Best Practices for Optimizing Your EHR: Lessons from the Field

Transcription

1 American College of Physicians Internal Medicine 2014 Best Practices for Optimizing Your EHR: Lessons from the Field Faculty Moderator: Peter Basch, MD, FACP Disclosure: Has no relationship with any proprietary entity producing health care goods or services consumed by or used on patients. Panelist(s): Mitchell A. Adler, MD, JD, MPH, FACP Disclosure: Has no relationship with any proprietary entity producing health care goods or services consumed by or used on patients. Thomas R. Yackel, MD, MPH, MS, FACP Disclosure: Has no relationship with any proprietary entity producing health care goods or services consumed by or used on patients. Clinical questions to be addressed: 1.ACP members will share experiences and perspectives on building effective, health IT-enabled practices. 2.How can workflow modifications maximize efficient and effective use of an EHR through the use of staff, patient, and clinical decision tools? 3.What general tips and tricks can enhance the use of the EHR (not vendor-specific)? 4.How to evaluate and use add-on EHR products, including registries? Posted Date: March 10, American College of Physicians. All rights reserved. Reproduction of Internal Medicine 2014 presentations, or print or electronic material associated with presentations, is prohibited without written permission from the ACP.

2 Reminders Best Practices for Optimizing Your EHR: Lessons from the Field Please put phones on silent/vibrate mode Please complete and return evaluations Please hold your questions till the end of the session Moderator Peter Basch, MD, FACP Panelists Mitchell A. Adler, MD, JD, MPH, FACP Thomas R. Yackel, MD, MPH, MS, FACP IM 2014 PN 033 Saturday - 12 April 2014 Disclosure of Financial Relationships Peter Basch Has disclosed relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. epocrates Clinical Advisory Board Disclosure of Financial Relationships Mitchell Adler Thomas Yackel Have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Peter Basch, MD, FACP General internist in Washington, DC Early adopter of EHRs, eprescribing, etc. Medical Director for EHR and Health IT Policy, Medical Director for MedStar Million Hearts MedStar Health Chair, Medical Informatics Committee, American College of Physicians Senior Fellow in Health IT Policy, Center for American Progress Visiting Scholar in Health IT Policy, Engelberg Center for Healthcare Reform, Brookings Institution Mitchell A. Adler, MD, JD, MPH, FACP General internist in New York Chief Medical Information Officer at North Shore-LIJ Health System Member, Medical Informatics Committee, American College of Physicians EMR implementer, user, and optimizer since

3 Thomas R. Yackel, MD, MPH, MS, FACP Medical Informatics Curriculum IM 2014 (Room 414 CD) General Internist at Oregon Health & Science University, Portland, OR Chief Health Information Officer and head of Clinical Informatics Department Member, Medical Informatics Committee, American College of Physicians Member, HIMSS Davies Award Selection Committee, Led enterprise EHR implementation Diagnosing EHR Pain: Can I Fix It? (PN 031) Thursday, 7:00-8:00 am Treating EHR Pain: Time to Replace It? (MTP 117) Thursday, 8:15-9:15 am Implementing emessaging, Non-Visit Based Care, and Social Media to Engage Patients and Improve Care (MTP 107) Thursday, 11:15 am-12:45 pm Preparing for Meaningful Use Stage 2 and Beyond (PN 003) Friday, 11:15 am-12:45 pm Best Practices for Optimizing Your EHR: Lessons from the Field (PN 033) Saturday, 11:15 am-12:45 pm Implementing Quality Measures and Clinical Guidance into the EHR to Improve Patient Care (PN 004) Saturday, 2:15-3:45 pm Clinical Questions / Learning Objectives ACP members will share experiences and perspectives on building effective, health IT enabled practices Enhancing your efficiency and effectiveness The role of workflow modifications Optimizing staff Inclusion of the patient / family member(s) General tips and tricks How to evaluate and use add-on products, such as registries 1 Why Is This Topic Necessary? Why is This Topic Necessary? 2 EHRs to the Rescue! Yarnell, et al., Am J Public Health 2003 April; 93(4): Ostbye, et al., Ann Fam Med 2005 May; 3(3): Yarnell, et al., Prev Chronic Dis 2009; 6(2): A59 2

