menu item: dashboards and analytics/business informatics

Fremont Family Care Menu Item: Dashboards and Analytics/Business Informatics

Cover Page

Menu Item: Dashboards and

Analytics/Business Informatics

Name of Applicant Organization: Fremont Family Care

Organization’s Address: 2540 N Healthy Way, Fremont,

NE 68025

Submitter’s Name: Elizabeth Belmont

Submitter’s Title: Advanced Practice Registered Nurse,

Director Primary Care Clinics

Submitter’s E-mail:[email protected]

Executive Summary

Fremont Family Care is part of Health Care Professionals which is a wholly owned 501(c) -3

subsidiary of Fremont Area Medical Center. The mission of our organization is to improve the

health and wellness of the people in the communities we serve. Fremont Family Care

implemented eClinicalWorks electronic medical record in October of 2010 and shortly after the

initial implementation and go live began tracking and improving population health in our

communities. This case study will describe the steps we took as a clinic to implement the

electronic medical record, utilize dashboards and analytics within the EMR to improve the health

and wellness of the patients we serve.

mailto:[email protected]


Background Knowledge

In October of 2010 Fremont Family Care implemented eClinicalWorks electronic medical record

with the help of an EMR support team and Curas our support/vendor. The goal was to improve

the care of the patients in the population we served. With the innovative forward thinking

leadership team we embarked on EMR implementation to achieve this goal. The team began to

develop population management and quality improvement goals. Within a year of

implementation of the EMR we felt that we had enough data entered in to the EMR to begin this

process.

Prior to the implementation of the EMR Fremont Family Care used a paper medical record to

store data and treat patients. The “front sheet” was the sheet on the left hand side of the chart

contained information including immunizations, social history, family history, medications,

allergies, and problem list. This list however was frequently out of date, illegible, and inaccurate.

The front sheet was something that we tried to maintain but despite our best efforts it was still

less than perfect. Providers were frequently frustrated with the inaccuracy of the data and if you

were seeing a patient for another provider it was difficult to read or determine the plan.

Transcription of dictated progress notes was inefficient and frequently behind by 1-2 weeks.

These issues left the providers, staff, and patients frequently frustrated with the inefficient paper

system.

Local Problem and Intended Improvement

The biggest and most urgent problem was inaccurate, out of date paper charts. The information

in the chart was frequently out of date by 1-2 weeks and this information was what we were

basing our medical decisions on. This left a lot to be desired.

Immunizations, social history, family history, medications, allergies, and problem list on the

front sheet was frequently out of date, inaccurate, or illegible. There was a great potential for

medication errors as providers would adjust medications and fail to update the front sheet. The

nursing staff would refill medications based on the front sheet. Also if allergies were not listed

accurately there was a potential for patient harm. We had no way of tracking quality of care

given to our patients as our problem lists were frequently out of date and the immunization list

was also frequently lacking accurate data. Laboratory and radiology reports being missed,

misplaced, or filed incorrectly in the chart leading to delay of care.

Implementation of eClinicalWorks electronic medical record was the way we were going to

solve all of these issues. With the EMR the front sheet would now be electronic and updated

automatically. We would now have structured data problem lists that would always be legible

and searchable from the registry. If there were medical problems that did not get placed on the

problem list we could look back at the past diagnoses to see if that was in fact a problem for the

patient. Immunizations would be entered into the EMR and this information would always be

found in the same place. We would also be able to track if the patient was up to date on

immunizations and be reminded to provide immunizations to patients who were due. Medication

lists would be accurate as the data would flow directly from our EMR to the pharmacy and vice

versa. Allergies would be entered as structured data, cross referenced with the medication list

and against any new prescriptions to prevent patient harm. The ultimate goal was to establish an

interface with the local hospital that provided the services for most of our laboratory and


radiology testing. With the interface results would flow electronically directly into the patient’s

chart real time. This would provide more accurate and timely patient care.

Design and Implementation

After our initial go live in October of 2010 the data from the front sheet was hand keyed in by a

transcriptionist. The front office staff asked all patients to bring their prescription bottles with

them to the appointment when making appointment reminder calls. The medications were then

corrected or entered from the prescription pill bottle at their appointment by a clinical staff

member. This process was implemented to help reduce the possibility of medication errors. The

patients were also asked to fill out new demographic information and health history information

at the time of their first appointment after go live. This information was then keyed in by clinical

staff members. The health history form listed medications, allergies, past medical history, family

history, and social history. The clinical staff members would have to verify this with the patient

and correct or key in new information that was not already entered into the patient’s electronic

medical record. Immunization history was keyed in by the transcriptionist based on the

information found on the front sheet of the paper record.

