By Callie Shanafelt
California Health Report
Community clinics are turning technologically savvy. Spurred on by federal funds, they are adopting electronic health records at rates exceeded only by HMOs.
Community health centers once had the lowest rate of electronic health record use. Only eight percent had them in place in 2006. Today community health centers have the second highest rate of use. Seventy-four percent have made the switch from paper to electronic records, according to the National Center for Health Statistics. The money that helped them do it came largely from stimulus funds through the Health Information Technology for Economic and Clinical Health Act, also known as HITECH.
Clinics expect to save money and improve care through the switch, but the change can be painful. Installing a system is expensive, and there is a learning curve for staff.
Glide Health Services, a nurse-managed community health center in San Francisco that serves the homeless and poor, was one of the first clinics in California to change to electronic records five years ago.
“We were early adopters—we have the scars,” said Glide Health Services director Patricia Dennehy.
The clinic paid for the new system by participating in a study at the University of Michigan. Changing to electronic health records means revising every part of how a clinic works. Glide started the switch with an electronic appointment system.
“That was very difficult for a small practice to manage,” Dennehy said.
After that the clinic began handling billing, scheduling and medical records electronically. But Dennehy says the biggest mistake Glide made was not including a lab interface at the beginning. It took three years before they were able to send and receive lab work electronically.
“That really stymied our process,” Dennehy said. But ultimately she says the switch was worth it.
“None of us would go back, it’s much much better than a paper record,” said Dennehy. “You can find it, it’s not lost, it’s legible, it’s organized, it’s just a hundred times better than paper.”
Federal legislators put $20 billion toward incentives to switch to electronic records in the HITECH act as a part of the stimulus package. Doctors serving Medicare and Medicaid patients are eligible for $44,000 to $63,750 if they demonstrate a meaningful use of electronic health records.
“It’s actually one of the best put-together programs that the government has ever done to promote the use of technology that’s actually in everyone’s best interest,” says Redwood Community Health Network CEO Lori Sklar.
The Redwood Community Health Network was created to implement and manage the electronic health records of the 16 community clinics in Sonoma, Marin, Napa, and Yolo counties that make up the Redwood Community Health Coalition. So far, ten of the clinics have gone live with electronic health records using eClinicalWorks software.
Sklar says Redwood was the first community clinic in California to use eClinicalWorks.
“Community health centers are their own animal,” Sklar said. “We had to do quite a bit of customization.”
The clinic’s biggest problem was that in the beginning they were only using the clinical aspects of the electronic health records system.
“Financial was an afterthought,” Sklar said. “That was definitely a barrier that needed a lot of work, but it got resolved. The advantages are enormous.”
Sklar says despite the initial challenges, today clinic staff appreciates having patient information at their fingertips whenever they need it.
“It helps the physician not to have to be the purveyor of every piece of information there is,” Sklar said. “Anyone on the care team, medical assistant or therapist can see what’s going on with that patient at a moment’s notice.”
She says the system even prompts a warning if the drugs being prescribed will interact with medicine the patient is already taking.
Patricia Dennehy says at Glide Health Services the EHR search capability helps them to better treat the whole person. She points out that some of their paper records were 3-4 inches thick, making it difficult to connect some of the information inside.
As an integrated practice, mental health practitioners also check blood pressure and enter it into a patient record.
“The tools that we have in the system are helpful in looking at our work in chronic diseases like diabetes as well as preventative care,” Dennehy said.
Dennehy says in the past the clinic over-tested patients because doctors and other staff weren’t sharing results. The ease of the new system helps to save on re-testing costs.
Figuring out a way for patients who don’t speak English or have limited access to technology to get their records is a unique challenge for community health clinics.
Glide Health Services will be creating an online patient portal.
“Even though we see a large amount of people who are economically challenged,” Dennehy said, “most people do have access to the internet at places like the library.”
Sklar says many of the Redwood Community Health Network patients have internet access on their phones. RCHN has the software for a patient portal and they’ve installed patient computer terminals at some of their clinics. Staff at the clinics help train patients how to use it. However, the software is not in Spanish, which is a problem for many of their clients.
Ultimately Sklar thinks electronic health records will help individuals manage their health by being able to email their doctors and order prescription refills online.
“There are a lot of things they can do that would have otherwise slowed people down or stopped them from taking care of themselves,” Sklar said.
Asian Health Services, an Oakland-based clinic, recently decided to switch to electronic health records. The clinic chose software, applied for HITECH funds and hired a new Chief Information Officer.
“This is not an IT project,” said CIO Patrick Oh, noting that the change touches every aspect of how a clinic runs.
So far the clinic has instituted a practice management system to handle billing and scheduling. They plan to flip the switch on the health records in the spring.
Asian Health Services will be opening a new clinic next year and it will use electronic health records from day one. There is nowhere in the floor plan to even store paper records.
The biggest concern about the switch to electronic records is that storing private medical and financial data online is less secure than storing it in a paper file in a clinic.
The HITECH act also expanded federal privacy and security requirements. The Secretary of Health and Human services is required to post security breaches affecting 500 or more individuals online. From September 2009 until now 3,668,127 people have been affected by these large information breaches in California. Stanford Hospital realized in August 2011, for instance, that a spreadsheet with the data of 20,000 emergency room patients had been posted online for a year.
The majority of the other incidents happened when a computer or laptop were stolen from the provider.
All clinics will be required to prove they have strict security measures in place to qualify for meaningful use funding. Sometimes that means Patrick Oh has to squash innovative ideas because of security concerns.
“Security is a tricky thing,” said Oh. “There’s always that balancing act of making it convenient but we also have to make it secure.”
He says sometimes thinking of security keeps him up at night. “It’s not just a penalty,” Oh said. “It will undermine what our patients think of us if we can’t keep our info secure.”
In the long term, Patricia Dennehy says electronic health records will save Glide Health Services a lot of money and time.
“We’ve seen bigger changes in the last 10-15 years than we have in decades before that,” Dennehy said. “The computer and the use of data is revolutionizing our practice. It won’t make everyone better, but it’s a great tool.”