A study evaluates information technology in community health center laboratory processes and offers valuable lessons.
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| Juliet Yonek |
Despite widespread agreement about the necessity of electronic health records, health care organizations have been slow to put EHRs to use, especially in ambulatory settings. In a national survey of 725 federally funded community health centers, Alexandra Shields, Ph.D., of Massachusetts General Hospital and her colleagues found that only 26 percent had either full or partial EHR capacity; an additional 13 percent had the minimum set of functions. Many of the centers that serve the most disadvantaged patients had no functional EHR system.
An EHR that can be used for safety and quality initiatives is able to transform the way care is delivered. EHRs can facilitate culturally appropriate care (by flagging that a patient may need an interpreter, for example); coordinate care by making available relevant data (such as medications, preventive services and screenings); identify opportunities for improvement across entire populations; and eventually produce data to inform national quality and safety initiatives.
To fully realize this potential, EHRs must be implemented with these goals in mind. Elements of health information technology that support quality improvement and patient safety include:
Most commercial products are not capable of performing some of these functions, particularly decision support and performance measurement. To develop these functions, health care organizations must invest significant time and resources. A detailed implementation plan and infrastructure that allows ongoing evaluation and staff support are necessary to ensure the best use of such functions following implementation.
As an example of improved care delivery, the Alliance of Chicago Community Health Services—a network of federally qualified community health centers (CHCs) formed in 2002—held a shared vision of EHR implementation. The EHR used by the Alliance CHCs integrates evidence-based practice recommendations into the end-user interface to provide decision support and to facilitate comparison against national measures. Initial clinical decision support was designed for clinical performance measures of diabetes, cardiovascular disease, asthma, depression, HIV and preventive care. The EHR was implemented to improve the quality, safety and equity of care delivered to the underserved, vulnerable populations at the health centers.
The Health Research & Educational Trust partnered with Alliance and researchers from Northwestern University, Ohio State University and the University of Maryland to assess the impact of using an EHR for laboratory ordering and disease management at two Alliance CHCs. The project was funded by the Agency for Healthcare Research and Quality.
Howard Brown Health Center and Heartland Health Outreach are two of the four founding members of Alliance. Howard Brown is the Midwest's premier lesbian, gay, bisexual and transgender health organization, leading the region in addressing the comprehensive health care needs of people in the LGBT community. Heartland Health Outreach provides primary health care, mental health and addiction services, and oral health care to homeless, immigrant, refugee, HIV-positive and working poor populations at several sites throughout Chicago.
Howard Brown and Heartland went live with Alliance's centrally hosted EHR in October and December 2006, respectively. Each center has multiple clinical sites and selected its largest site to "go live" first, then rolled out the EHR to the remaining sites throughout 2007. Howard Brown and Heartland went live with the full slate of Alliance EHR features.
In 2008 HRET and its collaborators evaluated how the Howard Brown and Heartland EHRs facilitate lab ordering and results communication in treating HIV and in screening for cervical cancer. Interviews were conducted with 27 staff members at both centers. Interviewees included eight clinicians as well as IT personnel, administrators, lab supervisors and technicians, nurses, and medical assistants.
Electronic laboratory ordering. Clinicians reported that the EHR has made the lab ordering process more efficient. Clinicians click on the test they want to order and the request is sent electronically to the lab—a process that takes less time than searching for and filling out a paper requisition. For HIV, customized test panels are also considered helpful because they let clinicians order multiple labs with a single click.
Laboratory staff, in contrast, reported that the EHR has had little impact on their efficiency in ordering tests. Although clinicians place orders electronically, the lab receives the information on paper printouts. Lab staff then must manually enter the order into the reference lab's system. In addition, electronic ordering does not prevent clinicians from placing orders with missing information or inaccurate diagnosis codes. If these errors occur, lab staff must search the record or contact the clinician.
Electronic results retrieval and viewing. Test results are sent electronically from the reference lab to the EHR, specifically to the ordering clinician's desktop. Once the clinician signs off, the results automatically appear in the patient record. All of the staff interviewed agreed that this process has notably improved access to test results. Physicians reported that having electronic access to test results helps in communicating with patients, especially when it comes to treatment.
There have been ongoing challenges with certain tests such as Pap smears. Results generally fail to show up in the EHR if the information received from the reference laboratory is formatted differently than in the EHR. Because orders are entered manually, the potential for formatting errors is fairly high. There is no system alert that warns when results fail to show up in the EHR, so clinicians may not notice a result is missing until the next patient visit. To resolve this problem, Alliance plans to replace its current laboratory interface with one that is bidirectional, so both orders and results can be transmitted electronically.
Laboratory-based decision support for chronic disease management. Many clinicians interviewed felt that the clinical decision support for ordering HIV tests and cervical cancer screening was ineffective. The primary reason is that lab results do not consistently show up in the system's decision support tools, such as disease management forms, which in turn render protocol-driven prompts for testing inaccurate. Consequently, clinicians ignore the prompts. Still, clinicians recognize the value of having clinical decision support in the EHR; they commented that the reminders for laboratory ordering are useful when they are accurate.
Lessons from the Alliance evaluation provide general lessons on the impact of EHRs in ambulatory settings, particularly for laboratory ordering and disease management:
Successfully implementing an EHR that improves delivery and quality of care calls for significant capital resources and technical expertise. It also requires ongoing evaluation and staff support to ensure the best use of advanced features such as clinical decision support for laboratory ordering and chronic disease management.
Juliet Yonek, M.P.H., is a senior researcher at Health Research & Educational Trust.
This article 1st appeared on December 14, 2009 in HHN Magazine online site.
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