EHR Exchange: Interview with Shannon Smith*

In this issue, we speak with Ms Shannon Smith, who is Program Director for Ryan White, Department of Medicine at the University of Arizona. The Ryan White program at the University of Arizona is a special project in the Section of Infectious Disease, providing primary medical care for people living with HIV. Ms Smith has supported HIV care and services in Southern Arizona since 2006 through the management of HIV programs in Tucson and along the US/Mexico border. At the University of Arizona, Ms Smith has provided the team with contract management, grant writing, program development, and fiscal oversight since 2010.

Tell us about the funding your HIV team receives at the University of Arizona

Our Infectious Disease specialists split their time between 2 sites which both provide HIV primary and specialty care. The majority of the program’s HIV support comes through federal funding of the Ryan White HIV/AIDS Treatment Extension Act of 2009. Grants are administered by the Health Resources and Services Administration (HRSA), and the University of Arizona contracts directly with HRSA for provision of the Ryan White Part C (Early Intervention Services) grant and through the Arizona Department of Health Services (ADHS) for provision of a multiservice Ryan White Part B grant. Both Ryan White Part B and C programs are contracted for the provision of HIV medical care; however, the Part B grant incorporates additional services, including health insurance support for underinsured patients (co-pays associated with medical visits), as well as medical case management and treatment adherence counseling by a clinical pharmacist.

Which HRSA-approved Ryan White database do you use?

We currently use LabTracker™ HIV (Janssen Diagnostics, Inc., formerly Virco Lab, Inc.), an EMR platform specifically designed for health care providers who are treating people living with HIV/AIDS. The program facilitates secure data integration and exchange among clinics, laboratories, radiologists, and pharmacies, automates certain US government reporting, and serves as a powerful data-mining engine for clinical trials, outcomes research, and grant proposals. We keep track of HIV standards of care as well as all aspects of HIV-related care and clinic preparation for our HIV patients. For example, it is easy to get a snapshot of patient health status through LabTrackerTM HIV using the FastLook report function, which provides a quick look at many of the clinical markers. This program allows for both list and graphic views of clinical data trends on a per patient basis. (Note: Although LabTracker™ HIV is a HRSA-approved Ryan White platform, it does not currently meet all the requirements for meaningful use outlined in the HITECH ACT.)

In addition to LabTracker™ HIV, we have opted to participate in a statewide initiative to use CAREWare. The Ryan White Part B program located within the ADHS implemented CAREWare with the hopes that the software would ease the reporting requirements for all Ryan White Part B entities, provide service agencies with an internal, Ryan White-specific referral system, and streamline eligibility documentation across Ryan White, Part B providers. Ryan White Part B services in Tucson are not always located within one agency, and, frequently, patients are required to visit a number of locations to access all of the Ryan White care services available in our community, such as dental, mental heath, or general medicine, to name a few. Presenting Ryan White eligibility documentation at each location can be cumbersome for patients and, potentially, become an obstacle where patients choose not to access much needed services. Although the statewide custom CAREWare build has been installed at our clinic, we are still working with ADHS for full deployment of the mentioned features and will continue to rely upon LabTracker™ HIV as our primary HIV clinical database.

How has your program managed HIV patient data?

We use 2 health record solutions in our institution: one is an electronic health record (EHR) and the other is an electronic medical record (EMR). Our primary ambulatory electronic EHR system is Allscripts™.^† Approximately 1 year ago, our 2 HIV clinics were separate entities from a patient database perspective. Both sites comprised large patient populations and presented us with significant challenges as we integrated data from different clinic management systems to LabTracker™ HIV. Operating the Ryan White programs within a hospital-based clinical setting provides the benefit of access to an EHR system, which allows us to easily follow and obtain patient data as they use outpatient services throughout the hospital network. In some cases, however, manual retrieval and scanning of documents into the EHR systems was needed, such as when our HIV patients who are privately insured use health services outside the university network.

Since our primary EHR does not capture inpatient services, we use an inpatient EMR program (Sunrise Clinical ManagerTM; formerly developed by Eclipsys Corporation, now owned by Allscripts™^‡) to capture patient data for our HIV patients who require inpatient health services. Our inpatient and outpatient systems are not bridged, and manual data entry of inpatient records from the EMR to the primary EHR system is required. We still need to scan patient data collected in the Sunrise Clinical Manager™ into our primary EHR as well as transfer it into our Ryan White-approved reporting programs.

What challenges have you encountered with your current EHR solution?

In our current EHR solution, it is not easy to navigate and it is difficult to query patient data. This is especially important with Ryan White programs because these functions are essential to query utilization, costs, and a variety of information required under the Ryan White reporting guidelines. However, our current EHR system does not have this capability, which requires us to physically extract data from our EHR system and manually input these data into a HRSA-approved reporting program. This is a long and costly process, as manually extracting and transferring data involves protracted interaction with our institution’s data management services and a considerable time burden on our staff.

What are important functions you feel are necessary for managing HIV services at your institution?

There are a number of programmatic and reporting functions that are important for our HIV data management requirements. Some of these include:

• Unduplicated patients served within a reporting timeframe
• Services accessed by patients
• Past and present patient health indicators (e.g., laboratory results)
• General healthcare needs per HIV standards of care
• A program that can interface with our quality management program
• An EHR system that is compatible with a HRSA-approved database

One of the biggest concerns with data migration when working with multiple systems is to ensure that information is correctly accounted for in all the systems. It is essential to plan the correct flow and accountability of data across the different tracks for reporting.

