rapid response evaluation for physician office electronic...
TRANSCRIPT
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Rapid Response Evaluation for Physician Office
Electronic Medical Records
Morgan Price, MD, PhD, CCFPFrancis Lau, PhD, eHealth Chair
1Tuesday, July 13, 2010
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Thank you to the team• Dr. Francis Lau the eHealth Chair
• eHealth Observatory Team:
• Tyrone Austen
• Jesdeep Bassi
• Heidi Bell
• UBC Enhanced Skills Trainees:
• Dr. Jeanette Boyd
• Dr. Jame Lai
• Dr. Colin Partridge
2Tuesday, July 13, 2010
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Who am I?
3Tuesday, July 13, 2010
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Who am I?Lead Researcher at eHealth Observatory
3Tuesday, July 13, 2010
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Who am I?Lead Researcher at eHealth Observatory
Family Doctor: Cool Aid CHC
3Tuesday, July 13, 2010
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Who am I?Lead Researcher at eHealth Observatory
Family Doctor: Cool Aid CHC
UBC Family Medicine Lead Faculty, Informatics
3Tuesday, July 13, 2010
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Who am I?Lead Researcher at eHealth Observatory
Family Doctor: Cool Aid CHC
UBC Family Medicine Lead Faculty, Informatics
Adjunct Faculty, Comp Sci
3Tuesday, July 13, 2010
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Who am I?Lead Researcher at eHealth Observatory
Family Doctor: Cool Aid CHC
UBC Family Medicine Lead Faculty, Informatics
Adjunct Faculty, Comp Sci
Informatics Consultant
3Tuesday, July 13, 2010
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Ground Rules
Please Interrupt
Me with Questions!
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Who are you?
5Tuesday, July 13, 2010
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My Assumptions(about you)
• You have some knowledge in terms of EMR functionality.
• Wanting hands-on / practical advice on evaluation of adoption.
• Want discussion, not lecture
• You are a mix of providers and IT / informatics professionals.
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Anything specific you want to discuss today?
7Tuesday, July 13, 2010
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How many of you attended this morning’s
workshop?
8Tuesday, July 13, 2010
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Objectives
• Appreciate Current State on EMR adoption evaluation
• Appreciate EMR adoption is a process
• Review formative evaluation methods that can help practices adopt EMR successfully.
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Activities
• Review Background from the Literature
• Overview of our evaluation framework
• Overview of the methods and tools
• Trial one of the tools
• Review Two Case Studies
• Discuss Discuss Discuss
10Tuesday, July 13, 2010
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EMR Background Literature
11Tuesday, July 13, 2010
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We are completing a systematic review of
EMR benefits in office practice.
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Question:What are the impacts of
EMR systems on physician office practices?
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Methods
Main sources MEDLINECINAHL
Supplemental searchesPublication years: 2000-2009CriteriaReviewers
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15Tuesday, July 13, 2010
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15,847 Papers
15Tuesday, July 13, 2010
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15,847 Papers
Analytic Studies22
Descriptive Studies24
Surveys26
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26 published surveys
9 (35%) clearly positive outcomes
14 (54%) reported mixed outcomes
2 (8%) reported negative outcomes
1 had ambiguous results
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72% of indicators were for User Satisfaction
System Quality
Information Quality
Service Quality
Use
User Satisfaction
Net Benefits
Quality
Access
Productivity
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Analytic Studies
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Country # of Studies
% of Total
Netherlands 5 23%
United Kingdom 5 23%
United States 5 23%
Canada 2 9%
Australia 2 9%
New Zealand 2 9%
Italy 1 5%
Total 22 100%
Location of Studies:
50% Europe
32% North America
18% Australia & NZ
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Quality of Studies
Study Design # of Studies Strong Moderate Weak % of Total
Randomized 10 6 4 0 67%
