Intégration de la Télémédecine dans le Dossier Médical Hospitalier

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1 Intégration de la Télémédecine dans le Dossier Médical Hospitalier Joshua L. Cohen, M.D. Professor of Medicine Division of Endocrinology & Metabolism Director, Medical Faculty Associates Diabetes Center

2 The George Washington University Medical Center

3 The George Washington University Medical Faculty Associates Multispecialty Faculty Practice Organization Approximately 350 physicians Provides comprehensive primary care and specialized care Accepts private insurance, Medicare, Medicaid

4 Medical Faculty Associates Diabetes Center MFA patient population includes approximately 6000 patients with type 1 or type 2 diabetes (2009) Diabetes Center Professional Staff: Endocrinologists, Midlevel Practitioners, Certified Diabetes Educators, Dieticians ADA recognized Diabetes Self- Management Program

5 Allscripts Enterprise Electronic Health Record (EHR) Web-based EHR Unified medical record shared by all providers Functions: Encounter notes Laboratory studies Imaging studies Medication records Electronic transmission of prescriptions Provider to provider communication Task management

6

7 Project Goal: Complete a system integration of the mobile and web-based components of the WellDoc DiabetesManager with the Allscripts Enterprise EHR to create the Integrated DiabetesManager supporting diabetes management for patients and providers

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9 Traditional EHR Provider Provider Provider Patient

10 Differences Between EHRs and Mobile Health Applications EHR Provider-centric Archival record General medical record Adheres to established standards Security Data validity Data exchange Medical practice functions: Auditable record User rights Quality Control functions Proprietary code Mobile Health App Patient-centric Personal empowerment Health maintenance Real time function Problem- or disease-specific Personal record-keeping Coaching Education and self-care May adhere to standards FDA-regulated mobile devices and applications May be open source code

11 Integration of Allscripts Enterprise and DiabetesManager Integration team: WellDoc, clinical, IT administration, software development Design Process 1. Agree on major project goals and priorities 2. Define use cases 3. Develop detailed flow charts of steps needed for implementation of each use case 4. Formal team decisions when alternate implementation options exist

12 Practitioner Priorities for Integrated DiabetesManager Provide practitioners with access to important clinical data which is not currently available Provide additional value to patients compared with standard care Aid in meeting current and upcoming regulatory requirements Seamless use with access through Enterprise EHR Intuitive use with minimal need for additional practitioner training Minimize additional tasks resulting from integration

13 Use Cases Approximately 20 use cases developed: Registration and deactivation Data transfer and coordination Clinical information Medication Laboratory results Messages from or to: Patient Provider Systems Reports System transfer and functional integration

14 Medication Reconciliation

15 DiabetesManager Summary Report

16 Issues Identified During Use Case Development Integration of different care models: DM - single primary care provider, Enterprise - multiple providers Provider rights Access for non-mfa providers Data repository functions: Where is the data, DM or Enterprise What is the source of truth? Distinguish patient-reported data in DM from validated data in Enterprise Reconciliation of medications

17 Medication Reconciliation Enterprise DiabetesManager

18 Medication Reconciliation Problems Lack of correspondence between medication data fields in Enterprise and DiabetesManager Patient not taking medication as prescribed Medication prescribed or changed by a non-mfa physician MFA provider does not update medication list with current prescription Alternate brand or generic prescribed

19 Mobile Health and the Regulatory Environment Device/Application: Efficacy and safety Food and Drug Administration (FDA) Communications: Bandwidth, Security Federal Communications Commission (FCC) National Institute of Standards (NIST) Cost-Effective Utilization (CMS) Medicare Meaningful use

20 Stage I Meaningful Use eprescribe Electronic exchange of health information Collect and submit health quality data Stage II: Advanced clinical processes Disease management Medication management Clinical decision support Patient access to their health information Stage III Improvements in quality, safety and efficiency Patient access to self-management tools Improving population health outcomes

21 To Qualify as Meaningful Use To qualify for the first wave of HITECH meaningful use incentives starting in 2011, eligible professionals -- such as doctors and nurse practitioners -- must meet 15 core requirements. In addition to those core requirements, healthcare providers also must meet five objectives of their choosing from a menu of 10.

22 Requirements for HCP 1. Use CPOE for at least one medication order for more than 30% of patients. 2. Implement drug-drug and drug interaction checks. 3. More than 40% of permissible prescriptions written are generated and transmitted electronically using certified EHR technology (for eligible providers only). 4. Record demographic info, such as gender and race, for 50% of patients seen by EP or admitted by hospital. 5. Maintain up to date problem list of current and active diagnoses for 80% of patients. 6. Maintain active medication list for 80% of patients seen by EP or admitted to hospital. 7. Maintain active drug allergy list for 80% of patients seen by EP or admitted to hospital. Kolbasuk M. Information Week, July 19, 2010

23 Requirements for HCP (2) 8. Record and chart changes in vital signs, such as height, weight, BMI, blood pressure, for more than 50% of patients over age Record smoking status for more than 50% of patients over age Implement one clinical decision support rule for EP's specialty or hospital's high priority condition and track compliance with that rule. 11.Report clinical quality measures to the Centers for Medicare and Medicaid Services. 12.Provide more than 50% of patients with electronic copy of health information upon request within 3 business days. Kolbasuk M. Information Week, July 19, 2010

24 Requirements for HCP (3) 13.Provide clinical summaries for each office visit to more than 50% of patients within 3 business days (eligible professionals only.) 14.Perform at least one test of certified e-health record's capability to electronically exchange key clinical information, such as problem list or medication list, among providers of care or patient-authorized entities. 15.Protect electronic health information created or maintained by certified EHR technology by conducting or reviewing security risk analysis and implementing security updates. Kolbasuk M. Information Week, July 19, 2010

25 Physician Concerns About EHRs and Telemedicine Increased time requirements during patient encounters Regulatory burden Overhead costs Controlling patient access to providers Increased demands on time

26 Patient-Centered Integrated Internet and Social Networks Provider Network Patient Sensors & Devices Personal Health Application

27 Potential Benefits of Integrated Mobile Health Systems Providers EHR becomes an active rather than archival record Clinical decision support Access to real time clinical data Pattern analysis and recognition Improved adherence to evidence-based guidelines Patients Improved treatment adherence Frequent reinforcement of treatment goals Improved patient understanding of the impact of behaviors on diabetes control Education resources Reminders

28 Example of Diabetes Care with Integrated Mobile Health System

29 Summary As Health Information Technology advances, integration of independentlydeveloped applications and devices will be an ongoing process Patients and providers will benefit from the additional capabilities of integrated clinical decision support systems Successful integration will require a team approach including clinicians and IT developers

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