The Digital Transformation of American Medicine

Transcription

1 The Digital Transformation of American Medicine Marshall Ruffin, MD, Chief Technology and Health Information Officer University of Virginia Health System U21 Health Sciences Conference September 16, 2008 Summary The digital transformation of all industries is driven by technology and economics. Health care is late to the digital transformation of its information and work because it is more complex & complicated than other industries. Technology and functions NOW are good enough that most physicians will prefer them to using paper and pen. Standards and Architecture Are Everything Health insurers, health care regulators, physicians professional associations all expect physicians to practice with electronic medical records. Federal government now is giving incentives to physicians to use EMRs, and soon will give penalties to physicians for not using EMRs. Unfortunately, CAVEAT EMPTOR Let The Buyer Beware. Page 2

2 Key Trends to Consider The Law of Accelerating Returns An analysis of the history of technology shows that technological change is exponential, contrary to the common-sense "intuitive linear" view. So we won't experience 100 years of progress in the 21st century -- it will be more like 20,000 years of progress (at today's rate). The "returns," such as chip speed and cost-effectiveness, also increase exponentially. There's even exponential growth in the rate of exponential growth. Within a few decades, machine intelligence will surpass human intelligence, leading to The Singularity -- technological change so rapid and profound it represents a rupture in the fabric of human history. The implications include the merger of biological and nonbiological intelligence, immortal software-based humans, and ultra-high levels of intelligence that expand outward in the universe at the speed of light. Ray Kurzweil, PhD, The Singularity Is Near, 2006 Page 4

3 Page 5 Key Trends Supply of Services from the Health Care Industry is Inadequate Producing Shortages Costs of health care services are rising faster than inflation Health care providers are in short supply Health care specialization continues to increase Page 6

4 Key Trends Analog to Digital Transformation in Information Management Continues Falling costs of digital technologies International digital standards emerging for interoperability Key Political Issues Health care services considered a right Patient safety increasing as a focus of concern Page 7 Key Trends Payroll costs are the largest costs in health care Payroll costs are rising faster than inflation for most providers of care in most locations of care Information management takes up a large proportion of the working time of clinicians Page 8

5 Key Trends The costs of technologies for digital information management are falling rapidly as their productivity increases. Conclusion: Managers of health care systems must offset rising payroll costs with digital information management technologies. Page 9 Analog to Digital Comparison Analog Information in atoms Information has weight Moves at courier speed In one location at a time Storage, sorting and retrieval expensive and slow Data collection idiosyncratic Retrospective analysis for knowledge creation expensive, unreliable and infrequent Digital Information in bytes Information weightless Moves at light speed In multiple locations simultaneously Storage, sorting and retrieval cheap and fast Data collection standardized Retrospective analysis for knowledge creation inexpensive, reliable and indispensable. Page 10

6 Institute of Medicine Report Computer-based Patient Records: An Essential Technology for Health Care Commissioned by Congress Institute of Medicine National Academies of Science Chaired by Don Detmer, MD 1991, Revised 1997 Page 11 IOM Report Definition: electronic patient record that resides in a system designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids. Page 12

7 IOM Report Definition: The set of components that form the mechanism by which patient records are created, used, stored and retrieved It includes people, data, rules, procedures, processing and storage devices, and communications and support procedures. Page 13 CPR - Essential Technologies - According to a Report from the IOM CPR CPR SYSTEM SYSTEM Database Database Management Management Systems Systems Workstations Workstations for for Knowledge Knowledge Workers Workers Data Data Acquisition Acquisition and and Retrieval Retrieval Text Text Processing Processing Image Image Processing Processing and and Storage Storage Links Links to to External External Databases Databases Data Data Exchange Exchange & N/W N/W Protocol Protocol Standards Standards Network Network Infrastructure Infrastructure Identified in the Institute of Medicine s report, The Computer- Based Patient Record: An Essential Technology for Health Care System System Security Security and and Reliability Reliability Page 14

8 Costs Electronic Health Records Planning Meetings to plan the EHR Cost/Benefit assessment Strategic fit analysis Staff work on materials for meetings Consultants to help with plan development Definition of functional requirements Definition of technical requirements Budget Page 16

9 Evaluating Screening of vendors Evaluation of vendors Down selection to several candidates Site visits to installations by vendors Meetings to summarize findings Page 17 Selecting and Contracting Time to vote on vendor(s) Work of contracting requires negotiation, lawyers and consultants Definition of requirements becomes a part of the contract Page 18

