The Electronic Health and Medical Record. Goals. The Electronic Health and Medical Record Dyanne P. Westerberg, D.O.

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1 The Electronic Health and Medical Record Dyanne P. Westerberg, DO, FAAFP Associate Professor and Chair Family and Community Medicine Cooper Medical School of Rowan University Goals Discuss the use of the electronic medical record in today s practice setting Review what physicians like about the EMR Review what the physicians do not like about the EMR An opportunity to discuss Why, oh Why, do we need this??? On February 17, 2009 the $787 Billion, the American Recovery and Reinvestment Act of 2009 was signed into law by the federal government. $19.2 Billion is intended to be used to increase the use of Electronic Health Records (EHR) by physicians and hospitals; This portion is called -the Health Information Technology for Economic and Clinical Health Act, or the HITECH Act. April 29 May 2,

2 Purpose "To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that, within five years, all of America's medical records are computerized. This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests But it just won't save billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health-care system." Purpose "To improve the quality of our health care while lowering its costs, we will make the immediate investments necessary to ensure that, within five years, all of America's medical records are computerized. This will cut waste, eliminate red tape and reduce the need to repeat expensive medical tests But it just won't save billions of dollars and thousands of jobs; it will save lives by reducing the deadly but preventable medical errors that pervade our health-care system." It is almost 6 years! The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 Mandates that physicians and hospitals adopt electronic records by 2014, or face penalties in the form of reduced Medicare/Medicaid payments. April 29 May 2,

3 Meaningful Use The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for electronic exchange of health information to improve quality of health care. The use of certified EHR technology to submit clinical quality and other measures. Stages Basic Function of the Electronic Health Record 2. Health Information Exchange 3. Still undetermined Core Measures Use computerized order entry for medication orders. Implement drug-drug, drug-allergy checks. Generate and transmit permissible prescriptions electronically. Record demographics. Maintain an up-to-date problem list of current and active diagnoses. Maintain active medication list. Maintain active medication allergy list. Record and chart changes in vital signs. Record smoking status for patients 13 years old or older. Implement one clinical decision support rule. Report ambulatory quality measures to CMS or the States. Provide patients with an electronic copy of their health information upon request. Provide clinical summaries to patients for each office visit. Capability to exchange key clinical information electronically among providers and patient authorized entities. Protect electronic health information (privacy & security) April 29 May 2,

4 Additional menu items Implement drug-formulary checks. Incorporate clinical lab-test results into certified EHR as structured data. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach. Send reminders to patients per patient preference for preventive/ followup care Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) Use certified EHR to identify patient-specific education resources and provide to patient if appropriate. Perform medication reconciliation as relevant Provide summary care record for transitions in care or referrals. Capability to submit electronic data to immunization registries and actual submission. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission. Incentives and Penalties Benefits Green Chart Storage Space can be used for something else View at multiple offices View at home Legibility Care coordination April 29 May 2,

5 Implementation and upkeep Cost A recent survey published in Health Affairs by Julia Adler-Milstein, Carol Green and David W. An initial loss of around $44,000 on their investment. Almost two-thirds of the practices using electronic records would lose money even with government subsidies, the researchers said. Why?? April 29 May 2,

6 Software as a Service SaaS On-demand software Cloud computing One of the biggest selling points for these companies is the potential to reduce IT support costs by outsourcing hardware and software maintenance and support to the SaaS provider. Quality Measures Tracking patient parameters April 29 May 2,

7 Flow sheets Interface with the labs allows information to settle into the flow sheet. Scanning: Robust system can allow information to enter the flow sheet also Poor scanning office flow - information is all over the place. Quality Reports Neither low-cost nor easy Can help a physician know how their patients are doing with a particular disease process. Examples: Number of Diabetics with A1C < 8 Number of patients > 65 with pneumococcal vaccine Dash board April 29 May 2,

8 Physician Quality Reporting System (PQRS) From the Tax Relief and Health Care Act of 2006 (TRHCA) Physicians may earn an incentive You must start reporting in 2013 to avoid a penalty in Provide information on the quality of care across different settings Legibility Voice Recognition Software Medical professionals can easily adjust to their new EHR system Increase reimbursements Save time because they are not typing. Focus on patients. Remember to proof read. April 29 May 2,

