Monday, March 17, 2008

Electronic Health Records for Non-owned Doctors - Creating the Model Office

There are many reasons for implementing electronic health records - enhancing quality, clinical integration, reducing redundant testing, and building workflow efficiency with technologies such as e-Prescribing.

Today, we have 300 closely affiliated non-owned doctors in 150 practices. Although these doctors are not employed by our system, they are part of the Beth Israel Deaconess Physician's Organization (BIDPO) which is a coordinated provider network of nearly 1500 physicians. Among other quality and safety measures, BIDPO focuses its Pay for Performance efforts on advanced diabetes care, appropriate radiology test ordering, and use of e-Prescribing.

Gathering metrics about physician practices requires consistent clinical and process data about the care delivered. This means that all our practices should maintain ICD9 codified problem lists, accurate medication histories, standard-based result reporting, and structured data about lifestyle choices such as smoking behavior. Unless our clinicians have a consistent way to record this data, quality and pay for performance reporting will be impossible since clinicians would implement their own unique ways of recording problems, medications, allergies and notes.

Hence, we're designing the "model office" configuration for eClinicalWorks 8.0, the version of the EMR software we'll be implementing. This means that before our first goal live, we're developing data dictionaries that will be used in all practices. We're loading the decision support rules which will provide identical alerts and reminders to every clinician. We're integrating all the lessons learned from the Massachusetts eHealth Collaborative rollouts to design the idealized configuration of each EMR screen which will ensure the best quality data capture and enhance the likelihood that we can do performance measurement as a clinically integrated community of clinicians.

Part of our model office also includes idealized workflow made possible by interoperability. Each office will have

1. New England Health EDI Network (NEHEN) which provides electronic links to our regional payers for HIPAA transactions including benefits/eligibility, referral/authorization, claim submission, and claim status
2. MA-Share RxGateway for e-Prescribing features such as formulary enforcement, community drug history, and routing to retail/mail order pharmacies.
3. Results interfaces for labs and radiology from local hospitals
4. Ordering of BIDMC-based testing including SafeMed radiology decision support
5. Quality and performance reporting via build in eClinicalWorks 8.0 data query system. Since our model office includes a standard configuration of all data dictionaries and input screens, we'll be able to use a federated approach to performance measurement. Here's how it works.
a. BIDPO has been given the authority to collect performance data by all BIDPO clinicians using eClinicalWorks
b. BIDPO devises a query such as "How many patients in each practice with diabetes have a hemoglobin a1c greater than 7"
c. At night, while the office is closed, the query runs on each clinician's database
d. The aggregate counts (not individual patient identified data) are returned to the medical director for use in pay for performance measurement and medical management

Creating the model office ensures that patients will receive the same quality care wherever they go, that doctors will be empowered with decision support tools, and that we'll be able to measure performance at all our practices as if they were a single integrated entity. We believe the up front work to design the model office will make our use of eClinicalWorks more effective, make training easier, and serve as a foundation for all our interoperability efforts. As we complete the model office designs, I'll post the details.