Quasi-Experimental 4 0 4 0 20%
Observational 8 2 4 2 13%
Total 22 8 12 2 100%
64% used an experimental or quasi-experimental design
90% had a moderate to strong quality score
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Function # of Studies
% of Total
Prescribing 7 32%Prevention 4 18%
CDM 4 18%
Test ordering 2 9%Recordkeeping 2 9%
Other 2 9%Referrals 1 5%
Total 22 100%
Prevention studies were primarily concerned with CVD screening
CDM studies focused on diabetes, arthritis, and CVD
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90% of measures were focused on Net Benefits
System Quality
Information Quality
Service Quality
Use
User Satisfaction
Net Benefits
Quality
Access
Productivity
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NET BENEFITSNET BENEFITSNET BENEFITSNET BENEFITSNET BENEFITSNET BENEFITSNET BENEFITSNET BENEFITS
QualityQualityQuality AccessAccess ProductivityProductivityProductivity
Patient Safety Appropriateness & effectiveness Health outcomes
Patient & provider access
to services
Patient & caregiver
participationEfficiency Care
coordination Net costs
1 29 5 0 1 4 0 2
There are 42 outcome measures83% quality, 14% productivity, 2% access69% appropriateness & effectiveness
Adherence and compliance with guidelinesRates of testing
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Function # of Studies Positive OutcomesPrescribing 7 3
Prevention 4 3CDM 4 2
Test ordering 2 2Recordkeeping 2 0
Other 2 0Referrals 1 1
Total 22 11
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Function # of Studies Positive OutcomesPrescribing 7 3
Prevention 4 3CDM 4 2
Test ordering 2 2Recordkeeping 2 0
Other 2 0Referrals 1 1
Total 22 11
Only 2 studies looked at clinical outcomes (no positive findings)
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Description of the Descriptive studies
In ProgressIn Progress
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There is some evidence of
mixed benefits...lots of room for
improvement
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We wanted to add to EMR evaluation.
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Overview of our Framework
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Scanning
LaboratoryResults
DI ReportsImages
Medications
OtherDocuments
ElectronicFeeds In
ElectronicFeeds Out?
Paper Charts
Paper / FaxOut to others
EMR
Other ElectronicRepositories
(Public and Private)
How to Evaluate?
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Scanning
LaboratoryResults
DI ReportsImages
Medications
OtherDocuments
ElectronicFeeds In
ElectronicFeeds Out?
Paper Charts
Paper / FaxOut to others
EMR
Other ElectronicRepositories
(Public and Private) How to Evaluate?
30Tuesday, July 13, 2010
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Scanning
LaboratoryResults
DI ReportsImages
Medications
OtherDocuments
ElectronicFeeds In
ElectronicFeeds Out?
Paper Charts
Paper / FaxOut to others
EMR
Other ElectronicRepositories
(Public and Private) How to Evaluate?
How to Provide
Feedback?
30Tuesday, July 13, 2010
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We wanted something timely, comprehensible, and useful for clinicians.
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We wanted something that could also aid in adoption / impact.
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We considered the premise that stepwise adoption limits change
and maintains productivity.
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From Stead, 2007
Time
Clin
ical
Tea
m P
erfo
rman
ce
ResultsViewer
CommunicationTools
CPOE
ClinicalDocumentation
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We assumed that offices adopt functions more organically over time.
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Time
Clin
ical
Per
form
ance
Increasing Performancewith Practice Improvement
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Adoption increases over time when change
is manageable and improvements are
perceived.
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Adoption may fail where benefit not seen.
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Time
Clin
ical
Per
form
ance
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Support change by showing improvements
and by providing guideposts.
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Our framework is built on two sources:
HIMSS & IOM.
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HIMSS Analytics
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HIMSS is well know for its 7 Levels for Hospitals
(and it has 5 levels for ambulatory care).
