Transforming geriatric practice and workforce development: Leveraging electronic health records to train healthcare teams

Electronic Health Records (EHRs) can support interprofessional collaboration in geriatric care and improve efficiencies if team-based protocols are embedded, guidelines for interprofessional use are developed, and teams are trained to effectively use EHRs for optimal patient outcomes and provider satisfaction.1, 2 This article shares strategies associated with reengineering the core functionalities of an EHR system to transform a primary care (PC) practice to deliver interprofessional team-based health care to older adults, integrating person-centered and age-friendly care, prioritizing individual patient needs, addressing biopsychosocial health needs, and developing goal-oriented team care plans ("the Model"). This transformation occurred in a Kentucky geriatric-focused PC clinic within an academic health system. The clinic transitioned to the Model explained above, integrating three geriatricians, two nurse practitioners, two medical assistants, two social workers, three behavioral health therapists, two healthcare navigators, two community health workers, and one pharmacist into care delivery. The Model necessitated a shift from traditional roles of geriatrician-led PC to team-based PC, promoting less restrictive roles and interprofessional support among providers. Team composition varied based on patient needs, blending professional boundaries for interprofessional efforts to meet these needs. The transition coincided with the adoption of Epic Systems Corporation's EHR platform and depended on integrating the Model into Epic, working collaboratively with the EHR team. The Normalization Process Model (NPM)3 provided a four factor framework crucial to the successful transformation as it focused on factors that could promote or inhibit the Model from becoming part of routine healthcare practice (Figure 1). This two-year process included redesigning workflows and enhancing interprofessional expertise for geriatric team-based care. Transformation action steps, the subsequent organizational changes, and main stakeholders are described in Figure S1. Initially, the clinic's PC was led by geriatricians with support from nurse practitioners, social workers, and medical assistants, with the EHR being used for task documentation. The new Model promoted an environment of collaborative care that enhanced role satisfaction, and reduced geriatrician burnout. To facilitate this change, we widened the scope of Epic workflows from centering on physicians to encompass the entire team. This required training for the Epic team in our Model and the appointment of a clinic liaison with IT expertise to facilitate the customization of team-based workflows. The clinic initially struggled with low MyChart portal usage by providers and patients. An education campaign trained patients on MyChart to improve self-advocacy and communication. Staff assisted inactive users and engaged patients via MyChart to build user trust. An age-friendly health assessment tool (the Index)4 was integrated into MyChart for pre-visit assessments, helping providers to use assessment data to discuss What Matters Most to patients. After 2 years, MyChart activation and eCheck-in usage in our clinic significantly outperformed the broader health system (76% vs. 55% and 61% vs. 20%, respectively). To encourage interprofessional collaboration, we initiated education on the significance of each role, developed interprofessional competencies, and began blending the boundaries between different professional roles. Periodic training on Epic's care coordination note features improved interprofessional care, showing significant improvements in mutual respect (t = −5.7, p < 0.001), role clarity (t = −7.0, p < 0.001), communication (t = 6.1, p < 0.001), and teamwork (t = −7.3, p < 0.001) measured by the Interprofessional Collaborative Practice Scale.5 Relational integration in Epic advanced as team members registered their roles and specialties on patient care teams, enhancing visibility on the services and team members involved in patient care. Team members were trained in using Epic's care coordination notes for timely patient updates, strengthening interprofessional collaboration. Pre- and post-implementation patient satisfaction data on the likelihood of recommending the practice to others showed a significant improvement after the two-year implementation period (t = −4.83, p < 0.001). The care model's success relied on comprehensive education for team members on age-friendly health care, featuring weekly didactics, online modules, case discussions, and simulations (Figure S1). Healthcare system leadership implemented a routine half-day closure of the clinic each week for ongoing education, allowing for an adjustment of the clinic's productivity targets. This recalibration meant restructuring operations and output expectations to accommodate educational activities without compromising the clinic's performance and patient care. Mandatory 8-h Epic physician-centric onboarding was realigned to support the model's team-based approach. Collaboration with Epic trainers led to ongoing, team-focused training sessions, integrating the Epic team as partners in refining workflows. Small learning communities were formed to boost professional communication skills, sharing best practices for EHR use, and promoting integrated care. This blend of education, tailored training, and collaboration enhanced the team's capacity to deliver person-centered, age-friendly health care, establishing the Model as both innovative and sustainable in the healthcare system. Longitudinal patient outcomes data showed patients significant improvements in overall Index scores, psychological health, and health behaviors whereas biological health measures remained stable. Having gained an improved understanding of Epic, the team collaboratively rebuilt the Index to fit into e-check in and rooming protocols. We utilized Epic's native features, such as built-in assessments, the social determinants of health wheel and care plans. This improved the tool's integration and usability during patient chart reviews. To enable team-based workflows for the Model in Epic we had to create new security profiles for noncredentialed staff. This was necessary to bypass limitations in existing profiles. With support from our healthcare system and Epic leadership, this development marked a significant milestone in geriatric care transformation. Many lessons were learned transitioning from a geriatrician-driven model to an interprofessional, team-based Epic integrated model. Dialogue on roles fostered a collaborative, respectful culture, aligning with patient-centered care. Emphasizing interprofessional collaboration reduced provider burnout and shifted focus to an age-friendly health approach. Integrating the Model into Epic necessitated specialized workflow-oriented training to mitigate team stressors. The training improved interprofessional competencies and highlighted the importance of EHR optimization training in PC. Updating security roles within Epic facilitated new roles and security profiles to support a team-based approach to care. The transformation highlighted the importance of ongoing review and modification of processes, centering the team, and continuously educating and reeducating current and new team members to prevent culture drift from team-based care back to dominant physician-centric models. We maintained a focus on unity, cooperation, and a collective commitment to patient-centered care to avoid cultural drift. Future initiatives can build upon these foundations, using EHRs as tools for change and exploring the implications of fully integrated, team-based models on patient outcomes and the efficiency of both PC settings and larger healthcare systems. All listed authors fully participated in the study concept and design, had full access to all the data in the study, taken responsibility for the integrity of the data and the accuracy of the data analysis, and had authority over manuscript preparation, the decision to submit the manuscript for publication, and approved its current contents. All authors meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. All members of the FlourishCare team who have helped to provide age-friendly patient-centered health care to older adults in our clinic and who continue to participate in our quality improvement projects aimed at improving the care of older adults. No personal or financial conflict of interest. This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $4,319,536 with zero percentage financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, HRSA, HHS, or the U.S. Government. Figure S1. Transformation action steps, health system organizational changes, and stakeholders. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.