American Telemedicine Association 2013 Annual Meeting May 5, 2013 Austin, Texas. The Telemedicine Based Medical Home

Transcription

1 American Telemedicine Association 2013 Annual Meeting May 5, 2013 Austin, Texas The Telemedicine Based Medical Home Half Day Course American Telemedicine Association 1100 Connecticut Avenue NW, Suite 540 Washington, DC , fax

2 American Telemedicine Association 18th Annual International Meeting and Exposition Austin, TX The Telemedicine Based Medical Home Half Day Course Agenda Sunday, May 5, 12:00pm - 3:00pm Course Description: This course consists of an overview of NCQA standards for Medical Home, the relationship of medical home to accountable care, and a discussion of new technology platforms that support comprehensive telemedicine (care plan management, , voice, video, health info exchange, biomonitoring) and opportunities for long-term comparative effectiveness research. Course participants will conduct a self-assessment of their current organizational readiness for Medical Home, accountable care and telemedicine, develop a roadmap for their organization to explore model adoption, and develop a strategy for multi-payer adoption for an organization or community. Objectives Understand NCQA Medical Home standards Understand relationship between telemedicine and the Medical Home Understand technical, financial, and clinical roadmap to transition to a user friendly telemedicine based Medical Home Moderator Kim Dunn, MD, PhD A Doctor s View: Value Based Care Via Medical Home and Telemedicine Faculty Jack Smith, MD, PhD A Systems View: The Integration Imperative Jiajie Zhang, PhD Usability for Communication- Putting the Patient First Self- Assessment

3 The Telemedicine Based Medical Home Kim Dunn, MD, Ph.D. Jiajie Zhang, Ph.D. Jack Smith, MD, Ph.D.

4 Overview» Introduction to Certificate» 3 Presentations» Kim Dunn: A Practitioner Perspective and Description of a Telemedicine Based Medical Home» Jack Smith: A Need for Integration and New Technology (MHealth, Biomonitoring, Bioinformatics)» Jiajie Zhang: The Usablity Imperative and a Framework for Integration» 2 SBMI development demonstrations» 2 Activities

5 Need for New Model Cover Texas Medicine Texas Medical Association September, 2012

6 Today s Healthcare System» 1980-Present» SOAP Note» SO: Payment episode based ROS/ Physical Exam / Procedures» AP:??? Payment for Outcomes, Education/ Engagement, Care Coordination, Telemedicine» EHRs structured for payment and not connected» Future Quality???: Legislated vs. Physician Leadership» Telemedicine» Financial Focus for Disease Management:» Current- Institution focused, Not integrated» Future: Patient focused, integrated into care for value» Barriers:» Physician Quality Concerns, Population Health, Telemedicine» Payment Structures and Model for Practice Transition» Technology Patient Centered Care, Quality and Telemedicine

7 Current System

8 The Team

9 New and Future Current Model» Fee-for-Service» Disparate Payments» Fixed Payment» Illness & Cure» Volume Incentive» Fragmentation New Model» Fixed payment» Bundled payment» Population Health» Value Incentive» Integration

10 Chronic Disease Cost (%Care) Chronic Disease 50% 5% 3+ 45% 45% 1-2 5% 50% 0 Population Source: 2010 Mayo Clinic HSER

11 N of One to N of Many Integration FUTURE STATE: VERIFIABLE QUALITY CLINICAL INTEGRATION..ACO/MH N=1 Fee for Service N=many Population Health Management CURRENT STATE Fragmentation

12 All payers Medicare ACO Key Principles» 2010 Health Reform Law» Intended to create doctor/hospital networks that share responsibility» Offers financial incentives for quality metrics and cost improvements» Must meet quality benchmarks, focusing on prevention and managing patients with chronic diseases Medical Home Key Principles» Physician Engagement in Quality» Whole-Person Orientation» Coordinated Care» Quality and Safety» Evidence-Based Medicine» Enhanced Access to Care

13 Payer Landscape Payers (Business/govt) Payment based on ROS/PE/ICD, not plan Interest in medical home for care coordination of high cost Quality reporting, med home variation Lack clinical quality data Disease management / case management divorced from care delivery Payer (Patient/ Family) Increasing co-pays, deductibles Willing to pay for telemedicine Recognize opportunity for improving access through e- health Recognize opportunity for self-management tools Recognize need for eliminating duplication of data

14 Meaningful Use Using certified EHR technology in a meaningful manner (which includes e- prescribing for EPs [eligible providers]) Connecting a certified EHR in a manner that provides for the electronic exchange of health information to improve the quality of care; Using the technology to submit information to CMS on clinical quality measures and other measures selected by CMS.

