top 10 ehr improvements for integrated care
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Top 10 EHR Improvements for Integrated Care . Christine A. Sinsky, MD FACP AMA Integrated Physicians Practice Section Washington, DC 11.15.13. Agenda. What ’ s working What ’ s not What ’ s needed Design Implementation Policy. EHRs. What ’ s working What ’ s not What ’ s needed. - PowerPoint PPT PresentationTRANSCRIPT
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Top 10 EHR Improvements for Integrated Care
Christine A. Sinsky, MD FACPAMA Integrated Physicians Practice Section
Washington, DC11.15.13
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Agenda
• What’s working• What’s not• What’s needed
– Design– Implementation– Policy
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EHRs
• What’s working• What’s not• What’s needed
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Shared Information with patient
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Shared Information with family
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Enhanced communication: web portal
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Shared Information virtual consults w/patient
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Shared Information across settings
BoiseDubuque
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EHRs
• What’s working• What’s not• What’s needed
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I used to be a doctor. Now I am a typist.
Personal communication. Beth Kohnen, MD, internist Anchorage AL 8.3.11
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Four Studies and an Email
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EHR: Top 3 Reason MDs Leave
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EHR: MD Dissatisfaction• Too much time, clerical• Decreases face-to-face timehttp
://www.rand.org/news/press/2013/10/09.html
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http://annfammed.org/content/11/3/272.full
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↑ EHR Functions MD Burnout and intent to leave practice
http://jamia.bmj.com/content/early/2013/09/04/amiajnl-2013-001875.short?rss=1
Fn’s: e-mail, order entry, alerts, reminders, e-communication with colleagues
JAMIA 2013
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Growing Dissatisfaction w EHRs20102013
• Not just learning curve• 12% dec in EHR satisfaction• 10% inc in “highly dissatisfied” • Fewer respondents
– Recommend their EHR– Fel
• http://www.acponline.org/pressroom/ehrs_survey.htm
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The EHR has been devastating. We can no longer teach medical students due to the time it takes to enter (primarily useless) data; I now see 4 patients per half-day whereas I used to see 8, and I actually spend less face time with these fewer patients. Working in clinic has become so painful that I have decided to leave my beloved patients—unbearable to think about.
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• 18 clicks to do one fn• EHR “so cluttered w/ non-information, hard to review past, so don’t”• “I used to leave at 6:30 and feel good about work; now leave several
hours later and spend time on weekends catching up.”
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EHRs
• What’s working• What’s not• What’s needed
– Design– Implementation– Policy
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Improvements: Design1. Better Information Display
– Clear, concise, reduced clutter– Cognitive workload– High fiber notes– Signal to noise
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What meds is this patient taking?Med List v.1
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Unclutter Med List v.2
1st order Grouped Symbols Clear Concise No Clutter Unambiguous Font One screen
Diabetic meds
clustered
CV meds
clustered
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Order Set:What goes with what?
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Improvements: Design1. Better Information Display
Clear, concise, reduced clutter2. Fewer clicks, scrolls, screen changes
– 21 clicks, 8 scrolls 5 screens billing invoice– Time = Q, access, safety
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Improvements: Design1. Better Information Display
Clear, concise, reduced clutter2. Fewer clicks, scrolls, screen changes
– 21 clicks, 8 scrolls 5 screens billing invoice
– Time is care, access, safety 3. E-workflows match clinical workflows
Rather than forcing rigid, sequence
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Improvements: Design4. Patient-centric, not billing – Six pages, no meaning – The patient presents with palpitations. The onset was just
prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: near syncope
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The patient’s story matters patient is more than sum of series of drop down boxeswhen record hx this way we risk seeing pts as generic
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http://host.madison.com/wsj/news/local/health_med_fit/madison-va-hospital-finds-stories-behind-the-patients/article_57659ff1-6f1a-5216-bd07-db4ebf2eef21.html
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Improvements: Design4. Patient-centric, not billing
– Pictures; social notes– Longitudinal care plan
• Visit note: driver of billing• Long portion: driver of care
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Improvements: Design5. Design for teamwork
Rhetoric and aspirations teamPolicies and technologies not
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20% power; brought to knees do work and follow rules when policy/technology not aligned w/team-based
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Improvements: Design5. Design for teamwork
– Multiple users, seamless transitions– Takes 1.5 min to change users – Team log-in– Not every element of care loop thru to MD
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Improvements: Institutions6. Upgrade Hardware
– Printer, screens
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Printer in every room Saves 20 min/day
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Flow StationsSaves 30 min/day
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Large monitorSaves 20 min/day
Space & technology saved > 1 hr/d MD time
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Improvements: Institutions7. Update staffing model
– Scribes
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As a patient I would prefer data entry be the responsibility of someone other than the physician. On a recent visit to a new doctor I believe we made eye contact twice—upon her arriving and leaving. Mary Base: http://www.npr.org/blogs/health/2013/08/13/211698062/doctors-look-for-a-way-off-the-medical-hamster-wheel?live=1
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Scribing at Cleveland ClinicKevin Hopkins M.D.
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I get to look at my patients and talk with them again. We’re reconnecting…. Our patient satisfaction numbers are up, our quality metrics have improved, our nurses are contributing more, and I am going home an hour earlier to be with my family.
Amy Haupert MD, family physician, Allina-Cambridge 11.29.11 personal communication
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Improvements: Institutions8. Avoid Compliance Creep
– A perfect audit trail is not attainable, and is not the goal
– Unintended consequences of diminishing Q
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Improvements: Policy Makers9. Performance measures
– Don’t apply to every aspect of clinical care– Costs of converting q thought/act into digital
10. Avoid regulatory micro-management
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MU 2 Micro-management• Visit planner
– 3 sec/pt• COE
– 2 min/pt• Micromanagement
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Approach MDs as knaves and you will eventually get knave-like behavior
I
Knights, Knaves or Pawns
JAMA. 2010;304(9):1009-1010 (doi:10.1001/jama.2010.1250)
Socio-technical-policy environment
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Take Home Message
• EHRs: Blessing and Burden best/worst– Never go back, need continue move forward – Not just EHR, but entire sociotechnical-policy
system• Recommendations
– New tech demands new delivery model Dr. secretary not winning; new support staff
– Policy/technology align with team-based care MU CPOE, security constrains teamwork
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Sign for Pre-natal Vitamins
• “It used to be that if a patient called in to report that they were pregnant the nurse would tell them to take pre-natal vitamins and that would be it.
• Now I get a message that I have to sign and forward back and …. To say I agree. – OB-GYN Michigan, personal communication
1.15.14