Story and photo by Mark Wolf

The stethoscope draped around Donna Nelligan’s neck as she sits in an exam room at the Doctors Care Clinic has been a diagnostic tool for medical practitioners for nearly 200 years. The computer terminal in front of her, a fixture in every Doctors Care exam room, not so long.

Nelligan, a physician assistant, types briskly on the keyboard while she talks with her patient, who sits a few feet away. On the screen, the patient’s medical information, including previous visits, procedures, which medications have been prescribed, when and by whom, appears instantly when Nelligan summons it from pull-down menus.

Just a few months ago, the patient’s information would have been bundled as a stack of paper in her medical chart. Today there is no physical chart and most of the paper generated results from specific orders, prescriptions or handouts that are printed on demand.

Doctors Care, which enlists nearly 900 providers, five hospitals and their pharmacies and labs to serve uninsured and under-insured patients in south metro Denver (6,000 individuals last year), has eliminated much of the paper from its practice at 609 W. Littleton Blvd. It instituted an electronic medical records system in mid-September.

Funds for those projects came from two grants totaling about $425,000 from the Colorado Health Foundation, which invested $9.4 million over the last four years through the Healthy Connections initiative to help 43 “safety net” providers throughout Colorado build and support Health Information Technology (HIT) systems.  The providers serve patients regardless of their ability to pay.

When Healthy Connections was being considered, funding for technology was outside the scope of the Colorado Health Foundation’s mission.

“The whole area of HIT was really outside the health care delivery system, particularly in populations we’re most focused on: the safety net organizations serving the uninsured and underinsured. (To these providers) HIT seemed out of grasp both in terms of people’s technical knowledge as well as their resources,” said Steve Lesky, program officer for health care for the foundation. “As HIT became more mainstream, organizations really looked ahead at the future of health care. We didn’t want safety net providers to be left behind.”

Lesky said implementation of the program was not just about hardware and software.

Technology empowers patients

“People really embraced the idea of technology as a tool for better health care for everyone involved, making it easier for the provider and most importantly for the patient so they have better access to information and to be a partner in determining their health outcome.”

The impact and scope of the initiative are documented in Healthy Connections in Colorado: A Primer for HIT Success, which cites the Colorado Community Health network’s findings that “12 of the 15 federally qualified health centers in the state have fully implemented a certified electronic health records (EHR) system and the remaining three are in the midst of implementing EHR systems.”

Some of the providers such as the Mountain Family Health Centers already had HIT systems in place and used funds from Healthy Connections to strengthen and expand them. Others such as the North Colorado Health Alliance had outdated systems that needed to be modernized.

The use of Electronic Health Records has doubled over the past three years, according to a report from the Center for Disease Control’s National Center for Health Statistics. The study indicated the use of EHR systems by office-based physicians had risen from 17 percent in 2008 to 33 percent in 2011.

A national survey by the Commonwealth Fund found an overwhelming majority of Americans want their health care providers to use health information technology.

The survey found that 88 percent thought it was important or very important for doctors to use electronic medical records, and 92 percent thought it was important or very important for doctors to be able to share information electronically with other doctors.

Colorado making quick progress

Colorado appears to be ahead of the curve in terms of sharing medical records among providers.

Phyllis Albritton

“We haven’t done a formal analysis of that, but for statewide (coverage), the robustness of the infrastructure and the point we’ve reached, I would say we’re probably top 10 in the nation,” said Phyllis Albritton, executive director of the Colorado Regional Health Information Organization (CORHIO).

CORHIO is a nonprofit public-private partnership that allows doctors, hospitals, clinics and other health care providers to exchange medical records across secure connections. The exchange allows providers who are connected to the exchange to electronically “talk” to each other regardless of their software.

“We have a significant number of hospitals (connected) because that’s the data the practices want, and we have about 427 providers with agreements waiting to get connected,” said Albritton.

She estimates that about 50 percent of Colorado providers are using some form of electronic health records. CORHIO’s goal is that 85 percent of providers be meaningful users of EHRs by 2015.

Users of EHRs say the change to electronic records has benefitted providers, patients, receptionists and billers, but implementing a system requires careful planning, training and a commitment from top management, said Bebe Kleinman, executive director for Doctors Care.

