Kentucky is one of eight states where the adoption rate of electronic health records by office-based providers is under 30 percent, according to a 2012 report by the Office of the National Coordinator for Health Information Technology (ONC). Not that the nation as a whole is doing much better – the same survey indicates barely a handful of states have a rate of EHR adoption over 50 percent.
Hospital adoption rates are slightly better. The ONC’s most recent survey indicates about 40 percent of Kentucky’s hospitals have made the transition to some kind of electronic health records. Those figures, however, are from a 2012 survey and, according to Dr. Carol Steltenkamp, chief medical information officer for University of Kentucky Healthcare and director of the Kentucky Regional Extension Center (Kentucky REC), paint a slightly distorted picture of state healthcare providers and resistance to adoption.
It’s a safe bet, she said, that adoption rates in Kentucky are much improved over the ONC’s 2012 surveys. EHR adoption in Kentucky is not only progressing, Steltenkamp said, but commonwealth hospitals and office-based practices are making the transition to EHR at an accelerating rate.
“Providers that have made the transition to an EHR have discovered how these systems improve patient care and office efficiency,” she said. “With few exceptions, once they go ‘live’ with an EHR, our clients often give us very positive feedback about how their system reduced charting errors, enabled more accurate and efficient billing for services, and streamlined their work flow in a way that they realized made sense.”
From a big picture perspective, the national transition to an electronic health record of some type is inevitable. There are too many benefits associated with electronic health records not to be proactive in making that change, Steltenkamp said. But the scale for such a transition is massive, and it will take years of careful coordination to realize. However, resistance to implementing an EHR system has more to do with concerns over costs than fear of change.
To help the nation’s clinics and medical centers make that transition by the January 2015 deadline set by the federal government, the ONC introduced two very significant programs. Steltenkamp attributes an improvement in Kentucky’s general progress toward EHR adoption to these programs and other factors. The first program is an incentive that reimburses some hospitals and medical clinics for their investment in a certified EHR system. The reimbursement comes either through Medicare or Medicaid.
The other program awarded grants for the creation of regional extension centers.
Kentucky REC program
Steltenkamp said she is generally skeptical of the efficiency of most federal programs. But in the national effort to encourage the wholesale adoption of electronic health records, she feels the federal government has done something right with the regional extension centers (REC) program.
Kentucky REC, based in Lexington, is one of 64 RECs throughout the United States that received grant funding. Another REC, Cincinnati-based Healthbridge, also serves Kentucky clients. The general mission of an REC is to assist hospitals and office-based medical practices in the adoption of an electronic health record system.
“They organized these national REC’s based on the agriculture extension model and it has functioned very well. We have our central office on Huguenard Lane near the Regency Center in Lexington. But we also have satellite offices that enable us to serve office-based practices and hospitals across the state,” Steltenkamp said.
In the last three years the Kentucky REC has overachieved.
The Kentucky REC has assisted or is in the process of assisting more than 2,000 medical clinics and hospitals in their effort to adopt a system, according to a recent ONC survey. The program has received awards and special recognition for exceeding its primary outreach goals of helping providers start the process of acquiring an electronic health records system; “going live” with a system; and achieving “meaningful use.”
“Depending on where an organization is in this process, Kentucky REC can get them to achieving meaningful use. We also advise our clients on changing work flows, best practices, and the best direction to go in order to capitalize on the federal incentive program,” Steltenkamp said.
One of the most interesting facets of implementing an EHR system is observing the change in attitude among administrative and clinical staff as their system goes “live.”
A classic case in point is the experience of VIP Pediatric Associates in Hopkinsville.
Michelle Steil, office manager for the clinic, said the reimbursement incentive program was a key motivating factor that finally pushed the partners toward an EHR system. Despite the leadership’s decision, though, Steil was prepared to face resistance.
“We were starting from ground zero. Our patient charts were all paper. Our operations did not involve much computer software, and we were going to replace that system completely with an EHR,” Steil said. “Our doctors and providers hated the idea. They really didn’t want to do it. But we knew we would have to eventually.”
VIP Pediatrics had already bought a system and acquired equipment when it reached out to Bethany Jones, a senior implementation specialist with the Kentucky REC whose specialty is working with office-based clinics. Jones assisted with training, arranged for clinical staff to participate in seminars and provided other informational programs that alleviated much of the staff’s anxiety.
“We did a study to determine the incentive program (Medicare or Medicaid) that would benefit them most. We also provided individual seminars and helped establish connections between their software and the Kentucky Health Information Exchange,” Jones said.
The office went live with its system in stages, beginning with billing and accounting systems, then progressing to scheduling and transfer of existing records. Charting and clinical programs, which directly involved the providers, was the last step in process.
Once committed to making the transition, resistance melted away and VIP Pediatrics’ providers began realizing just how effective and easy it was to input and access information. VIP Peds made some changes in the organization of its work stations and patient flow because of the system interface, but soon initial resistance became enthusiastic support.
“Kentucky REC helped us implement the program and guided us on what our system could do. They have been a valued partner ever since,” Steil said. The next challenge is for VIP Pediatrics’ EHR system to share patient-care data with the local hospital where it orders most of its tests and admits patients.
