using information technology to drive technology … information technology to drive technology ......
TRANSCRIPT
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Using InformationInformation TechnologyTechnology to Drive Patient Care: Case Study in EHR Patient Care: Case Study in EHR
ImplementationImplementation
Tom Goodwin, MHAMIT MedicalCambridge, MAMarch 2007
With Help From Monkeys, Mice, and PenguinsWith Help From Monkeys, Mice, and Penguins
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MIT MedicalStaff
122 Clinical Staff (Nearly all salaried)38 Administrative staff121 Support Staff
Scope of servicesInternal Medicine and SubspecialtiesCenter for Health Promotion and WellnessDental / Oral SurgeryGeneral Surgery and Subspecialties / Eye ServiceMental HealthNutritionObstetrics / GynecologyPediatrics / Adolescent medicineUrgent CareWorksite Health / Environmental Med / Health ScreenOn Site: •Laboratory •Radiology •Pharmacy
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Demographics / VisitsTotal Population 20,259
23%
39%2%
36%
Graduate Students
UndergraduateStudentsAffiliates
Employees
131,670 Visits to MIT Medical 2006
47%
33%
4%
8% 8%MIT Health PlansStudentsPrimary Care BenefitMedicareOther
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EMR Implementation:Major Goals
Improve Care
Control Costs
Increase Productivity
Increase clinician satisfaction
Increase patient satisfaction (Make clinical information available to
the patient)
Meet Compliance Guidelines
Interface With Practice Management System
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Our Journey Began in Late 1997
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Stages of Adopting to Technology
Duplication Phase Also Known as the Please Don’t Spank Me PhaseSubstitution PhaseInnovation PhaseTransformation Phase
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Duplication Via Building a Repository (beginning Late 1999)
Stock the Water!Data Repository
DictationsLab / X-ray / Cytology Pharmacy Interface (Pharm -> EMR)Provider SchedulesPatient Demographics
Duplicate The Existing Paper Record
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Duplication Phase at MIT Medical
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Another Example of the Duplication Phase
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Substitution Phase Begins Q1 2001
Phone Messages into the EMRNo paper messagesNo phone notes filed in the paper chartInteroffice communications
Referral NoteSpecialist ccFollow up from Urgent Care
E-mailCopy to EMR, no paper note
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No Substitution without aPhysician Champion
Any organization that wants to implement an EHR needs a Physician ChampionPlus a strong Medical Director
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A New Paradigm
Clinician Interacts With EMR
Need to look for TasksRetrieve clinical information here!Use EMR to communicateDocument all patient interactions in the EMR
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AdoptionNo Choice
Medical Director Mandate
Took Some Getting Used ToNo RebellionSet A Path To Widespread EMR UseGrumpy Old Men Will Go For A Swim!
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Our Medical Director meets with a reluctant clinician
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An Opportunity to SweepAway Bad Habits
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We Realized These Are Bad For Our Health
Deep fried outer shellLoaded with “trans” fatty acidsRed #5 DyeArtificial FlavoringLots of preservativesHigh in sodium
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And…The Paper Charts WereVery Difficult To Transport
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87% Reduction in Total Chart Pulls
Chart Pulls
150430
115332
75553
48323
19959
020000400006000080000
100000120000140000160000
2002 2003 2004 2005 2006
Year
Char
t Pul
ls
AppointmentChart Pulls
Non-AppointmentChart Pulls
Total Yearly
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Innovation Phase BeginsMarch 2003
Laboratory and Radiology results electronically verified by clinician Electronic PrescriptionsBegan scanning outside consults, diagnostic test results, and older notes One electronically signed note per visit required without printing for the paper chart.Remote access added
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Result Verification Made Easy
Annotate Here
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Electronic Prescribing
Two Way Interface With MIT PharmacyThree-Click Refills
Time Saving for Provider, Pharmacy and PatientError Reduction
Formulary InformationCost Saving for Health Plan, Pharmacy and Patient
Information To Improve Health OutcomesDrug – Drug InteractionsDrug – Allergy InteractionsDrug – Disease Interactions
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% Electronic PrescriptionsFilled at MIT Pharmacy
Electronic Prescriptions Filled at MIT Pharmacy
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan-05Apr-05
Jul-05Oct-05
Jan-06Apr-06
Jul-06Oct-06
Jan-07
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Scanning Items into our EHR
Implementation October 2003No New Papers Filed in Charts from October 15, 2003 ( →∞ )725,000+ Documents scanned in to dateNo New Paper ChartsEventually Reduced Staffing
5.5 FTE reduction in medical record staffing
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Scanned Items Viewed from the EHR
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The Remaining Paper ChartsAre Much Thinner
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Note Types in MIT Medical EHR
299,535 Notes entered into MIT Medical EHR in 2006
27%
45%
1%
25%2% Transcription
ScannedPOLDirect EntryCopied
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Remote Access Not Possiblewith 1980’s High Technology
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Further Innovation 2005 Forward
Problem List becomes more important Orders go mainstream with the addition of Laboratory and Radiology interfaces. Patient Portal comes into operationSignificant improvements in dictation procedure Mental Health Department begins using the EHR
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Direct Order Interface with MIT Laboratory
Electronic Laboratory Orders
0%10%20%30%40%50%60%70%80%90%
100%
M-0
5
M-0
5
J-05
S-0
5
N-0
5
J-06
M-0
6
M-0
6
J-06
S-0
6
N-0
6
J-07
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Direct Order Interface to MIT Medical Radiology System
Electronic Radiology Orders
60%72%
83%90% 91% 93% 95% 96% 97% 95% 97% 97% 98% 99% 99%
0%
20%
40%
60%
80%
100%
120%
Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07
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MIT Medical Patient Portal
Using our portal patients are able to:Exchange secure, encrypted messages with their providersRequest new appointments, view past and upcoming appointmentsReceive automated appointment remindersRequest updates to personal informationView certain clinical information including: Allergies, Immunization History and Medications
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Introducing the “Talking Mouse”
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Desktop Dictation has improved clinician satisfaction
No longer chained to a telephone.No need to identify yourself, dictate patient demographics, or punch in work types.Can easily pause for interruptions.Saves about 30 seconds per dictation over using the telephone. Learning is a snap!
