Sunday, May 3, 2009

EHRs on the Ground in Rural Oregon

I recently had the opportunity to participate in a discussion about practical health IT and EHR issues on the ground with several physician practices that participate in the Oregon Rural Practice-based Research Network (ORPRN). It is always extremely interesting for me to hear about real physicians and others who are trying to make this technology work. It is an effective antidote to participating in too many high-minded theoretical discussions, and an opportunity to test those theories against reality.

This entry is a summary of the minutes from a phone call I participated in with ORPRN members in February, 2009 concerning their health IT and EHR status. All of the participants have given me their approval to mention their names and comments. At the end, I will summarize the major themes discovered by Dr. LJ Fagnan of OHSU and myself.

This group is somewhat atypical, in that they represent practices that have agreed to participate in the rural practice-based research network. The fact that most have adapted EHRs sets them apart from average practices!

Topic of the phone call: Health Information Technology (HIT) in your practice – what do you have, what do you need, where do you go for assistance, how do you support your HIT needs?

William Hersh, MD, OHSU Department of Medical Informatics and Clinical Epidemiology Chair led the discussion about the representation of HIT in the economic stimulus package with an eye toward how Oregon can be positioned to receive stimulus dollars. There will be $17 billion in Medicare/Medicaid billing incentives and $2 billion toward standards development, IT workforce development, and other aspects of HIT infrastructure. Dr. David Blumenthal of Harvard has been appointed the new National Coordinator for HIT, so programs are likely to start being announced soon. A recent article by Dr. Blumenthal in the New England Journal of Medicine gives his views on a number of HIT issues. Finally, Dr. Hersh described the need for standards among electronic health/medical records (EHRs/EMRs) for helping to collect data for research.

Jon Schott, MD -Eastern Oregon Medical Clinic – Baker, OR

His practice has been using Centricity for 5 years. Local IT support is challenging as the clinic overwhelmed the capabilities of the local person. They now have IT support through Portland. The cost of the Centricity first cost about $5,000/seat and now is at $16,000, and so they feel trapped with the software.

Karl Ordelheide, MD -Lincoln City Medical Center

7 practitioners: IM-3, FP-2, Gyn-1, PA-1

Lincoln City, OR. Pop: 7000

His practice has been using Practice Partner since 2003. They have a one-way interface with medical manager office management system for demographics and with Meditech for lab, x-ray and hospital narrative reports. Also have interface to upload data to CDEMS Registry. There have been no changes to Practice Partner’s licensing fees and it is an affordable package. They have also had difficulty getting IT support to keep the system up and running; they are constantly behind. They bought the module for e-prescribing and it is not working. The company has apologized that it doesn’t work and cannot do anything more for them. Dr. Ordelheide’s group needs someone to dedicate time and energy to getting the module running. They also need someone to bring on new technology, to customize and set up the software and each box. In addition, communication with other systems is important.

Elizabeth Powers, MD - Winding Waters Clinic

Founded 1972, operates with 2 full-time MDs (Family Medicine), 1 part-time MD (Internal Medicine), 1 full-time NP (Family Medicine) and 1 part-time NP (Pediatrics).

Location - Enterprise OR with a satellite clinic in Wallowa, OR

Serves all of Wallowa County, population 6,991

Their practice involves 3 doctors and 2 NPs. They do not have an EHR, though do have electronic billing and e-prescribing. The hospital uses an EHR and allows their use of PAC for radiology and labs, but otherwise they use paper. They have wanted to switch to an EHR, but the two largest hurdles are: 1) Cost and logistics of installing the software, and 2) Finding an EHR that can talk to other systems. It would seem to be more feasible to use a personal health record instead. When referring patients to specialists, which they often do, will have to print to get the records to the specialists. A large benefit to having an EHR would be its function as a tool to manage population health. Currently they are tracking patient databases in Excel.

J. Bruin Rugge, MD, MPH -OHSU Scappoose

Founded in 1998 – 4 MDs (all FM) – 2 PAs – 2 FNP

Scappoose OR, population 6,500

Have been using OCHIN EPIC since 9/26/06

Sole source of health care for Scappoose OR, a community of 6,500 – see all ages and individuals from all backgrounds; and we provide the full scope of Family Medicine.

They use Epic through OCHIN (EHR for Safety Net clinics), though they have a more stripped-down version of Epic. He stated that the clinical outcome is not influenced by the charting method, and that providing excellent care can happen with paper charting. They do use e-prescribing, and have had problems. Also, being part of OCHIN, only so many seats are available for clinicians to use at a time, and he has had to try logging in multiple times in order to get into the record. The system has also gone down, and clinicians have had to log reports using hand-written forms that are later transcribed or scanned. He has noticed his workload taking on many more secretarial duties related to data entry and data housekeeping. When labs are received from outside sources, there is a considerable lag until it is scanned into the system, and often it may not be in the section he would anticipate finding it. One benefit is that when patients transfer care from another Safety Net Clinic to his that their records are available in the system.

