Choosing an HIT Vendor Solution

Independent Physician Office Scenario Partners in Health Care Associates (PHC) are a four-physician practice located in the Midwestern United States. Three physicians are board certified in internal medicine and a fourth is certified in geriatrics. The practice also has a full-time nurse practitioner, three part-time nurses, two medical assistants, and two front desk staff. Due to changes in physician leadership, the practice no longer has a functioning ambulatory electronic health record. There is a legacy physician practice management system in place for billing and scheduling which is no longer supported by the vendor but does process electronic claims. Current State The practice has not been able to participate in the CMS Meaningful Use program and is being assessed 5% reimbursement penalties on Medicare patient payments. Likewise, two commercial payers are offering pay for performance incentives for managing panels of patients with diabetes and asthma, but PHC cannot participate due to their inability to produce the required health maintenance clinical reporting for the program. The practice has an existing practice management system that does patient scheduling and automated claims submission via EDI (electronic data interfacing). This vendor system is unsupported and must be replaced as part of the search for an electronic health record. The goal of the practice is to be able to be financially and clinically viable and compliant with the CMS Meaningful Use phase 1 and 2 programs and prepared for Meaningful Use phase 3. Software vendors who have sold products to other physicians in the area have approached the medical director and administrator of the practice. These vendors include Practice Fusion and Next Gen. Recently a colleague of the medical director who has a practice in California is recommending that he examine a product called Athena. In addition, the Chief Medical Officer of Green Valley Regional Health System has approached PCH offering to implement and support Green Valley’s Epic Care product in this practice under an affiliate agreement. There is also an option to run an MSO (Management Services Option) of Green Valley’s Epic Practice Management suite for billing and scheduling. While PHC is an independently owned physician practice they refer about 65% of their patients to facilities and specialists of Green Valley. Currently PCH’s practice management system is non-supported by the vendor. Front desk office staffs have become very proficient in using this software to schedule patients, submit claims and follow up on denials. Office IT operations such as email printing and a basic website are run by a local information technology company who provides the services to PCH for a monthly fee. © 2016 Laureate Education, Inc. Page 1 of 2 About 75 of the other approximately 100 independent primary care practices in the region run either Next Gen or Practice Fusion as stand-alone systems. About 15 practices who have been approached by Green Valley are in the process of implementing their affiliate version of Epic Care. Three of the other five practices are divesting their practices due to financial hardships and two of them are in negotiations with Athena. Environmental Factors When examining the patient mix for both Green Valley and the regional primary care practices we see approximately 40% Medicare, 20% Medicaid, and 40% commercial insurance patients. The main commercial insurance carriers are Aetna and CIGNA. Green Valley is in final discussions with CMS in formulating an ACO organization that includes their facilities, the physicians who are running on the affiliation agreement, and a long-term care partner. In terms of financial pressures both Aetna and CIGNA have launched aggressive payfor-performance programs in areas such as diabetes management, asthma management, and medical management of congestive heart failure. For these programs, physicians who produce regular health maintenance reports on panels of commercially insured patients are receiving performance incentives. The reporting for these performance incentives is very similar to the core measures reporting requirement for the CMS program’s Meaningful Use phase 1. Another factor affecting the region is the launch of the standalone urgent care option called Doctors Care. These urgent care centers are open 12 hours a day, seven days a week and offer highly convenient urgent care and online care services to patients for non-urgent conditions. They have also recently begun doing campaigns to offer vaccinations, school and employment physicals, and health risk assessments required by Aetna and Cigna. Part of their overall customer campaign is a highly user-friendly secure Internet presence in the form of a consumer health record where consumers can do electronic visits and on-line chats with health coaches about common medical issues. What to Do? PCH must make a vendor choice regarding both a patient management and ambulatory electronic health record system. As the practice administrator you have been asked to investigate vendor options and provide an objective analysis to the PCH medical director. He has asked that this analysis include both standalone options and the Epic affiliate option offered by Green Valley. He has asked you to investigate at least three vendor partners and objectively document both the benefits and limitations of choosing each of these options. © 2016 Laureate Education, Inc. Page 2 of 2 Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 RESEARCH ARTICLE Open Access The interRAI Acute Care instrument incorporated in an eHealth system for standardized and web-based geriatric assessment: strengths, weaknesses, opportunities and threats in the acute hospital setting Els Devriendt1,2, Nathalie I H Wellens1, Johan Flamaing2,3, Anja Declercq4, Philip Moons1, Steven Boonen2,3,5 and Koen Milisen1,2* Abstract Background: The interRAI Acute Care instrument is a multidimensional geriatric assessment system intended to determine a hospitalized older persons’ medical, psychosocial and functional capacity and needs. Its objective is to develop an overall plan for treatment and long-term follow-up based on a common set of standardized items that can be used in various care settings. A Belgian web-based software system (BelRAI-software) was developed to enable clinicians to interpret the output and to communicate the patients’ data across wards and care organizations. The purpose of the study is to evaluate the (dis)advantages of the implementation of the interRAI Acute Care instrument as a comprehensive geriatric assessment instrument in an acute hospital context. Methods: In a cross-sectional multicenter study on four geriatric wards in three acute hospitals, trained clinical staff (nurses, occupational therapists, social workers, and geriatricians) assessed 410 inpatients in routine clinical practice. The BelRAI-system was evaluated by focus groups, observations, and questionnaires. The Strengths, Weaknesses, Opportunities and Threats were mapped (SWOT-analysis) and validated by the participants. Results: The primary strengths of the BelRAI-system were a structured overview of the patients’ condition early after admission and the promotion of multidisciplinary assessment. Our study was a first attempt to transfer standardized data between home care organizations, nursing homes and hospitals and a way to centralize medical, allied health professionals and nursing data. With the BelRAI-software, privacy of data is guaranteed. Weaknesses are the time-consuming character of the process and the overlap with other assessment instruments or (electronic) registration forms. There is room for improving the user-friendliness and the efficiency of the software, which needs hospital-specific adaptations. Opportunities are a timely and systematic problem detection and continuity of care. An actual shortage of funding of personnel to coordinate the assessment process is the most important threat. (Continued on next page) * Correspondence: koen.milisen@med.kuleuven.be 1 Department of Public Health and Primary Care, Health Services and Nursing Research, KU Leuven, Kapucijnenvoer 35, 4th floor, Leuven 3000, Belgium 2 Department of Internal Medicine, Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium Full list of author information is available at the end of the article © 2013 Devriendt et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 Page 2 of 10 (Continued from previous page) Conclusion: The BelRAI-software allows standardized transmural information transfer and the centralization of medical, allied health professionals and nursing data. It is strictly secured and follows strict privacy regulations, allowing hospitals to optimize (transmural) communication and interaction. However, weaknesses and threats exist and must be tackled in order to promote large scale implementation. Keywords: Aged, Comprehensive geriatric assessment, Hospital, InterRAI Acute Care, Software, SWOT-analysis Background Given the evolution of comprehensive geriatric assessment (CGA), three generations of CGA instruments are currently used in practice. First-generation CGA instruments use a collection of individually validated instruments that each focus on a single clinical domain of the patient (e.g. Mini Mental State Examination testing cognition [1], mini nutritional assessment evaluating nutritional status [2]) [3]. The assessment of a specific domain is usually triggered by the ‘impression’ of clinicians [4]. Secondgeneration geriatric assessment instruments include all geriatric domains, are setting-specific [5] and have been validated in each specific setting (e.g., MDS 2.0 [6]) [3]. While the first and the second generation of instruments allowed a systematic and standardized assessment of the patient, the items of the different instruments lacked the uniformity needed to transfer information across different settings (e.g. home care, long time care and acute care). Instruments of the third generation, such as the interRAI Suite, facilitate data transfer between healthcare settings, based on a common set of standardized items [5,7]. Supported by electronic standardized clinical data systems, assessment data can follow the patient across multiple care settings and optimize the coordination and quality of care. Although third generation CGA instruments exist, instruments of the first and second generation are still widely used. The interRAI Suite consists of CGA instruments of the third generation, designed for a range of clinical services across multiple care settings [7]. One of these instruments is the interRAI Acute Care (interRAI AC) instrument, released in 2006 in order to identify the needs of older and disabled people admitted to acute hospitals. It is one of the most recent instruments of the interRAI portfolio [8] and, as a multidimensional CGA system, intends to determine a hospitalized older persons’ medical, psychosocial, and functional capacity and needs [9]. Its ultimate goal is to develop an overall plan for treatment and long-term follow-up based on a common set of standardized items that are used in various care settings. A Belgian web-based software system, the BelRAIsoftware, was built to realize the assessment and transfer of uniform patient data across the home, residential and hospital settings. To the best of our knowledge, this software platform constitutes the first initiative to allow crossmural standardized data