Our Move to an EHR

The initial capital outlay for transitioning to an electronic health record (EHR) is not small. In fact, cost is one of the main reasons practices have been slow to adopt EHRs. These systems can cost tens of thousands per physician to set up and maintain; thus, the smaller the practice, the more economically daunting the endeavor. While adoption rates at the smaller practices are understandably low, even larger ones aren’t adopting these systems as quickly as the government would like, resulting in some recent incentives being offered, along with some potential penalties if an EHR is not implemented by 2015.

At RadAmerica II, LLC, a wholly-owned, for profit subsidiary of MedStar Health, Inc, which is currently the largest provider of technical radiation oncology services in the Baltimore—Washington region, the decision to adopt an EHR was based on the long-term benefits, including improved care coordination, compliance with impending regulations, and to improve efficiencies in personnel and operating costs. After performing a comprehensive review of the available products, we chose Impac. Our primary driver in the selection process was the company’s breadth and depth of services in the field of radiation oncology; however, multiple vendors have products available for oncology, and, specifically, radiation oncology. Other practices have used different EHR products successfully, so deciding on an EHR really depends on a practice’s needs and means. When we rolled out the Impac EHR, this was done in several phases, and while it was largely successful, we did learn some key lessons along the way.

Our rationale for implementing an EHR

• Improved care coordination and increased patient safety—First and foremost, successful implementation of an EHR improves communication and care coordination among providers. In the radiation therapy field, the EHR will aid in care coordination on two levels—improved communication with outside clinicians and all in-house care providers and time saved in identifying and reviewing patient records. Radiation therapy is one of the major treatment options for cancer patients. It can be used alone or in conjunction with surgery and/or chemotherapy; thus, in many cases, numerous other specialists are involved in caring for these patients.

Radiation therapy itself also involves numerous care providers, including clinicians, nurses, radiation therapists, physicists, dosimetrists, and schedulers. Because so many people are involved, and a patient’s radiation treatment can range from one treatment up to 40, it is important for everyone to be on the same page to prevent errors. This requires constant communication among the many people involved. We’ve found that our EHR has increased communication between different providers, ensuring each patient’s unique needs are addressed and that the best treatment options are identified. Care within the radiation therapy department has also been improved because time is no longer wasted looking for paper charts, allowing more time to be spent with patients.

• Federal regulations—Federal and state regulations are moving to convert all patient records to an electronic format over the next several years. While we do not know exactly what this will ultimately entail or look like, our approach is to be proactive and not reactive with compliance, especially because these regulations will ultimately benefit the patients we serve.

• Operational efficiencies—Over the past five years, there have been major advancements in the technology and complexity of treatments delivered. EHRs take these advancements and regimens into account, affording various efficiencies, including:

(1) Connectivity. Imaging, such as CT scanning and MRI, is essential to treatment planning and is needed before radiation therapy can be initiated. Our EHR allows us to import and fuse images, enabling us to create the best plans possible for our patients. These plans are then readily available in the EHR for future reference.

(2) Computerized physician order entry. Our EHR enables automated customizable patient treatment prescriptions. The physicians begin with a template and can modify the template to fit their needs.

(3) Pre-Treatment Quality Assurance. As part of the EHR, validation of a patient’s treatment plan occurs in a separate component of the electronic system; thus, only after the dose is validated and actually delivered, does it become recorded in the patient’s medical record.

(4) Patient positioning. Positioning technology is built into our EHR to assist with patient positioning during treatment. We can also perform trend analyses across multiple patients and modes of technology.

Benefits of EHRs

Clearly, implementing an EHR is an investment in the future; however, several benefits can be quantified at the outset, some of which have monetary value. What follows are some of the immediate benefits:

(1) Reduced costs in purchase of analog films, as these images are now being digitally obtained, and in the film jackets that used to house the analog films.

(2) Using the “Record and Verify” system within the EHR ensures all aspects of a patient’s treatment are verified before treatment is implemented, reducing the possibility of errors.

(3) Implementation of advanced technologies is enabled, such as Intensity Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), and Stereotactic Radiosurgery (SRS). RadAmerica II implemented IGRT and SRS at one site in 2007 and at another in 2009.

Implementation process for a multi-site practice

We required many functions at our practices, and these are now a part of our EHR. These functions include scheduling (patient and provider), transcription, treatment planning, order entry, charge capture, and treatment delivery. When implementing the EHR, we decided to proceed in a stepwise fashion, both at the function and site level.

