Electronic health records are here. Federal mandates and financial incentives have accelerated the transition to electronic documentation, a transition for which many providers of rehabilitation services have been eager.
At Affinity Health System (AHS), an integrated health care system located in the Fox River Valley of northeast Wisconsin, years of preparation and waiting were suddenly rewarded when a gap between major projects in our IT department provided a narrow window of opportunity to implement a rehab-specific, outpatient electronic documentation system. The project was approved on condition that, from start to finish, intensive IT resources would only be available and the project fully implemented within 5 months. Rehab Services’ commitment to “get the job done” required total immersion.
AHS consists of three hospitals (Calumet Medical Center in Chilton, Mercy Medical Center in Oshkosh, and St Elizabeth Hospital in Appleton), a physician group (Affinity Medical Group), and an insurance company (Network Health Plan). The mission of Affinity Health System is to live out a Christ-based healing ministry by providing services that promote the health and well-being of the communities we serve, especially to the poor. To meet our mission, one of AHS’ strategic goals is to “…invest in information technology to accelerate improvement in clinical quality, excellent service, and financial operations.” Acquiring superior information technology for outpatient rehabilitation clinical documentation was identified as Rehab Services’ “must do.”
Our focus was on the outpatient rehabilitation services we provide at our eight service locations. We employ 85+ outpatient therapy providers including occupational therapists, physical therapists, and speech-language pathologists who provide a wide range of services including, but not limited to, specialty programs in pediatric rehabilitation, workers’ rehabilitation, and chronic pain management. In fiscal 2010, AHS Rehab Services served just over 10,000 new outpatients.
WHY ELECTRONIC DOCUMENTATION?
Several years ago, AHS Rehab Services established a long-term vision to “Bring AHS Rehab into the 21st century with clinical documentation tools that are a pleasure to use.” Our goals included:
- Improve information to physicians, patients, and payors through legible, accessible clinical documentation,
- Improve the patient experience by eliminating waste and rework,
- Improve charge capture, decrease denials, and enhance reimbursement,
- Reduce risk exposure by assuring compliance (CMS, Joint Commission, etc).
We had prepared for electronic documentation for years. Our paper forms were standardized to be “computer ready” back in the 1990s. We had submitted annual requests for IT resources and made slow progress by implementing small “home grown” electronic formats within our organization’s existing electronic record system (designed for business functions and acute care documentation). We lived with the promise that “Your turn will come…. ”
Within our health system, AHS Rehab Services was not at the top of any IT priority lists, as we were repeatedly overshadowed by IT needs in acute care, physician services, registration, billing, and others.
As we waited during the past 3 years, we explored several options for electronic documentation systems, some rehab-specific and others that required “building” within our organization’s existing IT system. We used the resources of our organization, following our LEAN philosophy, to map how our paper medical records traveled from initial referral to discharge. The “Life of a Rehab Chart” project identified redundancies in information gathering, reduced lost charts, and helped us understand how an integrated electronic documentation system could minimize waste.
We used value-stream mapping to clarify our “current state,” identify key stakeholders to involve in our electronic journey, reduce cycle time, and redesign our “future state.” We engaged numerous rehab staff and other stakeholders (health information management and IT), to participate in e-documentation vendor presentations. We ranked the different systems by using our self-designed tools, which incorporated must-have items, desirable features, and one mandatory requirement: integration and interface with AHS existing and future electronic health records (EHR).
The processes we examined validated our strong preference for:
- A rehabilitation-specific clinical documentation and charge system; a tool that addressed all outpatient rehabilitation disciplines and specialty programs; a point of service tool; and a system that would be accessible at all AHS Rehab Services locations.
As we continued to push, it seemed like another year was about to pass when the vice president of IT (who had become one of our allies) convinced the AHS president that moving forward with the AHS Rehab Services electronic documentation project was the right thing to do. Factors that contributed to the final decision included a business case demonstrating a positive return on investment, a pause in major IT projects immediately preceding the projected 2-year implementation of the organization’s comprehensive EHR, and rehab leadership commitment to “just do it.”
TOTAL IMMERSION BEGINS
Our total immersion began, and we were thrilled to move forward with the e-documentation system that was clearly our first choice. We settled on the system with the following features:
- Comprehensive, rehab-specific, addressing occupational therapy, physical therapy, and speech-language pathology therapy,
- Addresses specialty program and practice areas,
- Supportive of documentation at the point of care,
- Proven to improve legibility and facilitate compliance with regulations,
- Proven to improve efficiency and produce a return on investment,
- HL7 certified, interface-ready, and compatible with our existing IT system,
- Compatible with the national outcome tool we have subscribed to for almost 15 years, and
- A strong reputation, including APTA and AOTA endorsement.
