Outline. Why keep medical records? Electronic Medical Records: key implementation issues. Paper Medical Records

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1 Electronic Medical Records: key implementation issues C.T. Lin MD Senior Medical Director, Informatics University of Colorado Hospital January, 2008 For CLSC 6800 HLTH 6071 Outline Paper Medical Records The burning platform Electronic Medical Records What and why EMR Current design challenges Translation vs. Transformation Why keep medical records? Historical record of care Communication/continuity Preventive Care Quality assurance Legal record Financial record Research 1

2 Paper disadvantages can t find the chart can t find the result in the chart can t read the chart can t easily collate the data can t compare across patients no analytic capacity Paper Medical Records Paper records: Legibility? One day s s worth of papers to be filed at UCH 2

3 Quick! Recall: : Find all the patients who take Vioxx! P4P: : Prove that we give Aspirin to all our CAD patients! NQF: : Have all our diabetes patients had a Pneumovax? Vaccine: : Call all high risk patients to get flu vaccine now! Screening: : We have free PFT screening next week! Who would benefit? by ctl Paper records: the burning platform Legibility suspect Costly to maintain Not disaster-proof Can t t qualify for pay-for for-performance Population and quality studies impractical Functional components of EMR Electronic Medical Records Integrated view of patient data Clinical decision support Clinician order entry Access to knowledge resources Integrated communication support Tang, McDonald, p333 in Shortliffe, Medical informatics,

4 Why must we have an EMR? Because the current system is inadequate Because expert bodies recommend it Because the government says so Because insurers are going to require it Because patients are going to demand it for better safety and improved service information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade. Institute of Medicine, 2001 EMR design challenges EMR design challenges Human-machine interface (user-friendly?) Data acquisition (how to get data in?) Coded data (how useful is the stored data?) Technology adoption (who will use it?) 4

5 The Human-Machine Interface Donald Norman The Design of Everyday Things The Invisible Computer Edward Tufte Visual Display of Quantitative Information Envisioning Information Visual Explanations The Cognitive Style of PowerPoint William Cole: Semantics of Graphic Data Display Data Acquisition Paper record of scribbled notes? (fast!) Scan handwritten notes? (DHH) Typing of narrative text? (VA) Dictation? (UCH) Voice recognition (Dragon: narrative) Templates, pick lists (Coded data) Narrative vs. Coded data Narrative Easily recorded as written or spoken No limits on nuances (choked on spaghetti?) (Difficult to analyze patterns across time and across patients) Coded Standardized definitions No ambiguity Powerful for aggregate analysis (Difficult to enter data) What is coded data? A finite enumerated set of terms intended to convey information unambiguously. (note that the English language fails all criteria). Current dictionaries have standardized definitions, but not all terms unique, not always reproducible (SNOMED, ICD9). (dyspnea = shortness of breath = respiratory distress = labored breathing = panting = winded = SOB = breathless = exacerbation of asthma) 5

6 Using coded data for research A senior resident wants to do a study on ER pain management in sickle cell anemia Full paper system very awkward (1+ year effort): Obtain ER registry for the past 5 years Obtain a list of 200,000 patients, Manually select those aged under 20, African-American, with hematocrits of less than 20%. Electronic registration system simplifies selection (1 month effort) Coded EMR (1 minute effort) Using coded data for billing A clinician wants help with appropriate billing of a Medicare patient Attend weeks of training for Evaluation and Management Coding Or, by electronically coding data, allow computer support of E/M coding as note is completed 6