Phase 1: The rollout

During phase I of the rollout, we first examined office and practice management functions. We started by transitioning patients’ schedules and then addressing transcription and document handling related to dictated notes. The final part of the rollout phase consisted of transitioning charge capture paper copy to electronic. Once all of these functions were successfully implemented at our pilot site, we then moved them to the remaining sites. Thereafter, we transitioned from using analog film to using the electronic portal imaging device (EPID) that is integrated with our linear accelerators, and our radiation therapists and physicians started reviewing patient treatment imaging electronically. This migration to electronic portal imaging was also rolled out one center at a time. At this point, we evaluated next steps and made two important decisions.

First, we decided that we wanted a fully functional EHR at our practices. Despite some glitches and lessons learned along the way, our pilot was successful at the centers we implemented; thus, our goal was to become completely paperless over the next five years. Second, after talking to all involved parties following implementation, we amended some of our initial decisions regarding the EHR. We realized that all of our disciplines needed to be involved in making process decisions related to our EHR components, and we formed a company EHR steering committee to facilitate this.

Two project managers were selected to co-chair the EHR steering committee: the technical director and the manager of information systems. The rest of the committee was comprised of the clinical department managers, administration, and quality management. Each department was required to conduct a workflow analysis. This allowed us to evaluate all positions in the organization and how each individual would use the various functionalities in the EHR software. Each department was also responsible for evaluating the paper chart to see where documents placed in the paper chart would be located in the EHR software and to develop policies and procedures for the EHR.

Phase 2: The complete EHR

One site was selected to pilot the full conversion from paper records to the EHR. After three months of testing, members of the EHR steering committee met with the staff at the site selected for the pilot to get their input on the value of the EHR and whether other sites should move forward with the conversion. The entire staff indicated that transitioning from a paper chart to an EHR presents an opportunity in which the positives outweigh the negatives, and they recommended moving forward.

After the first office was fully converted, an implementation schedule with timelines was established for the other practices. One month before an office went live, the project managers and members of administration would meet with the entire office staff to give a presentation on the workflow and implementation schedule. With staff input, a start date was selected at each site, ensuring that all new patients moving forward would have an EHR. The technical director and IT staff were on site for a full week when an office started transitioning.

Lessons learned

There are countless things we did right, including much deliberation and proactive planning; however, there is always room for improvement, and we learned some important lessons along the way. Some of these are as follows:

(1) At our pilot site, we tested each department separately. Feedback from the staff revealed that they would have preferred if all departments tested the EHR at the same time. This would have tested the interactivity of the system, minimizing the tweaking that was required once we were in a live environment.

(2) It is important to include all levels of staff , not just clinical managers, because this provides different perspectives from individuals who work with the system daily and can provide suggestions that could be incorporated to make for a better end product. It also obtains buy-in from all users, which is critical in moving users toward adopting the system rather than obstructing its implementation.

(3) Hardware should be considered. While we incorporated hardware in our planning eff orts, our predictions fell short in some cases. In the future, we will solicit more feedback in the planning stages on the extent and type of hardware needed, including desktops, monitors, scanners, and other equipment used with the EHR.

(4) It is best to install hardware in advance of implementation or before going live. This allows the staff to become proficient in the new hardware, preventing them from having to learn new hardware, software, and processes at the same time, which can be daunting.

(5) Computer literacy of the staff should not be overlooked. Performing an assessment up front, if time permits, is desirable. Then, if supplemental training is needed, it can be incorporated into the rollout schedule.

(6) It is more difficult to pull records out of the EHR to send to other physicians, and it is not possible to make the EHR look like the paper chart. Although staff may feel that it would be easier for them to use paper over the electronic format in such instances, this makes the transition harder in the long run. We find that analyzing software capabilities along with existing processes and amalgamating with best practices moving forward is the best approach.

(7) It is important to remember that working With an EHR will initially take longer than working with a paper chart; however, this investment is worth the return, as eventually time will be saved with the new system.

Our next steps

We will be taking several important steps in the near future. First and foremost, we will be upgrading to the new EHR platform. We will also start e-faxing reports to the referring physicians, thereby reducing mailing costs and improving office efficiency. Finally, we will be looking to interface with other hospital systems regarding lab results and document importing.

Linda Rogers, RN, MBA, CPA, is Vice President, RadAmerica II, LLC, and Christopher J. Osik, A. A. R.T. (R)(T), is Technical Director, RadAmerica II, LLC.