Delivering on the Promise of an Electronic Health Record

Transcription

1 Delivering on the Promise of an Electronic Health Record Neal R. Patel, MD, MPH Chief Medical Informatics Officer, Vanderbilt University Medical Center Medical Director, Pediatric Cardiac Critical Care Monroe Carell Jr. Children s Hospital at Vanderbilt

2 Rising Cost of Healthcare

3 Rising Cost of Healthcare

4 Typical Challenges Asset Utilization Equipment & People Tracking Required Maintenance Inventory Shrinkage Quality Patient Care / Satisfaction Drivers of Information Technology Initiatives Employee Satisfaction Staff Productivity Patient Safety Regulatory Compliance Net Patient Revenue Contributions by Accenture LLP and ABGI

5 Responses to Healthcare Trends Key Trends Cost Pressures Staffing Shortages Variability Increased Severity Scrutiny/ Transparency Government mandates Healthcare Providers Use IT intelligently Manage information Standardize care Change roles Change processes Results Reduced variability Reduced cost Reduced waste Improved outcomes

6 Are we getting what we pay for?

7 The Gap Between What We Know & What We Do 6,712 Individuals in 12 Cities Only 54.9% received recommended care Only 54.9% received recommended preventive care Only 53.5% received recommended acute care Only 56.1% received recommended chronic care Examples: Hip Fracture 22.8% (Range %) Atrial Fibrillation 24.7% Depression 57.2% Senile Cataract 78.7% (Best performance) McGlynn, et. al., NEJM 2003;348:

8 Too Err is Human 3.7% of all hospitalized patients suffer an adverse event (AE) 19 percent of all AE s are related to medications Approximately one-third of all adverse drug events are preventable 2009, Jack Starmer, MD Vanderbilt University Medical Center EBM Initiative

9 Meaningful Use of Health Information Technology Based on the HITECH - Health Information Technology for Economic and Clinical Health Act, (ARRA Stimulus Bill) Five to Six year transition from carrots to sticks to encourage advancing information technology in health care

10 15 Meaningful Use Core Objectives Use computerized provider order entry (CPOE) Implement drug-to-drug and drug-allergy interaction checks E-prescribing (EP only) Record demographics Maintain an up-to-date problem list Maintain active medication list Maintain active medication allergy list Record and chart changes in vital signs

11 15 Meaningful Use Core Objectives Record smoking status Implement one clinical decision support rule Report quality measures as specified by the Secretary Electronically exchange key clinical information Provide patients with an electronic copy of their health information Provide patients with an electronic copy of their summaries or discharge instructions Protect electronic health information created or maintained by certified EHR

12 HITECH ACT Incentives Incentive payments to eligible professionals (EPs) and eligible hospitals to promote the adoption and meaningful use of interoperable health information technology and qualified EHRs. $64k over 6 years for Medicaid providers $44k over 5 years for Medicare providers Hospital reimbursements based on % volumes of Medicare and Medicaid. $2M minimum

13 Medicare Sticks For No Meaningful Use Calendar Year On No Meaningful -1% -2% -3% -4% -5% Use

14 Central Conclusions of NRC Report 2009 Current efforts aimed at nationwide deployment of HCIT will not be sufficient to achieve the vision of 21 st century health care, and may even set back the cause Success will require emphasis on providing cognitive support (assistance for thinking about and solving problems). In the near term, embrace measurable health care quality improvement as the driving rationale for HCIT adoption efforts.

15 Root cause: Mismatch between Computational Technique & Scale of Problem Automation Connectivity Decision Support Data Mining In Press: Stead WW. Electronic Health Records. In: Rouse WB, Cortese DA, eds. Engineering the system of healthcare delivery. Tennenbaum Institute Series on Enterprise Systems, Vol. 3. Amsterdam: IOS Press; 2009.

16 Automation Robotics Connectivity Work Lists Hand offs Patient Portal Charting Business Process Digital Library Error Checks Evidence-based Order Sets Decision Support Aggregate Electronic Health Record Disease Management Dashboards Biosurveillance Phenotype/Genotype Correlation Data Mining Stead WW. Electronic Health Records. In: Rouse WB, Cortese DA, eds. Engineering the system of healthcare delivery. Tennenbaum Institute Series on Enterprise Systems, Vol. 3. Amsterdam: IOS Press; 2009.