Dr. Stephen Besson, a partner with Licking Valley Internal Medicine and Pediatrics, has medical offices in Harrison and Nicholas counties. Licking Valley’s clinics made the transition to an EHR system in 2006 but its was a decision of practicality. The two clinics often served the same patients, and before EHR staff wasted paper and toner faxing specific files or transporting bulky patient files back and forth to each office.
“With our EHR, we rarely use paper anymore. Wherever I am, I can easily access patient histories and records for the last six years,” Besson said, adding that he can’t conceive of working without an EHR anymore. “One of the best things about the system is the ability to make e-prescriptions. That feature is just fantastic. I have always hated writing out scrips, and this system makes it so easy. There are no callbacks for clarification. It’s just done.”
Because of his experience with EHRs, Besson has been able to lead his practice to the next level. He became one of the team leaders handling Harrison Memorial Hospital’s transition to an integrated EHR. Now almost all of the hospital’s outpatient procedures are linked up with its medical staff’s offices throughout Cynthiana so that information is never entered more than once.
“In terms of EHR, Harrison Memorial Hospital is among the most advanced in the state,” Besson said. The hospital is one of the very few in Kentucky to have achieved Health Information Management Service Level 6 certification, he said. All service lines at the hospital are now electronic and are mostly integrated with the medical offices in Harrison County.
Meaningful use and future directions
Working with Harrison Memorial has made Besson as enthusiastic a proponent of EHR system integration as Steltenkamp and the Kentucky REC. Between his two offices and the hospital, Besson has access to a robust information source that covers the entire perspective of care.
He has been fortunate also that his electronic health records provider has been proactive to keep its system compliant with federal certification standards. However, Besson differs somewhat in his definition of meaningful use compared to that of the ONC.
“As a practicing physician, what I consider to be meaningful use is a bit different from the federal definition. A lot of data that EHRs are being asked to gather is important to researchers, but it’s not that meaningful for patient-provider interaction on a given day,” he said.
Bessson’s observation is a common criticism but at this point in the development of EHR technology, Steltenkamp said, the objectives of accomplishing the goals of this first stage of meaningful use standards is geared simply toward clinics and hospitals capturing and sharing data. Such a goal is achievable on a local, state and national level, she said.
The current state of the system, as it functions for his medical clinics, Besson said, works well within the narrow framework of data sharing between his clinics and the local hospital. If one of his patients decides to get hospital care from a tertiary hospital outside of his system, “I’m stuck back in my old mode of waiting for a fax,” Besson said. “Greater sharing of information across multiple platforms is becoming more and more of an issue. There is yet to be a realistic region-to-region integration of care [through EHR] that goes beyond diagnosis codes or visit dates,” he said, acknowledging one of the goals of meaningful use.
Further demonstrating the significance of EHR meaningful use standards, Steltenkamp related the results of a project the Kentucky REC conducted in partnership with the Kentucky Cancer Registry, the Centers for Disease Control (CDC) and a dermatologist’s office in Paducah that was an REC client.
Implementation specialists helped align the dermatologist’s EHR system to share cancer-related data with the registry and CDC. When the dermatologist entered information on a melanoma diagnosis, pertinent data was received simultaneously, which is a classic example of the greater goals of meaningful use standards, Steltenkamp said. Only the pertinent data was shared between the parties; there were no unnecessary details nor did it violate patient confidentiality.
“The record was entered once, the data was shared and the potential for errors from having to enter information multiple times was reduced. Over a brief period of time, it is possible for information specialists and health researchers to use integrated EHR systems to track health data and trends,” she said.
Ultimately that information can be used to improve public health.
However, Steltenkamp and Besson agree there is room for improvement.
While EHRs have improved the efficiency of his private practice, Besson said, there is one way in which paper records are still superior to the standard electronic health records. Medical imaging and lab test results all have unique presentations, but most EHR systems have yet to present patient information that incorporates formats specific to the test results of a particular procedure.
“The paper medical record is cumbersome and inconvenient, but it contains information in its proper context. In addition to the next stages of meaningful use – however the ONC wants to define it – the next challenge of EHR companies is to develop a product that presents information that is clearly visible and interpretable in a digital setting,” Besson said.
Another sticking point is cost.
While the incentive programs have done a lot to alleviate costs, there is no indication EHR systems are any cheaper now than they were in 2006. If free market forces are allowed to work, Besson believes costs for EHR system maintenance and upgrades will be very affordable.
“That’s the way the market works. As long as competition among system developers is allowed to flourish, a company will develop a quality, low-cost system. Their competitors will be forced to lower their costs to stay in the market,” Besson said.
At this late date, hundreds of Kentucky practices are making the same jump that VIP Pediatrics and Licking Valley have made. Fortunately, those clinics and hospitals still hesitant about investing in an EHR system have an excellent partner and resource in the Kentucky REC.
“Kentucky REC’s services are available to any office-based practice, multi-specialty clinic or hospital system. You don’t have to be a primary care provider anymore to take advantage of Kentucky REC’s services,” Steltenkamp said.
The time to make the transition, however, is now. By 2015, the incentive program designed to move practitioners forward will be replaced by Medicare and Medicaid penalties. Of those who have gone ahead and made a careful investment in electronic health records, few have regretted it and many have come to embrace the change.
Josh Shepherd is a correspondent for The Lane Report. He can be reached at [email protected]