Clinica's Electronic Health Record System

Paper charts are history at Clinica. All of our clinicians now work in a completely electronic environment. Whether they want to schedule a follow-up appointment, look at a patient's history, review a list of current medications, order lab tests or write a prescription, our providers manage patient information using our electronic health record system (EHR).

Our desire to implement an EHR began with the realization that many clinicians in the southeastern part of Boulder County - including Clinica's providers - were caring for the same patients. A group of physicians began looking for a way to integrate and improve the quality of their ambulatory care services. They knew that as these patients moved from doctor to doctor, they were asked the same questions. They knew that, in some cases, tests were repeated because doctors didn't always share what they had learned about a patient's condition. By creating a comprehensive, electronic patient chart, physicians could easily access and share patient data, demographics, referrals, medications, allergies, diagnosis, procedures, alerts, and laboratory and radiology reports through a secure internet portal. This would mean fewer errors, fewer adverse medication interactions, and fewer opportunities for losing data.

Along with Avista Adventist Hospital - the hospital where our doctors admit most of their patients - Clinica and about 120 private practice physicians in southeastern Boulder County purchased an EHR package called NextGen Healthcare Information Systems. The EHR has created a community-based interface for ambulatory care. NextGen also interfaces completely with Meditech, the software used at Avista, so that no information is lost when patients receive in-hospital care. Now, if a diabetic Clinica patient goes to the Avista emergency department, doctors there will have immediate access to the person's medical chart, will know what medications he is taking and when he last saw his primary care physician. Similarly, if our clinicians need to refer a patient to a specialist in the NextGen group, they will be able to send an access code for the patient's chart. The specialist will be able to read the chart and add information from a consult into the record. That replaces the need for physicians to write a detailed patient summary, fill out referral forms and wait for the specialist's report to show up on the fax machine.

Clinica's EHR is compliant with all HIPAA standards. It is protected behind multiple firewalls and layers of state-of-the-art technology security.

Using the EHR in the Clinic

Each of our providers and medical assistants has a Lenovo Tablet instead of a personal computer. The tablets allow staff to type, write with a stylus pen or point-and-click to fill out forms. When the medical assistant brings a patient back for an appointment, he takes a set of vital signs, enters them into the EHR, and the provider has access to the information instantly. In the exam room, the provider takes the tablet into the exam room and uses it to store notes just as she would a paper chart. All lab work is ordered on the EHR, and all results come back to the provider's electronic mailbox in the EHR. Once the provider has checked the results of the labs, they are moved automatically into the patient's file. Via the tablet, providers can also use the EHR to order prescriptions, which are automatically faxed to any of a variety of pharmacies available in a drop-down list (including Clinica's own pharmacy).

Condition-specific templates help providers document patient care. These templates have prompts to help clinicians chart thoroughly and quickly, leaving more time to spend with the patient. These templates also streamline the process of coding each patient encounter.

Each of our facilities is equipped with a wireless network so that the tablets can be used anywhere in the clinic and can efficiently move with a provider from the lab to the exam room and back to the clinician's desk.

Using the EHR to Improve Care

For us, the most promising aspect of an EHR is the possibility that it can help us keep patients well. It can do this by gathering information collected during an individual doctor/patient visit and making it available to a broader health care community through the registries mentioned above. A recent study published in Health Affairs showed that while EHRs do little to increase revenue for community health centers because their patients are either on Medicaid or are uninsured, "most CHCs also launched EHR-enabled [quality improvement] changes that likely generated sizable QI gains. ...EHRs in CHCs were a clear value to patient and payer stakeholders, since patients received better care, and payers likely reaped some EHR-related downstream benefits in avoided specialist, emergency room and hospital spending - at no added cost to them."

That is exactly what we wanted to see from our EHR. While it functioned well as a data-collection system when we purchased it, NextGen lacked many of the quality-improvement components that physicians in our service area wanted. So we developed them ourselves. Centura Health, Avista's parent company, provided Clinica with the funding to develop the condition-specific templates that we use for population-based management of chronic diseases. Integrated Physician Network (iPN) provided the expertise for building the templates and getting all the participants linked together. To date, we have created population-based care templates for asthma, diabetes, depression, ADHD, chronic pain, abnormal PAPs, anticoagulation patients, tobacco use, and prenatal patients.

We use these templates to develop registries to care for patients in our clinics and to provide better care to the community as a whole. In a HIPAA-compliant manner, all the doctors using the EHR can compare their patient outcomes against those of other physicians. What are the blood sugar levels of Dr. Jones' patients? Why are they so much lower than those of Dr. Thompson's patients? What health care methods work best? What can we learn from each other? It allows us to practice community-based health care with a statistically significant patient pool.

Another quality-improvement component of the EHR is its flagging or reminder capabilities. If a diabetic patient is overdue for her annual retinal exam, a pop-up message will appear when the clinician opens the chart. These evidence-based reminders provide constant decision-making support. Each of our clinicians has more than 1,500 patients; these reminders help them assure that patients receive the recommended screenings.

Finally, EHRs will make it infinitely easier for medical practices to act on equipment recalls or pharmacy alerts. Medication recalls place a huge burden on physician offices when they need to quickly contact patients. For instance, Zelnorm was recently taken off the market after studies suggested a slight increase of cardiovascular disease associated with the medication. After the recall was issued, we were able to identify in a matter of minutes 92 patients in our user network who were taking the medication. With paper medical records, this would have been almost impossible.