Outline. Why keep medical records? Electronic Medical Records: key implementation issues. Paper Medical Records

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Electronic Medical Records:

key implementation issues

C.T. Lin MD

Senior Medical Director, Informatics University of Colorado Hospital

January, 2008 For CLSC 6800 HLTH 6071

Outline

Paper Medical Records

– The burning platform

Electronic Medical Records

– What and why

– EMR Current design challenges – Translation vs. Transformation

• Historical record of care • Communication/continuity • Preventive Care • Quality assurance • Legal record • Financial record • Research

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• can’t find the chart

• can’t find the result in the chart • can’t read the chart

• can’t easily collate the data • can’t compare across patients • no analytic capacity

Paper disadvantages

Paper

Medical

Records

Paper records: Legibility?

One

day

’

s worth of

papers to

be

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by ctl

Quick!

Recall

Recall: Find all the patients : Find all the patients who take Vioxx!

who take Vioxx!

P4P

P4P: Prove that we give : Prove that we give Aspirin to all our CAD

Aspirin to all our CAD

patients!

NQF

NQF: Have all our diabetes : Have all our diabetes

patients had a Pneumovax?

Vaccine

Vaccine: Call all high risk : Call all high risk

patients to get flu vaccine

now!

Screening

Screening: We have free : We have free

PFT screening next week!

Who would benefit?

Paper records:

the

burning platform

•

•Legibility suspectLegibility suspect •

•Costly to maintainCostly to maintain •

•Not disasterNot disaster--proofproof

•

•CanCan’’t qualify fort qualify for

pay

pay--forfor--performanceperformance •

•Population and quality Population and quality studies impractical

studies impractical

Electronic Medical

Records

Functional components of EMR

• Integrated view of patient data • Clinical decision support • Clinician order entry

• Access to knowledge resources • Integrated communication support

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Why must we have an EMR?

• Because the current system is inadequate

• Because expert bodies recommend it • Because the government says so • Because insurers are going to require it • Because patients are going to demand it for better safety and improved service

“…

information technology

must

play a central role in the redesign of

the health care system if a

substantial improvement in quality

is to be achieved over the coming

decade.”

– Institute of Medicine, 2001

EMR design challenges

• Human-machine interface (user-friendly?) • Data acquisition (how to get data in?) • Coded data (how useful is the stored data?) • Technology adoption (who will use it?)

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• Donald Norman

– The Design of Everyday Things – The Invisible Computer • Edward Tufte

– Visual Display of Quantitative Information – Envisioning Information

– Visual Explanations

– The Cognitive Style of PowerPoint • William Cole:

– Semantics of Graphic Data Display

The Human-Machine Interface

• Paper record of scribbled notes? (fast!) • Scan handwritten notes? (DHH) • Typing of narrative text? (VA) • Dictation? (UCH)

• Voice recognition (Dragon: narrative) • Templates, pick lists (Coded data)

Data Acquisition

• Narrative

– Easily recorded as written or spoken – No limits on nuances (choked on spaghetti?) – (Difficult to analyze patterns across time and

across patients)

• Coded

– Standardized definitions – No ambiguity

– Powerful for aggregate analysis – (Difficult to enter data)

Narrative vs. Coded data

• A finite enumerated set of terms intended to convey information unambiguously. (note that the English language fails all criteria).

• Current dictionaries have standardized definitions, but not all terms unique, not always reproducible (SNOMED, ICD9).

(dyspnea = shortness of breath = respiratory distress = labored breathing = panting = winded = SOB = breathless = exacerbation of asthma)

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• A senior resident wants to do a study on ER pain management in sickle cell anemia

• Full paper system very awkward (1+ year effort):

– Obtain ER registry for the past 5 years – Obtain a list of 200,000 patients,

– Manually select those aged under 20, African-American, with hematocrits of less than 20%.

• Electronic registration system simplifies selection (1 month effort)

• Coded EMR (1 minute effort)

Using coded data for research

• A clinician wants help with appropriate billing of a Medicare patient

– Attend weeks of training for Evaluation and Management Coding

– Or, by electronically coding data, allow computer support of E/M coding as note is completed

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Technology adoption

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The 80 - 20 rule

• In my opinion, the success of a project is perhaps 80 percent dependent on the development of the social and political interaction skills of the developer and 20 percent or less on the implementation of the hardware and software technology!