transfer for clinical purposes. The aim of this study was to provide an in-depth evaluation of the feasibility of the interRAI Acute Care instrument -integrated in the BelRAI web-based software system- in clinical practice in acute care hospitals. Methods Instrumentation The interRAI AC instrument was previously translated and adapted to the Belgian (Flemish region) acute care hospital context [10]. Aspects of validity and reliability of the Belgian interRAI AC instrument have been reported before [8,11-14]. A Belgian web-based software system (BelRAI-software) was developed to provide a uniform web-based (online) registration of patient data and assessments from the interRAI instruments e.g. interRAI Acute Care (interRAI AC), interRAI Home Care (interRAI HC) and interRAI Long Time Care Facilities (interRAI LTCF). The BelRAI-software was developed in 2008 for home care organizations (interRAI HC) and nursing homes (interRAI LTCF). Only at a later stage, the interRAI AC instrument for hospitals was integrated into the system. The pilot project was the first to test the interRAI AC software in an acute care hospital setting. The interRAI AC software enables clinicians to map a geriatric patient in the hospital based on 98 different standardized clinical items over 12 domains. Four assessment periods (preadmission, admission, reassessment, and discharge, respectively) map the fluctuations of the patient’s status during the hospital stay. Once the assessment is completed, outcome measures (outcomes) can be calculated based on a composition of items across domains [9]. For each domain, clinical outcome measures are generated in the form of scales and clinical assessment protocols (CAPs) designed to support clinical decision making for frail older patients in the acute care setting. Scales represent the severity of illness or disability of the patient and the evolution of the illness over time. CAPs identify geriatric syndromes with the possibility to take preventive measures or to intervene. Benchmarking can be performed on individual patient data or on a group (ward or hospital) level. A health summary report is given after each assessment. The system also offers the opportunity to Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 communicate about the patient’s health condition across wards and across care organizations (data transfer). A core set of items has been standardized across all instruments, enabling the uniformity of the assessment and the transfer of data. About 90-95% of the interRAI AC items are identical to those in the interRAI HC and LTCF. The latter instruments both contain substantially more items, up to 300. The items that are unique to the interRAI AC are for example being confined to bed for medical reasons, length of stay at emergency department, etc. Due to the uniform coding system, transfer of information to or from other participating organizations is possible for each older patient included in the BelRAI-system. All assessments of one patient are grouped and centrally stored in the BelRAI-system. All involved health professionals (within and outside the hospital) with permission to access the software, can consult this history of previous assessment data, on condition the patient has agreed that his or her file can be shared with others involved in his or her care. Both recent and older assessments are saved, and all items of each instrument are accessible. When consulting the record of a specific patient, an overview is given of all assessments labeled with date of the assessment, care setting, name of assessors and person responsible for the record. A previous assessment can be consulted in its entirety or the history of a specific item over different assessments can be checked. A history button on the screen allows the assessor to look at previous assessment dates, assessors’ names, type of instruments and scores. A health summary report of overall functioning and potential problem areas can be generated. This can be used as a transfer document. The access to the BelRAI-system is limited. Care professionals get access with their electronic identity card, with which the Belgian E-health systems checks their identity and subsequently, their profession via authentic sources (e.g. an official list that identifies each profession involved). Consequently, a person only gets access to the data of patients if he has a current care relation with the patient and on the condition the patient gave informed consent. The data moreover is encrypted and stored in secured servers. Access to aggregated data, e.g. for research, is only possible with the approval of the privacy commission. All privacy and legal requirements are fulfilled and strictly controlled by the Belgian e-health system (https:// www.ehealth.fgov.be/nl/home). The ‘BelRAI-process’ in the hospital context consists of five steps: (1) collecting the data based on the interRAI Acute Care instrument (98 items), (2) input of these data in the BelRAI-software, (3) interpretation and discussion of outcomes (CAPs and Scales), (4) the use of these outcomes in team discussions, and (5) transfer of the data to other settings (Figure 1). As mentioned above, patients are assessed at multiple points in time during hospital stay (Figure 1). Page 3 of 10 Procedure A cross-sectional multicenter study was done. A pilot project during one year (from June 2010 until July 2011) was set up with homecare organizations (n = 14), nursing homes (n = 5) and hospitals (n = 3). In three acute care hospitals, on four geriatric wards, trained clinical staff of multiple disciplines [(head)nurses (n = 14), occupational therapists (n = 2), social workers (n = 4) and geriatricians (n = 9)] assessed 410 hospitalized older persons. The interRAI AC assessment was conducted in routine clinical practice. Because of the complexity of the BelRAI-process, every caregiver had to pass through a learning process in order to manage the interRAI AC instrument and the BelRAIsoftware. Each participant was extensively trained during a 3-day course, including information on the interRAI instruments, the BelRAI-software, the security and privacy measures, and practical exercises on coding, patient cases and hands-on training. Participating hospitals were asked to gradually increase the number of BelRAI-assessments each month (e.g. 1st month: four assessments, 2nd to 4th month: six assessments each month, 5th month: eight assessments, …). Training and support during the project was organized at the request of the participating organizations. With regard to technical and other issues, hospital staff was supported by a helpdesk with daily availability by telephone or by e-mail. Participants could consult a wiki-website specifically designed to improve the data quality [12], with a built-in electronic manual, providing information about the BelRAI-instruments, the assessment and the BelRAI-software. During the project, the three hospitals were contacted monthly to evaluate, support and adjust the BelRAI-implementation in the participating wards. Target population Patients aged 75 years or older and verbally testable who were admitted to one of the participating acute geriatric units or with a geriatric profile according to a geriatric consultation team were included. Patients not speaking the local language, not verbally testable, transferred from another ward, or in very poor health condition (e.g., extreme pain, fatigue, dyspnea, medically unstable) were excluded. Ethics The study was approved by the Medical Ethics Committee of the Leuven University Hospitals and all participating hospitals. All participating patients or their proxies provided written informed consent. Evaluation techniques The balanced and detailed opinions of different participants with varying clinical backgrounds, all working in Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 Timing Page 4 of 10 The BelRAI-processin the hospitals Shortly after admission (within 48hours) Collecting data ‘preadmission’ and ‘admission’ Input of data ‘preadmission’ and ‘admission’ Interpretation and discussion on data ‘preadmission’, ‘admission’ Significant change in the health status Collecting data ‘reassessment ’ Input of data ‘reassessment’ Interpretation and discussion on data ‘reassessment’ At the moment of discharge(plan) Collecting data ‘discharge’ Input of data ‘discharge’ Interpretation and discussion on data ‘discharge’ Transfer of data Home care or residential care Figure 1 The BelRAI-process. the hospital but playing a different role in the BelRAIproject (coordinator, assessor, …) were evaluated with the following three evaluation techniques: questionnaires, focus groups and interviews. Both the AC assessment and the BelRAI software were evaluated. Interactions with home care organizations and nursing homes were taken into account, based on data transfer from and to the hospital. The evaluation techniques, the healthcare workers who took part in the evaluation and the main topics are summarized in Table 1. SWOT analysis In this study, a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis was used to summarize all results of the focus groups, interviews and questionnaires, which was constructed by the researchers reflecting the results of the participants’ opinions. It gives an overview of the feasibility of the interRAI AC instrument and its BelRAIsoftware in routine clinical hospital practice. The accuracy and correctness of the SWOT analysis was validated by the participating wards by asking the participants to provide feedback on the strengths, weaknesses, opportunities and threats of the BelRAI-process. Separate SWOT analyses were generated for the interRAI AC instrument and for the BelRAI-software, respectively. Analysis For each focus group and interview, a topic list was prepared and additional questions were asked until saturation was reached. The focus groups were all transcribed verbatim and were coded independently by two researchers (ED and NW), themes were identified and the codes were assigned to the themes. These qualitative analyses were done using QRS NVIVO 8. Results Sample characteristics The response rates for the first and second questionnaire in the hospital setting were 80% (n = 16/20) and 95% (n = 19/20), respectively. Most respondents were women 90% (n = 17). The average age of the healthcare workers was 39 years (range = 24-56, SD = 12). Six health professionals (30%) were employed part-time. Professional experience in care for older persons ranged between 2 and 5 years for six health professionals, between 5 and 10 years for three health professionals, and more than 10 years for nine health professionals. Completing the BelRAI-assessment In the three participating hospitals 194, 173 and 43 older persons were assessed, respectively. A complete assessment (preadmission, admission, reassessment and discharge) according to the respondents was not always possible, due to the workload and the fast turnover of patients. All above mentioned older persons received a premorbid and admission assessment, a reassessment was done in only two cases, and 17 older persons did not receive a discharge assessment. The experience with the BelRAI-assessment acquired by the healthcare workers during the project time varied widely. The number of interRAI AC assessments in the BelRAI-software varied from less than 10 assessments per caregiver (n = 7) up to more than 160 assessments (n = 6) (Figure 2). Transfer of patient data The