The Harbin Clinic: Early Adoption of EMR Advantages and Challenges Introduction Dr. Ken Davis leaned back in his desk chair, one ankle hooked on his knee, and reflected on the events of his day. Once again, the decision had been made to make another big change at The Harbin Clinic in order to improve patient care. The Clinic had made the decision to move from their current electronic medical record (EMR)1 vendor and select new software, a new electronic medical record, and a new vendor. Dr. Davis, along with the Information Technology director, Angie McWhorter, had taken all things into consideration- the support staff, the size of the company, how dedicated the company would be to The Harbin Clinic, and whether the new technology would allow The Harbin Clinic to successfully comply with the federal government’s meaningful use mandate. When he accepted the position of CEO in 2002, Davis had told the board of directors that he would only do this for two years. And yet here he was, ten years later. Davis sighed to himself. He realized that while they had made many advancements in the past decade, in some ways the Harbin Clinic was about to face the same issues once again. While the physicians and staff were now accustomed to using an electronic medical record, the Clinic would still have to undergo another implementation process, one that would include many difficulties. Given the amount of pressure on him today, he could only imagine how Dr. Ferguson, his predecessor, had felt when he had made the decision to introduce electronic medical records into the daily operations of the Harbin Clinic for the first time in 1999. 1 EMR: Electronic Medical Record, The 2003 IOM Patient Safety Report describes an EMR as encompassing : 1. A longitudinal collection of electronic health information for and about persons 2. Immediate electronic access to person- and population-level information by authorized users; 3. Provision of knowledge and decision-support systems [that enhance the quality, safety, and efficiency of patient care] and 4. Support for efficient processes for health care delivery. © 2012 by the Georgia Tech Research Corporation. This case was prepared by Professor William J. Todd and Margaret Singletary, Scheller College of Business, Georgia Tech. Cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. 1 Dr. Ferguson’s Epiphany Dr. J. Paul Ferguson, CEO of the Harbin Clinic in 1999, realized that he was able to vastly improve patient care. Years ahead of other hospitals and clinics, Ferguson decided that the best way to continue to provide superior patient care was to adopt electronic medical records. He knew that having this new technology would greatly reduce medical errors, but he didn’t have a way to prove it. He would have to find a way to convince the board and the shareholders, who relied on making the financial bottom line make sense for the business part of the clinic, that this was the right investment to make for the patients. He knew that it would be difficult because there was no other incentive for making this change for the Clinic. An EMR implementation would require much more than the Information Technology budget allowed for improvements. He would also have to convince the physicians to agree to change the entire flow of their workday as well as persuade them to participate in multiple days of training for the software. It would not be an easy adjustment for the Clinic, but he believed that it was a necessary change in order to improve patient care, patient safety, and would allow the Harbin Clinic to continue to effectively serve the Rome community. Harbin Clinic History The Harbin Clinic, founded in 1908 by Rome, Georgia natives Dr. Robert Harbin and Dr. William Harbin, is the product of five generations of medical history. Both brothers attended medical school at the Bellevue Medical College in New York City and decided to return to the south to practice medicine. The Harbin brothers established a surgical practice situated in northwest Georgia in the city of Rome in 1897 and practiced together until Robert’s death in 1939. In 1908, the brothers established the Harbin Hospital. By 1920, the hospital was the largest building in Rome and was recognized by the American College of Surgeons as one of only four hospitals in Georgia to meet the board’s quality standards of excellence. The Harbin Hospital continued to improve and innovate, and in 1919, after a generous gift from a local cotton broker, the hospital acquired a deep X-Ray therapy machine. The Harbin Hospital became one of the only medical facilities in the country to offer this treatment to cancer patients. The Harbin Hospital quickly became known both in Georgia as well as among the medical community across the nation as a leading facility. In the coming decades, the hospital established a department of internal medicine and diagnosis, an innovative orthopedic program, and performed new surgeries such as Cesareans, blood matching, blood transfusions, and one of the first goiter operations. Floyd Hospital, a county-owned medical facility, opened in July of 1942 and was direct competition for Harbin Hospital. In 1948 Floyd Hospital expanded its hospital to 120 beds. With this development, the Harbin Hospital made the decision to transform itself into a medical clinic. With this drastic change, the physicians would now only treat patients on an outpatient 2 basis with no overnight care. In 1969, the Clinic built a brand new 34,000 square foot building in Rome on land obtained from