Bringing Order to the Chaos of Electronic Health Record Implementation

The challenges of implementing electronic health records systems in large medical centers is enormous but the challenge can be just as great in rural primary care practice sites unaffiliated with a health care system.   The North Carolina AHEC Program has a history of working to improve the quality of health care in North Carolina, so when they were awarded a federal grant as part of the HITECH Act to create Regional Extension Centers (REC) to assist with the transition to electronic health records in rural, primary care practices it was a great opportunity to expand the scope of quality improvement across the state.  This marriage of existing quality improvement programs led a staff of one growing to 30, and a handful of practices served expanding to hundreds.

The nine AHECs throughout North Carolina have over 50 staff helping almost 3,900 health-care providers choose an electronic records system and make improvements to serving patients based on data collected through the records. Providers are required to meet federal and state standards for meaningful use of the electronic records to receive incentive payments.

The challenge was to share recommendations, advice, and best practices between the AHEC Quality Improvement staff (QI) across the state.  The details of getting to meaningful use were daunting, and the amount of information that was coming out on all fronts felt overwhelming at times. AHEC librarians were struck at the sense of information overload the REC consultants were feeling and they wanted to offer help in managing the information critical to achieving success for the project.

“In order to support the ongoing training and information needs of staff providing high-stakes, complex services to busy, time-constrained practice staff, our very small program office-based team needed a way to curate a constant stream of information efficiently and effectively and make it available immediately,” said NC AHEC QI manager Laura Brown.

AHEC leadership turned to the HSL for help in part because of the long-standing relationship between the two organizations.  That relationship includes HSL’s ongoing management of the AHEC Digital Library. “As field-based staff, [the REC consultants] require easy, web-based access to rapidly-changing information,” said Brown. “Given the constantly expanding body of knowledge our staff must synthesize and apply in order to support practices with whom they work our program’s dependence on information and knowledge management cannot be overstated.”

The HSL’s AHEC Digital Library staff had been working on providing a suite of tools that would allow AHEC staff to work collaboratively throughout the state. One of these tools was a wiki that would allow users to post, edit, and collaborative in creating documents. At first, HSL librarians used their wiki tool to create a space to archive consultant emails and other key files. However, because information hadn’t been standardized and collected appropriately, problems such as being able to find documents that had already been posted or creating duplicate copies of the same documentation, persisted. As a result, librarians came up with a three-part, comprehensive solution to organize the information in a standard format to organize the information better and make future retrieval easier:  AHEC Librarian Mary Beth Schell led the development of:

• A standardized, easy-to-read format for all emails, emphasizing key information and eliminating redundancy. To date approximately 1200 emails have been reformatted and included in the wiki.
• A tagging vocabulary of approximately 300 tags (and growing) addressing important concepts, including all aspects of the electronic health records incentive program. Top used examples include specific vendor names, Meaningful Use, NCQA, PCMH, EHR Implementation, and EHR attestation
• A set of 9 categories with which users can find information by browsing the wiki. . The categories with the most underlying links and pages are Certified Technology and Rules and Regulations

While librarians are known for their skills in evidence-based literature searching, this project relies heavily on the librarian’s information management skills to organize and categorize information so that it is more useful and retrievable.   NC AHEC Associate Director for Quality Improvement, Ann Lefebvre explains that there is no cookbook on how to do this and that is what makes this wiki so useful. It provides timely information that is readily available in the field. Each practice is unique so it is very useful to have one place where the consultants can login and find the information that they need when and where they need it.