BelRAI-assessments of 159 patients (39%) were exchanged with home care organizations (n = 127) and nursing homes (n = 32). The participating hospitals received Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 Page 5 of 10 Table 1 Overview of the evaluation techniques Type Healthcare workers taking part in the evaluation Number of healthcare workers taking part per setting Questionnaire 1 Assessors Healthcare workers AC n= 16/20 HC n= 21/57 NH n= 19/20 HC n= 44/57 NH n= 70/109 AC n= 3 HC n= 3 Local project coordinators NH Focus group 2 Focus group 3 Assessors Healthcare workers AC Focus group 4 n= / NH n= / Assessors Healthcare workers AC n= 6 Focus group 5 n= 5 AC n= 3 HC n= / NH n= / Assessors Healthcare workers AC n= 5 HC n= / Semi-structured Geriatrician interview Implementation, internal communication & financial implications Evaluation of training & the progress of the BelRAI-process Evaluation transfer of data n= 11 NH Middle management Evaluation of the BelRAI-process: demographic data, involvement of people in the BelRAI-process, own participation in the project, outcome measures, team discussion, transfer of data, evaluation of the BelRAI-software, helpdesk, comprehensive geriatric assessment, preconditions, barriers and levers and conclusions n= 5 n= 12 HC HC Time investment n= 60/109 Questionnaire 2 Assessors Healthcare workers AC Focus group 1 Main topic NH n= / AC n= 6 HC n= / NH n= / Preconditions for implementation of BelRAI Final evaluation of the project & the BelRAI-instrument Evaluation of the BelRAI-process & future implementation AC = Acute care = hospitals, HC = Home care, NH = Nursing homes. Number of assesors 35 assessments coming from home care (n = 4) or residential care (n = 31). This information was evaluated as useful by six health professionals, while nine other health professionals stated they did not receive a sufficient number of assessments in order to be able 8 7 6 5 4 3 2 1 0 to evaluate the quality of the received information. The health summary (n = 7), the CAPs (n = 8) and the items (n = 4) were consulted for collecting information about the patient coming in from another setting. Discussions in focus groups revealed that receiving an Hospital 3 Hospital 2 Hospital 1 Figure 2 Distribution of the number of assessors according to the number of completed interRAI AC assessments in the BelRAI-software throughout the project. Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 assessment from another setting made it possible to get a timely first insight in the overall health status of the patient and to detect problems at an early stage (e.g. early after admission in the hospital). Adaptations to the BelRAI-software could optimize this step in the BelRAI-process by making it faster and more efficient, e.g. by installing an automatic mailing system to fasten the transfer of data. SWOT analysis The SWOT analysis for the BelRAI-pilot implementation was reported and summarized separately for the interRAI AC instrument and the BelRAI-software in Figure 3. In the result section below, the results were reported according to their importance for practice. Strengths Primary strengths of the use of the BelRAI-system were (1) an understanding of the patients’ condition early after admission and (2) the promotion of multidisciplinary Figure 3 SWOT analysis. Page 6 of 10 teamwork. In addition (3), for participating hospitals, the BelRAI-system was a first introduction to standardized data transfer with other care settings (e.g. home care and nursing home setting) and (4) a way to centralize medical, allied health professional, and nursing data. Finally, (5) the secure nature of the BelRAI-software was considered a particular strength as well, because of its strict privacy regulations and its integration in the Belgian eHealth Platform. Preadmission and admission assessments were conducted between 24 and 48 hours after admission, as mandated in the interRAI guidelines. Health professionals got a global picture of the patient and could adapt the care planning early in the admission period (e.g. allowing early detection of a patient walking independently with an assistive device at home). All domains concerning the patient were mapped out, not only a selection of domains suspected to be problematic, allowing, for example, a patient with cognitive impairment before admission to be examined immediately and more extensively during the hospital stay. Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 All participating wards worked in a multidisciplinary way to complete the BelRAI-assessment, but the practical organization differed. Two hospitals collected data in a multidisciplinary way; in the other hospital the data collection was performed by one person who consulted other disciplines. Depending on the ward, the input of data was either done by one or by more health professionals. Data collection by multiple disciplines was considered to be more positively because of a higher accuracy of the data. Because a systematic standardized transfer of data with other settings was new to all participating hospitals (some hospitals did exchange some data before but only based on open entry fields), our study was the first opportunity to test a standardized way of data transfer between different settings. The completed data transfers were considered to be clinically useful and time saving by the hospital care team. Overall, data transfer using the BelRAI-software was considered to improve collaboration between different organizations significantly. Before using the BelRAI-software, most hospitals stored data from the different health professionals in a fragmented fashion, while some used electronic records, others worked with paper files. The introduction of the BelRAI-software resulted in centralization of data input from nurses, physicians and allied health professionals into a common electronic patient record. The centralization of the data made it possible for health professionals to consult relevant data entered by other health professionals. Through the internet, authorized healthcare workers in other organizations outside the hospitals had access to relevant patient data as well. It was of great importance that the BelRAI-software was strictly secured and strict privacy regulations were followed. Weaknesses The most important weaknesses were considered to be (1) the time consuming character of the process, (2) the limited collaboration of physicians and (3) the overlap with other assessment instruments or (electronic) registration forms. Room for improvement was also identified for (4) the user friendliness and (5) the efficiency of the BelRAI web-based software system, with an additional need for (6) hospital-specific modifications to the software. Because an acute care hospital is characterized by a short hospital stay, high turnover and consequently a high workload, the interRAI instruments were designed to collect 97% of the necessary data through observations during usual care. During the focus groups, health professionals confirmed that the instrument was mostly used as a systematic checklist in routine care, with the remaining 3% of the items easily obtained from the patient or from the available records. But time is needed to train health professionals in using the instrument and Page 7 of 10 the software. This learning phase requires a substantial investment of time. Going through security procedures, the input of medication and diagnosis are time consuming and improvements in user-friendliness and efficiency were considered important. Because interRAI prescribes that patient status should be assessed within 24 hours after admission, userfriendliness and efficiency are even more critical. In our project, organizational obstacles were often found to interfere with early assessment at the time of admission (e.g. the absence of assessors, need to give priority to clinical examinations, …). Overall, BelRAI-outcomes typically only became available during a later stage of the hospitalization when the acute episode was already over and (some of ) BelRAI-outcomes had already become less relevant. Although active participation of physicians is important in the BelRAI-process, involvement of physicians in our pilot project was low or even non-existent. In most cases, nurses completed all medical data based on the medical file or by consulting the attending physician, questioning the accuracy of some of the medical information. As the physician leads and supervises the clinical process, his or her support is crucial. Most of the hospitals were already familiar with some kind of geriatric assessment, but often not in a systematic, standardized and consistent way and not immediately upon admission. Different assessment instruments of the first generation are used in order to evaluate specific domains, including cognitive evaluation using the MMSE [1] and physical functioning using the Katz-scale [15]. Even when they used the interRAI AC, they continued using these first generation instruments. This was perceived as double work and as a waste of time. Integration with different (electronic) systems was considered a possible solution. Stop using first generation instruments could be an alternative solution. During this project the BelRAI-software for acute care was tested for the first time. All participants (n = 19) suggested changes to the BelRAI-software. Participants emphasized that the BelRAI-process needs to be carried out fast, safe, without technical problems and with as few steps as possible, given the large workload in the acute setting. Opportunities The greatest opportunities for the BelRAI-instrument we identified were a timely and systematic detection of (early) problems (1), the early development of a care plan (2) and its contribution to continuity of care (transfer of data) (3). Screening a patient systematically and in a standardized way makes it possible to detect problems that are not obvious and not reported spontaneously by the patient. Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 Assessment immediately after admission allows timely detection of problems and the development or adjustment of an individualized care plan. For instance, if a patient is admitted because of a fall and the interRAI assessment indicates cognitive problems, further assessment of cognitive performance can be done. However, during this project, BelRAI-health professionals seldom reviewed and analyzed the outcomes. A quarter (n = 5) of the participants never consulted the CAPs, 30% (n = 6) rarely consulted the CAPs, 20% (n = 4) did this occasionally and only 10% (n = 2) consulted the CAPs for most of the patients. Most of the health professionals, consulting the CAPs occasionally or regularly, considered the CAPs just to confirm risk factors. Only 35% (n = 7) discussed the CAPs once during a team meeting, while more than 50% (n = 10) never did. Scales were less frequently used, 15% (n = 3) consulted the scales occasionally or rarely and 40% (n = 8) never did. Again, for many health professionals, the scales simply confirmed their clinical feelings. Scales were never discussed during team meetings. Seventy-five percent of the health professionals never consulted the individual or ward benchmarking data and none of the participants introduced a systematic use of the BelRAI-outcomes during the weekly team meetings. Time pressure (n = 11) was the major reason why outcomes were not discussed at team meetings. BelRAIoutput was rarely used during this study, suggesting that efforts are needed to coach geriatric teams how to integrate the BelRAI-output in daily practice and care planning. BelRAI could support this by further developing the output delivered by the system. A major opportunity provided by BelRAI is transfer of patient data across settings or, within a hospital setting, across different wards, in particular because of standardization of items between different settings e.g. the scoring system to evaluate the patient’s physical functioning becomes identical in home care organizations, residential care organizations and the hospital. Threats Although health professionals could base the assessment on clinical observations, a lack of funding to allow dedicated staff to coordinate the assessment process as well as the shortage of assessment personnel for the scoring of the items were seen as the most important threats. In the initial phase, another burden is a roll-out of the system, which is time consuming as well. An investment in time for training, for a learning phase and for the change in organization of daily work is necessary. In addition, the complexity of the BelRAI-process requires continuing training and permanent education. Health professionals underline the importance of ‘practical’ training and exercises with the instrument and the software. Theoretical background about the development of the Page 8 of 10 system was to a large group of participants considered as less important. Two to three days of training in small groups was seen as an appropriate duration. To be useful across different settings, the BelRAI-process is strongly dependent on collaboration within and between the organization(s) (e.g. collaboration of physicians). Lack of collaboration caused problems with the efficiency of the BelRAI-process and the transfer of data. In this context, nationwide implementation across all geriatric care settings requires high-level support from policy makers. Discussion The interRAI suite is a 3rd generation standardized CGA instrument designed to support holistic care planning and data transfer across settings [7,16]. To date, no other system exists that made data transfer across settings possible. In this regard, the BelRAI-software is the first attempt to standardize data transfer between hospital, home care and residential care. Because a nationwide implementation is considered, our study was intended to provide an extensive evaluation of a pilotimplementation. A SWOT-analysis in Belgian acute care hospitals identified a set of barriers for the implementation of the BelRAIprocess, but also helped to reveal multiple strengths and opportunities. Solutions are at hand for the perceived weaknesses and threats, which must be taken care of before an implementation on a larger scale can be considered. Based on our SWOT-analysis, we first of all identified the need for dedicated funding of staff but also for the development and maintenance of software, hardware and security devices. Secondly, collaboration within the organization and between different organizations in different settings is needed. A multidisciplinary and crosssetting approach is essential to develop a system of continuous data transfer. Thirdly, the software developed for BelRAI must be adapted to the hospital context and should become more user-friendly. An improvement of the existing output (e.g. CAPs and scales) in the webbased software would enhance the understanding of the patient condition. A fourth precondition is the need for continued education and training, both theoretical and practical. A last precondition deals with the integration of the BelRAI-software with other software or discontinuation of older applications in order to prevent double encoding and to reduce extra time investment. The most important barriers identified during the project were the high turnover of patients the heavy workload in the acute setting, with a shortage of staff, insufficient knowledge of the instrument and the software and a lack of insight in the situation of the client before hospitalization when no previous BelRAI-assessment was available. Lack of interest from other team members was another barrier for the BelRAI-implementation. Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 Transfer of data over different settings was hampered by a lack of collaboration between different care partners. Because we only included a limited selection of hospitals, home care organizations and nursing homes in this pilot project, our findings should be interpreted with caution and future research on a larger scale is needed to confirm our findings. Also, we specifically tested the BelRAI-process in geriatric services in the hospital. Future studies should evaluate the assessment process for geriatric patients on non-geriatric wards. This will require appropriate screening strategies to identify the older patients at risk on non-geriatric wards who would benefit most from the BelRAI-process. This study has also limitations. Although the SWOTanalysis are recognized a useful tool to document the organization of health services and to develop action plans [17], little research is available on how to use the data in daily practice. Because a SWOT-analysis is an approach that is more intuitive and judgmental rather than mechanistic or measurable [17], the analysis can be a good starting point and helps identifying and prioritizing the information to guide choices [17]. However, we do acknowledge that the SWOT approach is a less powerful technique to evaluate the feasibility of the BelRAI-assessment method and that future studies will need to include cost-effectiveness analyses. A second limitation is the lack of data on the sample size, sample characteristics and patients not consenting or dropping out from the study. The focus of this research project was on the evaluation of the implementation process but not on the representativeness of the sample. Third, technical challenges to deal with incomplete assessments, inconsistencies and invalid codes were not addressed in the current study as these aspects of validity based on test content were extensively evaluated in a previous study [8]. These problems were tackled by adjusting the BelRAI-software aiming to improve the quality of data. InterRAI AC as an electronic web-based software system can give hospitals the possibility to evaluate patients systematically, in a standardized way, across all domains, centralizing medical, allied health professionals and nursing data, avoiding duplicated data and exchanging data with other settings. Software could be an innovative contribution to the implementation of CGA instruments. Before a nationwide implementation of the BelRAIinstrument can be considered, policy decisions will be required to support significant improvements and investments. Conclusion The BelRAI-software is the first attempt to standardize transmural transfer of information and centralize medical, Page 9 of 10 allied health professionals and nursing data, based on a secure system. Any implementation, however, will require improvements in user-friendliness and efficiency, and investments in staffing, training and education. Competing interests The authors declare that they have no competing interests. Authors’ contributions ED was responsible for the study concept and design, acquisition of data, analysis and interpretation of data, and drafting the manuscript. NW participated in the study concept and design, the acquisition of data, the analysis and interpretation of data, and drafting the manuscript. JF participated in the study concept and design, the acquisition of data, and the analysis and interpretation of data. AD participated in the study concept and design, and in the analysis and interpretation of data. PM participated in the study concept and design, the acquisition of data, and the analysis and interpretation of data. SB participated in the study concept and design, and in the analysis and interpretation of data. KM was responsible for the study concept and design, acquisition of data, analysis and interpretation of data and drafting the manuscript. All authors read, revised and approved the final manuscript. Supervision was done by KM. Acknowledgements This study was undertaken as part of a larger research project on the implementation of the BelRAI in a selection of Belgian hospitals, home care organizations and nursing homes, commissioned by the Federal Public Service Health, food Chain Safety and Environment (Belgium). The authors would like to thank the staff and the patients of the participating hospitals. Author details 1 Department of Public Health and Primary Care, Health Services and Nursing Research, KU Leuven, Kapucijnenvoer 35, 4th floor, Leuven 3000, Belgium. 2 Department of Internal Medicine, Division of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium. 3Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium. 4Lucas-Centre for Care Research and Consultancy, Policy Research Centre for Welfare, Public Health and the Family, Centre for Sociological Research, KU Leuven, Leuven, Belgium. 5 Leuven University Centre for Metabolic Bone Diseases, KU Leuven, Leuven, Belgium. Received: 17 April 2013 Accepted: 29 August 2013 Published: 5 September 2013 References 1. Folstein MF, Folstein SE, Mc Hugh PR: Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975, 12:189–198. 2. Knodrup J, Allison SP, Elia M, Vellas B, Plauth M: ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003, 22:415–421. 3. Wellens NI, Deschodt M, Flamaing J, Moons P, Boonen S, Boman X, Gosset C, Petermans J, Milisen K: First-generation versus third-generation comprehensive geriatric assessment instruments in the acute hospital setting: a comparison of the minimum geriatric screening tools (MGST) and the interRAI acute care (interRAI AC). J Nutr Health Ageing 2011, 15:638–644. 4. Rubenstein LZ, Stuck AE, Siu AL, Wieland D: Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Soc 1991, 39:8S–16S. 5. Bernabei R, Landi F, Onder G, Liperoti R, Gambassi G: Second and third generation assessment instruments: the birth of standardization in geriatric care. J Gerontol A Biol Sci Med Sci 2008, 63:308–313. 6. Carpenter GL, Teare GF, Steel K, Berg K, Murphy K, Bjornson J, Jonsson PV, Hirdes JP: A new assessment for elders admitted to acute care: reliability of the MDs-ac. Aging (Milano) 2001, 13:316–330. 