4 Why is This Topic Necessary? 3 American EHR Survey, Difficulty with improving care Difficulty returning to pre-ehr productivity Dissatisfaction with EHRs Rand Study on Physician Satisfaction The Pros and Cons of Electronic Health Records Physicians approved of EHRs in concept and appreciated having better ability to remotely access patient information and improvements in quality of care. However, for many physicians, the current state of EHR technology significantly worsened professional satisfaction in multiple ways. Aspects of current EHRs that were particularly common sources of dissatisfaction included poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information, and degradation of clinical documentation. Friedberg MW Et. Al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, reports/rr439. Inefficiency Correlated With Less time in training Less time in understanding processes in their offices An implementation approach such as this Efficiency Correlated With Previously efficient with paper records Training and demonstrated proficiency with EHR Focused on workflow Optimization of staff (not just themselves) Optimizing Your EHR Necessary, but not sufficient Technology better able to accelerate efficient processes Technology less likely to fix bad processes If poorly implemented and poorly used very likely to make bad processes even worse Optimization of Effectiveness and Efficiency Understanding processes and workflow Re-engineering processes workflow and process Optimizing existing technology Planning for / implementing additional technology (where needed) 3

5 Taxonomy of Optimization Taxonomy of Optimization Example: Pre-Visit When Pre-visit Visit Post-visit (between visits) What / How People Workflow Technology When Pre-visit What / How People On-time (staff, patients) On-time PLUS (you!) Workflow Front-desk pre-visit form(s) Technology Portal Other secure mobile technology Having all technology ready for you Example of Optimization Embedding Million Hearts into Practice THIS IS NOT ROCKET SCIENCE! Million Hearts Simply Asks for a More Consistent Application of What We Know (AND PERFECTION ISN T REQUIRED TO MAKE A DIFFERENCE) Of the ~2M heart attacks and strokes occur each year, achieving the 2017 goals would reduce the number of new heart attacks / strokes by 10% per year Over 5 years prevent 1M new heart attacks / strokes A Clinical Program to Provide Consistently Better CV Care for our Primary Care Patients Leveraging the EHR to Make Awareness and Adherence to the ABCS Easier What Nobody Sees (Unless They Choose To) All MedStar primary care sites will have information available about Million Hearts and MedStar's partnership efforts. Every adult patient who receives care from a MedStar primary care provider will be appropriately screened for high blood pressure and high cholesterol and will also be encouraged to discuss Million Hearts with their PCP and have their cardiac risk assessed. Every adult patient who should be on aspirin (without allergy or contraindication ) will be encouraged to take aspirin. Every adult patient will have evidence-based goals set for their BP and cholesterol results; those with elevated BP and/or cholesterol will be optimally treated towards those goals. Every adult patient will be assessed for smoking, and if they smoke, they will be optimally managed towards cessation. Every adult patient will be provided with an individualized end-of-visit summary showing their current ABCs report card, and reasonable steps they could take to further reduce their risk of heart disease and stroke. Form that opens in the background of all adult medicine visits Auto-calculates risks and goals 4

6 Our Approach to Avoid Alert Fatigue Embedded Protocols Targeted to PCP Providers ONLY Prompts When Necessary Information is Missing, Out of Date, or When a Goal is Unmet Our Approach to Make Doing the Right Thing Easier AND Reduce Documentation Burden This approach used for all protocols but for Million Hearts we lead with a global prompt, and we pre-check it such that it autocascades if goals are unmet ABCs prompts show protocol AND relevant prior information in the EHR The prompts also contain most all reasonable actions adding / changing meds, creating referrals, etc. Checkbox choices also create documentation in the note AND structured data for future analysis and reporting. Example of the Prompt Cascade When All of the ABCS Goals are Unmet Patient Engagement Poster in Reception Area and Personalized ABCS Report to Patients How Are We Doing 1 yr into this 5 Yr Plan? Already Surpassing All 2017 Targets! Intervention Baseline Target Aspirin for those at high risk Blood pressure control MedStar Health November % 70% 86% 46% 70% 71% Cholesterol control 33% 70% 77% Smoking cessation Smoking prevalence 23% 21% 70% 19% 76% 13% (down 11% from 2012) What Makes Million Hearts Possible? Compelling / understandable Built into office workflow Optimized EHR Automates Goal setting Algorithms for determining need for information, consideration of treatment At goal status Individualized information for patients Actionable information displays Minimal click burden for orders, documentation 5