The providers at Fremont Family Care decided as a group what laboratory and radiology reports

were important and needed to be scanned into the medical record. The transcriptionist would

scan into the patient documents section of the electronic medical record the last year of

laboratory reports and the last year of radiology reports. The providers also recommended certain

important reports be scanned in such as last colonoscopy and associated pathology report, last

mammogram, and last DEXA scan. Once the transcriptionist had scanned in all of these

documents a black line was drawn across the front of the paper chart indicating it had been

converted to the electronic medical record.

The paper record was brought back with the patient as was the workflow prior to implementing

EMR. This record was then reviewed by the provider and data was entered into the EMR. The

provider would then go through the paper chart and determine if any important documents were

missing from the electronic medical record. These documents were then flagged and scanned in

by the transcriptionist. The transcriptionist would then draw a second line across the front of the

paper chart indicating that it had been completed. This process was a simple way for providers

and staff to know the chart had been fully converted without opening the record or looking in the

electronic medical record.

Fremont Family Care following the initial go live period began to track and implement quality

care metrics around preventive and chronic care of our patients. Initially we tracked and reported

on blood pressure control in diabetics as well as colonoscopy, pneumonia vaccine, and screening

mammogram. The practice implemented a workflow for clinical staff to access the Clinical

Decision Support System (CDSS) tool within the EMR to identify patients who were in need of

screening tests. We implemented standing orders where clinical staff could order screening

mammogram, screening colonoscopy, and administer pneumonia vaccine if the patient was due

according to the CDSS alert functionality within the EMR.

Fremont Family Care as part of Fremont Area Medical Center develops two quality initiatives

each fiscal year to be placed on the Organizational Excellence Initiative Scorecard. These

initiatives are chosen with input from the providers at Fremont Family Care. After the quality


goals are developed a rating scale to determine our performance is developed based on National

guidelines. Fremont Family Care’s performance on the goals is then monitored throughout the

fiscal year. The providers and staff at Fremont Family Care are given a scorecard monthly with

the individual provider’s performance in relationship to these goals. The clinical teams are given

a graph that includes all providers in order to determine outliers and also create a team building

experience. The outliers are identified and there is a discussion with individual clinical teams to

determine any barriers or need for additional education. At the end of the fiscal year the staff are

financially rewarded based on the outcomes of these quality measures. The staff are given a

monetary bonus based on where the clinic as a whole fell on the rating scale. The financial bonus

is calculated solely on the outcome of the goal. This process has helped improve staff buy in and

gives them a incentive for improved performance. Fremont Family Care has seen an

improvement in goal performance using this model

Utilization of Health IT

Following the establishment of quality care metrics and implementing the MAQ Dashboard, FFC

established a quarterly review process of metrics. These results are shared with each clinical

team and across the practice (See figure below). The providers/clinical teams who are outliers

are identified. The director has a discussion with the clinical staff and the provider to determine

what barriers the staff are facing or if further education is necessary. This discussion typically

leads to improved performance as new individualized workflows by provider are developed.

These workflows are developed with input from the clinical team members which helps them to

buy in to the process and improve performance. This evaluation is done on at least a quarterly

basis, monthly for some quality metrics. The performance improvement is then determined and

improvements or workflow changes/updates occur on an as needed basis based on the outcomes

of the quality metrics. The clinical team members are then able to develop a process for

addressing any barriers or care gaps that are identified during this process. The process of

evaluating outcomes and reporting performance across the clinic has helped with staff and

physician engagement in the goals and their respective outcomes.


The development of clinical decision support best practice alerts provided reminders to busy

providers and medical assistants to make sure that diabetic patients were receiving the

appropriate interventions at the correct time to foster improvement in outcomes. Improved

documentation improved accountability and helped to foster friendly competitiveness to achieve

outcomes improvement throughout the practice.

Figure 2 shows an example of the CDSS window which is accessible from the top of the

progress note and also from the patient’s hub. The Clinical Decision Support System identifies

appropriate screening and chronic care items based on patient’s gender, age, and diagnoses.


The items in red indicate that the patient is due for these tests. The EMR leadership team linked

the CDSS alerts to orders so that clinical staff and providers are able to easily click on the arrow

next to the order to order the appropriate screening test and this will also link it to the appropriate

screening diagnosis. This process streamlined identifying testing needs and ordering the

appropriate tests. In the paper record identifying last screening tests, immunizations, etc was a

labor intensive inefficient process that was frequently overlooked by providers and staff.

Fremont Family Care also worked with Fremont Area Medical Center to implement a laboratory

and imaging interface. This process has been greatly successful and results now stream directly

into the EMR in a structured format which is searchable. The results are also back to the provider

typically the same day the test is ordered. Figure 3 shows laboratory tests that came across the

interface. This process allowed the practice to now track the patient’s progress as the results are

all visible from the most recent order, allowing for real time intervention in response to abnormal

results. The laboratory coming directly into the EMR in a structured format also allows the

practice to track quality metrics as this is now searchable through the registry and reporting

features within the EMR.

