Andrew Burton-Jones

October 29, 2014 abj@business.uq.edu.au

Using Integrated EHR/EMR Systems

Meaningfully

“Interoperability is the ability of

two or more systems to

exchange and subsequently use

that information.”

“Integration is … the process of

combining components into an

overall system.”

Where my talk fits in…

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I focus on the role of users. You can’t really get interoperability or integration in reality, or leverage them, without “meaningful” use.

http://www.testingstandards.co.uk/interop_et_al.htm

Innovation process from an organisation/client perspective

(Cooper and Zmud, Management Science 1990)

Vendor side

Client side

Where my talk fits in…

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Client side

Initiation: Scan the market and find initial matches

Adoption: Make investment decision

Adaptation: Get IT application ready for use

Acceptance: Organisational members use it

Routinisation: Use of the application is part of normal work

Infusion: The application is used to its fullest potential

Infusion, meaningful use, effective use – vs. adoption/use

Where my talk fits in…

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http://www.healthit.gov/sites/default/files/rtc_adoption_and_exchange9302014.pdf

Examples…

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US Approach – Meaningful Use

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf

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Canada – Benefits Evaluation Framework

https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/544-benefits-evaluation-indicators-technical-report-version-2-0

Benefits Evaluation Framework –self-reported measures

7https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/544-benefits-evaluation-indicators-technical-report-version-2-0

Benefits Evaluation Framework –non-self-report measures

8https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/544-benefits-evaluation-indicators-technical-report-version-2-0

Approaches like these are good for

getting adoption. They focus on…

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Is the system used?

Is the system used often?

Are specific features used (often)?

But they don’t really focus on:

…is the system used well? i.e., meaningfully/effectively

Example from my researchin a community care setting

What does it take to use an integrated EHR

system truly meaningfully?

Canadian Regional Care Provider

Enabling

Community Electronic

Health Records

Integrated, Safe and High Quality

Care

+

Operational Efficiencies

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• Over 5000 users, 100 sites

• Significant and continuing investment

Project Vision for HITS

A client centric electronic record for all community care

• Home Care

• Public Health

• Mental Health

• Addictions

• Communicable Disease

• Residential Care

• Transitional Care

• Palliative Care

Program F

Program A

Program B

Program E

Program D

Program C

Client’s Electronic Record

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Case study design

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Met ~150 staff

Level of data Relevant actor Relevant tasks Associated goal Workarounds

Administrative reports(classification of data)

Director/Manager

- Monitor operations

- Report data- Make

program/region-wide decisions

High-quality andcost-effective care the region

None available

Client trajectory(compilation of data)

Care team

Front-line staff

- Coordinate care- Make team-level

clinical decisions

- Make complex clinical decision

Continuity of care for whole person

High-quality care for whole person

Conversationswith clinicians and clients; shadow paper system

Individual record (original data)

Front-line staff - Input record- Access record- Make simple

clinical decision

High-quality care for client’s specific need

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Three views on meaningful use

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Three views on meaningful use

View 1: Adaptation of Canadian

Benefits Evaluation Framework

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B

A

Benefits evaluation approach

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Quality of EHR System

Meaningful use

Quality of outcomes

Outcomes for staff

Outcomes for clients

Drivers of …

Quality EHR System

Meaningful use

+/-(vicious/virtuous)

+

+

+

+

+/-(corrective feedback)

External factors

C D

E

F

G

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Construct Dimensions Example quotes for link A in the

model

Drivers of

the quality of

the EHR

system

- Investment in design and

implementation

Nobody had the appetite to

spend …what it would take,

because of cost resources.

- Investment in technical

infrastructure

…the upgrade [to] wireless

access, … it’s faster and it’s

more reliable … so it’s much

easier to use off-site.

- Investment in ongoing

maintenance

This immunization program…

would be awesome …but it isn’t,

because of the turnover in staff

maintaining this rules engine.

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Construct Dimensions Example quotes for link B in the

model

Drivers of

meaningful

use

- Personal factors (framing,

knowledge, experience)

...an effective user is really good

at sort of filtering...prioritizing,

...They’ve got that clinical lens.

- Organizational factors

(organizational structure,

culture, roles)

...it’s effectively used because

...there’s been a structure and an

interest for several years to make

this work [including] a planning

team and the educators and

everybody....

- System factors (transparency) ...the idea that other people...

have...access to their record, I

think builds in a bit more of …an

internal check-and-balance.

High-level view

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Construct Dimensions Example quotes for links C in the model

Quality of the

EHR system

- System quality (speed,

navigability, program

logic, ease of mistakes

and difficulty fixing

them)

- Information quality

(accuracy,

completeness,

relevance, clarity)

Vicious circle (i.e., poor system poor use

worse system)

...[HITS will ask] “why hasn’t [the referral

priority] been met?” …we have no idea. But

we have to enter something. So we

guess....So, there’s all this layer of inaccurate

information that is going to the Ministry,

…garbage in, garbage out.

Virtuous circle (i.e., good system good

use better system)

[over time] they’ve …done a much better

job of categorizing those clinical activities so

that it’s … aligned with what they’re actually

doing …. and so they just check them off …,

as opposed to having to write free-text

fields…. So, the design is helping the use of

it, and, … it sort of self-enforces.

Meaningful use - Inputting record

- Accessing record

- Coordinating care

- Monitoring operations

- Decision-making

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Construct Dimensions Example quotes for links D, E, F, in the model

Quality of

outcomes

- Client outcomes

(client care, client

coordination, client

satisfaction)

...[If] a client is struggling…I can access their

notes ...see the client, make sense, put [the plan]

in place ...And...part of the plan may be … that he

see his GP …and then boom – we can notify the GP

– there’s … a loop of communication, and the

client is served.

