Anatomy and Issues ofElectronic Medical Records Systems

Lyon, Popanz ForesterMay 26, 2009

This presentation provides a structure for the planning, management and continuous enhancement of electronic medical records systems in the context of an emerging nationwide health information infrastructure

It is based on our experience with development, implementation and litigation of large, complex systems including HIPAA, Y2K, ERP and corporate mergers

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Lyon, Popanz & Forester is a management consulting firm. The information presented here is based on our experience and sources we consider reliable. There is no further guarantee of usability of accuracy. LP&F does not provide accounting, financial, or legal advise; see an appropriate professional for those services.

Topics

Why electronic medical recordsScopeStatus of implementationAnatomy and Issues

ParticipantsSpecialtiesDataTechnologyImplementation

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Focus of $19.2 billion for health information technology

http://content.nejm.org/cgi/content/full/NEJMp0900665?query=TOC

Part of $787 billion economic stimulus packageAmerican Recovery and Reinvestment Act of 2009

The Health Information Technology for Economic and Clinical Health Act or HITECH

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Why electronic medical records?

What does HITECH require?Provides incentives to hospitals and doctors’ offices to move to electronic medical records

There are incentives to and penalties for failure to

Use a “certified” EMR systemDemonstrate “meaningful use” of an EMR

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Scope of EMR systemsPart of a larger health information infrastructure that is evolving as a result of HIPAA and HITECH plus related efforts of leaders in healthcare who see the need and value

Network based – scope extends to the interfaces with other systems and then links to the Internet

The scope ranges from individual consumers to very large healthcare organizations and essentially all supporting health care organizations in between.

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Scope: EMR & PHRHITECH

EMR

Hospitals Doctors’ Offices

Public Health

Support Services, e.g., Labs,

Pharmacies

Google/MicrosoftPHR

Pharmacye.g., refills

Medical Devices

e.g., monitors

Support Services e.g., Labs

Family authorized

access

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EMR – electronic medical records managed by source of the data, e.g., hospital, doctor, etc.PHR – personal health records managed by the patient/consumer using Google, Microsoft, etc.

Other systems: Billing and payments; HR; Hospital operations: dietary; etc.

Status of ImplementationThe Wall Street Journal identified 10 types of EMR systems and assessed their implementation in hospitals:

Highest: Laboratory Results 75%Lowest: Physician’s Notes & Clinical Guidelines:15%All others: 27% to 52%Full EMR: 1.5% of US hospitals*

The survey did not address the question of whether or not these systems can be integrated into a nationwide health information infrastructure without significant modification or replacement

http://online.wsj.com/article_email/SB124104350516570503-lMyQjAxMDI5NDAxMTAwNDEzWj.html April 30, 2009* There are about 5,000 hospitals of which about 3,000 have 100 beds or more 8

Basic Anatomy of an EMR

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EMR Systems & Context

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Systems: Context:

All of these elements are in the process of evolution

Participants

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Sponsors of a

system

ParticipantsSponsors: Typically a hospital or group of hospitals plus doctors interested in patients hospital and office records – funding and decisions

Interfaces: Other organizations that will exchange data with the sponsors – coordination for interoperability

Other existing systems: Typically doctors who already have EMR – coordination for interoperability

Future Growth: The value of a network is a function of the number of users – creativity for growth

Future Unknowns: New capabilities enable additional capabilities, e.g., devices and interfaces – need to build in flexibility

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Medical SpecialtiesBroad system capabilities that cut across specialties to gain user involvement and experience

Focused capabilities in response to expressed needs by specialties – develop and implement where support and standards exist

Cost/benefit analysis – demonstrate benefits

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Data

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Retain

Receive

Send

Exchange

Data – policies and issuesHow are any differences between multiple copies of a record or between different records to be reconciled?

Who has authority to release data to a patient or other non-medical entity?

Who has authority to release a patient’s data to new health care provider and under what circumstances?

Who has authority to restrict destruction if a lawsuit is pending?

When must some data be deleted?

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Data – types and issuesUser creates, captures and makes available – Who controls access? Deletion?

User retrieves from system data storage – Can they store a copy? How are subsequent changes managed?

User requests data from outside the system, e.g., results of lab tests – Can user store a copy? Must they?

Sponsors and users should focus on• Right information – what is needed• Standard content and format• Quality over time

Coordinate solutions with other systems and industry coordinating bodies

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Technology

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Technology

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Technology should produce standard answers from standard data – therefore use standard technology : generally buy, don’t build

Vendors are developing common solutions to common problems, e.g., Microsoft’s Amalga to deal with multiple data formats

Concentrate on delivery of data ready to use, simplicity of data capture, and data quality

Let vendors deal with the common technology issues

Implementation

Cost/benefit – best value to participants

Encourage participation – involve users

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EMR Systems & Context

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Systems: Context:

• Context provides standards• Vendors provide technology that satisfies standards• Sponsors tailor, implement and manage

We have worked in thewhite space of organizations …including HIPAA, Y2K,ERP, mergers and theimplementationof evolving regulations

The white spaces of organizations occur on organization charts between internal

departments, in contractual ambiguity and regulatory complexity.

They are places where functional misunderstandings occur,

communication falters, roles change,priorities conflict, rewards are unclear,

risks are unknown, and managers sometimes see threats to their careers

that outweigh the opportunities. We work in those white spaces to

define problems so they can be solved, design solutions so they can be

implemented, and structure implementation so it can be managed.

Hal Amenshal9007@gmail.com

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Additional resources:

Internet research on ERM: http://www.delicious.com/hal9007/emrTwitter links to EMR: http://www.twitter.com/hal9007Google Health (PHR+) http://www.google.com/health Microsoft Vault (PHR+) http://healthvault.comMicrosoft A malga http://microsoft.com/amalga