The Patient Centered EHR. How do you like your EHR? How did we get here? What s wrong? Is this fixable? 9/2/2015

Evidence-based practice in using the EHR to engage patients and improve the patient/clinician care experience

September 10, 2015 AHEC Statewide Conference

Steven Crane, MD Cathy Nielson, MPH

The Patient Centered EHR

How do you like your EHR?

Increasingly the EHR is seen by clinicians as a burden, and not a tool. Many patients are uncertain why or how to use the EHR.

What’s wrong?

How did we get here?

Traditional Paper Record Traditional Paper RecordTraditional Paper Record

Traditional Paper Record Current Electronic Health RecordCurrent Electronic Health RecordCurrent Electronic Health RecordCurrent Electronic Health Record

SUMMARY of a patient’s encounter with the practitioner

Medical/legal documentation

COMPLETE documentation of EVERY element of the patient’s encounter with the medical system.

Basis for coding/billing Quality reports Population management Incentive payments

Nobody really wants to go back to this. . .

There has to be a better way.

If we’re the hamster, our patients are the wheel

If is doesn’t feel good to us, how does it feel to our patients?

Patient Centered EHR Project

Funded by NC AHEC

3 stage quality improvement project based on these assumptions:

positive & effective models of shared EHR use exist;

best practice guidelines can be derived from those models;

clinicians and patients can be educated to be proactive users of the EHR;

widespread implementation of the shared use model can lead to measurable improvement in patent/clinician satisfaction & patient engagement.

3 Phases

Phase 1: Best Practice Guidelines

Phase 2: Multi-media Products & Curriculum

Phase 3: Pilot Testing

What we did

Literature review

Direct Observation

Structured Interviews

Focus Group

Patient Centered – Human Centered Design

What we read

Physicians PhysiciansPhysicians

Physicians PatientsPatientsPatientsPatients

Physicians are less enthused about the EHR for their own use, and as an engagement tool.

Physician encouragement is a key factor in promoting use by patients.

Physicians who share the EHR with patients report improved satisfaction and engagement

Most patients are enthusiastic about having access to their record (77-99%)

Very few actually do (3-9%)

Most patients think the EHR can improve their care (75%)

Most don’t mind having the EHR in the exam room (80%)

EHR Myths Dispelled

Older patients or low-socioeconomic patients won’t/can’t use a portal.

If patients have open communication with their PCPs they will abuse it.

Engaging patients through the EHR is just “one more thing” PCPs/staff need to do.

What we heard - Students told us…

With the EHR

it’s harder to connect with patients;

the notes aren't helpful;

the templates control what is documented;

clinical reasoning is limited.

What we observed

Physicians Physicians Physicians

Physicians _{PatientsPatientsPatientsPatients}

Highly valued by patients for their medical expertise, time spent listening, and the relationship that spanned visits.

Frustration as they struggle to incorporate the EHR into their practice

Efficiency/productivity

Autonomy

Practicing “good medicine”

Patients consistently positive about the shared EHR during the visit.

Appreciated functional aspects:

Prescription refills

Access to health information across the continuum

Patient education information

What we learned

First Order Change:

simple steps that can improve the

patient experience today

Second Order Change:

rethinking the care model to address

cost effectiveness for the practice

quality of work and life for the physician

quality of care/outcome for the patient

What we learned

A few simple things can make for a better care experience

The 10 Tips

1. Take a quick look at the EHR before entering the room.

2.

4. Place the computer so that it isn’t a barrier. 5. Own and use the whole exam room with the patient

What we learned

6. It’s OK to type—ask permission, tell the patient what you’re doing, stop and pay attention.

7. Silence is fine when you are thinking & typing. 8. There’s no role for the computer in the physical exam. 9. After the exam – record your findings – again, silence is OK. 10. Recommendations & treatment plan – this is the time for typing & talking - sharing, explaining, educating, reinforcing .

Remember to ask about the Extra Credit Tip!

Adapting the EHR for Learners

Students:

Consider read-only access

Student notes created in Word; scanned into chart. Residents:

Patient centered EHR practice as part of orientation

Direct observation; video precepting, in-room precepting; master class

First Order Change is Simple Change

Put the tips into practice.

Find out who is using the EHR well.

Time to complete a note per RVU

Performance on quality measures

Quality of the note

Empathy and patient connectedness

Watch to see how they do it.

Make the “Switch”

Second Order Change:

A new care model

Here’s the extra credit tip!

“The patient portal is the

ideal tool for practice

redesign—our entire workflow

is designed around the

portal”

Trillium Family Health Asheville, NC

Trillium Family Health

Concept ConceptConcept

Concept FunctionFunctionFunctionFunction Low-overhead model

Whole person care

Highly engaged patients

NOT a concierge practice

Total 1.75 FTE support staff

30 min appts for all patients; average 14 a day; fully open access

Previsit preparation; “homework”; intervisit communication

Takes Medicare, Medicaid, uninsured

So does it work?

Measurable Outcomes Measurable Outcomes Measurable Outcomes

Measurable Outcomes Patient satisfactionPatient satisfactionPatient satisfactionPatient satisfaction

Level III PCMH and Stage II MU a breeze—enhanced revenue

92% of patients use the portal; 75% of appts made on-line by patient

5-20 secure messages a day; <2 min MD time; response time <2 hours 98% of the time

New Patient Orientation

Handouts/posters are ok. Staff involvement even better. Nothing beats the physician’s endorsement of use.

The Sell

Making the sell

Staff train patients to use the portal Staff train patients to use the portalStaff train patients to use the portal

Staff train patients to use the portal Physician encouragement is keyPhysician encouragement is keyPhysician encouragement is keyPhysician encouragement is key

www.trilliumfamilymedicine.com

Video Link

Let’s Check it out

Reconnecting with patients without losing efficiency

Start with the easy wins

Start change on parallel tracks

First Order Change First Order ChangeFirst Order Change

First Order Change Second Order ChangeSecond Order ChangeSecond Order ChangeSecond Order Change Train staff and providers in

the simple steps to improve in-room EHR use. Measure important factors

that improve engagement

Face time

Time with EHR

Empathy

Make sure your portal is user-friendly.

Identify a champion and small team to test and implement change.

Be bold; go for the “full Monty”

Measure outcomes

Questions and Comments?

MAHEC Asheville, NC [email protected] [email protected]

Steven Crane, MD

Cathy Nielson, MPH