17 Clinician as Intermediary Evidence Clinician Synthesis & Decision Patient Record

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19 Cognitive Overload 900,000 Biomedical articles per year 10,000 Randomized controlled trials annually 1,000 s of Evidence Based Guidelines 20,000 Genes 1,700 Disease associated mutations

20 The demise of expert-based practice is inevitable Facts per Decision Proteomics and other effector molecules Functional Genetics: Gene expression profiles Human Cognitive Capacity 10 5 Structural Genetics: e.g. SNPs, haplotypes Decisions by Clinical Phenotype Stead WW. Beyond expert-based practice. IOM (Institute of Medicine). Evidence-based medicine and the changing nature of health care: 2007 IOM annual meeting summary,(introduction and Overview, p. 19). Washington, DC: The National Academies Press 2008.

21 Clinician as Interpreter and Coach Evidence Personalized Knowledge Base Clinician Patient Record Patient

22 Electronic Systems and Process Control Applications Process Architecture Devices

23 Norman s strategies for effective system design Make things visible Simply the structure of tasks Natural mapping or Intuitive design Make it hard to do the wrong thing Make it easy to recover from a mistake Standardize processes to reduce opportunities for errors Norman, D The Design of Everyday Things

24 National focus on safety

25 What is CPOE? Computer application which replaces traditional paper order sheets Glorified Word processor

26 Bates et al. JAMA 1998

27 Key Advantages to CPOE Key data aggregated for clinical use Clinician can interact with medical record away from the bedside Immediate routing of orders and requisitions to ancillary departments Smart prompts and checks can enhance safety and quality of care

28 Errors due to Computer Use

29 Drop-down Errors in Data Entry

30 Norman s strategies for effective system design Make things visible Simply the structure of tasks Natural mapping or Intuitive design Make it hard to do the wrong thing Make it easy to recover from a mistake Standardize processes to reduce opportunities for errors Norman, D The Design of Everyday Things

31 Sample ordering screen prior to implementation of decision support. Open field for doses with no menu options

32 CPOE in Pediatric Critical Care Errors per 100 Ord pre-cpoe post-cpoe Potential ADE's Medication Prescribing Errors Rule Violations Potts et al. Pediatrics 2004

33 Upon further review.

34 Screen shots Demographic information for patient Drug information tailored to patient age and weight Only those weight-based doses appropriate for patient appear on screen

35 Dose calculated and rounded from 65 MG to standard dose of 70 MG Only intervals appropriate for the age and weight of the patient appear on screen

36 Results Preimplementation Postimplementation Number of patients Number of orders Entered by prescriber Verbal orders ,047 20,095 16,396 (82%) 15,568 (77%) 3,447 (17%) 4,416 (22%)

37 Impact of PSDS on Potential ADE s Entered by prescriber Verbal orders 2.2* 2.2* 0 pre-psds post-psds *p value < 0.001

38 Jul-06 Who is Entering Orders All Orders Jan-00 Jul-00 Jan-01 Jul-01 Jan-02 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05 Jan-06 Date ALL ORDERS NURSE ENTERED Number of Orders

39 The model for good patient care?

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41 Vanderbilt Clinical IT Architecture Portal HEO HOM HED Care Record Admin Rx Lab Radiology Pharmacy Horizon Clinicals Communication Subsystem Clinical Repository Internet

42 Focus on the clinical workflow

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46 Aggregate View of MAR

47 Methods to Reduce Human Error Reduce reliance on memory Simplify processes Standardization of common tasks Use constraints or forcing functions Judicious use of protocols and checklists Decrease reliance on vigilance, handoffs, and redundant data entry

48 Handoff and Sign-out Aids

49 Systems Approach in Outcomes Practice Iterative Improvement Outcomes Iterative Improvement Visualization of Results vs. Plan Visualization of Results vs. Plan Consistent Process Evidence-based Medicine Consistent Process Evidence-based Medicine