--Reed Gardner, LDS Hospital

A formula for adoption

+ Executive support and clear vision

+ Physician champion(s) at executive and clinic levels + Alignment of incentives for individual docs

+ Adequate analyst support + Adequate time

+ Robust hardware and software performance! = Successful implementation

A formula for adoption

Executive support and clear vision

Organizational behavior change At least a cost neutral ROI Transcription cost reduction

Marketability of patient safety (e-RX) Necessary for future quality initiatives Necessary for Patient Centered IT

Transcription Cost Reductions in Clinics Completing Allscripts Deployment

$0.00 $10,000.00 $20,000.00 $30,000.00 $40,000.00 $50,000.00 $60,000.00 $70,000.00 $80,000.00 $90,000.00 04/0 5/20 05 05/05/ 2005 06/0 5/20 05 07/0 5/20 05 08/0 5/20 05 09/05/ 2005 10/05/ 2005 11/0 5/20 05 12/0 1/20 05 01/0 1/20 06 02/01/ 2006 03/0 1/20 06 04/0 6/20 06 05/0 6/20 06 06/06/ 200 6 07/0 7/20 06 08/08 /200 6 09/0 9/20 06 10/10 /200 6 11/11/ 2006 12/0 6/200 6 01/06/ 200 7 02/0 6/20 07 03/06 /200 7 04/0 4/20 07 05/0 5/200 7 06/0 6/20 07 Monthly Transcription $

Adv Reproductive Dermatology Endocrinology Interventional Pain Rheumatology Ophthalmology Spine Center Integrative Med UFM AFWilliams UFM Boulder

Urology Spine Pain Rheum Derm Endo IntegrativeAdv Repro UM Denver UFM Boulder UFM Park Mdw UM Anschutz UFM Westminster Greater than 80% Greater than 80%

reduction in monthly cost,

over $1M saved annually

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A formula for adoption

Physician champions at executive and clinic levels

Chief Medical Information Officer Seek out clinics with internal champions

(Not necessarily the geek, but the respected clinician instead. Rare that one person is both)

Photo apl

A formula for adoption

Align incentives for individual docs

Feds paying for quality (PQRI) University version:

Pay internal bonus based on use of EMR Physician billing improves by 14% Reduce workload by pre-loading data Generate useful reports (recall, quality)

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A formula for adoption

Analyst supportand/or Enough Time

You can bring a clinic live with 2 analysts and 40 physicians (20 faculty, 20 residents)… in about a year.

We have 3 teams of 4 analysts + 1 training specialist to implement 3 clinics every 10 weeks

Protect physician time for training, initial use Seeing 50-60 patients a day, and learning EMR is unrealistic

The impossible triangle

Successful implementations are like keeping all three sides of a triangle facing up. You can have 2 out of 3, but you’ll never get all 3.

cheap good

fast

Robust hardware and software

(performance)!

The goal: sub-second response

Counting clicks vs. fast systems

Tablet PC medical assistant story

“The tapper” story

Database server fiasco

Miscellaneous thoughts:

Include your patients in a media campaign (pardon our dust, we’re making improvements)

The attitude and efforts of 1 person can make all the difference in success or failure of a clinic

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QuickTime™ and a decompressor are needed to see this picture.

A formula for adoption

+ Executive support and clear vision

+ Physician champion(s) at executive and clinic levels + Alignment of incentives for individual docs

+ Adequate analyst support + Adequate time

+ Robust hardware and software performance! = A successful implementation must have all these

elements but should have at least one of these

in SPADES.

Assembling an EMR

So, you have 2 EMR systems.

Well, can’t you just hook the 2 systems up? What’s the big deal?

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EMR Systems Map

IDX Visit Management, Patient Billing, & Scheduling 3M Clinical Workstation: integrated viewer, clinics + hospital

Provider Portal (MedXplore -> McKesson) Patient Portal

Lab RIS Path Dictation

IDX ADT Allscripts: Deployed 20 of 40 Clinics Em er g enc y McKesson

RN docu, Bar Code, Inpt Pharmacy, CPOE

Viewer Interactive system Infra-structure GI p ro ce d CV proced OB GY N Ps yc h Pe ri -Op Onc ology Tr ans p la nt

EMR:

Substitution

versus

Transformation

EMR: Substitution

• Its faster to create a new patient chart

• EMR charts can’t be misplaced

• Notes are LEGIBLE

• Prescriptions are LEGIBLE

• No more sticky notes

• 2 people can use the chart at a time

Transformation: Safety

• Electronic documentation instantly

available, legible, longitudinal

• Safer prescribing (drug interactions,

allergy check, formulary check)

• Vioxx recall: Patients identified,

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Transformation: Quality

• Flu vaccine: identify highest risk

patients to immunize first

• Diabetes: Track patients with

highest Hemoglobin A1c’s

• Heart disease: monitor use of

ACE-I, Aspirin, beta-blockers

Transformation: Patients

• Patients and physicians both

contribute to a shared medical record

• Patients collaborate with providers to

set their own treatment goals

• Patient can access, or give access,

to their record anywhere in the world

Transformation: no EMR

• Conversations between physicians,

nurses, and patients undergo:

– Voice recognition

– Natural language processing

– Integrated, non-interruptive alerts based on latest evidence

Serious Creativity, de Bono, 1992

Substitution vs. Transformation

Like improvements in transportation, EMR developments generally are incremental at first…

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It was hard to foresee what the carriage could

become…

And in the broader sense, what transportation could become

Substitution vs. Transformation

And we will always dream…