10 Hardware Terminals Printers Servers Networking equipment Bridges, routers, gateways, cables, wireless Disk storage Redundant hardware back up sites Page 19 Software License fees On terminals, networks and servers Interface costs Between applications (including legacy applications) Configuration Setup of tables in each application Patients, providers, medications, order sets, laboratory studies, etc Conversion of old data to new architecture Page 20

11 Networks Complex, specially with public access through Internet Mix of wired and wireless networks Issues related to performance often deal with network and numbers of network devices (routers, bridges, gateways) between terminals and servers Page 21 Terminals Stationary personal computers Flat panel displays Tablet PCs (wireless) PDAs (Palm, ipaq, Ericsson) Resolution issues very important Don t put images on screens where they are not ledgible. Page 22

12 Integration A huge issue if new systems are being integrated with old legacy systems Adding EHR system for computer-based physician order entry and clinical document on top of preexisting laboratory and radiology and pharmacy systems. Integration of the applications to the network Page 23 Standardization Perhaps the largest cost of all though usually hidden from view at least initially: Standardizing: Information models for collecting data from users Structured format of tumor registry Reference terminologies for data to describe observations (SNOMED-CT) Forms for collecting data Work flow to complete forms and access them Where are terminals located, how are data entered in them? Page 24

13 Changes in Workflow Can be substantial, changing: From paper and pen to keyboard and mouse From free text to coded text and check boxes From common terms to SNOMED terms From writing orders to typing orders and receiving alerts on the screen From reviewing results in the hospital to reviewing results in home or office Page 25 Education The investment in education of staff who will be affected by the EHR application before they go to training Costs to develop and present materials Costs of audience to attend presentations Everyone who will receive training and acces to the system needs some preparatory education. Page 26

14 Training Payroll costs in lost time from work will be substantial, and larger than the costs of trainers and training materials. Training needs to be just in time a brief time (few weeks) before users begin to use the system. Space for training often difficult to find near to the location of care. Keep training local. Page 27 Lost Productivity EHR systems, depending on degree of complexity and number of functions to learn, clinicians will learn to use well in three to six months. During the learning curve, users will not be as productive as they were with the paper systems the EHR replaced. Page 28

15 Lost Staff and Employees Some staff will choose to leave the institution rather than change their work habits to accommodate an EHR. Especially older doctors and nurses nearing retirement. Page 29 Lost Idiosyncrasies The EHR requires vigorous and assiduous standardization of data terminologies, terminals, forms, information and knowledge content. The idiosyncracies of some people in how they collect and record information will tend to disappear when they are sharing and EHR. Page 30

16 Lost Anonymity Once the data about patient care are in the computer, studies of clinical efficiency and effectiveness, and of patients safety and quality of care, can be performed on the data studies that are nearly impossible, or prohibitively expensive, using paper records. Clinicians with measurable aberrancies in clinical practice will show up as outliers in the EHR. Page 31 But the Costs are Worth It Safer patient care Better informed clinicians Better preventive care Better informed patients Better scheduled and organized care Less redundant or unnecessary care More efficient and effective use of resources Page 32

17 Implications for The USA Federal, State and Private Initiatives Federal Initiatives Agency for Health Care Quality & Research (AHRQ) Funding most of EHR pilots Funding Local Health Information Infrastructure pilots with $100 million in grants announced by President Bush Centers for Disease Control (CDC) Public Health Information Network (PHIN) National Electronic Disease Surveillance System (NEDSS) Health Alert Network (HAN) Page 34

18 Federal Initiatives National Health Information Infrastructure (NHII) Goal of President George Bush, Secretary Tommy Thompson and the new IT Tsar for HHS David Brailer, MD, PhD Brailer led the creation of the Santa Barbara County Care Data Exchange Office of the National Coordinator for Health Information Technology (ONCHIT) Brailer resigned as NCHIT in 9/2006; Rob Kolodner, MD became the second NCHIT in 4/2007. Page 35 Federal Government Work for Interoperability American Health Information Community (AHIC) goes to AHIC 2.0 Provides oversight to the work of the following groups Health Information Technology Standards Panel (HITSP) Selecting the standards for digital information interoperability Certification Commission for Health Information Technology (CCHIT) Certifying vendors products that adhere to HITSP standards The Health Information Security and Privacy Collaboration (HISPC) Adopts security and privacy standards Nationwide Health Information Network Architecture Projects Page 36

19 ONCHIT RFI ONCHIT RFI in November, 2004, on the design of the National Health Information Network. > 500 responses Interoperability Consortium formed to offer a consensus architecture Accenture, Cisco, CSC, HP, IBM, Intel, Microsoft, Oracle Submitted the response in January, 2005 Page 37 ONCHIT RFPs 2005 Four RFPs announced in May, 2005 that are meant to develop the infrastructure for the National Health Information Network Standards Harmonization Process Compliance Certification Process Privacy and Security Assessment NHIN Demonstrations Accenture Orion Health, Oracle: WV, VA, KY, TN IBM NY, NC CSC MA, IN, CA Northrop Grumman Axolotl, OH Page 38

