the electronic medical record and the practicing physician: an oxymoron? carol steltenkamp, m.d.,...
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The Electronic Medical The Electronic Medical Record and the Practicing Record and the Practicing Physician: an Oxymoron?Physician: an Oxymoron?
Carol Steltenkamp, M.D., MBACarol Steltenkamp, M.D., MBA
Chief Medical Information OfficerChief Medical Information Officer
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ObjectivesObjectives
Discuss the role of the Electronic Medical Discuss the role of the Electronic Medical Record (EMR) in the office settingRecord (EMR) in the office setting
Identify what to look for in an EMRIdentify what to look for in an EMR
Review implementation challenges and Review implementation challenges and understand post-implementation outcomesunderstand post-implementation outcomes
Clinical Mission: AmbulatoryA multispecialty group practice A multispecialty group practice providing primary & specialty providing primary & specialty care care
106 106 Best DoctorsBest Doctors
80 specialized clinics, 150 80 specialized clinics, 150 outreach programs outreach programs
Provide services primarily in Provide services primarily in Lexington and Central and Lexington and Central and Eastern Kentucky Eastern Kentucky
400,000+ outpatient visits 400,000+ outpatient visits (2007) (2007)
at main campus localeat main campus locale
Greater than 1 million Greater than 1 million outpatient visits across the outpatient visits across the EnterpriseEnterprise
UK Chandler Hospital
Clinical Mission: InpatientClinical Mission: Inpatient
>800 beds>800 beds
>35, 000 discharges>35, 000 discharges
Level 1 Trauma Level 1 Trauma CenterCenter
Centers of Excellence Centers of Excellence in Cardiology, in Cardiology, Oncology, and Oncology, and NeurosciencesNeurosciences
Kentucky Children’s Kentucky Children’s HospitalHospital
Research MissionResearch Mission
$127.5 million grants & $127.5 million grants & contracts awarded at UK contracts awarded at UK College of Medicine*; College of Medicine*; $62.8 million in NIH $62.8 million in NIH fundingfunding
UK’s medical center UK’s medical center colleges account for colleges account for more than 55% of UK more than 55% of UK total research dollarstotal research dollars
Research figures Research figures prominently in quest for prominently in quest for Top 20 statusTop 20 status
*2007
Educational MissionEducational MissionSix colleges:Six colleges:
MedicineMedicineNursingNursingPharmacyPharmacyDentistryDentistryHealth SciencesHealth SciencesPublic Health Public Health
1000 clinical faculty 1000 clinical faculty
500 physicians in 500 physicians in residencyresidency
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WHY Health Information Technology (HIT)?WHY Health Information Technology (HIT)?
Implementation of HIT is proposed as a way to Implementation of HIT is proposed as a way to provide additional information to clinicians to provide additional information to clinicians to facilitate a reduction in serious medical errors, rising facilitate a reduction in serious medical errors, rising healthcare costs and system inefficiencies. healthcare costs and system inefficiencies. (Thompson, (Thompson, 2004)2004)
Estimate annual $10.6 billion outpatient savings and Estimate annual $10.6 billion outpatient savings and $31.2 billion inpatient savings based on HIT $31.2 billion inpatient savings based on HIT efficiency benefits efficiency benefits (Girosi, Meili,& Scoville, 2005)(Girosi, Meili,& Scoville, 2005)
President Bush State of the Union “we make wider President Bush State of the Union “we make wider use of electronic records and other HIT, to help use of electronic records and other HIT, to help control costs and reduce dangerous medical errors control costs and reduce dangerous medical errors (Jan 2006)(Jan 2006)
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Problem: Increased CostsProblem: Increased CostsIn 2003, U.S. health spending per capita was $5,635, ~ two and In 2003, U.S. health spending per capita was $5,635, ~ two and a half times more than the comparable median for industrialized a half times more than the comparable median for industrialized countries ($2,280 per capita). 15% of US GDP was spent on countries ($2,280 per capita). 15% of US GDP was spent on health care in 2003; other countries median was 8.4%health care in 2003; other countries median was 8.4% (Anderson et al, (Anderson et al, 2005)2005)
Higher medical care prices make health care unaffordable for Higher medical care prices make health care unaffordable for many Americans, yet the extra dollars spent are not yielding many Americans, yet the extra dollars spent are not yielding demonstrably better quality of care or patient satisfaction. demonstrably better quality of care or patient satisfaction. (Gerard (Gerard et al,2005)et al,2005)
U.S. spends 2.1 times as much on healthcare as Canada, U.S. spends 2.1 times as much on healthcare as Canada, France, Germany, Italy, Japan and the United Kingdom.France, Germany, Italy, Japan and the United Kingdom.
