Madalene CrowDirector, Service Line DeliveryMadalene.Crow@thehcigroup.com

Electronic MedicalRecords

Where from?What for?Where to?

AgendaHistory & development of the EMR- why did we need it? how has the need changed over time and how have evolutions in medicine and technology influenced this journey (transaction based to intelligence based/workflow enablement) 2. Typical benefits/goals of implementation, how these have evolved over time (also at a high level the key enablers/influences of benefits realisation), challenges in 'collecting' benefits of EMR implementation 3. What's in (and out) of a 'typical' EMR? (Clinical Application environment Vs 'typical' EMR offerings) 4. Modern day health system strategy for EMR implementation - (best of breed vs enterprise wide) 5. What are the pros/cons of each approach and why is integration of systems important? 6. Example 'pathway' to building capability - EMRAM 7. Approaches and challenges to building EMR capability - US and international perspectives

 8. Future trends set to impact EMR (both technology and policy/healthcare related) Over the next week or so I'll do some digging for a good paper that discusses benefits of EMR implementation or a case study of a clinical intervention that was enabled by an EMR- let me know if I'm on the right track for that as well. 

History of Data in Healthcare…HealthcareThe organized provision of medical care to individuals or a community

Knowledge of Medicine

Knowledge of the Patient/sApplied to…

“Care Setting” - a place where healthcare occurs

History of Data in Healthcare…

Priem J. 2010. Medline Literature Growth via custom PubMed queryhttp://jasonpriem.org/blog/

Knowledge of Medicine

Knowledge of the Patient/s

Elicited by Healthcare Provider

when needed

Organized & Managed by Healthcare Provider

Organizations

<1960s…. The early daysLate 50s- 60s: Mainframe computers, then Microprocessors Promise of digitization of data, but only available to organizations that could manage complex IT infrastructures (and afford them!)

Mid 1960s – LockheedClinical Information Management System – El Camino Hospital, Mountain View CaliforniaLater commercialized (Eclypsis)

1965 – National Library of Medicine converts to Index Medicus (forerunner to Medline)‘Knowledge of Medicine’ becomes more accessible

1970sSmaller computers & Terminals available –Departmental systems for lab, radiology, pharmacy, administrative & finance‘Silos’ of patient data

1974 – Regenstrief Medical Record SystemFirst EHR to implement rule-based reminders to inform clinical decisions

1976 – Dr Lawrence Weed – Problem Orientation Medical Information SystemThe mind of the physician could not effectively process the large amount of information received, and this could interfere with the care of the patient.

Organization of data is needed to make it more available to the physician

1980sPCs become mainstream, networking = connectivity, storage is cheaper

1987 HL7 founded – standards/basis for electronic health data sharing established

Mid 80s software vendors emerge, grow & mature their products• development & acquisitions; ambulatory care setting focus• Allscripts- Electronic prescribing software (later acquires Ambulatory EMRs, inc.

Eclypsis)• eClinical Works- Ambulatory EMR, Practice management, partner with Dell• Cerner- PathNet further developed into Millennium EMR• Epic- Practice Management further developed into EpicCare

Late 1980s Software to support scheduling and billing functions embraced

But… adoption for management clinical data comparatively lower

1990s:www!!EMRs are Web enabled – Remote access, disparate information sources and application of information comes together (integrated EMR offerings)

1996 Health Insurance Portability & Accountability Act of 1996 - HIPAA• Requirements on health record use, disclosure and confidentiality• Computers/software role in complying with security & privacy laws

1999 Veterans Health Administration mandate EHR use• Positive impact to quality of care is later demonstrated• “the availability of patients' charts at the point of clinical encounter increased from

60 to 100 percent between 1995 and 2004”

VA Health Information Software available for unrestricted public/private sector use: Information-driven care model

Healthcare providers increasingly shift to ‘managed care’ across across different care settings – Ambulatory and Acute

Oliver, A. The Veterans Health Administration: An American Success Story? The Milbank Quarterly, Vol. 85, No. 1, 2007 (pp. 5–35)

2000s….Secure communication enables data sharing with patients and other entities, storage “clouds,” policy & funding set to push EMR adoption