7 Technology adoption (who will use it?) IDDUINE M 7

8 The rule In my opinion, the success of a project is perhaps 80 percent dependent on the development of the social and political interaction skills of the developer and 20 percent or less on the implementation of the hardware and software technology! --Reed Gardner, LDS Hospital A formula for adoption + Executive support and clear vision + Physician champion(s) at executive and clinic levels + Alignment of incentives for individual docs + Adequate analyst support + Adequate time + Robust hardware and software performance! = Successful implementation A formula for adoption Executive support and clear vision Organizational behavior change At least a cost neutral ROI Transcription cost reduction Marketability of patient safety (e-rx) Necessary for future quality initiatives Necessary for Patient Centered IT Monthly Transcription $ Transcription Cost Reductions in Clinics Completing Allscripts Deployment $90, $80, $70, $60, $50, $40, $30, $20, $10, $ /05/ /05/ /05/ /05/2005 UFM Westminster UFM Boulder UFM Park Mdw UM Anschutz 08/05/ /05/ /05/ /05/ /01/ /01/2006 UM Denver Derm Endo Integrative Adv Repro Pain Rheum Urology Spine 02/01/ /01/ /06/ /06/ /06/ /07/2006 Greater than 80% reduction in monthly cost, over $1M saved annually 08/08/ /09/ /10/ /11/ /06/ /06/ /06/ /06/2007 Adv Reproductive Dermatology Endocrinology Interventional Pain Rheumatology Ophthalmology Spine Center Integrative Med UFM AFWilliams UFM Boulder UFM Park Meadows UFM Westminster UM Denver UM Anschutz Urology 04/04/ /05/ /06/2007 8

9 A formula for adoption Physician champions at executive and clinic levels Chief Medical Information Officer Seek out clinics with internal champions (Not necessarily the geek, but the respected clinician instead. Rare that one person is both) Photo apl A formula for adoption Align incentives for individual docs Feds paying for quality (PQRI) University version: Pay internal bonus based on use of EMR Physician billing improves by 14% Reduce workload by pre-loading data Generate useful reports (recall, quality) 9

10 A formula for adoption Analyst support and/or Enough Time You can bring a clinic live with 2 analysts and 40 physicians (20 faculty, 20 residents) in about a year. We have 3 teams of 4 analysts + 1 training specialist to implement 3 clinics every 10 weeks Protect physician time for training, initial use Seeing patients a day, and learning EMR is unrealistic The impossible triangle Successful implementations are like keeping all three sides of a triangle facing up. You can have 2 out of 3, but you ll never get all 3. cheap fast good A formula for adoption Robust hardware and software (performance)! The goal: sub-second response Counting clicks vs. fast systems Tablet PC medical assistant story The tapper story Database server fiasco A formula for adoption Miscellaneous thoughts: Include your patients in a media campaign (pardon our dust, we re making improvements) The attitude and efforts of 1 person can make all the difference in success or failure of a clinic 10

11 A formula for adoption QuickTime and a decompressor are needed to see this picture. + Executive support and clear vision + Physician champion(s) at executive and clinic levels + Alignment of incentives for individual docs + Adequate analyst support + Adequate time + Robust hardware and software performance! = A successful implementation must have all these elements but should have at least one of these in SPADES. Assembling an EMR So, you have 2 EMR systems. Well, can t you just hook the 2 systems up? What s the big deal? 11

12 Interactive system Viewer EMR Systems Map Provider Portal (MedXplore -> McKesson) McKesson RN docu, Bar Code, Inpt Pharmacy, CPOE GI proced CV proced Emergency Oncology Transplant OB GYN Psych Peri-Op Patient Portal Allscripts: Deployed 20 of 40 Clinics 3M Clinical Workstation: integrated viewer, clinics + hospital EMR: Substitution versus Transformation Infrastructure IDX ADT Lab RIS Path Dictation IDX Visit Management, Patient Billing, & Scheduling EMR: Substitution Transformation: Safety Its faster to create a new patient chart EMR charts can t be misplaced Notes are LEGIBLE Prescriptions are LEGIBLE No more sticky notes 2 people can use the chart at a time Electronic documentation instantly available, legible, longitudinal Safer prescribing (drug interactions, allergy check, formulary check) Vioxx recall: Patients identified, notified in 24 hours 12

13 Transformation: Quality Flu vaccine: identify highest risk patients to immunize first Diabetes: Track patients with highest Hemoglobin A1c s Heart disease: monitor use of ACE-I, Aspirin, beta-blockers Transformation: Patients Patients and physicians both contribute to a shared medical record Patients collaborate with providers to set their own treatment goals Patient can access, or give access, to their record anywhere in the world Transformation: no EMR Conversations between physicians, nurses, and patients undergo: Voice recognition Natural language processing Integrated, non-interruptive alerts based on latest evidence Substitution vs. Transformation Like improvements in transportation, EMR developments generally are incremental at first Serious Creativity, de Bono,

14 Substitution vs. Transformation It was hard to foresee what the carriage could become Substitution vs. Transformation And in the broader sense, what transportation could become Substitution vs. Transformation And we will always dream 14