Healthcare spending grew “faster than growth in both the Healthcare spending grew “faster than growth in both the aggregate economy and employee compensation, which aggregate economy and employee compensation, which suggests an increasing burden on sponsors and employers”suggests an increasing burden on sponsors and employers” (Smith et al., 2005, p. 193).(Smith et al., 2005, p. 193).
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Problem: Problem: Information ExplosionInformation Explosion
If only 1% of new literature in Medline is If only 1% of new literature in Medline is healthcare related, if the clinician reads 2 healthcare related, if the clinician reads 2 articles daily for a year, they will be 5 years articles daily for a year, they will be 5 years behind the current state of knowledge. behind the current state of knowledge. ((Masys, Masys, 20022002))
Medline indexes >560,000 new articles, and Medline indexes >560,000 new articles, and Cochrane Central adds 20,000 new Cochrane Central adds 20,000 new randomized trials annuallyrandomized trials annually~ 1500 new articles and 55 new trials per ~ 1500 new articles and 55 new trials per day day (Glaszious and Haynes, 2005)(Glaszious and Haynes, 2005)
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Institute of MedicineInstitute of Medicine
““despite more than 30 years of work and millions of despite more than 30 years of work and millions of dollars, patient care records are predominantly paper, dollars, patient care records are predominantly paper, which limits tools for effective decision-making from the which limits tools for effective decision-making from the bedside to national healthcare policy” bedside to national healthcare policy” (IOM, 1991).(IOM, 1991). “ “ A highly fragmented delivery system that largely lacks A highly fragmented delivery system that largely lacks even rudimentary clinical information capabilities results even rudimentary clinical information capabilities results in poorly designed care processes characterized by in poorly designed care processes characterized by unnecessary duplication of services, and long waiting unnecessary duplication of services, and long waiting times and delaystimes and delays.” (IOM, 2001).” (IOM, 2001) Medical errors, rising healthcare costs, and quality Medical errors, rising healthcare costs, and quality problems are cited as widespread issues that need to be problems are cited as widespread issues that need to be addressed addressed (Institute of Medicine, 2001)(Institute of Medicine, 2001)
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Electronic Health RecordElectronic Health RecordThe IOM presented eight core functions that The IOM presented eight core functions that should be provided in an electronic health should be provided in an electronic health record:record:
health information and data health information and data results management results management order entry/management order entry/management decision support decision support electronic communication and connectivity electronic communication and connectivity patient support patient support administrative support reporting administrative support reporting population health management population health management (Institute of (Institute of Medicine, 2003). Medicine, 2003).
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Current Issues in Ambulatory CareCurrent Issues in Ambulatory Care
Inability to find critical information quicklyInability to find critical information quickly30% of physician time spent searching, up to 30% of physician time spent searching, up to 81% of time information is still not found in 81% of time information is still not found in record. JAMArecord. JAMA
While quality of care is improving, While quality of care is improving, ambulatory care shows the least overall ambulatory care shows the least overall improvement (1.4% between 2003 and improvement (1.4% between 2003 and 2004). AHRQ 2004). AHRQ
Better Information = Better QualityBetter Information = Better Quality
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60
80
100
120
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HgbA1c
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DM C
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DM C
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Example: VA vs Best Performers on Quality
Percentage of office-based physicians using electronic Percentage of office-based physicians using electronic medical records and using comprehensive electronic medical records and using comprehensive electronic medical record systems: United States, 2001–2006 medical record systems: United States, 2001–2006
Percentage of medical practices using electronic medical records Percentage of medical practices using electronic medical records and using comprehensive electronic medical record systems: and using comprehensive electronic medical record systems:
United States, 2003–04 through 2006 United States, 2003–04 through 2006
Percentage of physicians using electronic medical Percentage of physicians using electronic medical records and using comprehensive electronic medical records and using comprehensive electronic medical record systems by practice size: United States, 2006 record systems by practice size: United States, 2006
Estimated Percentage of Office-Based Estimated Percentage of Office-Based Physicians Using Selected Electronic Physicians Using Selected Electronic