2004 Presidential support for Health IT adoption• Sub-cabinet position – National Health Information Coordinator• Calls for EHR adoption and standards development for transmission data, funding

available

2005 Patient Safety & Quality Improvement Act of 2005• Patient Safety Reporting requirements

2006 CCHIT Recognized by federal government as certifying body for EMR products • first comprehensive practical list of EMR capabilities established

2007 VA & Keiser Permanente create CONNECTOpen-source, cross-agency data sharing

2008 Google & Microsoft release PHR technologies

…to Meaningful Use…2009 American Recovery & Reinvestment Act of 2009 – ARRA

• ‘Meaningful Use’ of technology by healthcare providers incentivized

Health Information Technology for Economic & Clinical Health Act - HITECH • Empowers Office of National Coordinator for Health Information Technology (ONC)

through funding and legislation• ONC directed to support and promote meaningful use of certified EHR technology

nationwide• Initial Standards/Certification Criteria: “2011 Edition EHR Certification Criteria”• State Health Information Exchanges

2011 First payments made as part of Meaningful Use

2011 HHS propose Accountable Care Organizations• Another role for EHR – capture data and enable sharing between ACOs• Shift from fee-for-service to value based care & prevention

2013 10 EHR vendors account for 90% market (per CMS attestation data)

May 2014 CMS has paid out $14.6 bil since 2011

…soon to come: MACRA

MACRA consolidates existing reporting requirements & incentive payments• Physician Quality Reporting System• Physician Value-based Payment Modifier• Electronic Health Records Incentive Program

Scheduled January 1 2019

MU impact Hospital EHR Adoption

ONC Data Brief No. 23 Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008-2014

What’s in an EMR?EMR is a system that captures & presents clinical information for purpose of healthcare

• Not just scanned documents; discrete, reportable data too• Includes functionalities in conjunction with patient care process

Provider Ordering• Prescription/lab/rad order & results transmittal, medication history, formulary &

coverage integration

Clinical Decision Support• Drug-drug drug-allergy interactions, patient compliance, patient self-care, respond

to policy incentives (Meaningful Use), disease care protocols & population management

Documentation Tools• Record and communicate care delivery, standardize process, enable capture data in

computational format (research), protocol/workflow requirements in documentation templates

Patient Data Access – Portal• Patient access to data (medications, lab results, education content), clinician

correspondence (refill requests, appointment requests)

What’s in an EMR?

ONC Fact Sheet: Voluntary 2015 Edition EHR Certification Criteria (“2015 Edition”) Proposed Rule

44 45

54 53

Meaningful Use EHR Certification Criteria: One definition

Why the changes?• ?Different needs for managing data• ?Practice of Medicine changed• ?Take advantage new technology• Do we better understand how technology can enable care?

A different question: What does an EMR do?

What does an EMR do?Provide data access through connectivity

• Between providers & patients, patient groups, organizations (payors, providers, facilitators of care)

• Right data, Right person, Right time positive impact to outcomes

Facilitate clinical process • Embed ‘checks and balances’• Standardize clinical data capture & presentation• Reduce unwarranted variability in care process

Collect data to inform decision making• Inform Policy development, Organization Strategy development• Reporting to support operations management• ‘Feedback’ to inform delivery of care• At the bedside

How to “build” an “EMR”

Bit by bit:Emphasis on joining together the best software to support individual functions

“Best of Breed”

All in one:Emphasis on central shared ‘generalist’ EMR, supplemented if necessary by software to support individual functions

“Enterprise Wide”

Implementation strategy• Specific to organizations resources, requirements and ability to adopt

transformative change• Specialty hospital Vs General hospital• Large multi-site system Vs small independent practice

• General trend over time shows preference for an enterprise wide solution• Enabled by maturing of EMR solutions 1980s now

How to “build” an “EMR”HIMSS Analytics EMR Adoption Model

EMR “in situ”

EMR “in use”

Implementation/Adoption/Optimization

Implementation/Adoption/Optimization

Implementation:Putting the tools in

Adoption:Using the tools

Optimization:Tweaking the tools to enable use at fullest potential

(according to role of tool)

Tools include: People, process & technology (more than just the EMR!)

Closer to optimization = more benefits are realized

BUT this takes time, continued investment and CHANGE!

Who benefits?

