The Glory and Misery of Electronic Health Records. Barry Smith KAUST, January 27, 2016

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1 The Glory and Misery of Electronic Health Records Barry Smith KAUST, January 27,

2 Electronic Health Records the Glory no more redundant tests continuity of care improved quality of information improved no more lost charts no more illegible handwriting no more non standard codes 3

3 More Glory charts are accessible from multiple sites simultaneously efficient transfer of lab and patient demographics information support for e prescribing 4

4 But still more gloriously (they said, 2005) money will be saved if patients information were shared across health care settings so that personal health information seamlessly followed any patient through various settings of care $77 billion would be saved annually David Brailer (first U.S. National Coordinator for Health IT), Economic Perspectives on Health Information Technology,

patient through various settings of care $77 billion would be saved annually David Brailer (first

5 $77 billion 8

6 annually 9

7 The misery: two issues 1. Interoperability 2. Costs (of getting the data inside the computer, safely) 11

8 The Misery 1. Interoperability Interoperability =Def. Two systems A and B are interoperable if the data from system A can be used by system B in the same way that it is used by system A and vice versa As even David Brailer recognized, most of the glories will be realized only if EHR systems are interoperable and in the US (at least) they still (2016) mostly aren t and they don t want to be 12

same way that it is used by system A and vice versa As even David Brailer recognized, most of the

9 Big question how do we get the data inside the computer in a form that allows it to be shared? 13

10 14

11 Perhaps Epic (Prop: Judy Faulkner) will solve the problem 15

12 slowly, but surely, everyone will use Epic 16

13 in the US 17

14 in the Middle East Epic Middle East HQ Al Shatha Tower Dubai, UAE 18

15 tomorrow, the galaxy 19

16 unfortunately, even total victory of Epic would not imply interoperability RAND Corporation: Epic is a closed system that makes it challenging and costly for hospitals to interconnect. (New York Times, September 13, 2014) In some cases even two facilities running Epic within the same hospital cannot share data local codes local tweaks poor standards for cpding clinical data 20

(New York Times, September 13, 2014) In some cases even two facilities running Epic within the

17 More misery: the costs Duke University Health System: $700 million Partners HealthCare: $700 million University of California San Francisco: $150 million Forbes Magazine, June 18,

18 Cambridge University (Addenbrooke s) Hospitals 2014: first installation of an Epic system in the UK: 200 million 24

19 25

20 December 2014 After 2.1 million records were transferred to it, the system developed serious problems and the system became unstable. Ambulances were diverted to other hospitals for five hours and hospital consultants noted issues with blood transfusion and pathology services. 26

21 July 2015 the finances of Cambridge University Hospitals are being investigated. Problems with the Epic system were held to be contributory factors in the organisation's sudden failure. 27

22 Honey, my EHR system crashed the hospital! 28

23 More costs cost of training cost of adoption of new working practices cost of time that could otherwise go to patient care cost of local tweaks cost of alerts disruption of workflows alert fatigue from clinically insignificant alerts 29

24 The Cost of Technology, Journal of the American Medical Association, June 20, 2012, Vol 307, No

25 The computer becomes the conduit for all aspects of patient care 32

26 Epic, again Kaiser: Epic led to a persistent two minute increase in the length of time of an average patient encounter 33

27 American Medical Association cry for help in face of government mandates governing use of EHRs 34

28 Three reasons for failure magical thinking failure to work with clinical stakeholders at every stage lack of testing 35

29 Why all this misery? Epic is not to blame Good and bad in all of these: 36

30 HITECH Act (2009): let s bribe physicians to adopt existing EHR systems quickly, and then penalize them if they fail to do so Eligible health care professionals and hospitals can qualify for more than $27 billion in Medicare and Medicaid incentive payments available to eligible providers and hospitals 37

31 EHR incentive payments to Medicare providers TOTAL Adopt 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $0 $44,000 Adopt $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000 Adopt $15,000 $12,000 $8,000 $4,000 $0 $39,000 Adopt $12,000 $8,000 $4,000 $0 $24,000 Adopt $0 $0 $0 $0 After 2015 penalties, in the form of reduced Medicare reimbursements 38

32 followed by increasing penalties for non use TOTAL Adopt 2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $0 $44,000 Adopt $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000 Adopt $15,000 $12,000 $8,000 $4,000 $0 $39,000 Adopt $12,000 $8,000 $4,000 $0 $24,000 Adopt $0 $0 $0 $0 After 2015 penalties, in the form of reduced Medicare reimbursements 39

33 the rush to capitalize on the huge federal investment of $30 billion for the adoption of electronic medical records led to some unfortunate and unintended consequences tied to communication failure, poor data display, wrong order/wrong patient errors and alert fatigue. Annals of Emergency Medicine, June

34 COMPUTECH Act 1959 Let s bribe all computer users to use COBOL in all the work they do and then penalize them with bigger and bigger fines each year until they do so 41

35 Question: Why do it so quickly, when there are so few talented, trained personnel, and when EHR systems are so bad, and when there are so many systems, and when the systems are not interoperable? What, after all, could go wrong? 42

36 Answer: e iatrogenesis* *diseases caused by health IT 43

37 44

38 Health IT and Patient Safety Institute of Medicine Report, 2011 Recommendations Current market forces are not adequately addressing the potential risks associated with use of health IT. All stakeholders must coordinate efforts to identify and understand patient safety risks associated with health IT by creating a reporting and investigating system for health IT related deaths, serious injuries, or unsafe conditions 45

39 I interviewed Boeing s top cockpit designers, who wouldn t dream of green-lighting a new plane until they had spent thousands of hours watching pilots in simulators and on test flights. This principle of user-centered design is part of aviation s DNA, yet has been woefully lacking in health care software design. 46

40 Pressure on hospitals for compulsory use of EHRs costs lives Sam Bierstock, MD (2012): hospital EHRs are simply not yet adequately intuitive to meet the needs of clinicians. Most EHRs result in a percent decrease in efficiency of emergency room doctors and an increase in the people who leave without being seen due to extended wait times. 53

41 How is all of this important for computational bioscience? Come the day, when every patient s genome is sequenced as they walk through the hospital door 88

42 How ensure that we will have in digital form the clinical information we need to unlock th value of the sequence information? clinic computational bioscience 89

43 Three reasons for Brailer s failure magical thinking failure to work with clinical stakeholders at every stage lack of testing Don t impose immature, untested systems on all hospitals; rely on creativity and competition of research universities to create something entirely new 90

44 The problem How do we get computationally and biologically useful data inside the computer in a form that allows it to be used and accepted by clinicians and shared across many communities? Model solution: the Gene Ontology 91

45 Things you need to know about ICD Systematized Nomenclature for Medicine Ontology for General Medical Science (OGMS) 92

206-478-8227 www.healthdataconsulting.com. ICD-10 Now What? Joseph C Nichols MD Principal. A Health Data Consulting White Paper

206-478-8227 www.healthdataconsulting.com ICD-10 Now What? Joseph C Nichols MD Principal A Health Data Consulting White Paper Oct 1, 2015 TABLE OF CONTENTS IT S NOW THE STANDARD... 3 CHARTING A COURSE