Medical Record (EMR) FeaturesMedical Record (EMR) Features
National Ambulatory Medical Care Survey, United States, 2006
Percent distribution of physicians planning new or replacement electronic Percent distribution of physicians planning new or replacement electronic
medical record systems within next 3 years by whether current system is medical record systems within next 3 years by whether current system is fully or partially electronic: United States 2006fully or partially electronic: United States 2006
Barriers to AdoptionBarriers to Adoption
Capital costs*Capital costs*
Not finding a system that meets their Not finding a system that meets their needs*needs*
Uncertainty about return on investment*Uncertainty about return on investment*
Concern that a system would become Concern that a system would become obsolete*obsolete*
DesRoches, et. al., DesRoches, et. al., NEJM, July3, 2008NEJM, July3, 2008
Facilitators of AdoptionFacilitators of Adoption
Financial incentives for purchaseFinancial incentives for purchase
Payment for use of an electronic records Payment for use of an electronic records systemsystem
Protecting physicians from personal liabilityProtecting physicians from personal liability DesRoches, et. al., NEJM, July3, 2008DesRoches, et. al., NEJM, July3, 2008
Effect of Adoption of Electronic Effect of Adoption of Electronic Health Records SystemsHealth Records Systems
DesRoches, et. al., NEJM, July3, 2008
Case for ChangeCase for Change
Case for Case for ChangeChange
If you can If you can read it, how long read it, how long did it take you to did it take you to decipher the decipher the handwriting?handwriting?
A Moment in the Physician OfficeA Moment in the Physician Office
While promoting medical quality and E/M While promoting medical quality and E/M compliance, in compliance, in 15 minutes MD15 minutes MD must be able must be able to:to:
Perform and complete documentation of a Perform and complete documentation of a medically indicated, audit-proof, level 4 or medically indicated, audit-proof, level 4 or level 5 initial patient visit with individualized level 5 initial patient visit with individualized narrative information in all appropriate areas narrative information in all appropriate areas of the medical record including completion of of the medical record including completion of counseling the patient, ordering tests, counseling the patient, ordering tests, ordering treatment, and charge entry.ordering treatment, and charge entry.
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The Cost/Benefit RatioThe Cost/Benefit Ratio
Benefits Improved quality of care
Improved throughput
Charge capture
Costs
Cash outlay
High initial physician time and decreased patient volume
Getting StartedGetting Started
Announce the goal- even if it’s ambitiousAnnounce the goal- even if it’s ambitious
Test big ideas on a small scaleTest big ideas on a small scale
Find best practices and use them as Find best practices and use them as measurements (internal and external)measurements (internal and external)
Build the discipline and methods of Project Build the discipline and methods of Project Management into the workManagement into the work
Thomas Nolan.The Pursuit Continues. Pursuing Perfection: Raising the Bar for Thomas Nolan.The Pursuit Continues. Pursuing Perfection: Raising the Bar for Healthcare Performance. Healthcare Performance. Modern HealthcareModern Healthcare, Feb 28, 2005., Feb 28, 2005.
Ambulatory Workflow Ambulatory Workflow OptimizationOptimization
Together with the progress in medicine, Together with the progress in medicine, which provides for an earlier diagnosis and which provides for an earlier diagnosis and intervention, healthcare information intervention, healthcare information technology for process optimization will be technology for process optimization will be the prerequisite to further improve the the prerequisite to further improve the quality of care while reducing costsquality of care while reducing costs
EMR BarriersEMR Barriers
Implementations are costlyImplementations are costlyStart up, maintenance, workflow changesStart up, maintenance, workflow changes
Organizational influencesOrganizational influencesLevel of integration- what user wants globally vs what Level of integration- what user wants globally vs what user expects personallyuser expects personallyTypes of practicesTypes of practicesLeadershipLeadership
High initial physician timeHigh initial physician timeCustomizationCustomization
Miller & Sim. Physician’s Use of Electronic Medical Records: Barriers and Solutions. Miller & Sim. Physician’s Use of Electronic Medical Records: Barriers and Solutions. Health AffairsHealth Affairs. Vol 23, No 2. Vol 23, No 2
Why the reluctance by clinicians to adopt Why the reluctance by clinicians to adopt IT systemsIT systems
May partially be a generational issueMay partially be a generational issue
Main reason may be that so far EMR has not Main reason may be that so far EMR has not delivered time savings for physicians and delivered time savings for physicians and nurses, in fact, in many circumstances when nurses, in fact, in many circumstances when not fully deployed, costs timenot fully deployed, costs time
Main justification may be in addressing cost, Main justification may be in addressing cost, quality and safety issuesquality and safety issues
Source: Clinical Advisory Board interviews and analysis.