15 Meaningful Use Goals Improve quality, safety, and efficiency, and reduce health disparities Engage patients and families Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information From HIT Policy Committee Recommendations

16 Meaningful Use Requirements Using certified EHR technology, demonstrate: E-prescribing (ambulatory) Interoperability Reports on clinical quality measures Be sure current product and version number are certified for meaningful use. Product list available on ONC web site: Three stages of increasingly more meaningful use requirements in 2011, 2013, and 2015

17 Stages of Meaningful Use Stage II Advanced clinical processes Stage III Improved outcomes Stage I Data capture and sharing Stage 2 proposed by end of 2011 Stage 3 proposed by end of 2013

18 Requirement / Payment Years First Year Payment Year Stage I Stage I Stage 2 Stage 2 TBD Stage Stage I Stage I Stage 2 TBD Stage Stage I Stage 1 TBD Stage Stage I TBD Stage TBD Stage 3

19 Medical Home and Meaningful Use Caid/ Care: Meaningful use is a surrogate for physician quality management All payers: Medical Home criteria align with meaningful use so why not meaningful care?

20 Comparison Meaningful Use Goal A: Improve quality, safety, efficiency, & reduce health disparities Goal B: Engage Patients and Families Goal C: Improve Care Coordination Goal D: Improve Population and Public Health Goal E: Ensure Adequate Privacy & Security Protection for PHI Medical Home PPC1: Access and Communication PPC2: Patient Tracking & Registry PPC3: Care Management PPC4: Pt Self Management Support PPC5: Electronic Prescribing PPC6: Test Tracking PPC7: Referral Tracking PPC8: Performance Rpt/Imprvmnt PPC9: Advanced Electronic Comm

21 History of Medical Home Concept 1967 appeared in Standards of Child Health Care published by AAP Originally used to describe a place single source of all medical information Now refers to a partnership approach Especially important for children with special healthcare needs (CSHCN) Grassroots movements 1978 North Carolina 1980s Hawaii legislative initiatives; involvement of Maternal and Child Health Bureau 1990s Florida, Minnesota, Nebraska, Pennsylvania, Washington 1999 National Center of Medical Home Initiatives for CSHCN Healthy People 2010: CSHCN receive care in a medical home

22 2011 NCQA Must Haves PCMH 1, Element A: Access During Office Hours PCMH 2, Element D: Use Data for Population Management PCMH 3, Element C: Care Management PCMH 4, Element A: Support Self-Care Process PCMH 5, Element B: Referral Tracking and Follow-Up PCMH 6, Element C: Implement Continuous Quality Improvement

23 PCMH 1, Element A: Access During Office Hours The practice has a written process and defined standards and demonstrates that it monitors performance against the standards for Providing same-day appointments Providing timely clinical advice by telephone during office hours Providing timely clinical advice by secure electronic messages during office hours Documenting clinical advice in the medical record.

24 PCMH 2, Element D: Uses Data Population Management The practice uses patient information, clinical data and evidence-based guidelines to generate lists of patients and to proactively remind patients/ families and clinicians of services needed for: At least three different preventive care services At least three different chronic care services Patients not recently seen by the practice Specific medications

25 PCMH 3, Element C: Care Management The care team performs the following for at least 75 percent of the patients identified in Element A (Evidence based guidelines at point of care for top three patient conditions) for Element B (High risk patients). Conducts pre-visit preparations Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit Gives the patient/family a written plan of care Assesses and addresses barriers when the patient has not met treatment goals Gives the patient/family a clinical summary at each visit Identifies patients/families who might benefit from additional care management support Follows up with patients/families who have not kept important appointments

26 PCMH 4 Element A: Support Self-Care Process The practice conducts activities to support patients/families in self management: Provides educational resources or refers at least 50 percent of patients/families to educational resources to assist in self-management Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients, if appropriate Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/families Documents self-management abilities for at least 50 percent of patients/families Provides self-management tools to record self-care results for at least 50 percent of patients/families Counsels at least 50 percent of patients/families to adopt healthy behaviors

27 PCMH 5 Element B: Referral Tracking / Follow-Up The practice coordinates referrals by Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information Tracking the status of referrals, including required timing for receiving a specialist s report Following up to obtain a specialist s report Establishing and documenting agreements with specialists in the medical record if co-management is needed Asking patients/families about self-referrals and requesting reports from clinicians Demonstrating the capability for electronic exchange of key clinical information (e.g., problem list, medication list, allergies, diagnostic test results) between clinicians Providing an electronic summary of the care record to another provider for more than 50 percent of referrals.