7. Gray LC, Berg K, Fries BE, Henrard J, Hirdes JP, Steel K, Morris JN: Sharing clinical information across care settings: the birth of an integrated assessment system. BMC Health Serv Res 2009, 9:71. Devriendt et al. BMC Geriatrics 2013, 13:90 http://www.biomedcentral.com/1471-2318/13/90 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Page 10 of 10 Wellens NI, Deschodt M, Boonen S, Flamaing J, Gray L, Moons P, Milisen K: Validity of the interRAI Acute Care based on test content: a multi-center study. Aging Clin Exp Res 2011, 23:476–486. Gray LC, Bernabei R, Berg K, Finne-Soveri H, Fries BE, Hirdes JP, Jónsson PV, Morris JN, Steel K, Ariño-Blasco S: Standardizing assessment of elderly people in acute care: the interRAI acute care instrument. J Am Geriatr Soc 2008, 56:536–541. Wellens NI, Flamaing J, Moons P, Boonen S, Milisen K: Translation and adaptation of the interRAI suite to local requirements in Belgian hospitals. BMC Geriatr 2012, 12:53. Wellens NI, Milisen K, Flamaing J, Moons P: Methods to assess the reliability of the interRAI Acute Care: a framework to guide clinimetric testing. Part II. J Eval Clin Pract 2012, 18:822–827. Wellens NI, Van Lancker A, Flamaing J, Gray L, Moons P, Verbeke G, Boonen S, Milisen K: Interrater reliability of the interRAI Acute Care (interRAI AC). Arch Gerontol Geriatr 2012, 55:165–172. Wellens NI, Milisen K, Flamaing J, Moons P: Methods to assess the validity of the interRAI Acute Care: a framework to guide clinimetric testing. J Eval Clin Pract 2012, 18:293–309. Wellens NI, Hanon T, Flamaing J, Tournoy J, Moons P, Boonen S, Verbeke G, Milisen K: Convergent validity of the cognitive performance scale of the interRAI acute care and the mini-mental state examination. Am J of Geriatr Psychiatry 2013, 21:636–645. Katz S, Downs TD, Cash HR, Grotz RC: Progress in development of the index of ADL. Gerontologist 1970, 10:20–30. Gray L, Wootton R: Innovations in aged care: comprehensive geriatric assessement ‘online’. Australas J Ageing 2008, 27:205–208. Casebeer A: Application of SWOT analysis. Br J Hosp Med 1993, 49:430–431. doi:10.1186/1471-2318-13-90 Cite this article as: Devriendt et al.: The interRAI Acute Care instrument incorporated in an eHealth system for standardized and web-based geriatric assessment: strengths, weaknesses, opportunities and threats in the acute hospital setting. BMC Geriatrics 2013 13:90. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit BioMed Central publishes under the Creative Commons Attribution License (CCAL). Under the CCAL, authors retain copyright to the article but users are allowed to download, reprint, distribute and /or copy articles in BioMed Central journals, as long as the original work is properly cited. IS AMBULATORY EMR USABILITY IMPROVING? | JUNE 2015 | PERFORMANCE REPORT Is Ambulatory EMR Usability Improving? TABLE OF CONTENTS PAGE 2 5 30 63 73 SECTION DISCOVER FINDINGS DRILL DEEPER COMPARE VENDORS  Allscripts (TouchWorks EHR & SAC*)  athenahealth  Cerner  eClinicalWorks  Epic  GE Healthcare (Centricity Practice Solution)  Greenway (PrimeSUITE Chart)  NextGen Healthcare EXAMINE DETAILS SPECIAL QUESTIONS COMMENTARY *Allscripts SAC data is preliminary data Ambulatory EMR Usability 2015 I 1 IS AMBULATORY EMR USABILITY IMPROVING? EMR vendors are being tasked with developing increasingly complex systems that are faster, more intuitive, and easier to use. While around two-thirds of physicians and physician leaders reported that a certain amount of progress had been made since 2013, there is still much work to be done, and data reveals significant usability differences USABILITY: PRODUCTIVITY VS. EFFECTIVENESS Fully Rated 9.0 PHYSICIAN EFFECTIVENESS MORE EFFECTIVE THAN PRODUCTIVE 8.0 ALLSCRIPTS SAC EPIC 7.0 ECLINICALWORKS 6.0 ATHENAHEALTH CERNER Market Average ALLSCRIPTS TouchWorks EHR NEXTGEN GREENWAY HEALTHCARE 5.0 GE HEALTHCARE 4.0 3.0 3.0 Preliminary Data EFFECTIVE AND PRODUCTIVE LESS EFFECTIVE AND PRODUCTIVE 4.0 5.0 Market Average athenahealth and Epic lead the market in physician productivity and effectiveness. athenahealth is consistently improving their EMR’s usability by offering more effective quality improvement tools, engaging with physicians, and improving their CDS, problem list, and ePrescribing functionality, which is now robust. SAC’s customizability and Allscripts’ consistent development of SAC have enabled providers to reach a high degree of productivity and effectiveness. How well does the EMR help physicians do their jobs better? 1 ATHENAHEALTH AND EPIC HAVE THE BEST USABILITY MORE PRODUCTIVE THAN EFFECTIVE 6.0 7.0 8.0 9.0 PHYSICIAN PRODUCTIVITY How well can a typical physician accomplish what they need to in a day? EMR USABILITY IMPROVEMENT SIGNIFICANT IMPROVEMENT MODERATE IMPROVEMENT OVER THE PAST 2 YEARS LIMITED/NO IMPROVEMENT Preliminary Data 100% PERCENT REPORTING USABILITY IMPROVEMENTS 2 CERNER AND ECLINICALWORKS MAKE THE MOST PROGRESS 90% 1 3 7 80% 70% 4 9 5 10 5 60% 50% 4 10 40% 30% 9 12 5 9 4 7 20% 10% 0% 2 11 3 3 CERNER 6 (n=17) (n=11) ECLINICALWORKS (n=20) REPORTS 2015 ALLSCRIPTS (n=13) EPIC (n=24) 1 1 GREENWAY ATHENAHEALTH 2 4 3 ALLSCRIPTS SAC TOUCHWORKS EHR (n=15) NEXTGEN HEALTHCARE (n=18) (n=7) GE HEALTHCARE (n=15) Many Cerner and eClinicalWorks customers reported moderate to significant usability improvements. Cerner has moved into the top tier of performers by engaging more with physicians, improving Dynamic Documentation, and enabling their EMR to adapt better across multiple specialties. eClinicalWorks has made meaningful improvements to their product’s usability, jumping from the eighth spot to the fourth. They provide a visually appealing user interface and are steadily improving the core functionality, particularly for medication reconciliation. 4 5 GE DROPS THREE SPOTS While Greenway has pushed regular upgrades, providers have experienced post-upgrade software glitches, especially with v.17, that often hinder the usability. Customers also reported that the CDS functionality inhibits the overall usability, often describing the CDS piece as too complex, too intrusive, or not evident enough. Only 3 of 15 GE CPS EMR customers noted any overall usability improvement in the last two years. GE’s usability has suffered due to challenges with documentation and ePrescribing. WIDENING GAP BETWEEN ALLSCRIPTS TOUCHWORKS EHR, NEXTGEN, AND TOP PERFORMERS MODULAR USABILITY RATINGS How well can the typical physician efficiently and effectively accomplish the following? ATHENAHEALTH 7.1 Average Rating EPIC 7.1 CERNER 6.6 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS 7.4 7.2 6.9 7.0 5.8 Current Previous Ranking Ranking T1 1 T1 2 3 7 4 8 5 4 6 3 7 5 8 6 7.8 7.2 7.1 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS 7.6 6.5 6.2 6.4 ECLINICALWORKS 6.4 GREENWAY 6.1 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS VENDORS DRIVE USABILITY THROUGH ALLSCRIPTS SAC 5.7 7.2 6.4 6.4 7.0 4.8 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS 4.7 GE HEALTHCARE 7.2 6.5 6.4 6.5 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS 6.2 6.0 5.3 5.6 5.4 NEXTGEN HEALTHCARE 5.6 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS 6.4 5.6 5.6 5.4 4.9 ALLSCRIPTS TouchWorks EHR 5.5 7.1 DIFFERENT APPROACHES REPORTS 2015 6.7 6.5 ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS NextGen customers are able to highly customize the EHR, but these efforts are often lost and have to be redone because of complex upgrades that impede usability progress—less than half of providers say new features improve the usability. Allscripts TouchWorks EHR customers have found that strong customization tools are absent and promised ePrescribing functionality hasn’t come to fruition. athenahealth and eClinicalWorks are the primary drivers of their EMRs’ usability and provide frequent, meaningful updates to the user experience. Epic and Cerner achieve usability success through an equal partnership with providers. Epic shares best practices and consistently develops new workflows and functionality. Cerner is moving toward a mentoring role by offering new, helpful tools, like playbooks. Allscripts customers appreciate being able to customize the flexible SAC technology. 7.9 1.0 ePrescribing Medication Reconciliation Physician Documentation Problem Lists 4.3 CDS 5.0 5.8 Preliminary Data ePrescribing Medication Reconciliation Physician Documentation Problem Lists CDS 2.0 7.0 6.0 3.0 4.0 6.3 5.0 6.0 VENDOR CONTRIBUTION ALL/MOSTLY VENDOR CONTRIBUTION 7.4 7.5 7.3 7.7 7.0 8.0 TO EMR USABILITY EQUAL CONTRIBUTION ALL/MOSTLY PROVIDER CONTRIBUTION 100% 5 90% 80% 5 9 6 70% 60% 50% 10 9 2 4 40% 12 4 11 10 7 30% 20% 5 9 8 10% 0% ATHENAHEALTH (n=12) 3 EPIC (n=23) ECLINICALWORKS (n=21) 9.0 Preliminary Data 3 GREENWAY SEES NO IMPROVEMENT; CERNER (n=16) This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2015 KLAS Enterprises, LLC. All Rights Reserved. 1 3 2 2 GREENWAY (n=13) 1 2 2 1 ALLSCRIPTS TOUCHWORKS EHR NEXTGEN HEALTHCARE (n=17) (n=14) GE HEALTHCARE (n=12) 1 ALLSCRIPTS SAC (n=6) REPORT INFORMATION READER RESPONSIBILITY: KLAS’ website and reports are a compilation of research gathered from websites, healthcare industry reports, interviews with healthcare provider executives and managers, and interviews with vendor and consultant organizations. Data gathered from these sources includes strong opinions (which should not be interpreted as actual facts) reflecting the emotion of exceptional success and, at times, failure. The information is intended solely as a catalyst for a more meaningful and effective investigation on your organization’s part and is not intended, nor should it be used, to replace your organization’s due diligence. 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Technology Ave. Orem, UT 84097 www.KLASresearch.com Search in Google Play or App Store to DOWNLOAD the app today! Drill Deeper Ambulatory EMR Usability 2015 I 5  DRILL DEEPER Introduction For much of the healthcare industry, meaningful use caused a flourish of EMR adoption. Now the focus has shifted from implementations to adoption and usability, which continue to be industry-wide challenges with all EMRs. EMR vendors face the daunting task of creating systems that are the heart of healthcare delivery. In a sense, EMRs are living, breathing, adapting organisms of great complexity. They are responsible for very complex decision matrices and provider actions; they must support needs in real time and facilitate potentially life-saving care. To capture the best possible perspective on the state of EMR usability, KLAS has targeted providers in physician-leadership positions who have an understanding of the overall physician experience in the ambulatory environment and could share a representative perspective. KLAS has spoken with physician leaders at 145 organizations that are using the following EMR vendors:          6 I Ambulatory EMR Usability 2015 Allscripts (SAC) Allscripts (TouchWorks EHR) athenahealth Cerner eClinicalWorks Epic GE Healthcare (CPS) Greenway (PrimseSUITE Chart) NextGen Healthcare This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper Figure 1 Figure 2 Ambulatory EMR Usability 2015 I 7 While it is clear that EMR usability has a lot of room for improvement, two-thirds of respondents reported that they have experienced progress since KLAS’ last ambulatory care EMR usability report was published in 2013. In addition to asking about the usability of various modules (physician documentation, ePrescribing, medication reconciliation/management, problem lists, and CDS), KLAS asked these physicians and leaders to give perspectives on three overarching aspects of EMR usability:    Productivity: How efficiently a physician can accomplish what he or she needs to each day and whether that can be done with minimal disruption. When asked about productivity, providers often referred to the workflow, screen refreshes, number of clicks, templates, and overall navigability of the system. Effectiveness: How EMR functionality and tools help users deliver better and safer patient care. Do they enable physicians to be better doctors? Providers often pointed to aggregated patient data, decision support tools, patient safety alerts, and better ordering and communication as some of the major benefits of EMR adoption that have aided physicians’ effectiveness. User Interface: The overall look and feel of the system. In other words, how intuitive is the user interface? Is it easy to learn and interact with? Is it visually pleasing? Providers reflected on the overall navigability and screen flow of the system and often noted that the user