Electronic Medical RecordElectronic Medical Record
Leadership, Communication, Leadership, Communication, and Trainingand Training
Dealing with smaller staffsDealing with smaller staffs
Cooperation and input by all is a ‘must’Cooperation and input by all is a ‘must’
Just-in-time trainingJust-in-time training
3434
Current State WorkflowCurrent State Workflow
Customization for clinics is Key- filters, lists, etc.Customization for clinics is Key- filters, lists, etc.
Role identificationRole identification
Maximize efficiency and clinician focus while patient Maximize efficiency and clinician focus while patient is in clinic. is in clinic.
More chronic, episodic care in clinic More chronic, episodic care in clinic
Patient Focused InteractionPatient Focused Interaction
Schedule appointmentSchedule appointment
RegisterRegister
In roomIn room
Patient/clinician encounterPatient/clinician encounterClinical DocumentationClinical Documentation
ImmunizationsImmunizations
PharmacopeiaPharmacopeia
Check-outCheck-out
Scheduling and ArrivalScheduling and Arrival
Patient self-Patient self-schedulingscheduling
RegistrationRegistration
Completion of intake Completion of intake informationinformation
Tracking BoardTracking Board
In RoomIn Room
Not all “clinicians” are Not all “clinicians” are created equalcreated equal
What type of data entryWhat type of data entry
Considerations about data Considerations about data validityvalidity
Not all patients or Not all patients or clinicians are comfortable clinicians are comfortable with computer in roomwith computer in room
Match hardware to Match hardware to clinician job clinician job
Patient/Clinician EncounterPatient/Clinician Encounter
Clinical DocumentationClinical Documentation
Patient Care OrdersPatient Care Orders
PharmacopeiaPharmacopeiaImmunizationsImmunizations
MedicationsMedications
PrescriptionsPrescriptions
Check-OutCheck-Out
Clinical DocumentationClinical Documentation
Phone note(s)Phone note(s)
Dictation/transcription Dictation/transcription
or clinical documentationor clinical documentation
Copy forwardCopy forward
Ability to access other Ability to access other clinical data clinical data
Attestation statementsAttestation statements
Clinical DocumentationClinical Documentation
I can type anything in this text box.
Clinical DocumentationClinical Documentation
Automated Expansion of NoteAutomated Expansion of Note
Output of Structured NoteOutput of Structured Note
Patient Care OrdersPatient Care Orders
Does this add value to Does this add value to the outpatient visit?the outpatient visit?
Future datedFuture dated
Legal question- who Legal question- who can “take off order”can “take off order”
““CPOE” in AmbulatoryCPOE” in Ambulatory
Order setsOrder sets
Medications and ImmunizationsMedications and Immunizations
Documenting med Documenting med administrationadministration
Sample managementSample management
Central repository across Central repository across all locationsall locations
Who entersWho enters
Policy for historical entryPolicy for historical entry
ReportsReports
PrescriptionsPrescriptions
Prescriptions- Prescriptions- workflow is criticalworkflow is critical
Refill request Refill request processprocess
Who can enter “on Who can enter “on behalf of”behalf of”
PHARMACY
Check-outCheck-out
Superbill (Fee Sheet)Superbill (Fee Sheet)
Patient NamePatient Name
Date of serviceDate of service
Level of Level of service/procedure code(s)service/procedure code(s)
DiagnosisDiagnosis
Goals:Goals:
Interface with clinician Interface with clinician documentationdocumentation
Electronic feed to billingElectronic feed to billing
Clinician WorkflowClinician Workflow
Inbox/MailboxInbox/MailboxResults ReviewResults ReviewAlertsAlertsDocumentsDocumentsPrescriptionsPrescriptionsHealth MessagingHealth Messaging
Staffing Staffing BillingBilling
Encounter ReconciliationEncounter ReconciliationReportsReports
Inbox/MailboxInbox/Mailbox
Results Delegates- “the BOOK”Results Delegates- “the BOOK”
AlertsAlerts
DocumentsDocuments
Rx RefillsRx Refills
Health Messaging Health Messaging
Inbox/MailboxInbox/Mailbox
““The Book”The Book”
Labor intensiveLabor intensive
Re-workRe-work
End of day processEnd of day process
Single assigned taskSingle assigned task
Margin for errorMargin for error
Results DelegatesResults Delegates
Real-timeReal-time
Clinic centricClinic centric
Who can be Who can be delegate?delegate?