28 PCMH 6, Element C: Continuous Quality Improvement The practice uses an ongoing quality improvement process to Set goals and act to improve performance on at least three measures from Element A (Prevention, Chronic Disease, Utilization) Set goals and act to improve performance on at least one measure from Element B (Patient/Family Feedback- CAHPS) Set goals and address at least one identified disparity in care or service for vulnerable populations Involve patients/families in quality improvement teams or on the practice s advisory council.

29 The Patient-Centered Primary Care Collaborative Examples of Broad Stakeholder Support & Participation Providers ACP AAP AAFP AOA ABIM ACC ACOI AHI Payers The Patient-Centered Medical Home Purchasers IBM General Motors FedEx General Electric Pfizer Microsoft Business Coalitions Merck Patients BCBSA United CIGNA WellPoint Aetna Humana HCSC NCQA AFL-CIO National Partnership for Women and Families Foundation for Informed Decision Making SEIU

30 The Fundamental Question» Good doctor?» Do you have the data to prove it?

31 External Quality

32 Internal Quality» Quality refers to the degree of excellence» Assurance is a pledge of reliability» Therefore, quality assurance is a pledge of reliability in the pursuit of excellence

33 Physician Leadership» Staff: People / Process to improve service and education for patient engagement» Workflow internal» Workflow external» Doctors: Quality to improve population health» Understand your quality compared to others / standards» Plan to improve» Reduce variation» Improved over time

34 Bridging the Quality Chasm Where We Are Implementation Innovation Where We Want To Be Diffusion Adoption Partners for Quality,Carolyn Clancy, M.D., Director, Agency for Healthcare Research and Quality, March 20, 2003

35 Uncertainty, Tension and Distrust Lack of understanding among clinicians/administrators/patients/ payers Investment in information systems designed principally for a) administrative/billing; b) process ancillary care and not for outcomes data capture c) current generation EMRs Discomfort and disenfranchisement of clinicians information technology feedback on their performance population disciplines involvement of non-physicians in decision-

36 Cultural Transition: Hierarchy to Shared Responsibility IS/business/PH Clinicians / Patients Health care reform = information process reform (people, process, automation) Shared responsibility Value=Quality/Cost

37 Same issues, circa 1970

38 Houston Chronicle Editorial June 27, 2012

39 Patient Centered, Technology Based, Physician Quality Driven

40 Comprehensive Telemedicine» Med Home Portal as HIE Use Case» Document Management as Med vetted PHR» Care summary / coordination with follow up via secure messaging on service delivery» Secure messaging for care coordination» Specialty: Curbsides / Live interactive care» Biomonitoring for disease management

41 KDA Telemedicine Standards and Payment KDA Standard for NCQA Medical Home Access and communication have written policies and evidence of compliance Payment with future currently negotiated FFS but participate in P4P Co-pay for care plan change Physician care oversight / Med home FFS but participate in P4P Co-pay Participate in P4P Time Regular office hours After hours call group Patient disease mgt Specialist Inperson Telespecialist Emergency Center / Hospitals Posted hours on website Telephone Urgent questions Secure messaging Non-urgent questions answered in 24 hours Evidence of meeting standard / monitoring Medical home assessment Posted on website Patient secure messaging response times monitored Urgent On call group enrolled into portal Messaging from call groups to medical home on phone call, assigned tasks, care plan, follow up survey 1. Care Plan and Follow Up 2. Biomonitoring sheets Care plan follows the patient both via paper and via smartphone access 1. Curbside consults 2. Scheduled Video during office hours Care plan follows the patient both via paper and via smartphone access Patient has agreements and monitoring sheets for patient self management of prevention and disease management Network from medical home survey enrolled and defines HIE Patient physicians added to portal Utilization of use of messaging Number of live interactive scheduled Surveillance of ADT Discharge patient info to med home portal

42 Medical Home Portal Functional Ma Category Medically Vetted Personal Health Record Medical Home Annual: HRA/PE Ambulatory Specialists / Emergency Summary, Key labs, reports Institutional Hospital / Nursing facility Population Health/ Risk Management Chronic disease reporting for all physicians in patient s care network Regulatory reporting requirements Care Plan follows the patient across care locations I: Components by diagnosis: Risk factor, Interventions, Goals, Follow Up, Doctor II: Communication: Comprehensive telemedicine support User Roles for Portal Management Physician care oversight Med Home Attending Attending Data, process and patient education Medical Assist. Medical Assist. Patient Nurse Medical Assist.

