After a Successful Transition to a New EHR, Washoe County Health District NV Shares Insights Through an In-Depth Q&A
Washoe County Health District (WCHD), located in Reno Nevada, serves a population of around 400,000 people. They’re governed by a district board of health and have an appointed district health officer. The Community and Clinical Health Services division is comprised of approximately 56 full time equivalents and a budget of nearly $8 million. “ We had an antiquated Electronic Health Record EHR software with limited clinical functionality and billing was a problem with our previous vendor. We were being forced to upgrade by January, 2019 and since service was lacking, we decided to look for another EHR” stated Steve Kutz, RN, MPH, Division Director, Community and Clinical Health Services at Washoe County Health District. So the search began.
“I looked at pretty much everything out there and it seemed like they were all geared towards hospitals first and Public Health has very different needs” stated Brantley Hancock, Department Systems Specialist charged with finding a new solution. Steve, Brantley and the EHR selection team met regularly and after reviewing many options of EHR systems on the market, they decided to partner with Patagonia Health. In October 2015, the District Board of Health approved the contract with Patagonia Health. WCHD held a nationwide webinar on their transition to a new EHR. The following is an excerpt of questions asked by various health department staff. Through this peer-to-peer Q&A they share their story.
Health Departments Q&A
Q. What organizational needs were not being met by your previous EHR system?
A. Steve: Reporting and ease of use, ease of posting, and billing. Cleaning up of financial records. We were trying to invest in new modules to make things better but because of the lack of support for training and implementation we had to stop throwing good money after bad. So we just pulled the plug; just take our money and go away! With the decision to move to a new EHR, general excitement ensued. I took the whole team out that night to celebrate because we were going to end our bad relationship and move onto a new healthy and productive relationship. And I will give a shout out to Patagonia Health as they have been impressive from the first web demo and on-site demos throughout the implementation, go live, service, on-going collaboration for enhancements, and follow-up. They were helpful and really worked to get the appropriate information from us so that we could be as successful as possible with the implementation.
Q. Did the “script to PDF” process for data extraction completely fulfill the data record retention requirements or do you maintain a “read only” version of the previous EHR?
A. Brantley: I would say it met 80-90% of the data we needed. For the most part, my predecessor was a SQL expert. He had written a lot of EMR notes and EMR dashboards which already pull all these various data points into one coherent single PDF. So we finished all the SQL scripts of the dashboards and then converted them all into PDFs and migrated those over to the charts. We’re still currently using the previous EHR mostly for reviewing charts here or there, but there’s no new data being generated, it’s all being done predominately in Patagonia Health now.
Q. Who builds the tables behind the scenes?
A. Brantley: This is one of the biggest joys for me because I don’t have to anymore! Most of that is all done by Patagonia Health. It’s not like our old system where if you want to change a couple of things in a widget you have to modify 20 or 30 tables and write custom SQL code that we’d have to test and make sure it worked and was coded correctly – in the past, I manually had to get into the database and edit SQL code – I no longer have to do any of that. I just have the simple adding or removing users or changing users permission levels. Beyond that there are no cryptic table configurations at all.
Patagonia Health has a full development staff that manages all the enhancements as part of the subscription fees. They provide enhancements at no charge. The releases come out every six weeks.
Q. When updates or changes are provided, does it only effect the county that requested the change?
A. Brantley: It varies. When we approach them, we put in for what would work for everybody rather than just us. For example, the completely rebuilt Immunization widget, the automated applying charges for meds and immunizations on charts, the entire HIV widget, a one click report-out of all HIV data with 195 columns of data for CDC. So the stuff we’ve developed with Patagonia Health can be rolled out to everybody. There is some customization, like individual encounter notes you would use for your charting that would be specific to your agency and wouldn’t impact everybody.
Q. How much did you customize the baseline EHR?
A. Brantley: The base structure not much, other than rebuilding the Immunizations part. But for the most part there were just a few minor tweaks here and there.
Q. To what extent did you re-engineer your existing business & clinical processes?
A. Steve: I would say our biggest change has really been on the clerical side with checking insurance eligibility during the appointment-making process. We found it was taking way too much time on the back side and then we’d find out that people weren’t eligible and their account was inactive, especially when it comes to ACA plans, so they’re enrolled in it, but their account is inactive because they didn’t make their latest premium payment let’s say.
There are some smaller clinical changes but nothing major, and if anything, when we were implementing this, we said, “we know you like your processes but think about how you could do it better and different.” We don’t want to cram the new EHR into the old ways and now is the time to take the opportunity to see how we could improve on the ways we did things and hopefully be a little more efficient.
A. Brantley: When we used paper super bills, nurses relied on clerical staff to input the data and now it is all done on the nurses’ side. So this was a pretty big change but we have since moved past that. Also, we bought the optional Communicator App, so before, the busy clerical staff had to cold call every person that would be seen the next day to remind them of their appointments, and now we send voice mail and text reminders and that has freed up staff resources.