(?what EMR, ?is it fully ‘built’)

From ONC:

“Certified EHR products benefit many interested groups and individuals:• Physicians, hospitals, health care systems, safety net providers, public health

 agencies and other purchasers of HIT products, who seek quality, interoperability, dataportability and security

• Purchasers and payers – from government to the private sector – who are prepared to offer financial incentives for HIT adoption but need the assurance of having a mechanism in place to ensure that products deliver the expected benefits

• Quality improvement organizations that seek out an efficient means of measuring that criteria have been assessed and met

• Standards development and informatics experts that gain consensus on standards• Vendors who benefit from having to meet a single set of criteria and from having a

voice in the process• Healthcare consumers, ultimately the most important stakeholders, who will benefit

from a reliable, accurate and secure record of their health”

Early benefits: Paper EMREvidence available prior to EMR business case & MU incentivized ‘adoption boom’

Relate to data access• Improved workflow – instantaneous & remote access to patient information• Savings - reduced duplication tests

Relate to enhanced efficiency, quality & safety of care process• Improved care coordination & communication

• Legibility• Interdisciplinary clinical workflow support

• Avoid preventable ‘known’ errors – standardization of workflow

• Drug interactions & contraindications• Clinician task tracking & reminders• Care protocol enablement

Dr. Sanjaya Kumar, 2008, Fatal Care: Survive in the US Health System

More benefits: All About the Data

Unlock latent value in healthcare data

• Leverage data assets to identify and act on insights• “New” models of care

• Computation of data to facilitate decision making• “New” information to present to right person…..

• Supported by EMR functionality to “guide” clinician workflow

In the ‘real world’ ?

“Within two hours after contacting (Hurley’s) chief medical officer (Michael Jaggi, D.O.), we got the data we needed,” she said.

Crucial to the data collection, Hanna-Attisha said, was Hurley’s electronic medical record system. The EMR had data on blood samples of dozens of children in Flint.

“I wanted to know if kids were getting lead and how much."

So these EMRs are pretty great?

….Right?

Depends who you ask…https://www.youtube.com/watch?v=xB_tSFJsjsw

Adoption has challenges

Change Management

Adoption has challenges• Change can be difficult• Organizations must be ready!

Large organizations are complex environments• Benefit/Cost to Individual Adoption – my picture• Benefit/Cost to healthcare delivery – the big picture

Leadership & Preparedness are crucial• EMR is NOT an IT project

• Delivery of a tool for use in care delivery• Clinician engagement essential

• They are the adopters!!

Yes… there are also opportunities for improving tools• Usability

Facilitating change is an ongoing challenge: requires motivation

Who is most motivated to improve healthcare?

Rise of the e-Patient

“I was facing the grave. I thought, "What's my mother's face going to look like on the day of my funeral?" I had to sit down with my daughter and say, "Here's the situation…”

…Because if you wonder why patients are motivated and

want to help, think about this.”

PHR: the “Patient’s EMR”Personal enablement through technology is widespread, devices adopted

• This includes management of one’s health• Patients want more of ‘their’ data

Informed by secondary data from the Health Information National Trends Survey (HINTS) of US citizens for the survey years 2008, 2011, and 2013:

• Approx. 8 million people were using the 2 basic PHR functionalities tracked in 2008 (e.g. storing data on the Internet and communicating electronically with a clinical provider).

• PHR functionality uptake among consumers has grown rapidly and exceeded 31 million users in 2013

• The best-performing model indicates that PHR adoption will exceed 75% by 2020

Ford et al. Personal Health Record Use in the United States: Forecasting Future Adoption Levels (2016) J Med Internet Res 2016 vol. 18, iss. 3, e73

Patient Engagement

First FDA approved App

RCT compares prescriptionsMeds Vs App

What else is ahead?Technology: too much to name!

• Proliferation of Internet of Things• 3D printing• Virtual Reality• Biomedical Devices

Only constant is change…Care models continue to evolve

• Collaboration & Coordination• Globalization coming to healthcare• Consolidation• Quality V Quantity• Analytics to Inform• Genomics…..

Policy will continue to direct• Privacy, security, confidentiality • Reimbursement e.g. MACRA• Healthcare delivery Quality & Safety Standards

All that which we cannot see…..

Knowledge of Medicine

Knowledge of the Patient/sApplied to…

“Care Setting” - a place where healthcare occurs

Questions and Answers

Open DiscussionQ&A