Electronic Health Records: You will join the Borg

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1 Electronic Health Records: You will join the Borg John Luo, M.D. October 22, 2011

2 Disclosures John Luo has no conflicts of interest to disclose

3 Electronic Medical Records

4 Why Implement an EHR? Legibility of notes Accessibility of charts Transcription cost savings Space savings Decrease staffing needs Multiple simultaneous users Labs/X-rays Environmentally friendly Electronic prescriptions Incentives! Disaster recovery Drug-drug checking Drug-allergy checking Patient safety Improved workflow Increased efficiency Improved patient satisfaction Improved charge capture Improved submission claims

5 Number of Doctors Using EHR Software: Size of the Market Of the approximately 788,000 physicians in the United States, 65% of them work in an outpatient facility or physician s practice, according to the Bureau of Labor & Statistics. That s 512,000 possible physicians who are in the outpatient EHR software market.

6 Outpatient EHR software adoption, 2009 Center for Disease Control and Prevention (CDC) 2009

7 Trend in EHR Adoption

8 2009 Percentage of Office Based MDs using any EHR

9 Physicians Online 97% of physicians are online 90% are using the Web daily 33% are accessing it daily for professional purposes 79% of the doctors say the Web is essential to the way they practice medicine. Source: Manhattan Research

10 Physicians and Technology 579,000 physicians have high speed access at their office or at home or office 333,000 of U.S. physicians reporting use of some type of mobile device today (such as a PDA, smartphone with PDA, or a pen tablet) Approximately 40% report using an ipod or portable digital music player 87,000 physicians can be classified as users of new media, such as streaming video, downloadable audio content, or weblogs Source: Manhattan Research

11 Technology Adoption US vs EU Physicians Source: Manhattan Research

12 Drivers for EMR and E-Rx 2009 ARRA-HITECH Utilization Health Information Technology for Economic and Clinical Health American Recovery and Reinvestment Act Incentive payments by meeting qualitative and quantitative standards for meaningful use of a certified EMR by 2011 E-Rx is a key component of meaningful use Up to $44,000 Medicare incentive payments for eligible providers, $2 million base and more for hospitals Surescripts National Progress Report

13 Drivers for E-Rx Utilization 2009 Medicare Improvements for Patients and Providers Act (MIPPA) Providers using a qualified e-prescribing system to prepare and send prescriptions Eligible to receive higher levels of reimbursement under Medicare through 2013 Maximum reimbursement rate of 2% in 2010 Prescribers who DO NOT use e-prescriptions by 2012 suffer 1% reimbursement penalty Surescripts National Progress Report

14 Mistakes to Avoid

15 The Big Picture

16 EMR Functional Categories Alerts and decision support Charge capture & coding Dictation Document management Documentation Electronic prescriptions EMR functionality Integration and interfacing Laboratory data Orders and results Patient education Patient information tracking Patient self management PDA and wireless synchronization Provider user interface and administrative tools Reporting Specialty functionality Security and HIPAA System architecture Patient personal health records Formulary compliance

17 Office-Based EHR Local control, less worry about remote data loss May require on site IT staff or consultants Hardware replacement must be budgeted Increased responsibility for backup and maintenance Able to have onsite backup system for decreased down-time

18 Web-Based EHR Web technology and EHR are a natural fit Web simplifies access Benefits from web development technology Web-based systems can be hosted Locally and use an internal network Remotely and use a VPN over public internet ISP or Cloud provider and use HTTPS over public internet Implications of EHR system configuration System security Patient data privacy

19 Integration Practice Management System Laboratory Information System Rx HIS Hospital Information System Pharmacy LIS PT Communication to / from patient PMS EHR Prov Communication to/ from other providers

20 Costs Hardware Desktop Laptop Smartphone Internet Data plan Software License fee Support fee Service fee Upgrade fee

21 Customization Custom built forms will ease adoption Support current workflows to decrease implementation downtime Customer-led product enhancements

22 Meaningful Use of EHR 15 Core and 5 menu based objectives/measures need to be met for incentive pay 1. Use computer physician order entry 2. Implement drug-drug and drug-allergy interaction checks 3. Generate and transmit permissible prescriptions electronically 4. Record demographics 5. Maintain an up-to-date problem list of current and active dxs 6. Maintain active medication list 7. Maintain active medication allergies 8. Record and chart changes in vital signs 9. Record smoking status for patients 13 years old or older 10. Implement one clinical decision support rule 11. Report ambulatory clinical quality measures 12. Provide patients with an electronic copy of their electronic health info 13. Provide clinical summaries for patients each office visit 14. Ensure the capability to exchange key clinical information electronically 15. Protect electronic health information

23 Meaningful Use Plan 1. Understand Meaningful Use and what objectives/measures are applicable to your practice 2. Register at Will need National Provider Identifier Enroll in CMS Provider Enrollment, Chain, and Ownership System (PECOS) National Plan and Provider Enumeration System (NPPES) User ID and Password Register electronic health record program 3. Attest at https://ehrincentives.cms.gov/hitech/login.action Report numerator and denominator