43 Perspectives on automation» Patients: more efficient and timely care, understanding the delivery process» Physicians: costs of entry, risks of entry, how they will be paid, how they can exit» Employers: disease management, employee retention, efficient care» Payers: reductions in cost and efficiencies

44 Barriers to Automation» Culture Change» Financial» Clinical» Technical

45 Regulatory / Legal Issues» Licensure / authorities: Who and where» Risk management / malpractice» Fraud and abuse» Privacy and confidentiality» Device regulations» Accreditation

46 Approach to Implementation» Identify specific needs and requirements w/ process flow of information and practice business goals» Internal» External» Evaluate systems against these requirements» Budget sufficient funds for ongoing system changes and training» Flexibility to adjust to changes

47 Workflow Analysis: Internal and External» What information is needed» Who needs it» Why is it needed» Where is it needed» When is it needed» Is the information useful to the user

48 Ten Steps of Workflow» Proactively alerts user of required steps or action to be completed» Provides user w/ tools to complete tasks» Allow users to see where each work task fits into overall process» Manages specific reminders, alerts user to them, and follows up to keep proces moving in timely fashion» Automatically initiates regular process steps» Flexibly integrates into user s existing systems and processes» Routes work items in parallel flow» Provides cycle times and individual worker productivity statistics» Identifies person responsible for each part of the process» Identifies bottlenecks leading to decreasing productivity and delays

49 Comparing Systems» Compatibility with Current System» General Design» Data Input Methods» Technical Features» General Performance» Specific Features» Vendor Characteristics» Security» Cost/ Maintenance Fees» Training/ Technical Support» Legal Contracts

50 General Design» Integrate design: Modular vs. stand-alone» User-configurable options» Patient-centered» Work-flow driven and customized to practice» User-driven data analysis and reporting» Effective design and organization of reports

51 Take homes» Regulatory Reporting» Part of routine workflow» Reporting data (regulatory) vs. Population mgt (physician)» Effective automation for internal workflow (EMR) and external workflow (e-health)» Physician leadership for Practice Based CME/CNE

52 Helpful web resources» Regulatory» http: //medicaleconomics.com» Medical home» EMR resources» and TxRECs» Telemedicine» Quality»

53 The Telemedicine Based Medical Home: Integration and New Technology Jack Smith, MD, Ph.D.

54 What Does A Quality Driven Health Care System Look Like? Quality First Patient centered Accessible Understandable Outcomes driven Then Cost Affordable Transparent Enabled by: Information Management Real-time availability Information available when, where needed Patients and doctor roles and responsibilities defined

55 What is Needed? Communication, Training and Infrastructure to Support Standards

56 Medical Home with Standards for Total Quality Management Enabled with Telemedicine Hospital Specialists Medical Home/ Call Center Friends & Relatives Partnership with roles / responsibilities defined and outcomes driven care Care providers Alerts to Medical Home Pharmacy Home nurses

57 System of Systems Interactions Hospital Information Systems Physician Practices Electronic Health Record Labs / Radiology Quality Health Record Outcomes, Surveys E-prescribing / Medication Reconciliation and Reports Patient Protocol Customization Care Providers Knowledge / Evidence Base

58 New Needs for Data, Information and Knowledge Historic functionality of current electronic health records Emergence of personal health records What they don t do What we need to do for new model of care

59 Telehealth The delivery of health-related services and information via telecommunications technology Store and forward Images, video, audio and clinical data are captured, stored and forwarded to a specialist at another location Real-time Uses telecommunications technology Videoconferencing Remote patient monitoring Technology captures and transmits information

60 Telemedicine Examples Live interactive video: Primary care to specialist, Patient to doctor Curbside Consultation With Smartphone: Primary care to specialist

61 MH + Telehealth Increases access to care for those with Lack of transportation Physical limitations Telehealth can be used as a tool to manage care for PCMH patients with chronic conditions Reinforces self-management Allows for home monitoring via telephone, and biologic monitoring Provides for teleconsults with specialists + =

62 Elements of Access Geography / distance Availability of health facilities Complexity of illness Transportation system Social / cultural norms