Protocols for Protocols for normal/abnormalnormal/abnormal
Alerts/Decision SupportAlerts/Decision Support
ManagementManagementAcknowledgementAcknowledgement
““on behalf”on behalf”
MaintenanceMaintenance
Documents, Rx Refills, MessagingDocuments, Rx Refills, Messaging
DocumentationDocumentationIncomplete vs Incomplete vs “complete” “complete”
Rx RefillRx RefillClinic protocolsClinic protocols
Scope of practiceScope of practice
Appropriateness of Appropriateness of messagesmessages
Policy & procedurePolicy & procedure
StaffingStaffing
Scope of PracticeScope of PracticeRx refillsRx refills
Hardware ConsiderationsHardware ConsiderationsTypes of devicesTypes of devices
Number of devicesNumber of devices
Device locationDevice location
HardwareHardware
mobile
Capability required to be user’s main PC
cap
ab
ilit
y
fixed moveable ultra-mobile
Other ConsiderationsOther Considerations
Timing of implementationTiming of implementation
Decision-making authorityDecision-making authority
Budget/ResourcesBudget/Resources
Fighting desire for ‘over customization'Fighting desire for ‘over customization'
ConclusionConclusion
"We can't solve "We can't solve problems by using the problems by using the same kind of thinking same kind of thinking we used when we we used when we created them." created them." -Albert Einstein-Albert Einstein
Common eHealth ProjectsCommon eHealth Projects
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Registration(PM)
McKesson
Patient AccountsMcKesson
Medical RecordsSoft Med
SchedulingRSS
FinancialDecision Support(SDMS)
ERP/Inventory
Mgt.SAP
KMSFPhysician
Billing(SMS)
CaseManagement
Soft Med
Utilization Review
McKesson
2010
2009
2007
2008
UK HealthCare Information Technology Services Guiding Principles
Accountability- Based Practice
Access to Data at the Point of Service
Service Oriented Culture Patient Centric Care Innovation is Rewarded
Pre 2007
Single Sign OnSentillion
CitrixDevice
IntegrationRemedy
Support CenterRFID
Bar-CodingPatient
Identification
Mobile Devices(Hand held)(wireless)
RadiologySiemens
PathologyCerner
CoPathPlus
Laboratory Mysis
PharmacyMediware
Worx
Sunrise Clinical Viewer
PharmacyPyxis
CBORDDiet Office
Management
ElectronicEKG
ResultsTraceMaster
OB QS FetalMonitoring
System
EndoscopyProvation
Cardiology(Witt,
Phillips)
OtherAncillaryServices
PACS
ED Tracking (ED Manager)
ICU PredictorApache
Barcode Medication
Administration
OR ManagementPICIS
CPOE InterdisciplinaryDocumentation
Ambulatory Care
Data RepositoryData Warehouse
ClinicalDecisionSupport
Patient HealthRecord
Claims/Billing
SSI
ServerBased
Infrastructure
Dictation/ Transcription
Soft Med
Registry’s(Trauma, cancer,
OTTR, Tumor)
CapacityCommand
CenterPatient Tracking
EMAR
Physician Referral Secure Health
Messaging
ElectronicHealth Record
RHIO
Scanning
PortalsWeb
Enablers
President-Elect Obama President-Elect Obama and Healthcare ITand Healthcare IT
$10 Billion/year for 5 years to help $10 Billion/year for 5 years to help physicians and other providers adopt physicians and other providers adopt healthcare IThealthcare IT
After the first 5 years, phase in After the first 5 years, phase in requirements for providers to adopt ITrequirements for providers to adopt IT
Small providers and those serving rural Small providers and those serving rural and underserved populations would and underserved populations would receive top priority for financial supportreceive top priority for financial support