We signed the service agreement with the vendor early in November 2009, with an initial site “Go Live” schedule for late January 2010. We set a target of 90 days from that date for all outpatient documentation to be in our electronic system.
A major hurdle we encountered was the switch from networked desktop PCs used primarily for “business functions” to individually assigned, wireless laptop computers—replacing more than 50 devices. Some tech-savvy therapists made a seamless transition, while others required basic instruction in how to turn the wireless switch to the ON position. The short implementation period forced us to cope with the human reactions to quick change and challenged our skills in change management. There were a few tears, but no total meltdowns, because we had prepared and were given the resources to support success:
- Most of the Rehab Services staff members wanted the change,
- Everyone had “fair warning” that e-documentation was coming (we had espoused our vision for almost a decade),
- A high degree of support for the project from organizational leaders,
- Engaged, technically competent IT staff who provided exceptional support,
- An IT staff, with clinical backgrounds (RN, MedTech), were assigned full time to the project, and were absolutely committed to success.
At AHS, capital projects require metrics for success. We identified several measures and devised strategies for pre- and post-comparisons, including:
- Rehab Services staff satisfaction,
- Physician satisfaction,
- Financial performance (procedures/visit),
- Compliance, and
- Waste reduction.
We boldly announced that improvements in efficiency would not result in Full-Time Equivalent reductions. Instead, we would reinvest in customer service and quality, using our savings to improve the overall patient experience.
As we moved to implementation, we benefited greatly from the contributions of our vendor. The tool is rehabilitation specific and “intuitive” for therapist use because it was designed by therapists with “real world” experience. The vendor initially provided Web-based, interactive training for all of our staff. Next, the vendor’s training staff (practicing therapists) traveled to AHS for class sessions with all users, providing training to discipline-specific and clinical program groups, Super User training, and one-on-one attention. Support then transitioned to phone and e-mail consultation followed by repeat on-site presence during our first Go Live dates.
The IT components of the project (interface development, testing, monitoring) progressed through weekly conference calls and the use of a structured task list and progress reports on milestones. We went live as planned, and by June 1, over 95% of all AHS Rehab Services outpatients had their service documented electronically.
REPORT TO DATE
To date, we are seeing measurable success, including:
- Rehab staff satisfaction: Three questions 5-point rating scale
- Initial survey: Early 2009—52 responses
- Questions: How satisfied are you with? = Score
– Current documentation process = 2.46
– Current time requirements = 2.52
– Communication with physician = 2.55
Resurvey: September 2010—40 responses
- Current documentation process = 2.95
- Current time requirements: 2.35
- Communication with physicians: 3.05
Improvements in staff satisfaction reflect positive adoption of the tool and appreciation for ease in communication with referring physicians. Decreased satisfaction with “time” reflects that we are still learning and that more attention is required to develop templates and better use the shortcuts already built into the tool.
Improving financial performance was not one of our major goals for electronic documentation, but it is already clear that the system is paying for itself. Several financial performance measures were suggested by the vendor. However, our productivity measurement and charge system already afforded us with a “procedures per visit” statistic. We know this measure is affected by charge errors and under-billing. The business case for our IT Request identified that, across AHS Rehab Services, a factor of .05 procedures/visit equates to more than $175,000 per year in charges. After 90 days of full implementation, we have already exceeded expectations with an increase of .07 to .10 procedures/visit (varies by location).
What we learned—do again vs do better:
- Acknowledge that this is a process, a journey with no finish line,
- Deploy devices (laptops) earlier and “practice” earlier,
- Longer training period, enforced practice time, and extended testing during Go Live,
- Better understanding of some therapists’ “change curve,”
- Better understand electronic interfaces and effects on other departments,
- More focus and time devoted to customizing and tighter control on implementation rules,
- More management focus (dedicate one full-time manager to the project).
What is left to be done:
- Taking the next steps to go completely paperless,
- Continue to manage the change, and coach therapists to document concurrently during the treatment session and to learn from one another,
- Ongoing evaluation of outcomes and success metrics.
We do not recommend implementation of an electronic documentation system within a 5-month window. Then again, total immersion is stimulating—and can even be fun!
Janine M. Boldra, PT, is manager of rehab services, and Wayne L. Winistorfer, MPA, OTR, is director of rehab services, Affinity Health System, St Elizabeth Hospital, Appleton, Wis. Trevor Nebel, DPT, manager of rehab services, Affinity Health System, St Elizabeth Hospital, assisted with this article. For more information, go to affinityhealth.org.