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0 Paper Charts for Clinical Information
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1
0
Online access to reference materials
Paper Charts for Clinical Information
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2
1
0
Hybrid Electronic - Paper Chart
Online access to reference materials
Paper Charts for Clinical Information
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3
2
1
0
Electronic Medical Record Used (more passive record)
Hybrid Electronic - Paper Chart
Online access to reference materials
Paper Charts for Clinical Information
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4
3
2
1
0
Electronic Chart with Advanced Point of Care Clinical Decision Support
Electronic Medical Record Used (more passive record)
Hybrid Electronic - Paper Chart
Online access to reference materials
Paper Charts for Clinical Information
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5
4
3
2
1
0
EMR Integrated within Health SystemPoint of Reflection CDSS
Electronic Chart with Advanced Point of Care Clinical Decision Support
Electronic Medical Record Used (more passive record)
Hybrid Electronic - Paper Chart
Online access to reference materials
Paper Charts for Clinical Information
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Institute of Medicine
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IOM created a report on the Key Capabilities
of an EHRS(IOM 2003)
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IOM focused on care delivery functions and not
infrastructure / data standards.
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IOM - 8 Core Functions
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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IOM - 8 Core Functions
Health Information & Data
Results Management
Order Entry / Order Management
Decision Support
Electronic Communication
Patient Support
Administrative Processes
Reporting & Population Health
48Tuesday, July 13, 2010
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We created a complex matrix...IOM Features
HIM
SS L
evel
s
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and ended up with a simple graph
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
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that can show changes over time
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
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Next, we developed tools to assess adoption
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Next, we developed tools to assess adoption
Impact Assessment (I)
EMR Adoption (I)
Workflow Modelling / Rx Functions (I)
Usability Benchmarking (O)
Practice Reflection (G)
EMR System Analysis (I / S)
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Next, we developed tools to assess adoption
Impact Assessment (I)
EMR Adoption (I)
Workflow Modelling / Rx Functions (I)
Usability Benchmarking (O)
Practice Reflection (G)
EMR System Analysis (I / S)
52Tuesday, July 13, 2010
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Next, we developed tools to assess adoption
Impact Assessment (I)
EMR Adoption (I)
Workflow Modelling / Rx Functions (I)
Usability Benchmarking (O)
Practice Reflection (G)
EMR System Analysis (I / S)
52Tuesday, July 13, 2010
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Next, we developed tools to assess adoption
Impact Assessment (I)
EMR Adoption (I)
Workflow Modelling / Rx Functions (I)
Usability Benchmarking (O)
Practice Reflection (G)
EMR System Analysis (I / S)
52Tuesday, July 13, 2010
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Next, we developed tools to assess adoption
Impact Assessment (I)
EMR Adoption (I)
Workflow Modelling / Rx Functions (I)
Usability Benchmarking (O)
Practice Reflection (G)
EMR System Analysis (I / S)
52Tuesday, July 13, 2010
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Next, we developed tools to assess adoption
Impact Assessment (I)
EMR Adoption (I)
Workflow Modelling / Rx Functions (I)
Usability Benchmarking (O)
Practice Reflection (G)
EMR System Analysis (I / S)
52Tuesday, July 13, 2010
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Time
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Time
Focus on Use
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All resources are available at
ehealth.uvic.ca
(version 2.0 coming)
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METHOD: we travel
on site, tools in hand.
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Two researchers Three days
Focus Group
Feedback Focus Group
Interview
Interview
Interview
Interview
Observation
Observation
Interview
Interview
Usability
Usability
Interview
Interview
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EMR System Assessment
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Should be completed before site visits.
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Evaluation of functionality to provide
“ceiling” on scores.
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Necessary to know what the clinic can and
cannot do.
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Aligned our evaluation with existing functional
requirements.
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Our focus was on Medication
Management
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Impact Assessment Interview
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Two part interview
• Part 1
• Impact Assessment
• Mainly open-ended questions
• Part 2 (Pare)
• Focused on Change Management / Deployment
• 23 questions, 5 point scale
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Impact Assessment Examples
• What do you think about the quality of the system in terms of functionality and performance?