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53 2. Impact on Results Systems Approach to Care 1. Number of Ventilator Acquired Pneumonia (VAP) Cases/Year at Vanderbilt Fiscal Year 2009 Results c/w 2008 VAPs Prevented 108 Deaths Avoided 16 $ Saved $4.3M Hospital Days Avoided 1055 ICU Days Avoided Mortality for Vanderbilt Ventilator Patients Compare to all the other Hospitals Best in the U.S. Vanderbilt now # 1 O/E Vent Mortality O/E Length of Stay O/E Cost , Jack Starmer, MD Vanderbilt University Medical Center EBM Initiative Source: UHC and Vanderbilt Data

54 Electronic Outpatient Whiteboard Developed in-house, Initially for Pediatric and Adult Cancer Centers to facilitate workflow and communication. Placed in production Summer, Pediatric Primary Care was an early adopter and has used the OPWB since October, Apache/MySQL/PHP app which lives within the EMR environment and is integrated w/ other apps Current statistics: ~1,600 users per day across 110+ clinics in the Vanderbilt enterprise, tracking room movements of as many as 4,200+ patients per day. Weinberg and Patterson 2010

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58 Results Within the study period from Aug 31st, 2009 thru February 27th, 2010: 16,875 automated immunization assessments were generated: [D] 3,933 (23.3%) [n/a] 2,426 (14.4%) [E] 10,516 (62.3%) Weinberg and Patterson 2010

59 Results Of the 10,516 E alerts displayed, users responded to 9,514 (90.5%) by ordering the vaccine to be given, documenting the administration of vaccine, or selecting a reason for non-administration, including: refusals 829 (8.7% of 9,514) illness deferrals 604 (6.3% of 9,514) given elsewhere 380 (4.0% of 9,514) Weinberg and Patterson 2010

60 What is the Memphis Exchange? Developed by Vanderbilt University (funding: AHRQ, TN) Managed locally; commercial vendor (ICA) Five years of comprehensive data mainly from hospitals Total # of encounters: >7.5 million Total # of unique individuals: >1.7 million Monthly labs: 2.4 million Comprehensive privacy agreements patients can opt out Costs to participants less that $50,000 per hospital Overall annual operating cost under $1.5 million Vanderbilt University Do not copy or distribute

61 Community Leadership: MidSouth ehealth 15 hospitals; 14 clinics Alliance Baptist Memorial Health Care Corp. (4 facilities) Christ Community Health (4 primary care clinics) Methodist Healthcare (7 facilities including Le Bonheur Children s Medical Center) The Regional Medical Center (The MED) Saint Francis Hospital & St. Francis Bartlett (Tenet Healthcare) St. Jude Children s Research Hospital Shelby County/Health Loop Clinics (11 primary care clinics) UT Medical Group (300+ clinicians) Memphis Managed Care/TLC (MCO)

62 Real clinical data, real-time Data available patient identification/demographics lab results encounter data: date of service, physician and reason dictated reports imaging studies cardiology studies discharge summaries operative reports emergency room summaries history and physicals medication history (limited) allergies (limited) 2011, Mark Frisse 62

63 Examples of the HIE Interface 2011, Mark Frisse Clinical History

64 Examples of the HIE Interface 2011, Mark Frisse Encounters

65 Impact of HIE used to care for 7% of patients in the emergency departments and in other settings saved lives changed workflow changed test ordering behavior reduced CT scans reduced admissions from EDs conservatively, saves $1.5 million per year Vanderbilt University Do not copy or distribute

66 Health IT Systems and Clinical Functionality Applications Process Architecture Devices

67 Integrated Presence Concept Focus more of our human resources on direct care by creating an enabling technology that allows providers to: Practice with confidence Reduce variability of care Easily achieve situational awareness

68 Current Goals Monitor display providing clinicians with situational awareness on individual patients and provide a foundation for later phases Aggregate specific patient data for trending Consolidate key EMR information Ensure adherence to patient plans Improve care consistency across patients

69 Integrated Presence Unit level Dashboard Census/location Provider/Team data High level Alerts (future) Predicitive monitoring (future) Patient Level Display Monitor data Trending (in development) Status/Plan (in development) Aggregate data/emr

70 Don Norman, The Invisible Computer

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