Berry College on Martha Berry Boulevard. This new facility provided office space for doctors as well as central services and a pharmacy. In 2007, the Clinic opened the Harbin Clinic Specialty Center that currently houses the vascular lab, vascular surgery, and ophthalmology. In 2010 The Harbin Clinic completed a brand new cancer center focused on patient-centered care and support. The new cancer center is designed to meet patient needs throughout all points of cancer care including diagnosis, patient navigation, radiation and medical oncology treatment, follow up care, and patient support. The Harbin Clinic Today Today the Harbin Clinic is the largest privately owned for-profit multi-specialty group in the state of Georgia. The staff includes 140 doctors representing 30 different medical specialties with a governing board comprised of 12 on-staff physicians. Its main location still resides in Rome with 20 satellite offices throughout Rome, Calhoun, Cartersville, Cedartown, Adairsville, and Summerville. The Clinic offers full lab and radiology services, CT and MRI scanners, and will soon acquire a dialysis facility. Because of its rich history of innovation, the Harbin Clinic is still known to take risks while offering superior patient care. The Clinic had established itself as a leading medical facility and earned the trust and respect of the Rome community. Dr. Ferguson’s introduction of electronic medical records, while radical at the time, seemed to fit into the natural advanced progression for the Clinic. Managing a Change for Quality Care After speaking with his colleague, Tony Warren, Ferguson realized that something must be done. Warren was right; having nine different charts for one patient was absolutely ludicrous. The current system allowed too many opportunities for mistakes that could include prescription drug interference with patient allergies, incorrect medical histories, and multiple separate paper charts made coordination of care among the different specialties too difficult. It didn’t allow for proper patient care, so a change was necessary in order to serve the patients more completely. He considered Warren’s suggestion of introducing an electronic medical record into the Clinic’s daily work activities. He knew about this new technology but would need to do some more research. He was easily convinced that it was the right thing to do for the patient with regards to patient quality of care and patient safety. The electronic medical record would allow The Clinic to coordinate care, completely eliminate expensive duplicate testing, and prescribe medication with accurate information about patients’ medical history and allergies. An electronic medical record could also allow the Clinic to streamline procedures such as patient check in and patient prescriptions in a more efficient manner. He realized that the Harbin Clinic had a unique opportunity. The Clinic was a microcosm of our entire health system, but because of its smaller size and private governance, they would be able to more quickly and easily implement this radical change to better serve their patients. 3 Ferguson now needed a plan to convince the board, the shareholders, and most importantly, the other physicians. This would be a big change in the daily lives of each physician and Ferguson knew it would be a hard sell. He reflected on the past decade. The 90s had been an era of change for the Harbin Clinic. The Clinic entered 1990 as medical arts group, acting as separate mini-clinics. They were simply affiliated physicians with individualized governances sharing one facility. Gradually, the physicians began to share personnel and eventually combined insurance plans. The Clinic began to grow and expand, adding four satellite clinics. They had attempted to join Floyd Medical Center under a PHO2, but this campaign had miserably failed due to differing philosophies between the two providers. Would a change in technology as big as an EMR implementation affect the unity the Clinic had finally achieved? He knew he would need outside consultation from someone with experience in new product implementation. In the fall of 2001, Dr. Ferguson approached Tom Fricks with his new idea- he did not know the costs involved, did not know if the doctors in the clinic would commit to the project, and had not yet built a business plan. Fricks was a Rome, Georgia native with experience in information technology at a prominent Fortune 100 telecommunications company. He was familiar with advanced IT as well as the implementation process that went along with a project this size. With little information about the financial soundness of the project, Fricks agreed to join the Harbin Clinic in November of 2001. His first step was to immediately begin a structured selection process to choose the proper electronic medical record for the Clinic. Choosing the Product While Fricks had no previous experience in a healthcare setting, he was able bring a businessman’s logic perspective and analysis to a product selection, and he initiated a very structured process to find the proper EMR for The Harbin Clinic. He wanted to remove all emotion from the selection process but wanted to ensure that each division of the organization was represented; he knew that the implementation would be successful only if each stratum was able to effectively learn and use the software correctly. He formed a selection committee of fifteen members representing four main divisions of the Clinic: ten doctors, two office administration managers, two nurse practitioners, and one member from the IT staff. He wanted this project to be centered on its users and how they would interact with the product and not just the perspectives and opinions of the IT staff. Fricks first performed market research using KLAS3 industry ratings as well as HIMSS4 to 2 PHO: Physician-Hospital Organization, a management service organization in which the partners are physicians and hospitals. The PHO organization contracts for physician and hospital services. 