Figure 3: Interfaced laboratory results.


Fremont Family Care also implemented a patient portal which allows patients secure online

access to their medical record. The patient portal allows secure messing to the practice. Patients

are able to communicate with their care team using the patient portal. The portal is an integral

part of our population management initiatives. Patients are able to see their lab results as soon as

they are reviewed by their health care provider. This allows patients to track their results over

time. The vital signs are also available on the patient portal so patients are able to track their

weight and blood pressure. The portal has allowed us to communicate more effectively with

patients. Fremont Family Care makes the CDSS alerts available on the patient portal. This gives

the patient real time information on which preventive health care items they are due for and

which have been completed. The Clinical Decision Support tool the patient sees on their secure

patient portal is the same screen the providers use in the practice. Using the patient portal we are

also able to send letters to patients letting them know that they are due for certain preventive care

items. This is done by letter for those who are not web enabled but using the patient portal gives

the patient real time access to this information and the ability to communicate with the practice

in a secure environment at their convenience. The popularity of our patient portal feature

continues to grow over time.

This figure shows the secure

messaging feature using our

patient portal.


Preventive care letter screenshot from the patient portal.

Value Derived

Implementation of eClinicalWorks EMR has allowed our practice to have instant access to the

patient’s record from any location. This has streamlined patient care, decreased repeating testing

unnecessarily, and improved the management of the patient’s in the population we serve. The

data in the EMR is now accurate and up to date. We are able to track and demonstrate quality

patient care across our practice and by provider. The ability to track and benchmark the quality

of care our clinics provide has allowed us to implement quality care goals and strive to improve

upon those goals. We have been able to run registry reports to identify patients who are due for

screening testing, send registry letters to these patients through the mail or electronically through

our secure patient portal. This process has prompted patients to contact our office and schedule

screening examinations, appointments, or receive the pneumonia vaccine. We believe that this

proactive process of identifying and contacting patients due for preventive testing and/or

immunizations has allowed us to reach patients who otherwise may have been lost to follow up

in the paper record.

Our effort to analyze care outcomes for our diabetic patients and the resulting changes to

workflow to ensure that the appropriate coordinated preventative care is delivered has seen

immediate and significant results. Since the implementation of the FFC diabetic workflow and

tracking in 2013, we have seen a significant increase in the number of diabetic patients who have

maintained hemoglobin A1C levels under 7.


Lessons Learned

Implementation of an EMR system is a challenge across the practice however it is a much better

way to care for our patients. Starting from paper charts and converting to electronic medical

record is a challenge for staff and providers. It is essential to have a strong EMR leadership team

with clinical background.

Developing a process of converting charts from the paper record to the electronic medical record

was key to our practice. Input from the providers and clinical staff regarding what information

was important to transfer to the electronic chart was also very helpful. Our practice had a

dedicated person to scan and enter information into the electronic medical record from the paper

chart. This was helpful to us this person became familiar with the data that needed to be

converted which streamlined the process.

The medication list was a challenge for our practice as the medication list on the front sheet of

the paper chart was typically not updated. The workflow of having patients bring their

prescription bottles with them to their first appointment was very beneficial so that the data could

be entered into the EMR accurately and then would be updated with any change made to the

medication within the EMR. This helped us to reduce medication errors.

The ability to set, monitor, and improve upon quality goals has been an asset to our practice.

Quality goals were not monitored in the paper record and this data was very beneficial to our

practice. We were able to track and report these goals across our practice by provider. This

process allowed us to identify gaps in care and improve patient care. Detailed data identifying

improvement in quality goals is identified in the menu case study on population management.

Financial Considerations

Fremont Family Care’s initial investment in the EMR has been detailed in the ROI core case

study. The additional costs include staff training including paying wages outside of patient care

hours. This time has not been significant as training is typically added in to our monthly staff

meetings. Our nurse practitioner has been the clinical quality leader for our practice. There has

been additional overhead for using her as a resource outside of patient care hours to develop,


implement, train staff, and report on the quality measures. Seeing real time data demonstrating

improvement in clinical measures and population management is something that is invaluable to

the practice and the population we serve.

The financial return on investment for these measures has been in additional revenue from

increasing the number of pneumonia vaccines administered. We also realized a return in

investment by increasing the number of colonoscopies performed by the two physicians within

our practice who perform colonoscopies which has been detailed in the menu case study on

population management.

As result of improvements in morbidity of our diabetic patients, FFC has demonstrated a cost

savings for our diabetic population.

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