Intégration de la
Télémédecine dans le Dossier
Médical Hospitalier
Joshua L. Cohen, M.D.
Professor of Medicine
Professor of Medicine
Division of Endocrinology & Metabolism
Director, Medical Faculty Associates
The George Washington
University Medical Center
The George Washington University
Medical Faculty Associates
•
Multispecialty Faculty Practice
Organization
•
Approximately 350 physicians
•
Provides comprehensive primary care
•
Provides comprehensive primary care
and specialized care
•
Accepts private insurance, Medicare,
Medicaid
Medical Faculty Associates
Diabetes Center
•
MFA patient population includes
approximately 6000 patients with type 1
or type 2 diabetes (2009)
•
Diabetes Center Professional Staff:
•
Diabetes Center Professional Staff:
Endocrinologists, Midlevel Practitioners,
Certified Diabetes Educators, Dieticians
•
ADA recognized Diabetes
Self-Management Program
Allscripts Enterprise
Electronic
Health Record (EHR)
•
Web-based EHR
•
Unified medical record shared by all providers
•
Functions:
Encounter notes Encounter notes Laboratory studies Imaging studies
Medication records
Electronic transmission of prescriptions Provider to provider communication
Project Goal: Complete a system integration of the mobile and web-based components of the WellDoc DiabetesManager® with the Allscripts Enterprise EHR to create the Integrated DiabetesManager® supporting diabetes management for patients and providers
Traditional EHR
Provider
Provider
Provider
Patient
Provider
Provider
Differences Between EHRs and
Mobile Health Applications
EHR
• Provider-centric Archival record
• General medical record • Adheres to established
standards
Mobile Health App
• Patient-centric
Personal empowerment Health maintenance • “Real time” function standards
Security
Data validity Data exchange
• Medical practice functions: Auditable record
User rights
Quality Control functions • Proprietary code
• Problem- or disease-specific Personal record-keeping
Coaching
Education and self-care • May adhere to standards
FDA-regulated mobile devices and applications
Integration of Allscripts Enterprise
®
and DiabetesManager
®
Integration team
: WellDoc, clinical, IT
administration, software development
1.
Agree on major project goals and priorities
Design Process
1.
Agree on major project goals and priorities
2.
Define “use cases”
3.
Develop detailed flow charts of steps needed
for implementation of each use case
4.
Formal team decisions when alternate
implementation options exist
Practitioner Priorities for
Integrated DiabetesManager
•
Provide practitioners with access to important
clinical data which is not currently available
•
Provide additional value to patients compared
with standard care
•
Aid in meeting current and upcoming
•
Aid in meeting current and upcoming
regulatory requirements
•
Seamless use with access through
Enterprise
®EHR
•
Intuitive use with minimal need for additional
practitioner training
•
Minimize additional “tasks” resulting from
integration
Use Cases
•
Registration and deactivation
•
Data transfer and coordination
Clinical information
Medication
Laboratory results
Approximately 20 use cases developed:
Laboratory results
•
Messages from or to:
Patient
Provider
Systems
•
Reports
Issues Identified During Use
Case Development
•
Integration of different care models:
DM
®- single primary care provider,
Enterprise
®- multiple providers
Provider rights
Access for non-MFA providers
Access for non-MFA providers
•
Data repository functions:
Where is the data, DM
®or Enterprise
®What is the “source of truth”?
Distinguish patient-reported data in DM
®from validated data in Enterprise
®Medication Reconciliation
Medication Reconciliation Problems
•
Lack of correspondence between
medication data fields in Enterprise
®and DiabetesManager
®•
Patient not taking medication as
prescribed
prescribed
•
Medication prescribed or changed by a
non-MFA physician
•
MFA provider does not update
medication list with current prescription
Mobile Health and the
Regulatory Environment
•
Device/Application: Efficacy and safety
Food and Drug Administration (FDA)
•
Communications: Bandwidth, Security
•
Communications: Bandwidth, Security
Federal Communications Commission (FCC)
National Institute of Standards (NIST)
•
Cost-Effective Utilization (CMS)
Meaningful Use
•
Stage I
ePrescribe
Electronic exchange of health information Collect and submit health quality data
•
Stage II: Advanced clinical processes
Disease managementMedication management Clinical decision support
Patient access to their health information
•
Stage III
Improvements in quality, safety and efficiency Patient access to self-management tools
To Qualify as Meaningful Use
•
To qualify for the first wave of HITECH
meaningful use incentives starting in 2011,
eligible professionals -- such as doctors and
nurse practitioners -- must meet 15 core
requirements.
•
In addition to those core requirements,
healthcare providers also must meet five
objectives of their choosing from a menu of
10.
Requirements for HCP
1. Use CPOE for at least one medication order for more than 30% of patients.
2. Implement drug-drug and drug interaction checks. 3. More than 40% of permissible prescriptions written
are generated and transmitted electronically using certified EHR technology (for eligible providers only). certified EHR technology (for eligible providers only). 4. Record demographic info, such as gender and race,
for 50% of patients seen by EP or admitted by hospital. 5. Maintain up to date problem list of current and active
diagnoses for 80% of patients.
6. Maintain active medication list for 80% of patients seen by EP or admitted to hospital.
7. Maintain active drug allergy list for 80% of patients seen by EP or admitted to hospital.
8. Record and chart changes in vital signs, such as height, weight, BMI, blood pressure, for more than 50% of patients over age 2.
9. Record smoking status for more than 50% of patients over age 13.
10.Implement one clinical decision support rule for
Requirements for HCP (2)
10.Implement one clinical decision support rule for EP's specialty or hospital's high priority condition and track compliance with that rule.
11.Report clinical quality measures to the Centers for Medicare and Medicaid Services.
12.Provide more than 50% of patients with electronic copy of health information upon request within 3 business days.
13.Provide clinical summaries for each office visit to more than 50% of patients within 3 business days (eligible professionals only.)
14.Perform at least one test of certified e-health record's capability to electronically exchange key clinical information, such as problem list or medication list,
Requirements for HCP (3)
information, such as problem list or medication list, among providers of care or patient-authorized entities.
15.Protect electronic health information created or
maintained by certified EHR technology by conducting or reviewing security risk analysis and implementing security updates.
Physician Concerns About
EHRs and Telemedicine
•
Increased time requirements during
patient encounters
•
Regulatory burden
•
Regulatory burden
•
Overhead costs
•
Controlling patient access to providers
Patient-Centered Integrated
Network
Patient
Internet and
Social
Networks
Sensors
& Devices
Provider
Personal
Health
Application
Potential Benefits of Integrated
Mobile Health Systems
Providers
• EHR becomes an active rather than archival record • Clinical decision support
Patients
• Improved treatment adherence
• Frequent reinforcement of • Clinical decision support
• Access to real time clinical data
• Pattern analysis and recognition
• Improved adherence to evidence-based guidelines
• Frequent reinforcement of treatment goals
• Improved patient
understanding of the impact of behaviors on diabetes control
• Education resources • Reminders