- Staff outcomes

(satisfaction,

efficiency,

teamwork,

professional

readiness, culture

change)

...we can catch errors better ...we can audit and

say, “OK, who booked it? …And it’s not about

going back and finger wagging, it’s about saying,

“Well how do we educate that person?” “Oh, it

was a casual, what are we doing wrong in our

education of casuals? How do we support them

better, you know?”

- Corrective feedback

back to the drivers

of quality (e.g.,

informing users’

knowledge/

experience)

… if they do not see the motivation of putting

some data there… they don’t do it. …if that data is

needed, we go back to them with a report … and

then they see the reason for which we’re asking,

and it improves. So it’s a …back-and-forth process.

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Construct Dimensions Example quote for link G in the

model

External

factors

- Factors outside the authority’s

control

...you never know what the

ministry wants, or how they’re

going to change their programs,

or when, … so it’s difficult.

Three views on meaningful use

View 2: A closer look at meaningful

use

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A closer look at meaningful use…

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forms

part of

Meaningful use

Accuracy

- Truth

- Whole truth

- Nothing but

the truth

Reflective practice

- Client

- Clinical and co-

worker workflow

- System workflow

forms

part of

forms

part of

influencesinfluencesinfluences

Consistency

- Utilization

- Place

- Form

- Amount

- Meaning

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Sub-dimension Quote

Truth … when it comes to an area that I can see that when you look at

the numbers and you just compare it to the work that they’re

doing, it just doesn’t match up, is child and youth. …it looks like

they’ve only seen two or three people [which isn’t true].

Whole truth … some of their counselling team will just write one or two lines …

and it’s really quite cryptic, and you just have no idea what was

discussed, whereas I find at this site there’s more robust meat of,

“These are the challenges…, this is the plan.” …for

multidisciplinary team working together [my other site’s practice]

is not the ideal.

Nothing but the

truth

[Case notes should be] clear…, pithy …to the point [and] there

shouldn’t be any writing that people could misconstrue

Dimensions - Accuracy

Dimensions - Consistency

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Sub-dimension Quote

Utilization In HITS there’s a form in the central index module, where you can collect a

person’s ethnicity…some programs do it, some don’t. Some staff do it, some

don’t. … So you really need …to inform the staff, “we need this information

to be captured so that we can actually report it.”

Place …some nurses are … putting ...the information where it’s supposed to go…

Other nurses… don’t get the information where it is [supposed to go], or it

can be in two places or even three places, and they’re still phoning,… and

leaving sticky notes….

Form …different people chart differently, so … you have to read the whole case

note to get what you’re looking for … so you’re flipping through just to see if

they happen to mention it, ‘cause it’s not highlighted.

Amount I know there’s tons of variance out there in …what they document and how

much they document. And in some cases, I think some nurses are over-

documenting and in some cases they are under-documenting.

Meaning …because that form is accessible to multiple people from multiple programs,

one will put it in, someone else will come along, will change it to something

different. Because their interpretation could be different.

Dimensions - Reflective practice

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Sub-dimension Quote

Client [Using HITS effectively is] thinking clinically and saying, “OK,

what’s, what’s important,” … you want to communicate the

important things [about the client].

Clinical and

co-worker

workflow

I put information that I know will be relevant for that person

[taking over]. I know to do that from experience, from

feedback [from the person taking over] and because I've

worked on that side of healthcare and I know [it] would be

relevant for me....

HITS

workflow

…a good use of HITS is using the proper …grids, making sure

that if I’m going to put [data] in …, it may take longer to initially

put it in, but it saves time in the long-run because then it

carries over to all the screens [and] reports.

Importance of reflective practice

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…as professionals, we meet regularly. … Where is that information going? Are you putting that information in the case note …or … the plan…? I’ve heard [people ask], “Do your managers give you time for things,” and my immediate professional response is, “we don’t ask for that time, we make that time,” because … to provide good care …we are ethically bound to spend time with our colleagues making sure our education [and] standards are good.”

Three views on meaningful use

View 3: Mapping out meaningful use

across the organisation

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Process view

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Relevant

functionality offered

by the EHRMeaningful use

Achievement of

immediate goal

Data input

functionality

Meaningful use

(Accuracy, consistency,

reflective practice)

Relevant data input

…By mapping functionality to work processes, we can map out meaningful use across the organisation

Example Map

What did we learn from the three

views?

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Lessons learned

• For the organisation we studied:

– An integrated/interoperable system is not really integrated or

interoperable if different users/units are using it inconsistently

– Mapping out more meaningful use across the organisation

provided a road-map to get more value

– Helped guide new interventions and funding

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Lessons learned

• In general:

– A mindset for getting value from more meaningful use of IT

• What does meaningful use of your system involve?

• Is your system being used in that way? (need evidence)

• Align evidence with priority (e.g., rough vs. detailed evidence)

• This message is equally relevant for clients and vendors

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Three main priorities based on our findings:

- From View 1: Ensure that staff can distinguish between the quality of a system and the quality of its use. If unclear, staff may blame the system for problems caused by their use of it.

- From View 2: Focus on reflective practice (in training and leadership) because it underpins the other dimensions of meaningful use.

- From View 3: Focus on front-line inputs because they are the foundation of all other uses of the EHR

Prioritisation

Conclusion

• The meaningful use regulations and similar incentive

schemes are well-placed to increase adoption and use

• But they will not necessarily increase truly meaningful use

• Getting meaningful use requires attention to how a

systems need to be used, and how it is used, to obtain

desired outcomes

– Some lessons: Need to distinguish the system from its use,

encourage reflective practice, and focus on front-line value 36