9 Watch for errors Should be Normal male genitalia, he is circumcised What the voice recognition heard Normal male genitalia, he is circus size Watch for errors Should be Normal male genitalia, he is circumcised What the voice recognition heard Normal male genitalia, he is circus size Make sure you fix this before you close the chart. An intern recently presented a newly admitted patient on morning rounds, reporting that the patient was status post BKA (below the knee amputation). How do you know? the attending physician inquired. It has been noted on each of the patient s prior three discharge notes, replied the intern, looking up from his computer screen. Okay, responded the attending physician. Let s go see the patient. Chart errors April 29 May 2,

10 When the team arrived in the patient s room, they made a surprising discovery. The patient had two feet and ten toes. Where did the history of BKA come from? It turned out that four hospitalizations ago, the voice recognition dictation system had misunderstood DKA (diabetic ketoacidosis) as BKA, and none of the physicians who reviewed the chart had detected the error. It had now become a permanent part of the electronic medical record as if written in stone. Too legible? This 14 yo male patient presents to the office with a complaint of wheeze and increasing SOB that has been going on for a week. He is using his albuterol inhaler about 4 times per day and now he cannot sleep at night because the wheeze is worse. With the warmer weather he is playing outside and so his allergy symptoms such as the runny nose and itchy eyes are present. ROS: no chest pain, no fever, no chills PMH: Reactive Airway Disease Meds: albuterol inhaler PRN Social: non one in the home smokes Vital signs: BP 110/70, HR 94, RR 24, temperature 98.6 PO Physical Exam: Disposition: Patient is alert and oriented x 3 and in no distress HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge Heart: Regular Rate and normal Rhythm Lungs CTAB EXT no edema Skin warm and dry Assessment: Reactive Airway Disease with exacerbation: add steroid inhaler and loratadine Too legible? This 14 yo male patient presents to the office with a complaint of wheeze and increasing SOB that has been going on for a week. He is using his albuterol inhaler about 4 times per day and now he cannot sleep at night because the wheeze is worse. With the warmer weather he is playing outside and so his allergy symptoms such as the runny nose and itchy eyes are present. ROS: no chest pain, no fever, no chills PMH: Reactive Airway Disease Meds: albuterol inhaler PRN Social: non one in the home smokes Vital signs: BP 110/70, HR 94, RR 24, temperature 98.6 PO Physical Exam: Disposition: Patient is alert and oriented x 3 and in no distress HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge Heart: Regular Rate and normal Rhythm Lungs CTAB EXT no edema Skin warm and dry Assessment: Reactive Airway Disease with exacerbation: add steroid inhaler and loratadine April 29 May 2,

11 Cloning notes This patient is a 15 yo female who presents with a sore throat x 3 days. She has cough and rhinorrhea. She tried no medications for this problem ROS: no chest pain, no fever, no chills PMH: migraine headaches Meds: Tylenol PRN Social: No one in the house smokes Physical Exam: Disposition: Patient is alert and oriented x 3 and in no distress HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge Heart: Regular Rate and normal Rhythm Lungs CTAB EXT no edema Skin warm and dry Next Patient This patient is a 35 yo female who presents with a sore throat x 3 days. She has cough and rhinorrhea. She tried no medications for this problem ROS: no chest pain, no fever, no chills PMH: migraine headaches Meds: Tylenol PRN Social: No one in the house smokes Physical Exam: Disposition: Patient is alert and oriented x 3 and in no distress HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge Heart: Regular Rate and normal Rhythm Lungs CTAB EXT no edema Skin warm and dry What happens in a malpractice case? April 29 May 2,

12 Improper documentation can undermine the entire record!!! What is real and what is not real? The lawyer can cast doubt on all documentation. Watch for cut and paste abilities Watch for cloning. Example Patient has a right BKA from a non-healing fracture... Neuro Exam: CN 2-12 intact Strength = R and L (upper and lower extremities) DTR: Achilles and Patellar: +2/+4 = R and L Documentation Tips Concise and accurate Avoid extraneous information You are responsible for the entire content of the note Reference original source if taking from another note Avoid default to the negative templates Avoid Physical Exam templates April 29 May 2,