Albert Thompson, MD

Practice—founded in 1982 with 1 provider, ABFP

Location Pacific City, unincorporated, primary drawing area ~ 4000. Lincoln City secondary area, ~10k

They have used SOAPWare for 10 years, and are using a hybrid version of it. He began using an installation that is all electronic as of December. He would like to use a different EHR, but it is too expensive to change systems currently. He is dissatisfied with SOAPWare for a variety of reasons, including that it lacks some basic functionality Microsoft Office users are accustomed to, like double-clicking to select text. However, the EHR has been extremely helpful for medication management, and he could not imagine going back to paper refills. SOAPWare is also an excellent report-writing tool and provides a patient instructions form with an assessment and plan that is very useful. Each encounter takes quite a bit of typing, and when his data entry demands increased, his patient count decreased. Currently they fax prescriptions to pharmacies and have not yet explored e-prescribing. Inter-connectivity is lacking and switching to Practice Partner is too expensive. They do have an IT specialist and the practice administrator also has IT skills that keeps their systems functional.

Robert Law, MD -Dunes Family Health Care, Reedsport, OR

Currently 5 family physicians (4 are partners), an FNP, and a PA-c.

Clinic uses paper charts, though they also use tele-radiology quite a bit, which they can access through the internet. They also use electronic billing. He and his colleagues suffer from EMR envy as they have wanted to get an EMR for 10 yrs, but the cost is daunting and they do not have the capital for licensing and implementation, though they do have the necessary hardware. Access to an IT person is also a serious limitation as they currently subcontract to the single person who maintains the hospital. There is not money in the budget to hire another person to fill that role. For population management, they have created registries using diagnostic data in their electronic billing records, and this has worked well for management and quality improvement. Overall, they are poised to make the leap, but have not yet done it.

Scott Graham, MD

Started practice August 1999. Solo practice in which he hired a FNP 5 years ago. Family Practice. Rural community, Population 1800.

He falls into the same category as Dr. Law. Their hospital and clinics continue to explore the option, but nothing has really been closely looked at. IT is a big concern. A program that communicates with each clinic and the hospital is another road block and cost is a huge concern. There is interest, but we are not excited about spending more money, hiring more staff, seeing less patients, having to spend more time at a computer and less with patients, and the headache of EMR, yet. He is not convinced this would be an easy transition and until something comes along that is user friendly and not so expensive, so they are sticking with paper.

Some discussion that followed those presentations:

Hersh – Epic has encouraged its customers like OHSU to work with smaller practices to use the software, as Epic doesn’t focus on the smaller market. This could be a good solution in some cases. Overall, the barriers presented by the Steering Committee members are not unknown in the HIT world, and all can be solved with resources. Dr. Tom Yackel, the Chief Health Information Officer at OHSU, could provide information related to some issues, including expanding Epic as well as secure email needs.

Fagnan – There is a group from NYC that uses eClinicalWorks for 1,200 clinicians in their area. Perhaps ORPRN could meet with their medical director, Dr. Farzad Mostashari, to explore the possibility of partnering with them and using it. This would provide an alternative to Epic. He also echoed the request by Liz Powers to explore personal health records as an option.

Hersh –The Director of the New York Health Department recently published a paper describing their approach in Health Affairs and ORPRN may wish to talk with him about the work he’s been doing. Dr. Hersh summarized by noting the impressive efforts by practices on the call and recognizing that there were three main challenges: support, costs, and integration of data across systems.

Hersh and Fagnan noted some clear themes from this discussion. There are three major barriers to EHR adoption and use in these small rural physician practices:

1. Cost and return on investment – there are substantial expenses and risks for those expenses in these practices.

2. IT and informatics support – need help both with basic IT as well as clinical issues, yet it is not readily available, especially locally. There are explicit difficulties with e-prescribing as well as decreased number of patients visits per day because of time to document.

3. Lack of interoperability – cannot move data across practices or to centers in larger urban areas. Despite electronic systems, providers must scan in reports and lab results, as there is a lack of interfaces with the local hospital.


  1. Dr. Thompson's comments illustrate the nature of a major implementation challenge. Many physicians expect that learning/using an advanced EMR will be more like riding a bicycle or using a word processor. Besides... clinicians know how to ride a bicycle, and they can hop on just about any bicycle and just ride it. Clinicians also know how to create medical records, so they sometimes expect to be able to just walk up to an advanced, comprehensive EMR and jump right in. They often don’t realize that using a more advanced EMR is more like jumping into an airplane than jumping onto a bicycle. Only after clinicians realize they are shifting to a completely different paradigm, are they likely to budget adequate time and resources for implementation. None plan to fail, but many fail to plan. See my comments at
    Medical care is increasingly reliant on information technology. Entities seeking to improve medical care, and payers, are flying around in airplanes while most doctors are still walking (i.e. using paper charts). Our greatest challenge and weakness as an EMR vendor is figuring out how to convince physicians to advance (and budget) beyond bicycles. We have certainly been lacking in providing adequate implementation guidance and insistence. In the near future, physicians not budgeting adequately will only be able to purchase SOAPware after signing a disclaimer.
    Randall Oates, M.D.
    President, SOAPware, Inc.

  2. Hey there, awesome blog. I really like it.
    This is an awesome radiology software program. Check it out!
Radiology Software
    Let me know what you think.