20 ONCHIT RFPs For Trial Implementations of the NHIN Design Integrating 9 Health Information Exchanges Using NHIN Standards CareSpark -- Tricities region of Eastern Tennessee and Southwestern Virginia Delaware Health Information Network Delaware Indiana University -- Indianapolis metroplex Long Beach Network for Health -- Long Beach and Los Angeles, California Lovelace Clinic Foundation -- New Mexico MedVirginia -- Central Virginia New York ehealth Collaborative -- New York North Carolina Healthcare Information and Communications Alliance, Inc. -- North Carolina West Virginia Health Information Network -- West Virginia In September, 2008 Cooperative Interoperability Testing Event Real Time Information Exchange Page 39 EMRs for Ambulatory Care Certified by CCHIT ABELMed PM EMR, Version v8* Acumen EHR 5 Allscripts Professional 8.1 The CareData Solution, Version 2.7* CareRevolution, Version 5.2 CareSeries EHR 2.0 Centricity EMR, Version 9.0* Centricity Enterprise, Version 6.7* Cerner Millennium PowerChart/PowerWorks EMR, Version 2007 ChartMaker, Version Physician Practice Documentation (PPD), Version digichart OB-GYN Version 7.0 Doctations, Version v * DocuTAP EMR and Practice Management Solution ecast EMR 7.0 eclinicalworks e-mds Solution Series e-medsys Electronic Health Record 5.0 EMRge, Version 7.0 Release 1.0* EpicCare Ambulatory EMR Spring 2007 gcare, Version 4.0 Release 6.2* gloemr, Version 4.0 Healthmatics EHR Version HealthPort EMR V9.0 imedica PRM2008 Build 8.1 Ingenix CareTracker, Version 6.2 InSync, Version 4.1 Intergy EHR by Sage, Version V4 isuite version 3.5 MD-Navigator Clinical 5.0 MedcomSoft Record, Version UE (V 4.5) MEDENT 17 Medical and Practice Management (MPM) Suite, Version: Client Server 5.54 MediNotes e Version 5.2 Misys EMR, Version 9.10 Misys MyWay, Version 2008 NetPractice EHR 6.0 NextGen EMR NextGen EMR 5.5 Nightingale On-Demand, Version 8.2 Ochsner Clinical Workstation, Version 1.9.8* Practice Partner Practice Partner PrimeSuite 2007 R2 Sevocity, Version 5.0 SOAPware 2008 SRS CareCast, Version 7.0 STIX EHR, Release 9.0 Sunrise Ambulatory Care 5.0 SP1 with Eclipsys Auditing Services 1.0 XA and Eclipsys Security Services 1.0 XA * TouchWorks, V11.1 TransMed CS, Version 3.0 Wellogic Consult Version 3.10 Release 10 and GBA MEDfx Version 2.8 * Pre-market conditional certification Page 40

21 EMRs for Inpatient Care Certified by CCHIT Cerner Corporation: (Cerner Millennium PowerChart 2007) 1/22/2008 Computer Programs and Systems, Inc. (CPSI) (CPSI System, 15) 11/5/2007 Dairyland Healthcare Solutions (Clinical Information System (CIS), Version 9.0.0) 6/13/2008 Eclipsys Corporation (Sunrise Acute Care, 4.5 SP4) 11/5/2007 Epic Systems Corporation (EpicCare Inpatient, Spring 2007) 11/5/2007 GE Healthcare, Integrated IT Solutions, Enterprise Solutions Pre-market, conditional certification (Centricity Enterprise, Version 6.7) 6/30/2008 Healthcare Management Systems, Inc. (Healthcare Management Systems, 7.0) 11/5/2007 McKesson Pre-market, conditional certification (Horizon Clinicals Suite Horizon Expert Orders, Horizon Order Management, Care Organizer, Horizon Expert Documentation and Horizon AdminRx, Version ER 7.8.2) 5/29/2008 MEDITECH (Advanced Clinical Systems, Client Server 5.6) 1/22/2008 MEDITECH (Advanced Clinical Systems, MAGIC 5.6) 1/22/2008 Prognosis Health Information Systems (ChartAccess 1.0) 11/5/2007 Siemens Medical Solutions USA Inc. (INVISION Clinicals Version 27.0 with Siemens Pharmacy and Med Administration Check (MAK), Version 24.0) 1/22/2008 Siemens Medical Solutions USA Inc. (MedSeries4 WebConnect Clinical Suite with Siemens Pharmacy and Med Administration Check (MAK), Version and V24) emar ONLY 6/12/2008 Siemens Medical Solutions USA Inc. (Soarian Clinicals 2.0C5 with Siemens Pharmacy and Med Administration Check 24.0) 11/5/2007 Page 41 Integrating the Health Care Enterprise (IHE) IHE is an international organization, founded in The primary sponsors were and still are the American College of Cardiology, HIMSS and RSNA. IHE develops and advocates for standards for interoperable electronic health information exchange An association of professional societies, vendors, government agencies, standards organizations, trade associations, health care IT and consulting companies, health care providers. Page 42