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A Video Representation of Our Dictation System
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Drastic Improvement in Transcription Turnaround Time
Mean Turnaround Time
30 31.5 31
8.15.47 3.54
7.111.26 10.26 10.1
05
101520253035
Oct
-03
Nov
-03
Dec
-03
Jun-
05
Jul-0
5
Aug-
05
Sep
-05
Oct
-05
Nov
-05
Dec
-05
Hou
rs
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Mice can keep secrets!MIT Medical requires all 27 Mental Health clinicians to put their notes into TouchWorks as of September 2005.Ability to segregate Mental Health notes with added security.7 of 27 Mental Health clinicians use dictate, the rest use direct note entry.
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MIT Medical has saved a lot of cheese.
Dictation Charges
$0.00$5,000.00
$10,000.00$15,000.00
$20,000.00$25,000.00
$30,000.00
Jul-0
3
Sep-
03
Nov
-03
Jan-
04
Mar
-04
May
-04
Jul-0
4
Sep-
04
Nov
-04
Jan-
05
Mar
-05
May
-05
Jul-0
5
Sep-
05
Nov
-05
Jan-
06
Clinicians Dictating at MIT
01020304050607080
Aug-
04
Oct-0
4
Dec
-04
Feb-
05
Apr
-05
Jun-
05
Aug-
05
Oct-0
5
Dec
-05
Num
ber o
f Clin
icia
n
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Transformation Sneaks Up On You
Anticoagulation ClinicDiabetes Care GroupReferrals entered into EHRDisease ManagementEnhanced role of Triage NursesFantastic reporting capacityAnd we got a grant to look at potential safety issues with electronic prescribing!
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Anticoagulation Clinic
120 patients taking coumadin are managed via protocol by triage nursesNurses verify PT / INR results, contact patient, change dosage if necessary, and inform Attending MD.Within the first 3 months a much higher percentage of patients are within therapeutic range than before.
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Diabetes Care Group
Triage Nurses also participate in the care of approximately 550 Diabetic patientsMonitor orders and results of HBA1C, ensure that patient has had yearly eye and foot exams, and is scheduled to see Attending MD.All functions done through the EHR
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Flow Sheets Allow for Better Disease Management
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Reporting Allows Us To Know Our Patients and Clinicians
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Medication Safety Grant
MIT Pharmacy error rate is well below the industry average of 1.6%Electronic Prescribing poses new opportunities for errors.We are using a Human Factors Engineer to review the whole process
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Lots of Interest In EHRs But…
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Slow EHR Adoption Rate in U.S.
EHR Adoption Among U.S. Physicians and Health Centers (2005 - 2006)
11.2% 12.7%
76.1%
8.6%15.9%
75.5%
0.0%
20.0%
40.0%
60.0%
80.0%
Full EMR Partial EMR None
EMR Adoption Status
Prop
ortio
n of
Res
pons
esin
Per
cent
PhysiciansCHCs
Health Information Technology in the United States: The information Base for Progress, Robert Wood Johnson Foundation, 2006
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Benefits of the EHR at MIT
Patient care has improved with the availability of information.Reduction of 5.5 FTE in Medical RecordsCredit from Medical Liability Insurance CarrierTime savings for ancillary staffExpanded role for Triage NursesClinicians are more satisfiedPatients like the availability of information in our portalImproved HIPAA and JCAHO compliance
Specific positive feedback from reviewersA collection of solo clinicians becomes a Group Practice
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