3 KLAS: Gives accurate and impartial ratings of healthcare technology to help providers make informed decisions, the company’s mission is improve healthcare technology delivery by measuring vendor performance data for our provider partners. 4 analyze prominent vendors available in the market. Because this technology was brand new and very dynamic, the general industry for electronic medical records was very unstable. He wanted to choose a vendor that would still be around for the next decade so that the company would be able to provide upgrades as well as technological support for the product after implementation. Fricks chose twelve vendors to present to the selection committee that he believed showed stability and ease of use. From this initial twelve, Fricks narrowed it down to four vendors that he believed would meet all of the Harbin Clinic’s needs. These four companies seemed stable and would have the ability to provide IT support after implementation, would be able to provide standard upgrades on a regular basis, and allowed the ability for physicians to use mobile devices for standard access and data input. Fricks also considered the unique needs a multi-physician provider required. Many EMRs catered toward one specialty, but this wouldn’t work for The Harbin Clinic. To achieve continuity and to have successful care coordination among the specialties, the EMR would have to be able to provide functions for every specialty in one single product. He then presented the four vendors to the selection committee and, with input from the committee, assigned percentage values representing degree of importance for each aspect of the electronic medical record. Categories included ease of use, the quality of the data input templates, whether the medical record could provide the proper templates for each specialty, as well as other requirements the committee included. This was a difficult process. Many of the physicians on the committee had attended conferences for their particular specialties and had seen electronic medical records built particularly with their specialty in mind that would cater to their individual patient visits. It was a constant battle to get the committee to understand that they had to make compromises in order to share information across all forty specialties. The selection committee finally agreed on one vendor that they confidently felt would meet the Clinic’s needs. Fricks immediately set to work on a business plan to present to the board of directors. Without their approval, the implementation would not happen. He conducted a financial analysis of the project and determined that the return on investment would not be realized for five and a half years. He presented his analysis and findings to Ferguson with some concern. After looking over Fricks’ analysis, he said simply, “It’s the right thing for the patient. It always has to go back to the patient.” With a product selected and a business plan in place, Ferguson and Fricks realized that the most difficult part was still ahead of them: convincing The Harbin Clinic’s stakeholders. The governing board would be reluctant to make such a large investment in a new technology that no one else, including the Clinic’s direct competitors, was using. They had limited ability to benchmark their efforts against data from other firms because other healthcare providers were not yet using this technology. The shareholders would be wary of a lack of return on such a large investment in IT, and the physicians would object to the severe change in their daily workflow. Ferguson knew that the changes to come wouldn’t be made without objection. As they had suspected, the staff and board meetings had been difficult. The board was wary of 4 HIMMS: Healthcare Information and Management Systems Society, HIMSS is a cause-based, not-for-profit organization exclusively focused on providing global leadership for the optimal use of information technology and management systems for the betterment of healthcare. 5 this increase in the IT budget, especially with no hard data to guarantee success for the project. Convincing the physicians had been an even greater challenge. They strongly objected to this fundamental change in their workday. Ferguson had to repeat his mantra: “It’s about the patient. It will improve quality of care for our patients.” After many one-on-one confrontations from the physicians and group meetings to convince the doctors of the promise of improved care with an electronic medical record, Ferguson had achieved his goal. In 2002, after his project had been approved for implementation, Dr. Ferguson made the decision to retire. A New Leader for Implementation Dr. Ken Davis, a Rome, Georgia native, received his medical degree from Emory Medical School and completed his residency in general and thoracic surgery at Emory University Hospital. He arrived at the Harbin Clinic in 1986 and became one of four surgeons at the Clinic. After three years in surgery, Dr. Davis entered his first administrative role and