22 State Initiatives Patient Safety systems More than 40 states with laws requiring patient safety information systems in hospitals and nursing homes Public Health Information Networks CDC pushing standardized networks in all states Local Health Information Infrastructure AHRQ funding pilots with $100 million National Governors Association State Alliance for ehealth Promoting statewide utility services for health information exchange Page 43 Start Collaboration Now Create a RHIO for Your State Create a trusted organization to shepherd standardization and capital allocation Include doctor groups, hospitals and payers Apply for State and Federal Grants Study successful RHIO programs such as INPC, SBCCRE and NEHEN Page 44

23 Your State Medical Society Can Lead Try to identify EHR architecture that will serve most medical groups in your state Negotiate with EHR vendors based on common principles of sharing EHR data. Hospitals do the same share standards (rather than vendors). Model your system after the architecture of the NHIN. Page 45 Examples of EMRs and EHRs and PHRs Cleveland Clinic

24 The Cleveland Clinic Cleveland Clinic 2,012 physicians Residents and Fellows 1,160 Fourth largest training program in the USA 12 large ambulatory care centers in NE Ohio 9 community hospitals in NE Ohio Rated one of four best hospitals in the USA by US News & World Report in Page The Cleveland Clinic Health System Hospitals Page 48 48

25 ecleveland Clinic ecleveland Clinic is a Web-based extension of the Cleveland Clinic's role as one of America's most respected academic medical institutions. Proudly carrying on the tradition of the innovative application of technology for the benefit of all patients, ecleveland Clinic utilizes state-of-the-art digital information systems to eliminate geographic barriers and deliver a variety of quality e-health services, including: MyConsult website, patients around the world can request specialist second medical opinions for over 600 life-threatening/life-altering diagnoses. Second opinions are rendered by Cleveland Clinic physicians specializing in each diagnoses, are completed quickly, usually within five to seven working days, and are thorough and detailed, providing patients with the information they need to make important treatment choices. MyChart - Your Personal Health Connection, patients have access to portions of their own medical history, with special health reminders, educational information access, and options to receive the results of certain laboratory and test results, 24-hours-a-day, seven-days-a-week. Dr.Connect is an Internet-based service specially developed to provide physicians who refer patients to The Cleveland Clinic secure, real-time information about their patientsý treatment progress. Dr.Connect provides immediate access to the electronic medical record information regarding encounters and results generated when a patient receives treatment at The Cleveland Clinic. Page Page 50 50

26 EpicCare in the Cleveland Clinic Implementation of EpicCare began five years ago, and will continue for a least three more years before all functions are installed in all locations. >75% of office visits do NOT include a paper record By November, 2006, paper charts were be available only by exception Physicians document their care by keyboard (70%) and dictation (30%) Clerk order entry now; physician order entry began in January, 2007 All medications are ordered in a structured way. Page EpicCare at the Cleveland Clinic Patients have access to MyChart a personal version of the EMR Physicians release information to MyChart, so patients do not receive bad news from MyChart without first discussing the news with their physicians. MyChart sends reminders for medications, follow-up appointments and preventive measures to patients. 100,000 patients of primary care physicians using MyChart now, adding 4,000-5,000 each month. Cleveland Clinic has 800,000 active patients of whom 200,000 are patients of primary care physicians. >50% of those patients are using MyChart already. Page 52 52

27 A National Health Information Exchange HealthLink in New Zealand healthlink Population of New Zealand 4,250,000 4,000 health sector organizations 3,500 medical practices 15,000 clinicians use healthlink daily in New Zealand. healthlink established in 1996 as an electronic data interchange for hospitals, physicians offices and health insurers Reports pathology and radiology results; administers payments to physicians; manages health insurance claims submission; sophisticated disease management programs; laboratory results; eprescribing; telemedicine. 50,000,000 health care messages annually, about 137,000 messages a day. Page 54

28 healthlink model ( Page 55