7 Panelists Drs. Adler & Yackel Walk us thru a visit / multiple visits pointing out practical optimization opportunities Comments on optimization taxonomy How to evaluate the need / benefits of technology add-ons Provide examples from your experience of best practices for optimizing efficiency and effectiveness How can we collectively share / adopt best practices for health-it enabled care optimization Lifecycle of Optimization Questions to ask before beginning an optimization What are we optimizing for? Efficiency? For whom? (provider, staff, patient) Quality and Safety? Patient experience? Privacy? Compliance? What are our biggest goals and opportunities? What problems are we trying to solve? Early Optimization Efforts Rollout Status Assembled 2 optimization teams of 5 FTE that returned to practices 1-2 years after go-live to address issues Included scheduling/patient access, billing, clinical workflow, and trainers Optimization Oversight Committee assembled metrics, reviewed plans, made decisions on scope and timing As of Monday 11/15/10 Meaningful Use Metrics Efficiency Metrics 6

8 Issues Addressed became a major measure of success Results were mixed at best Optimization 2.0 revamping the team Identifying a problem Optimization team was disbanded IT resources returned to their individual teams Reorganization to assign IT resources to a portfolio of practices IT resources got to know their practices, working on issues continuously Participated in institution-wide topic-driven optimizations Optimization 2.0 Improving communication with referring providers Problem: Referring providers told us our practice was a black hole Diagnosis: Workflow and tools were studied to determine the underlying problems Creating letters fell to providers Time consuming, extra work Optional Implementation: Designed with vendor, implemented within the practice Results continuously measured and fed back AutoLetter was born! A letter was automatically queued up for the provider to the appropriate referring provider(s) and PCP(s) Consultants can use the default letter or edit on their own Letters automatically sent when the visit is finalized Consultants could delete the communication if not appropriate for the visit 7

9 Results First Live Department Optimization 2.0 The approach Leadership was engaged to determine what needed to be improved based upon anecdotes which lead to data collection The workflow was studied and the requirements for a solution were determined Implementation was conducted Results continuously measured Lifecycle of Optimization: Is the EHR really the problem? The EHR is frequently identified as the problem but root cause analysis often shows there are workflow problems EHR may shine a bright light on previously loosely coupled workflows Workflow analysis with focus on underlying assumptions and documentation of standard work an early step in diagnostic stages of optimization effort Lifecycle of Optimization: How do we implement the solution? Disrupting existing workflows is hard for everyone Expect some people to lose with the changes (especially in big organizations) Standardize communication, update documentation Optimization will put your change management system to the test Lifecycle of Optimization: How do you know if it worked? From the start make sure your goals are measurable If you re not willing to measure it, consider how important it really is Take the time to prove the benefits of optimization Optimization is expensive; benefits must be demonstrated to ensure ongoing resource commitment Lifecycle of Optimization Set a goal Perform diagnosis Implement the solution 8

10 Radiology Report Delivery Pre-Optimization Enhancing EMR Usability with Work Flow Improvements Radiology Report Delivery Post-Optimization Lab Result Delivery Private Offices Lab Result Delivery Clinic Pre-Optimization Lab Result Delivery Clinic Post-Optimization 9

11 Questions??? ACP Resources 10

12 ACP Resources AmericanEHR Partners ( ACP Practice Advisor ( ACP Physician & Practice Time Line ( _timeline/) ACP Running a Practice ( MGMA/ACP Collaboration Benchmarking & Resources ( Where to find answers to your questions at IM 2014 College Resource Center Briefings in the Exhibit Hall Tools for Practice Improvement Thursday, 4:05 pm Friday, 3:55 pm Saturday, 1:05 pm Tools to Meet Federal Requirements and Reporting Friday, 4:05 pm Saturday, 12:55 pm ACP staff experts will be on hand to answer questions and discuss concerns. 11