13 Pop up Reminders Patient is due for Pneumococcal vaccine! Last Hemoglobin A1C was 3 months ago. Do you want to order this? Drug Interaction Drug Interactions Allergies Incorrect dosing Do not have to write each one out. Accurate date of script. Goes directly to the pharmacy. Except scheduled drugs. If they change their mind- call the pharmacy. E- Prescribing April 29 May 2,

14 E- Prescribing Do not have to write each one out. Accurate date of script. Goes directly to the pharmacy. Except scheduled drugs. If they change their mind -call the pharmacy. You could cause a medication error!! At home At another office By the specialist By the billing department Record Retrieval Patient interaction Forbes Magazine - February 2014 suggests that the Electronic Medical Record may be contributing to medical errors because doctors and nurses are spending so much time documenting that they spend less time with the patient and make medical errors. April 29 May 2,

15 EHRs distracting physicians from patient encounters The study by Northwestern University and published by the International Journal of Medical Informatics in January Paper charts: 9% of visit looking at the paper chart EMR: 33% of the visit looking at the computer screen. JAMA 2012 Enid Montague, PhD When doctors spend that much time looking at the computer, it can be difficult for patients to get their attention It s likely that the ability to listen, problem-solve and think creatively is not optimal when physicians eyes are glued to the screen. April 29 May 2,

16 After Visit Summary Reflective of the visit Helps the patient understand changes made during the visit Cooper Family Medicine After Visit Summary It was great to see you in the office today. Today you were treated for the following problems: Essential Hypertension Hyperlipidemia These are the medications you should stop: Hydrochlorthiazide 25 mg These are the medications you should start: Linsinopril 10 mg Atorvastatin 20 mg This is when you should return to the office: 2 months or sooner if you experience problems Goal Setting Specific Measurable Mutually defined Patient centered Cooper Family Medicine After Visit Summary It was great to see you in the office today. To improve your health we discussed these goals today: Goals: I will exercise for 15 minutes 4 days a week. I will eat less rice at dinnertime I will not skip any medication doses Patient Portal April 29 May 2,

17 Potentials View labs View immunizations View medication list Make appointments Enter billing information Take questionnaires. Potentials View labs View immunizations View medication list Make appointments Enter billing information Take questionnaires. Patients can you all of their questions some do! Anywhere information Allows another treating physician to view the medical record and learn about the patient. Prevent duplication of expensive tests Provides better care??? April 29 May 2,

18 Transmission Between Systems Not yet! New York Times, 9/21/12 56 April 29 May 2,

19 Office of the Inspector General expects physicians and hospital to insure that proper safe guards are in place to prevent fraud. Annual cost of health care fraud is between $75 billion and $250 billion Concerns: cloning and over documentation Fraud Prevention Audit logs Monitor of user ID s to see who is actually entering the note. Possibly allow patients to view their record and identify fraud What physicians do not like about the EMR? Time-Consuming Data Entry User Interfaces That Do Not Match Clinical Workflow Interference with Face-to-Face Care Insufficient Health Information Exchange Information Overload Mismatch Between Meaningful-Use Criteria and Clinical Practice EHRs Threaten Practice Finances EHRs Require Physicians to Perform Lower-Skilled Work Template-Based Notes Degrade the Quality of Clinical Documentation April 29 May 2,

20 What physicians like? 1) Better Access to Patient Data "Physicians in multiple specialties and practice models noted that their EHRs improved their abilities to access patient data, both in health care settings and at home." 2) Improved Tracking of Guideline Compliance and Disease Markers "Physicians and administrators in some practices described how EHRs improved their ability to provide guideline-based care and track patients' markers of disease control over time. These advantages were predominantly noted in primary care practices." 3) Better Communication with Patients and Between Providers. "Interviewees described enhanced communication through the medical record itself (e.g., by facilitating access to other providers' notes and eliminating illegible handwriting) and through EHR-based messaging applications (e.g., patient portals). Improvements in between-provider communication were most commonly noted in larger practices, where all providers were on the same EHR." Comments? April 29 May 2,