the electronic medical record and the practicing physician: an oxymoron? carol steltenkamp, m.d.,...

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

An Equal Opportunity UniversityAn Equal Opportunity University 22

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


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)


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).

An Equal Opportunity UniversityAn Equal Opportunity University

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)


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)


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).


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

0

20

40

60

80

100

120

Tob Cou

nsel

B-block

p M

I

Mam

mog

ram

PAP S

mea

r

Chol S

cree

n

Chol p

MI

LDLC

<13

0 p MI

Color

ectal S

cree

n

HgbA1c

ann

ually

HgbA1c

< 9.5

DM C

hol

DM C

hol <

130

DM eye

exa

m

HTN con

trolle

d

Flu

vacc

ine, >

65yo

Pneum

ovax

, >65

yo

MH f/

u p D/C

Pe

rce

nt

Go

als

Me

tVABest Other

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.


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


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


I can type anything in this text box.

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


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

the electronic medical record and the practicing physician: an oxymoron? carol steltenkamp, m.d.,...

Documents

new articles

health care unaffordable

higher medical care

implementation of hit

new trials

health spending

serious medical errors

dangerous medical errors