interface was outdated, confusing, or not logical compared to other, familiar, contemporary tools, such as smartphones and tablets. Figure 3 8 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper athenahealth and Epic Are Ambulatory EMR Usability Leaders Achieving high usability of a system that is complex and extremely impactful to the physician workflow is no easy task. That requires much more than development and adoption. athenahealth and Epic have come out on top as ambulatory EMR usability leaders. Each of these vendors provides modules (ePrescribing, physician documentation, etc.) that are mature and relatively usable. Although far fewer customers are on Allscripts Sunrise Ambulatory Care (SAC) than are on the other EMRs in this report, it is important to note SAC’s success and high marks when it comes to usability. Specific usability details around all vendors—coming directly from physicians and physician leadership of customer organizations—is below: athenahealth By improving algorithms, increasing their focus on patient outcomes, and engaging with physicians, athenahealth has proven to be a competitive player and one of the leaders in usability. Providers rated athenahealth high in all of the usability aspects KLAS asked about for this report, from the effectiveness and productivity of the overall system to several of the actual EMR modules and tools (particularly those for ePrescribing, problem lists, and CDS). Steady and consistent improvements to the workflow for quality measures led around two-thirds of customers to say that athenahealth has made noticeable improvements to the system’s usability over the past two years. Figure 4 Ambulatory EMR Usability 2015 I 9 The true value for many providers has come from athenahealth’s heavy engagement. Physicians benefit from working directly with athenahealth, as this relationship helps them better learn, maximize, and leverage the EMR’s functionality. One customer noted, “athena has really helped us in the past two years. They have been more involved with the doctors who are using athenaClinicals instead of just the production end and their programs. I think athena is really listening more to physician groups to find out what they need. They have been trying to reduce the number of clicks it takes to work in the system, and that is doing a lot to improve the physicians’ workflow.” Additionally, because athenahealth is a web-based solution, customers are able to measure their own productivity and benchmark it against their peers.’ athenahealth is currently working on a new version that will include an update to the user interface experience (data in this report does not reflect feedback on this new release). Epic Satisfaction with Epic is largely due to the improvements from v.2012 to v.2014. Providers have noticed that as Epic’s focus has shifted from regulatory compliance, usability has become a higher priority. Customers are seeing better decision support, fewer clicks, and an improved ability to customize the system. Providers on v.2012 have seen smaller improvements, and most are looking forward to the upgrade: “I don’t think the usability of Epic’s software has declined in the last two years. It is definitely improving. Every year, Epic comes out with something that makes certain workflows better. They have continued to improve the product, but it continues to have the same look and feel. We are going to the 2014 version soon, and I know that there is a fair amount of improvement there. Epic has done a nice job for both acute and ambulatory.” 10 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper Figure 5 Epic has made improvements to medication reconciliation/management and physician documentation. According to one provider, “Medication reconciliation is a real strength with Epic. It could be better, but it is pretty good. It is seamless across the inpatient and outpatient areas, and that is a big advantage. The layout is usable and teachable. Medication reconciliation is a very difficult process, but we have had a relatively good experience with it.” Providers noted that Epic strongly encourages an equal partnership between vendor and provider and that they encourage contributions from both sides to improve the usability. Some explained that although Epic plays a crucial role, providers themselves need to be prepared to dedicate the necessary resources to be successful in improving the EMR’s usability. For example, many Epic customers reported that they had put forth a large amount of effort and many resources for EMR optimization and standardization across their organization in order to drive consistent usability progress. Allscripts SAC Providers using Allscripts SAC have achieved a high level of usability, earning favorable ratings in the areas of productivity and effectiveness. This is largely due to the product’s high level of customizability and the provider organizations’ ability to leverage inpatient expertise gained during Allscripts SCM development (all Allscripts SAC customers are Ambulatory EMR Usability 2015 I 11 also using Allscripts SCM for their acute care/hospital EMR). And with time and resources, customers reported success in crafting Allscripts SAC to achieve the desired outcomes, as evidenced by the system’s strong CDS ratings: “Allscripts has made a number of improvements to Sunrise Ambulatory Care. They have added tabs for things like scheduling and letters that are working quite well. Allscripts has definitely made strides since we began using Sunrise Ambulatory Care.” Figure 6 However, providers want more guidance from Allscripts. Generally providers attributed their usability success to their own efforts while crediting Allscripts with providing the underlying, flexible technology and backbone. One CMIO explained, “We do not see any real enhancements for Sunrise Ambulatory Care coming from Allscripts. When there is anything we want to do, we have to do it on our own.” Compared to other EMRs, provider efforts play a much larger role when it comes to Allscripts SAC’s usability success. Cerner and eClinicalWorks Make the Most Progress Cerner During the past two years, Cerner has made the most improvements to EMR usability, moving from eighth place overall to third. Providers have been impressed by Cerner’s shift toward a mentoring role regarding usability and particularly by Cerner’s account managers, who have a heightened focus on the providers’ experiences. Cerner 12 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper customers reported that their vendor has been an equal partner, if not the primary driver, in making usability improvements. Moderate to significant improvements were noted by almost all Cerner customers, who credited steady product improvement and Cerner’s focus on adapting to physician needs. One provider commented on this shift by saying, “Improving usability, particularly the usability for physicians, has been a big focus of Cerner’s. Over the last few months, we have started to implement some new things. . . . I think the vendor has done a lot of work themselves. They have made significant strides in what they are offering.” Customers specifically pointed to improvements to Dynamic Documentation, MPages, and PowerNote as wins for their organizations. One shared, “The move toward Dynamic Documentation and a menu-driven workflow for the different specialties is taking longer than anticipated, but Cerner is making progress. Over the past year, Cerner has also made very significant progress in improving the usability of PowerChart. They continue to develop Dynamic Documentation and the menu-driven workflow, and that is a good step in the right direction. Cerner is doing a good job of executing on their strategy, even though there are still some missing elements or elements that aren’t there yet. But their progress is very promising.” Figure 7 Cerner’s EMR also stands out for its success in adapting across multiple specialties. One customer explained how Cerner enabled this success with playbooks: “We have done the playbooks with several specialties. The specialties were uncomfortable for two or three Ambulatory EMR Usability 2015 I 13 weeks in both the ambulatory and inpatient settings, but after that I really got to liking the playbooks. We are starting to see a decrease in the time spent on the common activities of documenting and being in the chart. Cerner is definitely heading down the right road for usability.” eClinicalWorks Like Cerner, eClinicalWorks has made gains in the last two years, jumping to fourth overall from eighth. eClinicalWorks ranks mid-tier for physician productivity and effectiveness, and they score well for having a visually pleasing user interface. Out of the core EMR modules measured, eClinicalWorks’ rated strongest for problem lists. Many customers noted that this is an area of strength for eClinicalWorks because of the robust tools that are available. Providers have seen incremental improvements. One medical director expressed, “eClinicalWorks continues to make improvements with each upgrade. The improvements have been incremental. The CDS module that tracks chronic care measures and preventive measures also makes seeing what the patient is due for a little easier. With v.10 of eClinicalWorks EHR, eClinicalWorks has improved the CDS piece and made it modifiable.” However, while the system is regularly updated, the changes are often not intuitive, and there is little guidance or training, which hinders productivity. Customers reported that the usability of the core functionality remains generally unchanged, and the number of clicks necessary to navigate through the system is high. Greenway and GE Healthcare See No Improvement Greenway Customer feedback regarding Greenway is mixed. Some customers feel that the usability has improved because there are fewer clicks and consistent upgrades; however, significant provider effort is required to make these upgrades successful. One customer explained, “Greenway has made significant improvements over the past two years. But when we go through an upgrade, we have to manually redo all of our procedure-code categories. We have two IT people on staff who modify things to meet our needs. They improve the bidirectional communication with the labs and the MRI centers, they improve all of our diagnostic codes so that those are tailored to fit our needs, and so on. The problem is when we have an upgrade, it dispels all those codes, so we have to go back and redo all of them manually. That takes two weeks of full-time work for our IT people. That is one of our biggest complaints with Greenway PrimeSUITE Chart. The upgrades violate all of the system’s codes that we have tailored for our needs.” For other Greenway customers, the usability has not improved and has, in fact, gotten worse, particularly with the release of v.17: “PrimeSUITE Chart has gotten worse. It is much worse than it was. For instance, Greenway did an upgrade that we didn’t have a choice in 14 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper accepting, and now many of the things that worked before no longer work. When I do a note, I get a bunch of things to check at the end, and I had the system all set up the way I wanted it. When Greenway did the upgrade, they put a whole bunch of other junk in there that we can’t get out, and they won’t help us get rid of it. PrimeSUITE Chart is really a very difficult product to use.” These challenges have led to a 7% drop in ePrescribing adoption. Although