• What opportunities do you see with the use of the EMR as compared to how things were previously done?
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EMR Deployment Examples
• 1-5 Scale of Agreement to statements like:
• There was alignment of the system with local practices and processes.
• There were positive attitudes on the part of project team members.
• It was a small and simple project.
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EMR Adoption Interview
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EMR Adoption Interview
• Covers all eight functional areas
• Currently an interview
• Could be survey, after validation
• Each question scored based on current use
• Developing MOA and MD versions.
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EMR Adoption Interview is a good level of detail for an
office.
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We are going to trial this 25 question interview today.
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Activity: (45 min)
EMR Adoption Interview
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Instructions• Act as a clinician who is using an EMR.
• Answer as a single user.
• Try to be realistic.
• Score to the highest score (if multiple options correct)
• Use judgement if not quite fitting the five levels precisely.
• Comment on the challenges
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Break(and scoring)
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Debrief the Interview - what did you find?
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SCORES
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One
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
76Tuesday, July 13, 2010
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Two
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
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Three
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
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Anything Unclear
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Anything we missed?
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Any surprises from the scores?
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Workflow Modelling / Medication
Management Interview
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Explores detailed processes of medication
management.
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Takes a broad view of the workflows of
medication management.
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85Tuesday, July 13, 2010
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Distilled to a set of questions with answers
that map to the five levels.
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Some questions BC specific.
(Special Authority)
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These questions also
tend to educate.
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Usability Benchmarking
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Observation (in this case) of
prescribing activity.
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We developed six standardized cases.
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Standardized cases allow for comparison at three levels: user, clinic, & EMR.
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Feedback: early to users, later to users and
to vendor.
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Practice ReflectionFocus Group
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First, we open the floor to their reflection, as a
group.
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We provide feedback and recommendations
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Focus Group reviews findings, agrees to
priorities and discusses how to implement.
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240 6 12 18
Months
Adoption
Finally, we repeat the study.
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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240 6 12 18
Months
Adoption
and look for change over time.
99Tuesday, July 13, 2010
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Two Case Studies
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Case Study 1
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Here are the scores.
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
102Tuesday, July 13, 2010
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Change Management - variable, based on role.
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Prescription Management
• Variable use of EMR
• No alerting
• Not using advanced features
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Usability
• Multiple errors from system / GUI
• Users did not use tools efficiently
• Drug selection issues (generic / brand)
• Complexity for newer users
• icons not clear
• Complex prescriptions not handled well.
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Other Issues
• Participants quick to highlight challenges.
• Many are relative complaints:
• it is slower now
• scanning takes way more mouse clicks than it used to.
• Technical glitches: freezing
• Training issues.
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They didn’t complain about what they didn’t know.
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Case Study 2(more briefly)
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0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
Here are the scores.
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Let’s Compare the Two Cases110Tuesday, July 13, 2010
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Case 1
0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
111Tuesday, July 13, 2010
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0
1
2
3
4
5
Health Inform
ation
Order E
ntry
Results M
anagement
Decision S
upport
Electronic C
omm
unication
Patient S
upport
Scheduling B
illing
Practice R
eflection
Case 2
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Who implemented when?
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Case 2 implemented 10 years before Case 1
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Why so little difference?
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User Challenges
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I know how paper works...
117Tuesday, July 13, 2010
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I didn’t know what I didn’t know
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Short term fixes have long term implications
119Tuesday, July 13, 2010
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Terminology, shmerminology - let me write down what I want.
120Tuesday, July 13, 2010
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System Challenges
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Group1,000s
Classification10,000s
Reference Terminology100,000s
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“Flexible Data models”“Add your own terminologies”
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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From my office...
124Tuesday, July 13, 2010
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How can I see my practice with data like that?
125Tuesday, July 13, 2010
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How can we share data in the future?
126Tuesday, July 13, 2010
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127Tuesday, July 13, 2010
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Question for you:What is missing from
our tools?
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Materials available atehealth.uvic.ca
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