PCC EHR Panel Part I: Doctors Discuss Implementation Strategies at The UC

Want to trace the evolution of PCC's pediatric-focused EHR? You could start by skimming the agendas of PCC's last four annual Users' Conferences, starting with 2008's, in which classes centered on “the future” of PCC EHR.

Now fast-forward to last week's UC, where nearly half of the 160 providers in attendance are users of PCC EHR. The three-day conference in Burlington, Vt., featured a bevy of EHR-related classes and a panel discussion among a group of providers whose practices have been on-line with PCC EHR for up to two years. The panel allowed these four physicians from around the country to share with other PCC clients how they implemented the rapidly developing PCC EHR.

This week, we'll present Part I of the two-hour discussion, in which the panelists talked about implementation strategies for setting up protocols, scanning charts, choosing hardware and personnel training.

The Panel

Dr. Krekamy Craig, of Denville Pediatric Group (DPG), in Denville, N.J., is one of four providers whose practice went on-line with PCC EHR eight months ago. DPG will soon merge with two other PCC Partner practices – Broadway Pediatric Associates and Chestnut Ridge Pediatric Associates, both of which plan to go live with PCC EHR in December.

Dr. Jeff Bernstein is the managing partner at Pediatric and Adolescent Care of Silver Spring (PACSS), Md. His five-pediatrician, one nurse practitioner practice switched from Chartcare to PCC EHR following Chartcare's acquisition by a Canadian company that planned future development of its EHR around Canadian standards. A PCC Partner practice management system client since 1989, PACC went live with PCC EHR in November 2010.

Dr. Robert Dowse's practice, Premier Pediatrics, of Cedar City, Utah, went online with PCC EHR in October 2010. Dr. Dowse said his practice of three to four full-time pediatricians began preparing for electronic medical records in 2004, when a new clinic was built and laid out to accommodate for EHR installation. Premier, which started with Partner in 2006, purposely waited for PCC to develop its EHR so the office could have electronic records that would be compatible with its practice management system. The office went live with PCC EHR in October 2010.

A return panelist from 2010, Dr. Glen Bartlett's Hershey, Pa. practice of three pediatricians and one physician assistant went live with PCC EHR in December 2009. Hershey Pediatric Center (HPC) has been a partner client since 1999.

The Questions

Which office roles were involved in championing your EHR implementation?

Dr. Bartlett: Preparations for HPC's transition began some four months before go-live. Providers and staff were divided into four teams – physicians, front desk, back office and nurses. Each team was in charge of planning its role in implementing EHR.

Dr. Bernstein: Dr. Bernstein took the lead in planning for the clinical aspect of EHR, while his office manager championed the non-clinical duties and workflow issues.

Dr. Dowse: Dr. Dowse championed the clinical segment of EHR planning and was in charge of protocol development, while the office and billing managers took on the role of training and ensuring the necessary hardware was purchased and in place. It's important to recognize the impact the EHR has on billing and non-clinical processes, he said.

Dr. Craig: As her office's overall EHR champion, Dr. Craig was the focal point for clinical and office workflow planning. It was Craig who wrote the initial visit templates and decided on which hardware to purchase.

What training approaches worked best – weblabs, structured classes, etc. – as your office was preparing for PCC EHR?

Dr. Craig: Most of the learning among staff and clinicians takes place at and around the time of go-live, when PCC support staff is on-site to help with hands-on training. “The weblabs were fine, but PCC EHR is so user-friendly, it only takes about an hour to learn each aspect of the EHR. You just have to have a sense of how it works.”

Dr. Bartlett: “It takes about 15, maybe 20 minutes with a resident or student who is new to the system to go over how it works. It took me longer to get people off paper scheduling in Partner in 1999, than it did with EHR. It's so intuitive, we used weblabs more for Partner than for EHR.

How did your office decide how to set up visit templates (protocols)?

Dr. Craig: Doctor Craig wrote all the well care visits herself. When it came to developing protocols for chronic care, each doctor was assigned to write a protocol for chronic care treatment for ADHD, obesity etc. The practice also worked with PCC's templates using Bright Futures, as the guidelines already lay out treatment programs and plans for disease management. When writing templates, she said, attention to the implied workflow involved is as important as the clinical content.

Dr. Bernstein: Initial protocols were developed by Dr. Bernstein, but the practice's other providers were brought into the process after go-live. The practice uses templates with Bright Futures guidelines for well visits, but uses a generic sick visit that allows for flexibility in symptom assessment and meets clinical needs in most situations. The practice has developed a separate template for ADHD, however.

Dr. Bartlett: Clinical protocols Dr. Bartlett developed on paper years ago were transferred onto PCC EHR. Protocols are discussed and updated, as needed, by providers during monthly meetings. Unlike Dr. Bernstein's practice, HPC has created templates for some specific sick visits, such as acute asthma.

Dr. Dowse: Dr. Dowse built the protocols first, then shared them with colleagues for recommendations before going live. Once the practice was online, doctors jotted down recommendations and/or concerns about protocols and relayed them to Dr. Dowse. The number of suggestions has decreased drastically in recent months, he added.

What was your approach to scanning? Did you scan everything within each chart or only selected documents?

Dr. Craig: Nothing was scanned in advance of PCC EHR go-live, said Dr. Craig. Once online, doctors began reviewing charts, flagging important details. These charts are then put in a box to be scanned at the end of the day. Some 40 charts are scanned each day. About 65 percent of the relevant chart information has been scanned so far. For now, old paper charts are being stored in the basement of the practice. Scanning has been so efficient, Dr. Craig says, she rarely needs to reference paper charts.

Dr. Bernstein: The goal is to retire paper charts within one year of going live with PCC EHR. Well visits are scanned first, then sick visits. Specifically, each child's chart is archived as he or she came in for a well visit. Basic chart elements were scanned each week by clerical staff, freeing up doctors to see patients. It was the physicians, however, who transcribed the problem list and other key clinical reports into the system. As time becomes available, staff scan charts of active patients who have not yet been seen.

Dr. Bartlett: As a rule, no charts dating earlier than 2009 (the year HPC went online) were scanned. Staff teams began scanning paper charts two months before go-live, as patients came in for visits. The only details scanned from older charts were significant items, such as a consultation, that tie in with the newer charts.

Are you using laptops or desktops to access the EHR? Where is this equipment located and why?

Dr. Craig: The practice purchased Mac laptops for the practice's 14 providers and staff because of Apple's efficient, dependable software support. The dual support from PCC and Apple, she said, will save the practice a lot of money on in-house tech support. Also, by carrying around their own laptops, physicians avoid having to constantly login and logout of their systems, she said.

Dr. Dowse: Premier has a desktop computer in every exam room so hardware doesn't have to be carried around. Computer screens are fixed to the wall, and keyboards are tucked away in drawers that can be shut and locked.

Dr. Bernstein: Physicians have been using tablet notebook computers for the last three to five years. New laptops have been reissued as the tablet notebooks die, and each physician gets to select a laptop that suits his needs. Nurses prefer to carry paper notebooks, from which they later copy relevant visit information into desktop computers in the nurses station.

Dr. Bartlett: Having been online with PCC EHR for nearly two years, the physicians at HPC are used to carrying around laptops throughout the day, he said. “Everyone was already used to carrying paper charts,” said Bartlett. “This is no different.”

Next Monday – Part II of the UC's PCC EHR Panel Discussion: Show Me The Ropes. Read how our four panelists use task queues for communicating with each other, take advantage of monthly PCC EHR updates, and keep eye contact with patients while entering information electronically. Panelists will also weigh in on the value of PCC EHR customer support and share some of their go-live precautionary tales.