24 CPOE Objective: Use computerized physician order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local,and professional guidelines Measure: More than 30% of unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE Exclusions: Any EP who writes fewer than 100 prescriptions during the EHR reporting period

25 Drug-Drug and Drug-Allergy Objective: Implement drug-drug and drug-allergy interaction checks Measure: The EP has enabled this functionality for the entire EHR reporting period Exclusions: None

26 Electronic Prescribing Objective: Generate and transmit permissible prescriptions electronically (erx) Measure: More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology Exclusions: Any EP who writes fewer than 100 prescriptions during the EHR reporting period

27 Meaningful Use Stages Stage I: Health information in electronic format Monitor patient s conditions Communicate information Report quality measures and public health Stage II: Health care management Disease management Medication management Assist patients in accessing their health information Stage III: Long term Greater quality and safety improvements Improving health outcomes

28 Research the Vendors Product functionality Company viability End-user satisfaction Delivery Training Pricing Structure Technology Structure APA EHR reviews APA Committee on Electronic Health Records

29 CCHIT Certification Listing of all certified products to meet meaningful use criteria Certification done by authorized 3 rd party EHR Alternative Certification for Hospitals (EACH) allows hospitals, mostly academic medical centers, to have existing legacy or self-created system certified

30 UNFORESEEN ISSUES

31 Master Person Index Important to prevent mistaken identity Reconcile records if patients are registered twice Mechanism to address any data changes

32 Workflows and Attitudes

33 Degrees of Decision Support Basic Alerting Checking for duplicates, drug/allergy, drug/drug interaction Advanced Alerting Age-specific weight-based, renal function alerts, drug/lab checks Basic Decision Support Predefined orders, structured orders, simple logic edits Advanced Decision Support Rules engine with conditional logic, checking across multiple clinical databases

34 Death by Template Note lacks personality and does not reflect the patient How find what is important? Multiple lists, but what does the patient have? Fragmentation of information without a flow Death of the SOAP note

35 Backup is a Priority Computers never forget, right? I m positive it was in there yesterday! Oh, oh. We just deleted the Schmidt family. What exactly do you mean by backup? Know how your EMR data is backed up Have multiple copies available at different sites What is your offline plan? Paper?

36 EHR System Security Security against what? Illegal EHR system access EHR data theft HIPPA violations Security is An end-to-end process Dependent on personnel with legitimate access Only as good as the weakest link A legal responsibility Every EHR system has security strengths and weaknesses that can change over time

37 Top Selection Tips Focus on workflows versus features during demos Have clause in contract that your system will be automatically updated fee of charge when federal regulations change Find average implementation timeline and speak to customers about their experience Assemble selection committee to include end users (billing, clinical, front office) and executives Request demo using current computers and Internet Find out how long vendor will be on-site for setup & configuration, training, go-live, and first month n-tips.pdf

38 Common Large Scale EHR Vendors Center for Disease Control and Prevention (CDC) 2009

39 Outpatient EHR software market share by vendor in 2010 Center for Disease Control and Prevention (CDC) 2009

40 Psychiatric EHR Vendors for Small Practices Helper EMR Valant EMR RevenueXL - OmniMD - ICANotes - Psychnotes EMR - Unicharts - Therapy Notes

41 Open Source Veterans Health Information Systems and Technology Architecture (VistA) Expanded modules by WorldVistA.org Easy installer at OpenMRS (http://openmrs.org) Based on Regenstrief Institute EMR Open EMR (http://open-emr.org/) Supported by OEMR organization Ambulatory certified by ONC-ATCB for MU Typically for enterprise, not solo practitioner

42 Request for Proposal Describe current architecture/system Size of organization (# employees, sites, expected user count) Selection timeline Vendor information History, location, executive summary Size (staff number, breakdown by department) Customer base (services supported, similar clients) Average implementation timeframe, timeline References System overview

43 E-PRESCRIBING ONLY

44 E-Prescribing Benefits Prescription security Financial gain Office efficiency Medication safety Formulary issues Pharmacy communication

45 eprescribing Generate prescriptions electronically PDA vs. EMR vs. online National E-prescribing Patient Safety Initiative Online - free to physicians (desktop, PDA) Connected to pharmacies Sponsored by Allscripts, Dell, Surescripts, Google, Microsoft, Wellpoint, etc. iphone/android App requires paid subscription

46 erxnow

47 erxnow on mobile devices App available Windows Mobile iphone WebOS Android

48 Personal Health Record Source:

49 Personal Health Records Health records generated by or for the consumer Web based, desktop software, app Microsoft Health Vault Exchange data Devices (glucose, BP, pedometer, HR, pulse ox) Services (labs, prescriptions, etc.)

50 Questions? John Luo, M.D. Physician Informaticist UCLA Health System 760 Westwood Plaza, mailcode Los Angeles, CA Phone: Web:

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