Bostrom AC et al. 2006 "Electronic health record: implementation across the Michigan Academic Consortium."

Bostrom AC, Schafer P, Dontje K, et al. Electronic health record: implementation across the Michigan Academic Consortium. CIN 2006;24(1):44-52.
"The Michigan Academic Consortium of academic nurse-managed primary care centers supported member sites to venture into computer-based advances with the potential to improve quality of health services and students' educational experiences. The experiences of this consortium as it incorporated electronic health records in tandem with an electronic patient management system at several of its member sites reveal the benefits and challenges of such an endeavor. The processes of selection, adoption, and implementation of the electronic health record are discussed in this article. Many lessons learned in the process are discussed."
To report "the experiences of this consortium as it incorporated electronic health records in tandem with an electronic patient management system at several of its member sites reveal the benefits and challenges of such an endeavor."
Type Clinic
Primary care
Type of Health IT
Electronic health records (EHR)
Practice management system
Type of Health IT Functions
The practice management system included coding and billing, financial reporting, and data analysis, and "was essential for basic functions such as scheduling, patient tracking, and patient demographic data." The functions of the Grand Valley EHR are not described. The EHR at Michigan State University (MSU) is "is a well-established and comprehensive EHR" that includes point-of-care reminders, "practitioner notes, labs, and radiology reports and a link to pharmacy to order and renew medications. It allows access to the records from other [affiliated centers] of the patient currently being examined. For example, the practitioner can access records for a specialist referral from a ... center in Ann Arbor or Detroit or even other states such as Florida." It is "a complete system and requires the provider to document everything in the EHR."
Workflow-Related Findings
At MSU, the choice of a large existing EHR system "made the complementary changes of individualizing templates challenging. Many system changes are made nationally and cannot take into consideration individual clinic and practitioner needs. Although some individualization of templates is possible, this makes data retrieval more challenging. Collecting statistics from a patient sample can only be accomplished with the national templates or a common language. Individualized templates make the retrieval of data from the EHR almost as cumbersome as using a paper record."
At Grand Valley, the lesson about complementary changes became evident because the EHR screens were formatted around a medical model of care. The choice had to be made to either use the screens as developed and make the nursing model of primary care invisible or assertively work with the vendor to modify the health screens. The GVSU users decided on the latter. This was a costly endeavor in terms of both time and money due to the required communication between the vendor and each staff member at the health center. The NPs, nurse case manager, and receptionist were key to the success of these dialogues. In addition, the administrator of the center spent many hours gathering data from the practice environment, organizing those data into meaningful clusters, and sharing them with the software company. From these interactions, the software developers and the practicing staff were able to negotiate time for product refinement and additional training.
Grand Valley "found that the long-term success of the implementation is dependent on continuous collaboration [with] the vendor. This has required one person to gain skills in troubleshooting issues on site and communicating problems via phone for vendor problem-solving. Although the nurse clinicians have gained significant skills in managing the EHR, there is no substitute for a technically astute staff member or two."
At Grand Valley, "the EHR screens were not intuitive to the practice of the NPs... The solutions included reconfiguration of the screens."
At Grand Valley, "the NPs and the professional staff nurse used the opportunities to share documentation and plans of care with their clients via the portable computer's screen display."
At Grand Valley, "in 2005, ...[b]oth the PM [practice management] and EHR software systems have continued to evolve. These upgrades and changing interfaces continue to challenge the staff, administrator, and students to exploit the capabilities of the system."
At MSU, "practitioners who had previously used only paper records were required to jump right in and document entirely on the computer system."
At MSU, "an activity such as ordering a laboratory test often required several entries because once the lab was drawn the order disappeared from the system. This required the practitioner also to chart that the lab was requested for future reference and follow-up."
At MSU, "[t]he distance of the clinic from the central [affiliated] health center contributed to technology problems. Specifically, the initial Internet connection to the central site was a dial-up line that at midday often became overwhelmed and disconnected. This frequently resulted in lost data that had not been saved to the system. The resolution to this was to add larger capacity direct lines between the health center and the central server while increasing the server capacity at the [central] site."
At MSU, "although [the point-of-care reminder system] has added extra documentation time, preventive reminders have proven useful in making sure that what is done for the patient is actually documented. Using pull-down reminders available for most of the HEDIS measures, the NP can record a variety of required interventions, such as pneumococcal immunizations, depression screenings, and beta-blockers and echocardiograms for all post-myocardial infarction or heart failure patients."
At MSU, "computerized pharmacy ordering is ... extremely important ... for the quality care of those patients with comorbid conditions and multiple medications. All medications are ordered centrally and mailed to the patient. This allows the clinician to monitor possible interactions, contraindications, and use by the patient. In addition, the system recently has added a nonprescription section to this area so the pharmacy can be aware of over-the-counter and herbal medications taken by the patient."
Study Design
Only postintervention (no control group)
Study Participants
Experiences with electronic health record (EHR) implementation are described at three research sites. Two were established health centers near Grand Rapids, Michigan that implemented an EHR. "One site had opened in 1995 as a screening and health promotion center in the inner city and began operation as a full primary care site in 1998. The second site ... opened in 1999 on the main campus of [Grand Valley University] to provide primary care to university faculty, staff, and their families. In 2000, this clinic expanded to serve the primary healthcare needs of the approximately 20,000 enrolled university students." The third research site was a Michigan State University "College of Nursing HealthCare center that opened in ... 1999" and partnered with the Veterans Administration.