served on the board of managers for the Clinic. He found that he enjoyed the business side of the Clinic immensely. In 1999, Dr. Davis curtailed his practice in Rome and moved to Boston where he began a surgical breast cancer residency. He had wanted to focus on thoracic surgery with an emphasis on breast cancer research and surgery. In late 2002, The Harbin Clinic board of directors approached Dr. Davis about the open CEO position at the Harbin Clinic. Dr. Davis was honored to be considered for the position, and it seemed like the proper move for him and his wife. They both wanted to return to Rome, and Dr. Davis had strong ties to The Harbin Clinic. In a word, Davis was reluctant. He was reluctant to take over as CEO, especially during a time of such drastic change. Ferguson had put the wheels in motion for the EMR implementation. He had done the “heavy lifting” of convincing the board, convincing the shareholders, and convincing most physicians to get on board with this new decision. But the implementation had not yet begun, and he dreaded the problems ahead. With a feeling of obligation Davis had accepted the job, but told the board he would only do it for two years. EMR Implementation Tom Fricks’ continuous commitment to the project greatly contributed to its success. He was able to hold the project together as Dr. Davis transitioned into the CEO role. Now that a vendor and product had been selected, Fricks turned to planning its implementation. At the time, The Harbin Clinic had ninety doctors on staff, and most were not comfortable using a computer. He knew that it would take time for them to be familiar with using a keyboard as well as using icons on the desktop. He chose to do the implementation is stages, installing a different functionality of the EMR in each stage. He believed he would have increasing physician buy-in at each stage as doctors could begin to see the value of each platform of the EMR. He wanted to start with the 6 simplest functions first. He began by implementing the “Dictation” aspect of the EMR, as this was one of the more similar aspects of the EMR to their current method of dictation. For Dictation, each physician was given a personal “IPAC,” a small electronic device with a microphone that doctors could dictate their notes into. This would replace their current analog headsets. The new EMR software would automatically transcribe the dictated notes online. They could then view their dictated notes, make changes using their own personal computer keyboards, and approve them online. The physicians were very pleased with this new change. They could take their IPACs anywhere- at home, at the Clinic, as well as at other hospitals, and dictate their notes. The second stage to be implemented was “E-Prescribe.” The Clinic faced a few barriers with this change. In 2002, pharmacies in Rome still filled handwritten prescriptions brought to them by the patients. With E-Prescribe, the physicians at The Harbin Clinic could enter their patients’ prescriptions online and the EMR system would automatically send that prescription to the patients’ choice of pharmacy online. There was a problem: at this time, many pharmacies did not have the necessary operating network computers to allow this information exchange. In an effort to allow their patients to continue to use their own pharmacies, The Harbin Clinic purchased fax machines for these pharmacies to install that would allow E-Prescribe to work in every pharmacy throughout Rome. E-Prescribe was the most welcome change for the physicians. It completely eliminated the need to write their patients a prescription. The software also gave the physicians their patients’ current medication list, allowed the physicians to have a “favorites” list of their most commonly prescribed medications, and listed all their patients’ allergies and drug interactions as well as formulary information about each drug. The patients were also very pleased with this change. It allowed the pharmacies to have their prescriptions waiting for them when they arrived. “Templating” was the most difficult stage to implement, but it was also one of the most important aspects of the EMR. By having the physicians enter their data in preformed “templates,” in the future they would be able to mine discrete data about patient care from the EMR. This discrete data could help them provide better care for future patients. However, with so many diverse specialties using one EMR, the templates were difficult to standardize. What a cardiologist wanted on his preformed “template” was very different from what an orthopedist wanted on his “template”. Fricks had to constantly remind them that they would have to make some compromises in order to share their data across all forty specialties. The implementation continued in this manner until all functions of the EMR were in use. The Clinic’s next challenge would be achieving this degree of information exchange in all facilities in Rome. In 2003, the Clinic installed network segments on the surgical floors of Redmond Regional and Floyd Medical center that would allow the physicians to enter information online about their patients in these hospitals and have it included in the EMR at the Harbin Clinic. The Clinic also facilitated an information exchange between Floyd Medical and Redmond Regional. They pushed for both facilities to adopt the IPAC system that would allow them to share all radiology scans and information. This greatly reduced duplicate tests not only within The Harbin Clinic but also between all three healthcare facilities. 