Q. Since you were functioning in two EHR systems, did you maintain a service/support contract with your previous vendor?
A. Steve: No, we did not! We terminated our contract with them in December 2015. Since it’s a system that we bought and it’s on our servers, we still have access to everything.
A. Brantley: With the contract terminated, we don’t get anymore bug fixes or updates from the old system – it is just a read only database at this point. The SQL server that it runs on is also going out of support as of January 2019, so that will be dismantled completely.
Q. Did you look into any other EHR software besides Patagonia Health?
A. Steve: I remember Brantley coming into our meetings saying I have reviewed this one, this one, and this one and I haven’t found anything that meets our needs. And then he came in one day talking about Patagonia Health and we said OK, let’s take a look at it.
A. Brantley: It wasn’t like I was unimpressed by the other vendors, I just knew in the back of my head the amount of work it would take to modify a hospital grade system that does everything and cut it down to the core public health functionalities. I just didn’t think anyone would be up to that task.
Q. It is clear you have been very pleased with the Patagonia Health system and process. What is one area where the system or process could have been better?
A. Linda Gabor (Implementation Team Manager and Maternal Child Immunizations Supervisor): All in all in the Immunizations area we have embraced it. The nursing time has not increased even though they are doing more on the super bill stuff. I hear from other departments’ nurses that it is still taking a bit more time with the medication component because it is new to them, but it is getting better every day.
A. Brantley: It has the ePrescription functionality so it does drug-to-drug, allergy-to-drug check and all that, so it is a little slower than just being able to click a drop down, find Ibuprofen and move on; you have to prescribe 5 Ibuprofen then go back and actually dispense it. That is probably the one area that has slowed us down a little bit.
Q. Why did you select Patagonia Health?
A. Steve: We were just impressed with the company. The level of support, their engagement, their commitment, their willingness to work with us, meeting our needs and their follow through from the time of the first webinar, on-site demo, implementation, go live, on-going enhancements and through to even today. And they’re a good group to work with – they’re fun.
Q. Were you able to calculate a ROI? How many months did it take you to recoup your one-time costs?
A. Steve: No, we have not calculated an ROI. Our contract is spread out over 5 years, so it’s hard to say, but if you think about it in terms of our reimbursement from just our third party payers alone (and that doesn’t include any of the fees that we collect at our counter) Patagonia Health has been a big part of us successfully increasing the revenue stream, so it helps our bottom line for sure! And how we see it, for every dollar we collect from the third party payer, it really helps sustain and stabilize all of our clinical programs. We posted fiscal year-to-date (9 months in) over $149,000 after implementing Patagonia Health. This is the best we have ever done. Our prior fiscal year was only $9,300.
A. Brantley: From a strictly math standpoint, we’re already bringing in more annual revenue since the integration with the EHR and the clearinghouse, than the amount of our yearly contract!
A. Steve: I would say that based on the cost of the system, Patagonia Health’s commitment and follow through, I would absolutely do it again and I think it was a very good investment in our time, our money, and our resources.
DEVELOPING AN IMMUNIZATION APP
“While most of the staff was very excited and loved the demo provided by the Patagonia Health team, there was a strong hesitancy on the Immunization supervisor’s part as the system just did not meet their program and reporting needs. Despite not even being sure we would go with Patagonia Health, we started working with them to develop a new Immunization app.” -Steve Kutz
Health department patients bring their immunization records from various countries, schools, etc. The process of entering immunizations, especially families, at registration takes too long and slows things down. WCHD wanted an EHR which will be fast for immunization entries.
WCHD staff worked with Patagonia Health developers directly to collaborate in design of the immunization App to make it robust and fast.
The immunization improvements included:
- User interface designs for adding patient immunization history quickly
- User interface designs to allow easy entry of multiple vaccine administration records on a single page
- Registration of families
- Official reporting for patient vaccinations and vaccine inventory
- Best practices when handling vaccines with diluent
- Processes supporting the bar-code scanning of vials to pull from inventory lots and then send specific packaging NDCs to billing
Thanks to the involvement of the team at WCHD, the Immunization App is now a robust immunization platform available to all customers.
“From the initial conversation in late 2014 though now (2.5 years later), Patagonia Health has been a joy to work with. They have not let the foot off the pedal. They are fun to collaborate with.”
Steve Kutz, RN, MPH, Director Community & Clinical Health Services, Washoe County Health District
“Patagonia Health’s migration process was far less painful than any of us at Washoe County thought it would have been. We were used to years of struggling to pull data out of our previous EHR for even day-to-day reporting. Instead, over the course of 4 to 5 sessions, I was able to work with Patagonia Health developers and pinpoint all the various types of data that could be feasibly migrated between the old and new systems. Once we had all of the necessary SQL queries written, 2 weeks before our go live, I just simply ran the pre-written queries and uploaded the data. The day of the official data migration took me a total of 2 hours to complete everything. Over the weekend Patagonia Health handled all of the uploading into their system and Monday morning all of our data was ready to go in our new Patagonia Health EHR.”
Brantley Hancock, Systems Specialist, Washoe County Health District