v.17 caused significant usability challenges, Greenway is working to rectify these issues and help providers realize improvements. GE Healthcare GE Healthcare has seen the least improvement in the past two years, with only 3 of 15 customers noting any improvement. Customers reported more challenges with the physician documentation and ePrescribing usability and said the responsibility of enhancing the usability in these areas falls on their own shoulders. One vice president shared his organization’s experience this way: “We need to have adequate physician documentation in order to meet meaningful use and ACO requirements. Because the documentation is such an important attribute of the core competency of an EMR, my team members have developed things and forced themselves to get better. This way, we can meet the metrics we need to meet. The system didn’t come with everything we need for documentation; we made it work.” As with other vendors, customers largely attributed the lack of usability improvement to meaningful use, although they acknowledged that other factors (like a lack of vendor involvement and communication) have also been at play. One provider explained that his organization uses add-ons to compensate for GE’s focus on meaningful use rather than usability: “GE Healthcare has been focused only on meaningful use. They have not been concerned about making Centricity Practice Solution EMR more usable. Fortunately, we have the ability to use add-ons to make the product more usable.” Widening Gap between NextGen, Allscripts TouchWorks EHR, and Top Performers NextGen Fewer than half of NextGen customers said they noticed any improvements to their EMR’s usability during the last two years. Several customers feel that product upgrades strictly revolve around regulatory compliance, not around usability enhancements. One customer said, “The update to v.8.3 made the usability of NextGen EHR even worse. NextGen Healthcare made some attempts at improving the usability; they changed the user interface to modernize it and make it more user friendly. But meaningful use came out, and obviously NextGen Healthcare didn’t get much further with usability. There is no ability to automate things, and the amount of necessary clicking hasn’t decreased. There is actually more navigation and clicking required with v.8.3.” Ambulatory EMR Usability 2015 I 15 Providers reported that new features do not necessarily improve the usability, and many are nervous to upgrade in the future, fearing impediments to existing interfaces and fearing that many of their provider-driven customizations will be undone. Allscripts TouchWorks EHR TouchWorks EHR customers are also hesitant to take upgrades, as many have experienced issues with software bugs and broken interfaces in the past. One of the chief concerns physicians have is the lack of out-of-the-box functionality. One medical director described her experience this way: “I would say that TouchWorks EHR has not improved. Allscripts keeps promising that improvements are coming, so we are hopeful that things will be better. We just had a hotfix that broke several things, and they did not tell us anything about it. So now we have to throw a newsletter at all of our doctors to let them know that some things in TouchWorks EHR have improved while other things have been broken. We are just constantly losing faith in the system.” Additionally, some feel that customization is difficult. For example, one provider stated that editing templates was very difficult and time consuming. However, those providers that have been able to put the time into customization have found that the changes significantly increase the usability. Impact of the User Interface Providers agree that solid, consistent EMR functionality trumps flashy and slick computer screens. Some providers clarified that the EMR is a work solution—a tool meant to facilitate better care delivery throughout the workday. One provider explained, “I care more about the workflow than I do about the look and feel of the EMR. I want the EMR to be intuitive, and I want it to be fast. I don’t care how pretty it is.” 16 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper Figure 8 That said, most providers reported that the look and feel of EMRs has not fully kept up with the look and feel of other, everyday consumer tools, such as smartphones and tablets. Today, no ambulatory EMR is described consistently by providers as having a sleek, intuitive user interface. athenahealth’s EMR comes the closest, but providers said that even athenahealth’s still has room to improve. In fact, a sleek design did not necessarily improve perspectives on usability if the windows were not formatted or displayed correctly. One provider explained, “The window users actually look at is about a third to half the size of the screen, and then there are a lot of dashboard things around it. It is great to have those dashboard things, but the dashboard should be smaller. The window that has the document or chart in it should be bigger. It is the main part we work in.” Ambulatory EMR Usability 2015 I 17 Usability Overview for Select EMR Modules Physicians interact with many aspects of an EMR on a daily basis, and the overall usability of these core functions greatly impacts the providers’ experience. KLAS asked physicians and their leadership about the usability of some of the key functions or pieces that providers deal with each day, including physician documentation, ePrescribing, problem lists, medication reconciliation, clinical decision support (CDS), and native mobile apps. The responses are below: Physician Documentation For the majority of providers, meaningful use has increased adoption of physician documentation. However, today, no system is proving to consistently meet providers’ expectations, and the majority of respondents in this study reported spending more time documenting than they would like. Despite the importance of physician documentation and medication reconciliation, those two modules are the least usable with most vendors. Figure 9  18 I Ambulatory EMR Usability 2015 Epic: Providers praised the breadth of Epic’s documentation tools (transcription, templates, voice recognition, manual entry). Documentation usability has increased as the system has become more capable of adapting to physician needs. This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper         athenahealth: The number of templates available is a win for many providers. However, the number of clicks and the difficulty using face sheets are challenges for some. Greenway: Providers reported that the documentation is slow and cumbersome, and overdocumenting, especially in front of the patient, is a concern for many. eClinicalWorks: Providers experience a lack of templates, and the number of clicks required is high. Many have had success with voice recognition. Cerner: The transition from PowerNote to Dynamic Documentation has been a struggle for many, and that setup requires much provider effort. While customers want a more intuitive tool, they are optimistic about the direction of the documentation. NextGen Healthcare: The navigation can be difficult, and several providers reported glitches that require workarounds. The format of the patient questions in the EHR causes confusion. GE Healthcare: Poor customization capabilities are experienced by some, and others reported a lack of functionality when using remote-desktop protocols. Allscripts TouchWorks EHR: The workflows are clunky and require lots of clicks. The ability to modify templates is missing. Allscripts SAC: Providers have had success using voice recognition systems with their documentation piece. While the actual technology developed by Allscripts was described by some as dated, provider customization has allowed some organizations to be very successful. Ambulatory EMR Usability 2015 I 19 ePrescribing ePrescribing is an integral part of a provider’s everyday EMR use. Fueled by meaningful use, ePrescribing adoption has increased. This is generally regarded as one of the more usable modules offered by vendors. Figure 10       20 I Ambulatory EMR Usability 2015 athenahealth: The ePrescribing piece is fast and highly usable. Providers appreciate athenahealth’s ability to tie results to orders. Epic: Epic’s module is easy to use, provided it is set up correctly. Providers said the newest version has improved ePrescribing. Cerner: Prescribing controlled substances is difficult and requires more clicks than in other systems. The ePrescribing piece is stronger on the inpatient side than on the outpatient side. Greenway: Some providers reported difficulty connecting to third-party systems, but most are having a positive experience. eClinicalWorks: For some providers, the medication lists are messy and the ePrescribing piece can be glitchy. Others reported that the ePrescribing piece is decent and gets the job done. Allscripts TouchWorks EHR: This module is generally easy to navigate in, although it is slow for some. Promised improvements have not come to fruition. This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper    NextGen Healthcare: Many consider ePrescribing to be a strength of NextGen’s. The functionality works as expected, but the workflow and navigation are clunky. GE Healthcare: GE’s tool requires providers to set up workflows but successfully sends data to needed locations after being set up. Allscripts SAC: Providers are generally having a positive experience with SAC’s ePrescribing solution, but some have experienced errors and difficulty prescribing controlled substances. Problem Lists Though most organizations—regardless of vendor—are using problem lists, many reported that they struggle to get buy-in for this complicated process across all physicians. Figure 11   athenahealth: Those using athenahealth’s problem lists report that they are simple and cause no trouble. However, several providers have not adopted the tool due to the number of clicks and the inability to prioritize diagnoses. eClinicalWorks: Adding to and editing the list is fairly easy, and providers feel this is one of eClinicalWorks’ strengths. However, the lack of detail contained is a struggle for some. Ambulatory EMR Usability 2015 I 21        Epic: Epic’s problem lists are easy for providers to navigate in and are simple to digest. For the most part, providers pointed to poor training as the cause of issues. Greenway: Greenway’s problem lists are simple for end users, and providers noted that Greenway is working to improve this piece. Several shared that much of their success is provider driven. Cerner: Many feel that the problem lists are not fully functional and are cumbersome, and said they lack the ability to contextualize the information. Allscripts TouchWorks EHR: For many, this functionality is difficult to manage. Lists can be difficult to arrange and hard to modify, and there is no ability to easily reconcile the list. GE Healthcare: Development around GE’s problem lists has become stagnant, and issues are not being resolved. Physicians would like the see the ability to manage chronic diseases, as well as a more intuitive workflow. NextGen Healthcare: Chronic disease management is not based on ICD-9 or ICD-10; the clinical nomenclature is often inaccurate. Allscripts SAC: Providers noted that while the problem lists are improving with each upgrade, providers must add custom codes to fully leverage it. Adoption has been challenged by the length of the lists and challenges transitioning to ICD-10. Medication Reconciliation Medication reconciliation is one of the toughest tasks physicians face as they try to create an accurate list of drugs, doses, frequencies, and routes across multiple patient encounters and, often, across multiple provider organizations. Only Epic is excelling in delivering this functionality. Many providers admitted that they themselves don’t know how vendors can best handle the challenging task of medication reconciliation. 