Richard D. LangWith roots in Colonial America and bucolic Bucks County, Pa., Doylestown is quintessential small-town America. Thirty miles north of Philadelphia, the town of 8,600 is also home to Doylestown Hospital, which serves its countywide population of 620,000 and has earned distinction for implementing a successful health information exchange (HIE).

Doylestown Hospital, the only U.S. hospital founded and still operated by a women’s club (the Village Improvement Association), serves as a hub for 400-plus independent physicians practicing 42 specialties at more than 100 practices in the region. So, it was a natural move to launch the Doylestown Clinical Network (DCN) HIE in 2007.

The DCN HIE has become a common link among the hospital’s medical staff. The HIE has helped community physicians improve care and reduce costs – and it has propelled Doylestown Hospital to the ranks of Thomson Reuters 100 Top Hospitals and 50 Top Cardio Hospitals for 2012.

To date, community providers have accessed the HIE more than 2.5 million times for the electronic records of about 350,000 patients. Of the HIE accesses, 1.3 million were then downloaded to physician electronic health records (EHRs); 1 million of those data retrievals have been medication associated, 100,000 have been for allergies and another 100,000 for problem lists. However, achieving the level of physician acceptance and sustainable network traffic required for a successful HIE did not occur overnight.

If you build it

As states, communities and health systems plan and implement HIEs, many healthcare leaders assume that physicians will access the data simply because it is finally available. Doylestown Hospital has discovered launching an HIE that connects independent, office-based physicians and a hospital does not in itself automatically translate to clinician acceptance and usage. Collaborative policies and seamless data integration are critical. To put it another way: Clinicians must be engaged in a “cultural interface” as well as a user interface.

Doylestown’s healthcare community is inherently collaborative. At the time of Y2K, for instance, local physicians approached the hospital for help selecting an EHR platform that would bring them as a collective group into the 21st century. As a result, about eight in 10 doctors in the community now share the same EHR system as the hospital. Given the common platform, it was only a matter of time before doctors wanted to share patient data like demographics, laboratory results, allergies and medications.

It was a logical next step to facilitate this information sharing through NextGen Healthcare’s HIE. The hospital was able to build interfaces to connect the few physician offices on disparate EHR platforms, and launched the HIE initially as a portal.

Single point of entry

When DCN first was launched, accessing HIE information required physicians to leave their practice EHR systems and log into a portal. This extra step represented a disruption to physician workflow and negatively impacted usage. IT surveys at the time, in fact, revealed the surprising truth that after initial enthusiasm, HIE usage dropped off. That was when Doylestown realized that data from an HIE must be seamlessly integrated into the patient’s electronic record prior to an encounter in order to obtain maximum usage.

Doylestown worked with the hospital’s HIE/EHR technology vendor and its own information technology staff to ensure that updated data were automatically pushed to the patient record. Now, when a patient arrives in the hospital’s emergency department or any DCN-linked practice, the most current data has already been uploaded into the record. Physicians do not need to remember to request the updated information or manually reconcile the chart. The integration was so effective that physicians now do not realize they are using an HIE because it does not add extra steps to a physician’s workflow.

Not hospital-centric

Achieving physician buy-in and adoption of an HIE is a multidimensional process. At Doylestown, it began with engaging doctors to agree on policies for the types of test results, medications, allergies and other patient data that would be shared across the HIE. The doctors determined how the data would be collected and updated at the point of care and in the EHR.

Ultimately, Doylestown believes that physician buy-in was achieved because it was the independent doctors deciding and collectively agreeing on the data collection and sharing policies – not the hospital dictating the rules. DCN’s hybrid federated HIE model, which keeps data decentralized while combining data “push” and “pull,” reinforces physician ownership by taking the hospital out of the center. That factor is critical, because when doctors view an HIE as hospital controlled, they often shy away from it.

The hospital and community physicians examined every aspect of patient safety and prioritized the data to be shared based on those issues. The objective was to derive the highest quality of care from sharing patient information while incorporating it as seamlessly as possible into clinician workflow.

Doylestown took an incremental approach to rolling out the various data elements physicians were able to access on the HIE, so as to not overwhelm them. The HIE started with patient demographics, brought up lab results (including feeds from reference labs) and then radiology, cardiology, endoscopy and other hospital reports. That way, the hospital was able to sequence value by adding features that simultaneously improved care, patient safety and physician workflow.

The selection and prioritization of reporting features – such as the integration of the HIE feed into the EHR – was a byproduct of the HIE design, which was based on the simple but critical elements of patient safety, quality and physician workflow. An HIE must demonstrate value.

Early on, physicians doing e-prescribing, for example, were able to accrue a 2 percent bonus from Medicare. E-prescribing will not work without a comprehensive medications list across an enterprise, because the provider must know what medications the patient is already taking and how those medications may have changed.

Laboratory and radiology reports have traditionally drowned physician offices in faxing and scanning. Automating functions such as prescription drug refills and telephone tasks has allowed doctors to see more patients.

In Doylestown, if a patient sees any physician in the community and then shows up at an emergency department (ED) – and is registered – the system quickly queries the DCN for any clinical data. If any exists, the HIE automatically populates the hospital EHR with the patient’s lab or radiology reports or clinical summaries. The ED doctor does not have to look up anything; he simply clicks on an icon and the information automatically pops up on the ED tracker board.

Being able to access this kind of real-time patient information onscreen at the point of care is testament to both the amazing workflow improvements and the quality care enhancements possible through an HIE.

Richard D. Lang, Ed.D, PMP, FHIMSS, is VP and CIO at Doylestown Hospital. For more on NextGen Healthcare: click here.

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