What steps are you taking to improve the management of HIV services at your institution?

One of the major challenges we face on a daily basis is working with multiple systems/programs. To address this issue, we are currently evaluating one EHR solution to meet our complete HIV data management needs instead of relying on multiple programs. We are evaluating AVIGA™, a next generation EHR from Janssen Diagnostics, Inc. (formerly Virco Lab, Inc.) that has been designed to meet all the requirements for meaningful use. AVIGA™ is a Drummond-certified™^§ (EHR Modular), web-based (SaaS) EHR solution. This program is completely suitable as a general purpose EHR for use in the ambulatory care setting, yet it retains functionalities uniquely required for healthcare professionals involved in HIV/AIDS care. It is also designed to simplify, collect, assemble, and report all information required by the Ryan White CARE program. The AVIGA™ EHR solution includes AVIGA REPORTER™, an HIV-specific data reporting and querying module. Our hope is that the AVIGA™ EHR solution will streamline and optimize management of our client level data for our HIV patients.

Making the Most of the HITECH Act Incentives**

Case Example of How Meaningful Use of EHRs May Improve Quality of Care

The adoption of healthcare information technologies, such as electronic health records (EHRs), is expected to improve patient management decisions, outcomes, and quality of care.^1,2 Until recently, there were few published data demonstrating that adoption of EHR solutions yields a significant improvement in either quality of care or financial return over traditional paper-based medical record systems.^1-5 In the September 1, 2011 issue of the New England Journal of Medicine, Dr. Randall Cebul and colleagues reported that the use of EHRs at their primary care sites was independently associated with a significantly higher achievement of outcome standards and greater improvement in diabetes care compared with paper-based systems.⁶

In this retrospective cohort, the authors analyzed composite diabetes standards of care and outcomes from 27,207 adults with diabetes. The study included data from 569 primary care providers in 46 practices. Composite standards for diabetes care included receipt of a glycated hemoglobin value, testing for urinary microalbumin or prescription of an angiotensin-converting-enzyme inhibitor or an angiotensin-receptor blocker, an eye examination to screen for diabetic retinopathy, and administration of a pneumococcal vaccination. Composite diabetes-outcome standards included glycated hemoglobin <8%, blood pressure <140/80 mm Hg, low-density lipoprotein cholesterol <100 mg/dL (or prescription for a statin), body-mass index <30 kg/m2, and nonsmoking status. Data were stratified by insurance type, race or ethnic group, age, sex, estimated household income, and level of education.

The investigators found that EHR sites were associated with higher levels of achievement of and improvement in regionally vetted standards for diabetes care and outcomes. From July 2009 through June 2010, achievement of composite standards for diabetes care was 35.1% higher at EHR sites compared with paper-based sites (P<0.001) (Table 1). Achievement of composite standards for diabetes outcomes was 15.2% higher (P=0.005). Similar improvements were seen in 8 of the 9 individual component standards for EHR sites over the paper-based sites. In a sub-analyses, EHR sites were associated with a significantly higher achievement of care and outcome standards and greater improvement in diabetes care regardless of insurance type.

Table 1. Achievement of Composite Standards of Diabetes Care and Outcomes

	All Practices (%)	EHR Sites (%)	Paper-Based Sites (%)	Adjusted Difference
Care	46.6	50.9	6.6	35.1 (28.3-41.9)
Outcomes	41.0	43.7	15.7	15.2 (4.5-25.9)

 

The authors speculated that their promising results might dispel concerns other sites may have on the failure to improve quality of ambulatory care with adoption of EHRs. The authors acknowledge the limitations of the observational and retrospective nature of their study and noted it as unknown if the significant improvements they achieved with EHR use can be achieved by other primary care practices. Given these limitations, the authors concluded that their study results supported the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types.

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AVIGA™ QuickTips: Custom Reports and Data Querying

Ms. Yadira Ortega of the Implementation Team at Janssen Diagnostics, Inc. (formerly Virco Lab, Inc.)

“HIV clinicians frequently have a need to organize, analyze, and evaluate HIV/AIDS patient data. Reports play a critical role in satisfying the “meaningful use” requirements for the HITECH Act and incentives.”

One of the unique features shared by AVIGA™ and AVIGA REPORTER™ is that both applications allow users to design and conduct custom queries of their databases from their desktop without the need for outside IT support. Both products incorporate a state-of-the-art clinical intelligence function from MicroStrategy®, which allows all the discrete data for a particular site or sites to be queried by your clinical staff. Customized reports can be designed and executed directly from the user’s desktop.

For example, from a patient list, users can conduct a basic search from a number of prepopulated criteria (e.g., name, date of birth, date of visit, current laboratory results). From that basic query, the user can filter based on the data in which they are interested, such as selecting for all females in the practice and then sorting them based on CD4 cell count or medications. All search criteria are based on the data recorded in the program and can be visually explored when querying the database. To this end, a user does not need to be a database expert to build these custom query reports. You need to know what you are looking for and the system can compile the report. Results from your custom queries can be saved for future use, or exported and used as needed.