An Update in Electronic Health Records

An Update in Electronic Health Records Mark Seigel, MD, FACOG Assistant Professor, Obstetrics and Gynecology, George Washington University School of Medicine

Disclosure I have no financial interests or industry relationships to disclose. 2

Learning Objectives Understanding the advantages and disadvantages of Electronic Health Records. Deciding if Meaningful Use is for you. Seeing how the EHR field is changing. 3

EHR survey by state

EHR Features Single record per patient Document management system Clinical Decision Support Secure messaging system Patient portal Lab portal E-Prescribing Meaningful Use 5

Office Infrastructure 6

Office Infrastructure Desktop workstations Tablets Scanner Printer Camera Wireless network Internet service provider 7

User Interface 8

9

Disadvantages of EHR The Betamax factor The fear it will soon be obsolete! 12

Disadvantages of EHR Making the transition EHR Purgatory 13

Disadvantages of EHR Vendor lock! 14

15

Cost Software purchase $30,000 Hardware purchase $10,000 Software maintenance $6,000/year Internet contract $4,000/year First year expenses $50,000 16

American Recovery and Reinvestment Act of 2009 $17 billion to fund physician adoption of EHR by 2015 Meeting criteria of meaningful use may allow physicians to receive $44,000 over 5 years, depending on Medicare/Medicaid patient mix and meeting meaningful use objectives. 17

MU Payment 18

MU Stages

MU Payment, Penalty

MU Core Objective CPOE Implement Drug Drug, Drug Allergy checks Measure CPOE is used for at least 30% of all Medication orders EP has this functionality enabled Maintain an Up To Date Problems list 80% of unique patients seen during reporting period have at least one entry or an indication no problems exist. E Prescribing Maintain an Up To Date Medication list At least 40% of prescriptions are sent electronically. 80% of unique patients seen during reporting period have at least one entry or an indication no medications exist. Maintain an Up To Date Allergy list Patient Demographics Vital Signs 80% of unique patients seen during reporting period have at least one entry or an indication no allergies exist. At least 50% of unique patients seen during reporting period have the following data for each patient: DOB, Gender, Race, Ethnicity, Preferred Language At least 50% of unique patients (2 and older) seen during reporting period have the following data recorded for each patient: Blood Pressure, BMI, Height, Weight Smoking Status At least 50% of unique patients (13 and older) seen during reporting period have a Smoking Status dd

MU Core Objective Report Clinical Quality Measures Clinical Decision Support Rule Provide electronic copies of health information Clinical Summaries Electronically exchange key clinical information Protect Electronic Health Information MU Menu Options Implement Drug Formulary Checks Incorporate Lab test results as structured data Generate a list of patients by condition Send reminders to patients for care Measure Report numerators/denominators for 6-9 CQMs. No performance measures required Implement one clinical decision support rule Provide electronic copies of health information for more than 50% of patients who request it electronically. Provide a clinical summary to patients for more than 50% of all office visits within 3 business days. Perform at least one test of EHR technology to electronically exchange key clinical information. Conduct or review a security risk analysis. Measure This functionality has been enabled. More than 40% of lab orders have their results entered into the EHR. Generate at least one report of patients by a condition More than 20% of patients between ages 5-65 are sent an appropriate reminder.

MU 1 MU Menu Options Provide patients with access to patient portal Identify patient-specific education resources Medication Reconciliation Transitions of Care Submit Immunization Record Submit electronic syndromic surveillance Measure At least 10% of patients are provided access within 4 business days of when data was updated in the record. More than 10% of all patients seen by the EP are provided patient-specific education resources. Med Rec is performed for more than 50% of patients that are transitioned to the provider. A summary of care record is provided to another care setting for more than 50% of patients transitioned to another care setting. At least one immunization record is submitted electronically to immunization registries At least one test is performed to provide electronic syndromic surveillance data to public health agencies.

Meaningful Use Dashboard The tool depicted below allows providers to have an up-to-date perspective on their compliance with MU measures Providers can filter the report to an exact 90-day period. Indication of a passing or failing performance to the MU goal. Listing of the Meaningful Use Objectives Numerator/Denominator and corresponding % for each measure.

MU Requirements In order to receive incentive payment, practices must attest to meaningful use and report to CMS that objectives are being met. Stage 1 requires meeting 13 core objectives and 5/10 menu objectives Stage 2 requires 17 core objectives and 3/6 menu objectives. Both require reporting on quality measures.

Meaningful Use 2 Yes or No?

Problems with EHRs and MU EHRs can improve healthcare, but are expensive. Few are designed to improve documentation. Documentation needed to justify level of service, but too much makes it unreadable and wastes time. E-prescribing has built-in flaws.

Consequences of MU

Physician Shortage

Less Docs Independent

HIT Problems

ACO

Early Retirement?

MU 2 Problems Requirement of patients to participate in patient portals depends on patients to do it. Communication with immunization and cancer registries depends on state exchanges. Only 200 of 1400 Vendors have been MU 2 certified. This could require a change in EHR.

Choices? For many independent obgyns, simple option is not to participate in MU 2. Following the first year payments, incentive is less than $8500. Loss in productivity and real cost of compliance may not be worth it. If employed physician, may not have a choice.

Recommendation Over 500,000 eligible professionals and hospitals are registered in Medicare and Medicaid EHR Incentive programs. As of end of 2014, only 1203 providers attested to MU 2. Recommend continue to use EHR to improve patient care, help improve EHR products, but not participate in MU 2.

SERMO Poll 55% of physicians do not plan to attest to MU 2. Only 4% had met Stage 2 requirements. AMA has urged eliminating penalties and shortening the reporting period to ease the MU burden on physicians.

MU Mandates Lost Their Purpose Metrics we are required to report often have no relevance to patient. Useful information is often buried in chart surrounded by clutter. Tedious box checking does not promote good clinical outcome. More time charting leads to less time with patients.

MU Mandates Lost their Purpose MU 2 requires patients to use patient portal. Active portals require vendors to provide interface. Patients don t always want to use portals. Poor and elderly don t have email ability.

MU Mandates Lost their Purpose Compliance is difficult, costly and time consuming. Hospitals and large networks have IT departments devoted to this, smaller practices do not. Need more docs involved with the design process for a realworld, workable system to benefit patients.

A Changing EHR field Consolidation of Vendors Internet of Things Apple Watch

ONC Statistics

Battle of the Titans

Epic versus Cerner

Epic versus Cerner

Internet of Things Electronic devices that monitor data and are connected to a cloud, enabling them to trigger events. This can include car maintenance, smart homes, smart cities, and healthcare applications. Connected devices with unique identifiers can deliver health care data to physicians to monitor health parameters, or to hospitals to monitor bed use, location of equipment, dispensing of medications.

Internet of Things

Internet of Things

58

Apple Watch Wearable technology that is linked to a healthcare platform aids clinical communication. It could lead to a more customized experience at hospital, clinic or at home. Could it begin to monitor health on a personal level and look at health risks and issue alerts?

Apple Watch Apps Messages gives haptic feedback, easiest way to look at messages at work. Mail can be provided securely Social media Badge entry, check in Appointment information Note dictation

Apple watch in clinic

Clue iphone app

Clue iwatch app

64

65

66

69

Mobile Health

71

Resources ACOG Office of the National Coordinator for Health Information Technology Agency for Health Research and Quality 2014 Survey of America s Physicians, Copyright 2014, The Physicians Foundation Community Hospital EHR 2015 Quick Report Meaningful use 2? Just say no. Contemporary Pediatrics Nov 1, 2014 Healthcare Informatics Aug 12, 2015 Survey: Docs Growing Unhappier with EHRs

73