7 Measuring Success One of the main challenges associated with the implementation of the electronic medical record was the inability to measure the success of the new software and its impact on patient care. The Harbin Clinic could not claim that a specific number of medical errors had been avoided because before the electronic medical record, medical errors simply went undetected. They now knew that medical errors had been eliminated and duplicate tests had been avoided, but no one knew by how much. This lack of quantitative data was irritating for the IT department. After this huge effort to bring about such a large change in the Clinic for the goal of improved patient care, it was frustrating to not be able to concretely report on its impact. Dr. Matt Mumber’s radiation oncology practice had merged with the Harbin Clinic in late 2005. One drawing factor for the practice had been the presence of an established EMR. The physicians in his practice adapted to the EMR relatively easily after two days of training and had integrated the new aspects and changes to patient care caused by the EMR into their daily treatment. Part of the Clinic’s electronic medical record that was new to Dr. Mumber and his partners included a place to report and record the patient’s pain on the Wong Baker Scale5, which had patients rate their pain on a simple scale of 1-10. Before using the EMR at the Harbin Clinic, Dr. Mumber’s previous practice had asked patients about their pain, but had not recorded it and had not tracked its progress throughout their patients’ treatments. With this new tool on the electronic medical record, pain became something recorded as a vital sign would be recorded. Dr. Mumber’s patients had their pain recorded and it was automatically tracked. They were able to institute a pain management plan for all of the cancer patients by recording pain and graphing the results. They began to address all of their patients’ issues with pain before beginning treatment. In 2004, the Georgia Cancer Coalition6 began an initiative to monitor the state of Georgia’s progress in improving cancer care. They sought advice from the Institute of Medicine (IOM)7 who responded with the study: Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. This study identified fifty-two metrics to identify and assess the quality of cancer care, and they estimated that it would take five to ten years for epidemiologists to mine data from paper records and analyze Georgia’s standing with the fifty-two metrics. 5 The Wong Baker Scale is pain assessment tool used for adults and children. Patients self-report pain on a scale of 1-10, 1 indicating no pain and 10 indicating intense pain. 6 The Georgia Cancer Coalition: a private, nonprofit venture launched from the 1998 Master Settlement Agreement between the tobacco industry and the fifty states. Georgia’s plan invested a portion of this money to establish the Coalition. The Georgia Cancer Coalition unites the state’s doctors, hospitals, governmental agencies, public health services, community health and survivor groups, universities, industries, and non-profit organizations around a common goal: to reduce the number of cancer-related deaths in Georgia. 7 IOM: Institute of Medicine, an independent nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public, goal is to help those in government and the private sector make informed health decisions by providing data-driven evidence upon which they can rely. 8 This timeline was too long. By the time the data was available it would be irrelevant. The Georgia Cancer Coalition decided to take on the project themselves. They enlisted the help of two healthcare consulting firms: one with technology experience and process-specific expertise and a second with cancer-specific expertise. They named their project the “Demonstration Project” and decided to center their study around lung cancer and focus on one of the fifty-two quality metrics: pain. They were now faced with the task of mining the data from paper records as much of the state still used traditional paper records. The Harbin Clinic stepped in. They pushed for the Georgia Cancer Coalition to conduct the research in Rome, Georgia. They were the most automated care provider and could offer data from three facilities: The Harbin Clinic, Redmond Regional Hospital, and Floyd Medical Center. The Harbin Clinic had the political pull to bring these two hospitals in on the project because they referred so many of their patients to these hospitals. And even though these three providers used different electronic medical records from different vendors, they all had implemented the IPAC system so they could share radiology reports. Rome became the perfect place to conduct this research because of the high level of automation of its providers’ electronic medical records. The Demonstration Project was able to efficiently mine data from the electronic medical records. Because of the presence of an EMR at The Harbin Clinic with this unique feature, The Demonstration Project team data mined results from Dr. Mumber’s patients and found some fascinating results. After analyzing data from The Harbin Clinic, Redmond Regional Hospital, and Floyd Medical Center, they found that The Harbin Clinic had better outcomes for cancer patients because they addressed their patients’ pain before beginning cancer treatment. The Harbin Clinic and met and exceeded the quality standard on pain management adopted by the Institute of Medicine in