Rural Physician EHR Adoption: a report from the trenches

1. Rural Physician EHR Adoption: a report from the trenches Kim J. Horowitz, MD Agency for Healthcare Research and Quality September 26, 2007

2. Goals for Today • Who we are • What did it take to get “us” to do this? • What were the barriers along the way? • Where we are today • What I’d like you to know

3. In the beginning….. Agency for Healthcare Research and Quality funded initiatives • October, 2004 – 1 year planning • October, 2005 – 3 year Implementation grant Purpose is to “promote the use of health information technology (health IT) to”….. “Increase our knowledge and understanding of the clinical, safety, quality, financial, and organizational value and benefits of health IT”.

4. Rural Medical Service Study Areas Frontier – less than 7 persons per square mile Rural – less than 250 persons per square mile Non-Rural 80% of land mass 14% (and growing) of population live in rural California 4.9 million residents Source: 2000 census data

6. Status of IT in the Region - 2005 • Approximately 17 primary care physicians and 7 midlevels in 17 sites in 4 towns • Various stages of IT adoptions • Some with no computerized practice management systems • Some without internet access • No customized databases • One with an EHR • No data exchange occurring • System not being used for reporting • Hospital with multiple systems at different levels of functionality and not interfaced

7. Before….no infrastructure to facilitate information technology, quality or disease management Hospital and RHCs Providers Negotiation leverage Return on Investment Presence of consistent and coordinated community oriented approach ??? X X X X X X X Workforce Development Evidence Based Medicine Acquisition and Dissemination of information technology Continuing Education Practice Management Support Research Community Based Quality Improvement Programs and Monitoring

8. Smith, Joe 123 Main St. Anytown, USA Tw2-5053 DOB 12.1.17 Date Dx Tx Date Dx Tx 6.3.52 FXR wrist cast 12.21.68 MVA ASA, letter to Atty 7.12.58 Luies PCN 3.24.62 Tonsilectomy 9.21.66 Obesity Dex Inj 10.15.68 CHF Digitalis

14. Tehachapi Hospital

15. 98.7% outward migration for inpatient care

16. What did it take to get “us” to do this?

17. Inertia “The tendency of an object to continue in motion at the same speed and in the same direction, unless acted upon by force”.

18. I’m not a magician Spock, just an old country doctor

19. Key Informant Interviews • Key informant interviews • Listening and maintaining confidentiality • Identifying a Common Passion and Vision to Save our Hospital • Opportunity to improve Physician-Hospital and Physician-Physician Relations

20. Perceptions of the ability to“Remove ALL Barriers” Dollar Cost Issues Time Cost Issues Personal Skill Set Inequality Issues Issues of Culture Change

21. Breaking down the Barriers

22. Dollar Cost Issues • Dollar Cost Issues • What will it cost me? • Hardware and software expense • Time lost from practice • Re-tasking of employees • New, recurring expensives (ie support, connectivity, upgrades, maintenance)

23. Time Cost Issues Will I lose even more family time? Training time System Personalization

24. Personal Skill Set Inequality Issues • Computer literacy • Physical limitations

25. Challenges with Vendors

26. It’s A lot of Work!!!!!

27. Interfacing X $25,000 $3,000 $ 500

28. Vocabulary Test • CCR • Granular • Domain • Network • Secure • HL7 • Use Case

29. CCR Creedence Clearwater Revival OR Continuity Care Record

30. Granular?

31. Domain?

33. Real-a-noia

34. Issues of Culture Change • Fear • Local politics • Control issues • Deep scars • Hunkered down community

35. Changing the Culture Happy! LAPTOPS

36. Workflow Analysis LAPTOP

37. So…Where are we today?

38. Before….no infrastructure to facilitate information technology, quality or disease management Hospital and RHCs Providers Negotiation leverage Return on Investment Presence of consistent and coordinated community oriented approach ??? X X X X X X X Workforce Development Evidence Based Medicine Acquisition and Dissemination of information technology Continuing Education Practice Management Support Research Community Based Quality Improvement Programs and Monitoring

39. Building infrastructure to address the quality chasm in Rural Communities Provider leadership team Governance EAST KERN COUNTY INTEGRATED TECHNOLOGY ASSOCIATION “EKCITA” (a 501(c)3 public benefit corporation) Providers in SE Kern Hospital and RHCs Consistent, Coordinated, Integrated, Community Approach to Health Workforce Development Evidence Based Medicine Acquisition and Dissemination of information technology Continuing Education Practice Management Support Research Community Based Quality Improvement Programs and Monitoring

40. Scope of our Project • Infrastructure • Telemedicine • EHRs and CHIE • PHRs • Diabetes Education • Health professions training

41. What I’d like you to know • There is so much more to report, and….

42. Need for custom solutions • HIE implementation is NOT a One Size Fits All • Plan for individualization that allows maximum participation opportunities in order to capture key data points • ie Full EHR vs. Scantron + Fax • ie Kiosks, Browser/Clinical messaging

43. Additional Challenges • Insurance • Legal support is IMPERATIVE but expensive and time consuming • HIE via Grant Dollars • sustainability model? • or “Helicopter Research” • Teach them to fish or leave no trace

44. What results in physician buy-in • Relevance • How does EHR implementation help my patients or my practice or my community? • Is the data collection/time effort/culture change worth it? • Fear Resolution • Big Brother • Unethical competitive Practices (data stealing) • Security assurances (HIPAA, System Failure) • Unobtrusive Paced Implementation of EHR • Cost Mitigation

45. Who’s Your Buddy?!! Funder? Academia? Community? With whom have you built rapport?