aspects of the comprehensive record could be addressed within a facility."
So if a particular facility wanted to provide more in-depth patient education on a particular topic, they could modify the electronic program to do so, Hamilton says.
"Or if you're doing something in treatment adherence, there might be additional fields at your discretion that you may use," she adds.
For example, mental health screening is generally a part of a comprehensive mental examination, and some parts of this screen are mandatory, Hamilton explains.
"But at one of our hospitals they wanted to do an extensive screen on mental health assessment, so they made all these fields mandatory," she adds. "Some facilities have used it to look at patient adherence and to look at clinical outcomes, and other facilities have used it to examine more closely their HIV testing program."
HIV clinicians needed some time to adjust to the change in how they documented patient visits, particularly since they now were using computers in patient examination rooms and typing in notes as they met with patients, Aberg notes.
"A lot of us felt it was really imposing on the visit because you were sitting there typing," she explains. "But before we were jotting down notes either on formal charts or paper, or we'd make little notes and later do dictation of more formal notes."
The electronic documentation made the entire process more efficient.
"What I do on a first visit is inform the patient that we have an electronic medical record," Aberg says.
Then Aberg purposely lets the patient see the screen as she asks about the patient's weight loss or gain and goes down the list of questions.
"In many private practices what providers do is use sheets on a clipboard and have patients fill out that information and then hand it to someone," Aberg says. "This is a similar process, but you're doing it with the patient."
Patients have grown used to the computers, and they aren't an issue, she adds.
From physicians' perspective, another benefit is that the screen serves as a reminder about questions that might be overlooked.
The screen will prompt the physician to ask if the patient smokes, and if the answer is "yes," then the screen asks if the patient would consider smoking cessation classes or assistance with stopping.
"Another mandated screen is about domestic violence," Aberg says. "At every visit, you must ask about domestic violence and safety."
If the physician documents that there is a problem with domestic violence and safety, then the screen asks the physician what he or she is doing about it, and the physician has to type in that a call was made to protective services or that the patient was referred to mental health services or a counselor, she adds.
The federal stimulus package with billions in health care and technology funding will help hospitals nationwide to transform paper-driven processes to electronic health records (EHRs).Subscribe Now for Access
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