their 2004 report. The electronic medical record made pain management an obvious issue, and effectively treating that pain led to better patient outcomes. The Harbin Clinic was finally able to quantitatively show the improvement in patient care due to the implementation of the electronic medical record. The Future for Electronic Medical Records Initial data from electronic medical record use across the country excited healthcare professionals. Physician practices and hospitals realized that with an EMR they could track patient progress more efficiently, improve pay for performance, more effectively manage chronic diseases, and significantly reduce medical costs by eliminating duplicate tests and reducing medical errors. The future for electronic medical records showed great promise. With widespread adoption, many hoped to be able to track data on a national scale. Patients could seek treatment across venues and have their medical history follow them between different care providers. Researchers and doctors could utilize a central database to improve the quality of care and could engage in a nationwide quality information exchange and The Harbin Clinic had successfully implemented this inevitable change in its early stages. 9 Today’s Regulatory Environment Though Dr. Ferguson and Dr. Davis didn’t know it at the time of implementation, the healthcare regulatory environment would soon be going through some drastic changes. In February of 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act8 was signed into law. This act represents a new opportunity to improve health care delivery in the U.S. through an unprecedented investment in health information technology. Its goal is to encourage efficient health care through the use of technology and to reduce the total cost of care for patients. In order to encourage early adoption of new healthcare technology, the HITECH Act has set aside $17 billion to give to providers implementing these new technologies. Part of the HITECH Act issues a mandate for all healthcare providers to not only adopt an electronic medical record but to establish meaningful use of the electronic medical record. The meaningful use criterion requires providers to electronically capture health information in a coded format, use that coded information to track key clinical conditions, and to communicate that information to help coordinate care. This meaningful use criterion gives monetary incentives for providers participating in Medicare and Medicaid who can prove meaningful use. For healthcare providers, this means that they would be required to enter information into templates that allow them to collect discrete data about their patient care and patient outcomes. Beginning in 2010, those providers who had adopted an EMR and qualified for this meaningful use criterion received monetary incentives. The HITECH Act also enacts a penalty for those providers who have not adopted a meaningful use EMR by 2014. Continuous Improvement In 2011, as the Clinic neared its ten year anniversary of its first electronic medical record, Dr. Davis and Angie McWhorter decided to re-evaluate their current system. Looking ahead, they saw the rising necessity for increased gigabytes of storage, the rising cost of servers, and the ever increasing money they would need to spend to keep their current electronic medical record up to HITECH Act: Health Information Technology for Economic and Clinical Health, seeks to improve American health care delivery and patient care through an unprecedented investment in health information technology. The provisions of the HITECH Act are specifically designed to work together to provide the necessary assistance and technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EMRs. The funds for the HITECH Act are allocated from the American Reinvestment and Recovery Act of 2009. 8 10 date and working properly. They began to consider another option- a cloud based electronic medical record that would allow them to store their information without servers. This new option was also appealing because it would allow physicians to access the EMR from any computer through a secure cloud-based portal. They began to explore the cloud-based options available to them, looking closely at the size of the firm and how much support they would receive during the implementation as well as support in the years following implementation. They chose a cloud-based option from a new, quickly growing company and set their go-live date for June of 2012. The new EMR would include flags with reminders for physicians during patient exams that would ensure qualification for meaningful use. Because The Harbin Clinic has consistently been ahead of the curve, they would be quick to claim the government financial incentives in 2012. They now have the advantage of a prime position and an opportunity for a major advance using this new technology for improved patient care. How could The Harbin Clinic benefit from this early adoption in today’s environment? Could this progressive move now give The Harbin Clinic an advantage in recruiting top tier physicians to this mid-sized town? How can Davis manage these opportunities for maximum benefit for his patients and the physicians? 11 © by the Georgia Institute of Technology Research Corporation. This case was prepared by Professor William J. Todd and Margaret Singletary, Scheller College of Business, Georgia Tech. Cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. 12
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