Tuesday, April 1, 2008

Electronic Health Records for Non-Owned Doctors - Implementation Order

This is the ninth entry in my series about providing electronic health records for non-owned clinicians. We'll call this one "triaging the practices". Since we have 300 non-owned clinicians who need electronic health records, where do we begin? If new clinicians join the Beth Israel Deaconess Physician's Organization during our rollout, how do their practices fit into the rollout?

We need specific triage rules to decide on the order of implementation.

In a for profit business, some metric like referral volume might be used, but in the non-profit healthcare world, such an approach would be a violation of Stark anti-kickback rules.

In our case, we want to ensure the highest quality care, coordinated through the use of interoperable electronic records. We want to ensure decision support is enabled for those who needed it most. We want to invest our effort into those practices which require the most clinical integration with the hospital to ensure high performance medicine. Based on a quality/safety approach, a rational implementation order would be:

1. Primary Care Physicians are the first priority - PCPs see a high volume of patients and are the "air traffic controllers" for care, ensuring coordination among all the clinicians a patient sees. An EHR enables an accurate problem list, an up to date medication list and alerts/reminders for wellness care. We want every patient's PCP to have the benefits for an EHR. Yes, we know that the first few months of using an EHR will impact a PCPs productivity, but our experience with other EHR implementations is that with appropriate training and a "model office" configuration, productivity rapidly returns to baseline.

2. Specialists who serve as a kind of primary care giver, managing diseases such as congestive heart failure, cancer and diabetes are also a priority to be early EHR users. Tracking diabetes care requires data coordination among endocrinologists, Ophthalmologists, and Vascular surgeons. Ob/Gyns are primary care givers. Chronic diseases such as COPD and CHF require coordination among pulmonologists, cardiologists and PCPs. Specialties that require significant care coordination with primary care givers or deliver primary care themselves include Cardiology, Ophthalmology, OB/GYN, Dermatology, Orthopaedics, Urology, Gastroenterology, Surgery, Pulmonary, Neurology, Endocrinology, Vascular, and Rheumatology.

3. As we are rolling out EHRs to these PCPs and specialists, it's likely that new clinicians will become affiliated with BIDMC. As we plan our rollout calendar, we will need to stay flexible so that new PCPs get priority and the specialists who most benefit from care coordination are placed ahead in the queue.

This approach to triage ensures that patients and providers get the maximal benefit from our efforts as we rollout 6 practices per month starting this Summer. We may need to refine our rules even further as we learn more from our rollouts:

* PCPs with a closer geographical location to BIDMC/a local hospital go first, since they have the most data interoperability needs. * Clinicians near retirement may choose not to be early adopters and may want to stay on paper.
* Some practices may more easily adapt to new technology than others and should go sooner

Over the next few months, the hospital and the physician organization will finalize the triage rules based on quality, safety and data sharing benefits, so it is very clear that we are Stark compliant and can easily explain to every non-owned physician when their EHR will be implemented based on objective criteria. I'll let you know how it goes!