63 Telemedicine: Secure Messaging, Smart phone, Video, Health Information Exchange

64 Home Monitoring Examples Teaching Home Monitoring- blood pressure, glucose, weight, pulse oximetry, Monitoring by Medical Home Critical Alerts Routed to Doctor

65 Elias A. Zerhouni, M.D Budget Hearings House Appropriations Subcommittee on Labor/HHS/Education

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68 DNA expression microarray Source: accessed May 7, 2003

69 Information overload Source: NCBI, Accessed: March 24, 2010

70 Differential Expression of Genes: Scatter Plots Coombs K, www3.mdanderson.org/depts/cancergenomics/basicanalysis.html 2002

71 Expression of 1,753 genes in 84 samples Each row represents a gene Each column represents a sample 1753 genes whose abundance varied at least 4X from median in 3 or more samples Hierarchical clustering to organize samples based on similarity of gene expression Two tumor samples from same individual more similar to each other than to any other sample Perou et al, Nature, 2000

72 Bioinformatics The science of collecting, storing, and analyzing biological information ( omics )

73 Impact of Genomics Impact on clinical care Diagnosis Do genetic test to identify presence/absence of disease Cystic fibrosis, Philadelphia chromosome Pharmacogenetics Do genetic test prior to giving medication Chemotherapy (6-MP) and fatal gene variant (TPMT) Impact on clinical information systems Clinicians need rapid access to information Genetic disorders, genetic tests, drugs affected by genetic variants Need vocabularies for genes and genetic tests

74 Microarrays: Role of Bioinformatics Experimental Step Selection of clinical samples Creation of microarrays Creation of image Quantify images Analyze data Identify differences Centralization Informatics Step Query of clinical database Sequence database Storing of image Image analysis software Statistical and bioinformatics software Compare with other genomics databases and PUBMED

75 Not viable for billions of options Need true decision support System that recommends drug dosage based on what is known about the patient and indication How do you do that?

76 GuideView User Interface makes it easy to apply and use complex clinical guidelines

77 GuideView Supports Mobility User Interface almost identical to that on a laptop/ desktop Full motion video and voice output available Weight/form factor of PDAs very desirable in many contexts including space and combat GuideView executes on cell phones

78 Understanding Quality Improvement as Systems Design Driver

79 Primary Focus Quality Improvement Goal: Continuous Quality of Care Improvement Means: Understanding Care as a System of Systems New Perspectives for Patient and Provider: Embedded Cycles of Quality Improvement, Process Diagrams, Aggregated Case Scenarios

80 System of Systems Quality Management Cycle Act: Once you ve identified key opportunities for improvement you address them by evolving your processes and tools Focus: What key opportunities for improvement are the priority

81 Goal: Continuous Quality of Care Improvement

82 System of Systems Quality Management Cycle Plan: Define and institutionalize the processes that you intend to follow. Consider what your processes are and what they should be, and put a plan in place to get there Do: Execute processes

83 System of Systems Quality Management Cycle Check: Reports on the organization-wide metrics that indicate how your quality improvement activities are progressing Static reports generated for traditional management necessary for accreditation/compiiance reports Dynamically generated reports that identify problems and extract insights that would have otherwise gone unnoticed

84 System of Systems Quality Management Institutional oversight changes from a large, timeconsuming activity that occurs once every several years to an ongoing, incremental process of continuous improvement Accreditation/compliance reporting becomes a demonstration of the quality management activities that the institution already undertakes on a daily basis More emphasis on self direction and self evaluation of individuals and groups is critical to success

85 Understanding the System of Systems Process Diagrams Cycles Within Cycles of Quality Improvement Use Case Scenarios: Slices of Who, Why, What, Where, How

86 It s Time To Bury The Old EMR

87 Automation for EMR. NO. The Quality Health Record People Process Automation Incentives: Time and Money

88 Quality Health Record New model for documentation Assures NCQA medical home standards met Model for clinical approach to health information exchange Medically vetted personal health record and patient support tool Care reconciliation and patient education Collects outcomes of care on all patient encounters to support quality improvement Integrates comprehensive telemedicine

89 The Quality Health Record Patients have multiple doctors prescribing multiple medications Cardiologist medications Endocrinologist medications Primary care medications 1. Translate into a reconciled care plan in the Quality Health Record. 2. Follow up with the patient after changes to the patient s care plan. 3. Review outcomes to improve.