22 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper Figure 12        Epic: Epic’s workflow is easy to use and allows physicians to navigate the system and use the tools. However, there is little flexibility, and physicians have found that doing anything outside of the standard workflow can be challenging. athenahealth: The number of clicks can be cumbersome, and the most recent version of the system does not indicate which medications a patient has started and stopped taking; rather, it shows all prescribed medications. Cerner: Despite the number of clicks required, this tool is easy to use for most providers. Cerner has developed additional functionality, although few usability improvements were reported. Greenway: The tool is easy to navigate in, and some providers have had great success. However, providers would like to see automated medication removal, fewer clicks, and better interfacing with outside data sources. eClinicalWorks: Some users reported that medications occasionally are not documented and that a lack of transparency makes it difficult to trust the system. Allscripts TouchWorks EHR: Improvements to the adding and verification of outside medications are needed. Challenges reconciling brand-name and generic medications were reported. GE Healthcare: Many physicians find this tool to be time consuming, and some feel that the functionality lends itself to medication reviews rather than true reconciliation. Ambulatory EMR Usability 2015 I 23   NextGen Healthcare: Users struggle with the number of clicks, frequent alerts, and delayed documentation. Allscripts SAC: Navigation through multiple screens is a frustration for some, although recent versions have improved in general functionality. For example, the system now has the ability to handle multiple medications at once. Clinical Decision Support (CDS) CDS functionality often builds on other functionality within the system. Because of this, some providers are not yet using CDS functionality to the fullest extent. Another commonly noted challenge is striking the proper balance between too many alerts and too few. Pop-ups, reminders, and care gaps are all part of CDS. Figure 13   24 I Ambulatory EMR Usability 2015 athenahealth: This vendor is primarily focused on the medication portion of decision support. Some providers are pleased with the navigation of the standard model and find that the tool helps fill in care gaps; others feel that the tool is not robust and would like to be able to interface with outside software packages. Epic: The tools are not as functional out of the box as physicians would like, but providers reported that additional CDS-rules functionality has made it easier to build within the system. This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper        Cerner: A lot of manual work is required to make the system meet needs. Providers build alerts, catch-up schedules, and other tools on their own. However, providers do feel that the usability is improving as more specialtyspecific functionality is added. GE Healthcare: Providers are using basic functionality. For many, deeper CDS tools have not been usable because of errors with alerts. NextGen Healthcare: Users reported rudimentary alerts, errors in the templates, a lack of usable chronic-disease flow sheets, and holes around care-gap reminders. eClinicalWorks: Providers would like to see improved ways to track data and would like to see eClinicalWorks remove some of the need to manually populate structured data. Many feel the tool has potential but is difficult to fully leverage. Greenway: Physicians have had difficulty making adjustments to alerts. In general, they feel that the tools are either too intrusive or not evident enough. Allscripts TouchWorks EHR: Many find the alerts to be overwhelming and difficult to navigate in. Additionally, this tool deals only with drug/drug interactions and meaningful use. Users would like to be able to write general rules. Allscripts SAC: SAC’s tool is very flexible, allowing organizations to derive a lot of value. Physicians would like to see more out-of-the-box capabilities. Ambulatory EMR Usability 2015 I 25 Are Native Mobile Apps Making a Difference? Figure 14 As the world moves toward a mobile environment, EMR vendors are following suit. Providers KLAS spoke with stated that most apps available to them today offer readonly or view-only functionality. Although mobile app adoption rates are highest with Allscripts SAC, athenahealth, and Epic, the overall provider satisfaction across all vendors is low, primarily due to limited clinical functionality and screens that are too small. 26 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper Figure 15 Note: Vendors with no data shown did not have sufficient responses to display provider ratings in this category.      athenahealth: Some stated that the look and feel of the mobile app is completely different from the look and feel of the desktop version. Some applauded the fact that they can review charts while out of the office. The slow speed of the app is an issue. Epic: Customers pointed to the use of Haiku and Canto. Many feel limited in their abilities, as they still need to log in to the desktop version. For those who are on older versions, optimism looms because of increased mobile capabilities in v.2014. Most see that these tools are still maturing. eClinicalWorks: Physicians are optimistic about the eClinicalWorks app, with several sharing that they have seen improvements over the past year. Some reported that the app requires few clicks and that the ability to make notes in the charts is improving. The slow speed can be an issue. Allscripts TouchWorks EHR: The app provides physicians with the ability to view information, but significant documentation is unavailable. Providers feel the functionality was overpromised. Cerner: The app is still maturing, and providers must use the desktop version to complete what is required for meaningful use, such as medication reconciliation and visit summaries. Providers have had particular success when pairing the app with Dragon dictation. Ambulatory EMR Usability 2015 I 27     GE Healthcare: Currently, no native mobile app is available. Greenway: The app’s crashes and the inability to do meaningful work outside of ePrescribing are challenges for many. Few are adopting the app; they are hoping to see additional maturation before use. NextGen Healthcare: Providers are wary of adopting NextGen’s mobile app due to the high cost. Instead, most use a remote desktop. Those using the app feel it is on the right track and noted being able to search for medications and review patient information. Allscripts SAC: The SAC app is more of a peripheral, view-only tool. The small screen size and lacking ability to document are common complaints. Some appreciate being able to do sign-offs and review medications. Owning Your EMR Vendor guidance is ideal when it comes to improving EMR usability, but the most successful providers are proactive on their own with their current EMR, regardless of the vendor. When providers shared their thoughts about what they have done (or wish they had done) to improve their EMR’s usability regardless of the vendor’s efforts, they mentioned a few key pieces of advice:  Don’t by shy to deliver straightforward EMR-usability feedback The most successful providers are not shy in delivering honest feedback to their EMR vendors about usability. They own the communication to ensure that the vendor understands their key usability successes and shortcomings. Obviously, vendors react in different ways, but successful providers continue to vocalize their experiences directly to their vendors as partners.  Take the time up front Dedicating the sufficient amount of time sooner (preferably up front) rather than later to standardize the EMR’s workflows across the organization will allow clinicians to get off on the right foot. This helps establish a consistent usability experience across the organization rather than making people wait until years down the road, when workarounds and, often, misuses of the system will already be set hard in place. 28 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Drill Deeper  Enforce physician training No one enjoys sitting through hours of EMR training, especially the physician who is extremely focused on patient care. However, successful and proactive providers, together with their vendors, work on required training to enable all physicians to take full advantage of the EMR functionality at hand. Having a physician EMR champion, or someone in a role of this type, who is an advocate for EMR adoption and utilization is one effective method. Many providers blamed their usability woes on a lack of functionality, only to learn that they simply didn’t realize what was already available.  EMR customizability and configurations form the ultimate double-edged sword Providers who are successful and proactive around EMR usability recognize that the ability to customize workflows, templates, protocols, and so on within the EMR is the ultimate weapon. Many pointed out that high usability had come from their own efforts and resources put toward customizing the EMR to make it better suit their physicians’ needs and expectations. The vendor provides the flexible foundation and backbone, and then the customer is able to tweak and customize from there. However, proactive providers also own the fact that the more an EMR is customized, the more difficult it is to maintain a stable, standardized environment, especially when upgrades are rolled out. Proactive providers think through potential consequences and predict unintended impacts. Ambulatory EMR Usability 2015 I 29 Compare Vendors 30 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the retail price.  Compare Vendors  ALLSCRIPTS TOUCHWORKS EHR ALLSCRIPTS SAC (PRELIMINARY DATA) Figure 16 Ambulatory EMR Usability 2015 I 31 Figure 17 Figure 18 32 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Compare Vendors Figure 19 Figure 20 Ambulatory EMR Usability 2015 I 33 Figure 21 34 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Compare Vendors  ATHENAHEALTH ATHENACLINICALS Figure 22 Ambulatory EMR Usability 2015 I 35 Figure 23 Figure 24 36 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate

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KLAS for the full retail price.  Compare Vendors Figure 25 Figure 26 Ambulatory EMR Usability 2015 I 37 Figure 27 38 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Compare Vendors  CERNER Figure 28 Ambulatory EMR Usability 2015 I 39 Figure 29 Figure 30 40 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Compare Vendors Figure 31 Figure 32 Ambulatory EMR Usability 2015 I 41 Figure 33 42 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.  Compare Vendors  ECLINICALWORKS EHR Figure 34 Ambulatory EMR Usability 2015 I 43 Figure 35 Figure 36 44 I Ambulatory EMR Usability 2015 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for…