“Technology for most of us was faxing, e-mail and communication, but you can’t practice now without it. It’s mission-critical,” said Kleinman.

“What motivated all of this is the dream that (patients’) quality of care will improve when they can be their own champion. Those that struggle with health care access aren’t going to be left off the journey the rest of us are on. If you’re uninsured, there isn’t that (information stored). We don’t want to create two classes of people: those who have health care information and those who don’t.”

Providers reluctant to change

Many of the providers faced skepticism from within their ranks at the prospect of shifting from paper charts to electronic medical records. Some providers said they would leave rather than switch.

“We had a lot of fear and resistance. People were saying ‘It can’t work.’ How were medical providers going to transition themselves after so many years of doing it one way?” said Kleinman.

She and her IT staff devoted substantial time to training and to developing an institutional commitment that the software exists to support people, not the other way around.

“We took away (the providers’) biggest tool, which is the chart. We pried it from their hands and said, ‘Sorry, we’re going to change the tools you use to practice medicine,” said Jeff Gayle, information technology manager.

Staffers have taken steps to ease the transition.

“One of our doctors didn’t like the pre-built templates so we’ve been able to compromise and create templates that allow him to free-text (his chart material) but with prompts for the same kind of information on the template so there’s a continuity on the kind of data that’s being collected. But he has the freedom to write out what he needs and feel comfortable with his charting,” said Alisa Spillman, systems manager.

EHR transition takes time

Practices transitioning to electronic records should plan for a dip in patients who can be seen during training, said Kleinman, although those numbers are returning to normal two months into the implementation.

In the early stages, practitioners tend to spend more time entering information on electronic forms than they did with paper forms, said Gayle.

“In the old charts they knew ‘I flip to this page, write the information and I’m done.’ That took them two seconds and now it might take them five minutes because they have to figure out how to enter it the right way,” he said.

Nelligan, who has practiced as a pediatric physician assistant for 20 years, was initially skeptical about switching to electronic records.

“My main concern is that the ability to listen and make eye contact with people (while you are typing) was going to decrease the intimacy of the appointment,” said Nelligan.

“In most of the rooms it works out OK. What I’ve done with people is I’ve said this is hard for me to adjust to talking and typing so how about we talk a little bit and I’ll type a little bit. Now some of them will wait for me to log on before they start talking.”

Nelligan said that the electronic records are a real asset for her practice.

“When you have a patient who is really complicated, if everything gets scanned into EMR in a timely manner, you can have everything at your fingertips. EMR allows you to click on each encounter, it generates a problem list for you, shows you chronic meds and refills. What you get is a better snapshot of the overall longevity of the patient’s medical history.”

Each of the terminals at Doctors Care has a “thin client” attached, which connects to the main computers where the records are housed and allows doctors and other practitioners to move seamlessly from one workstation to another.

Some practitioners type their notes into the system while they are interviewing patients, but much of the electronic charting at Doctors Care is done in a central room (staffers refer to it as “the pod”) equipped with several computer terminals – and a fax machine that’s not nearly so busy these days.

Electronic records more efficient

“There used to be 50 pages sitting there every day. That all happens electronically now and that two-week period of moving paper into a chart has now become more like hours,” said Gayle.

The paper chart may be headed the way of the buggy whip.

“We’re pretty close to the day where you’re going to hand a chart to a residency student and they’re going to look at you like you’re crazy: ‘What do I do with this? ’ That day is coming,” said Gayle.

Although the Healthy Connections initiative has ended, the Colorado Health Foundation will continue to support technology.

“When Healthy Connections started, we needed a separate process that had a lot of education as part of it and a lot of technical assistance. Now it has become mainstream and part of the culture around providing care. We’re going to move it from a separate funding stream to making it part of our overall funding strategy that looks at increasing access to care and improving quality,” said Lesky.

“It will be embedded in everything we do much like technology is embedded into everything an organization does these days. When you look at what a capital campaign looks like (today) people think about buildings and parking lots but with every segment of society, not just health care, it’s more virtual, technology based. (Organizations will be) looking at a big investment and upkeep around these technology infrastructures that are going to be important.”