90 Quality Health Record Managed by Medical Home Supports Electronic Coordination of Care Quality Health Record 1.1 Patient goals based on current knowledge guidelines and physician preferences Reconciliation of treatment plans and medications among treating physicians Treatment outcomes, satisfaction and risk factor linked to each condition in the Careplan Outcomes follow-up with patient and their understanding of treatment plan Teleaccess with Specialists and Patient Outcomes, Surveys and Reports Peer review Quality improvement plans Avoidable ER visits / hospitalizations Adverse events evaluation

91 EHR Usability and Workflow: The SHARPC Perspective Jiajie Zhang, PhD Director, SHARPC U of Texas School of Biomedical Informatics at Houston May 5, 2013

92 August 10, 2011 Wall Street Exxon Mobil: $331 Billion Usability is More Valuable than Oil! Apple: $337 Billion Apple became the biggest US company in market value 2

93 Market Cap in $Billion June 8, Facebook 400 Google Exxon Mobil Apple Microsoft

94 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 4

95 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 5

96 Heffler et al., Health Affairs, 2005 US Health Care Spending

97 OECD - Organization for Economic Co-operation and Development (From Keith Butler)

98 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 8

99 Potential Benefits of HIT Improve the quality of care along the IOM defined measures Safer More effective More timely More efficient More equitable More patient-centered

100 How Much Can HIT Reduce US Healthcare Costs? 8% of Total Healthcare Costs 1.2% of GDP = $162 Billion > Total US R&D = 1.0% of GDP or $140B 140 UTHealth 9 NASA 5 NIH (National Institutes of Health) $162 Billion/year could be saved by HIT in US $Billions Increased efficiencies 4 Reduced adverse drug events 81 Prevention & Management RAND 2005 report

101 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 11

102 Office of National Coordinator for Health IT (ONC) Health Information Technology for Economic and Clinical Health (HITECH) Act $19 billion (CMS and ONC) 12

103 Challenge: EHR Adoption Levels

104 HIMSS Convention Attendance: An Indicator of Health IT Market Growth # Attendees 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, (HIMSS - Healthcare Information and Management Systems Society)

105 EHR Market in US $6 B 18.1% annual growth rate $2.2 B From MarketsandMarkets, Healthcare IT News, 6/15/

106 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 16

107 ONC SHARP Program Conduct breakthrough research for health information technology (HIT) $15 million for each center ( ) Mayo Clinic Harvard UIUC UTHealth

108 National Center for Cognitive Informatics and Decision Making in Healthcare (NCCD) SHARP-Cognitive

109 Research Sites Consultants Advisory Board UW Harvard VAPAHCS InterMountain UK UMD Navy Research ASU BHCS BCM UTH 11 sites 40 investigators 15 consultants 20 advisory committee members Other personnel 14 states

110 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 20

111 EHR is the Future If given a choice to stay with current EHR or to go back to paper, Nearly all users want to stay with EHR But, EHR can be much better 21

112 Decrease of Productivity An outpatient CPOE increased encounter time per patient by 2.12 minutes from 9.8 to 12. (Overhage, 1997) An inpatient CPOE increased the time spent on patient order entry from 2.1% to 9% workday. (Shu, 2001) An outpatient EMR reduced patient volume from 5/hour to 4/hour and stayed at 4/hour after four years of use

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115 AHLTA $4 billion to develop; much more to maintain Large user base 412 medical clinics 414 dental clinics 65 military hospitals in US and bases across the world Poor usability of AHLTA is one of the Top Three Reasons for physicians leaving military services Now considering replacement options for AHLTA

116 Good usability is achieved through usercentered design To Design technology to fit user needs and characteristics NOT to train users to adapt to poorly designed technology

117 Why Usability? (HIMSS)

118 TURF - A Unified Framework of EHR Usability An Acronym for Task, User, Representation, & Function A Theory for defining, describing, explaining, and predicting usability A Method for evaluating and measuring usability designing usability categorizing usability and safety problems A Software Tool for (partially) automating usability evaluation conducting user testing building EHR ontology generating evidence-based designs conducting usability and patient safety analytics

119 What is Usability? 29 Under TURF, usability is defined as how useful, usable, satisfying a system is for the intended users to accomplish goals in the work domain by performing certain sequences of tasks

120 Zhang, J., & Walji, M. (2011). TURF: Toward a unified framework of EHR usability. Journal of Biomedical Informatics, 44 (6), TURF Framework for EHR Usability 30 Functions Useful Intrinsic Complexity Users Satisfying Extrinsic Difficulty Representations Usable Electronic Health Record Tasks System Usability

121 Dr. Townshend prescribes 90 day supply of Metformin 500 mg tablets by mouth twice daily to patient John Doe who is a pre-diabetic patient with a glucose level of 110. JOHN DOE REPRESENTATIONS manipulate USERS Dr. Townshend Dose Instructions Dose Operation: Route Check drug-drug Frequency interaction Pt. Instructions Object: Patient Medication = John Doe Name/Strength Goal: Treat high glucose level Duration Dispense Operation: Prescribe medication Object: Medication Start = Metformin Dosage / Date Instructions Generic name Brand name Strength Refill Dose Route Duration Properties: Dispense Quantity Other Instructions FUNCTIONS Operation: Check drug allergy Object: Diagnosis Quantity= diabetes Refills Dosage Form Frequency Date Ordered support Extrinsic Difficulty--Usableness Intrinsic Complexity--Usefulness execute TASKS Find the Medication" tab Point to Medication" tab Click Medication" tab Click New Med button Wait for the system to show Medication" window Find the "Search all Meds" Click "Search All Meds" Wait for the system to show "Order a Med" pop-up window Find Search" field Point to Search" field Type Metformin" Point to Metformin" on the list Click Metformin" on the list Wait for the system to show Dose Instructions" window Etc. etc. etc.

122 Measuring Extrinsic Difficulty -- Usableness: Task Time and Usability Problems 32 Task Time (seconds) Task Analysis Representation Analysis Usability Problems

123 Measuring Extrinsic Difficulty -- Usableness: Mental Workload 33 Physical Mental CPOE eprescribing Clinical Summary Smoking Status Problem List Growth Chart BMI Vital signs Demographics 0% 20% 40% 60% 80% 100%

124 Measuring Intrinsic Complexity-- Usefulness: Overhead Function Overhead in EHR # Overhead Functions in EHR = #Domain Functions in EHR + #Overhead Functions in EHR Domain Functions in EHR Overhead Functions in EHR CPOE 2 64% 36% CPOE 1 58% 42% 0% 20% 40% 60% 80% 100%

125 Measuring Intrinsic Complexity-- Usefulness: Domain Function Completeness 35 Domain Function Completeness = #Domain Functions in EHR #Domain Functions in Entire Work Domain A Small EDR System (From Chen, 2008) 37 = 80 46%

126 TURF Software Tool Architecture Users Usability Evaluator System administrator Developer Provider Other Users Presentation layer Data Collection Modeling Analysis & Report Business layer Data Capturing Representation data: Screenshot, video, widget Interaction data: Keystroke & mouse movement User data: Profiles and Personas Function Data: Work domain ontology Mapping editor Data integration Modeling Populate TURF models Modeling engine Repository management Model-Driven Analysis Usability Metrics Usability Benchmarks Usability & safety patterns EHR domain ontology Data Layer Data access components Data utilities Service agents Entity-relational database Ontology database Other usability test/analysis services (e.g., Cogtool, Ulog, Noldus, etc.)

127 TURF Software Tool: Assess, measure, and improve EHR usability 37 Semi-automate usability expert reviews Build cognitive models to predict clinical task performance times Capture user testing data Build EHR ontology from usage data Generate evidence-based designs TURF 1.0 & TURF Personal 1.0 under Beta testing

128 Using TURF to Redesign EHR

129 TURF in Action: Redesigning EHR OpenVista: Open Source EHR NIST Use Case (e) Maintain active medication allergy list Add allergy; Modify allergy; Review allergy Harrington, Wood, Breuer, Pinzon, Howell, Pednekar, Zhu, & Zhang (2011) 39

130 TURF in Action: Redesigning EHR Harrington, Wood, Breuer, Pinzon, Howell, Pednekar, Zhu, & Zhang (2011) 40

131 TURF in Action: Redesigning EHR 81% reduction in Overhead Functions 89% increase in Domain Functions Overhead Functions Domain Functions Harrington, Wood, Breuer, Pinzon, Howell, Pednekar, Zhu, & Zhang (2011)

132 Project 1A: EHR Usability & Workflow Work-Centered Design of Care Process Improvements in HIT Project Leaders: Project Co-Is: Postdocs, GRAs, Programmers: Jiajie Zhang Muhammad Walji Consultants: Mark Musen David Woods Amy Franklin Brent King Emeka Okafor Yan Xiao Min Zhu Velma Payne Zhen Zhang Krisanne Graves Yuanyuan Li Yingliu (Meg) Gu Craig Harrington Deevakar Rogith Dinesh Gottipati Vickie Nguyen Peter Killoran Claire Loe

133 Project 1B: EHR Usability & Workflow Work-Centered Design of Care Process Improvements in HIT Project Leaders: Keith Butler Project Advisor: Mark Haselkorn Project Co-Is: Axel Roessler Consultants: Ali Bahrami Ellen Bass Chris Esposito David Kieras Mark Musen Postdocs, GRAs, Programmers: Konrad Schroder Mike Watt

134 MATH Workflow Modeling Tool

135 Project 2A: Cognitive Support for Clinical Comprehension Project Leader: Trevor Cohen Project Co-Is: Amy Franklin T. Kannampallil Consultants/Cli nicians: Gary Klein John Flach Bela Patel Khalid Almoosa Kevin Hwang John Joe A. Laxmisan Postdocs, GRAs, Programmers: Zhe Li Ram Vedam Katie Vasser Rashmi Mishra Dinesh Gottipatti

136 Cognitive Support System Cognitive Support System (back-end) computer-interpretable decision models SIRS-specific Prototype User Interface populate knowledge models with data collect data from SMART/M IMIC 2 Navigation traverses characterized decision points Information organized in accordance with decision models

137 Project 2B: Facilitation of CDS Adoption through Modeling of Setting-Specific Factors 47 Project Leaders: Robert A. Greenes Mary K. Goldstein Peter Haug Project Advisor: Robert Jenders Project Co-Is: Emory A. Fry Samson Tu Nathan Hulse Consultants: None Postdocs, GRAs, Support staff: David Yauch Bharath Shive Gowda Pamela Kum Matt Ebert Chai Young Dananjayan Thirumalai

138 Multiple rules have similar intent Differences relate to how triggered, how delivered, thresholds, process/workflow integration, etc. Challenge is to identify core medical knowledge and to develop a process to capture differences in settings so that the knowledge can be adapted to them Analysis by Saverio Maviglia, Morningside Initiative, 2008

139 Development of Clinical Knowledge Models for Summarizing EHR Data

140 Figure 3b: Annotated example of automatic clinical summarization TX John Q. Smith 375 Plantation Rd. Luling, TX W: Insurance: BC/BS 67yr white male lbs ( 4 lbs in 12 mo.) BMI-28.8 Link to pt insurance info Patient photo View graph of weight Diabetes Risk Management Summary View graph of HbA1c s Glycemic Control: Type 2 DM (dx: 10/1/09): HbA1c-7.0% (10/01/10) ( 3.0% in 12 mo.) on metformin (1000 mg BID). Glycemic control is acceptable according to ADA guidelines. View graph of lipid panels Lipid Control: Hyperlipidemia (dx: 10/01/09): Total cholesterol-250 mg/dl, HDL 40 mg/dl, LDL 175 mg/dl (10/1/10) ( from 180/60/125 4 mo. ago) on simvastatin (20 mg QD) Print patient ed sheet ATP III 10 yr risk of MI or death - 23% Pat Ed: Cardiac Risk Factors ATP III guidelines recommend adjusting dosage. Link to medication list View graph of BP s Blood Pressure Control: Hypertension (dx: 10/01/09): BP-135/90 (today) ( on Hydrochlorothiazide (25 mg QD) Link to medication list JNC VII guidelines recommend adding a medication. from 150/105 in 12 mo.) Visit History: Clinic Urgent Follow-up (6/15/10); ED Hospital chest pain (6/1/10); Clinic Well Visit (2/1/09); Clinic Physical (10/1/09) Link to related note

141 Project 4: Cognitive Information Design & Visualization Project Leaders: Todd R. Johnson Ben Shneiderman Catherine Plaisant Project manager: Project Co-Is: Jorge Herskovic Elmer Bernstram Consultants: John Flach Postdocs, GRAs, Programmers: Eliz Markowitz Surreya Tarkan Tiffany Chao Chitra Shriram

142 Medication Reconciliation 52

143 Outline US Healthcare US Health IT ONC HITECH ONC Research: SHARP Usability Conclusion 53

144 54 You already knew how to use it!

145 Acknowledgments ONC SHARPC for Patient-Centered Cognitive Support ONC Gulf Coast Regional Extension Center National Institute for Standards and Technology 55

146 sharpc.org 56