Stephen Adams, M.D. Professor of Family Medicine CMIO Erlanger Health Systems Discuss benefits of EHR use. Discuss negative aspects of EHRs. List situations where EHR usage results in cost savings. Review the histories of the largest hospital EHR vendors. EHRs promised to deliver: Better documentation Greater clinical efficiency Improved patient safety Reduced cost Portability and better availability of records Better quality care Improvements: Accuracy Timely access to up to date patient information Access to patient charts Completeness of data Improved legibility of physician notes Detrimental: Excessive amounts of information Most EHR users are bothered by technical limitations of the product Most liked: Usability/usefulness Alerts and reminders 1
Most disliked: Slow system responsiveness Decreased clinical communication between areas Complex screen navigation Poor support for decision making Intraoperability Copy and paste overuse Difficult communication with physicians outside of the system Patients perceive portals as useful, but Often poorly designed Frequently not well integrated Anxious over privacy Multiple studies show good training improves doctors proficiency and successful adoption. Six to twelve months support after implementation is typical The data on patient and clinician satisfaction with EHRs is variable, but in general clinicians like EHRs more than patients. 2
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Improves quality of clinical documentation Trade off: increased documentation time and more time spent on computers Workflow: Nurses generally believe it makes them more productive Physicians do not Physicians believe EHRs improve patient communication, but They spend less time with patients post implementation Outpatient practices Massachusetts ehealth Initiative 2004 2009 Average loss per physician over five years: $43,000 1 in 4 practices had positive return in investment Health Aff (Millwood) 2013; 32: 562 570. Medical Economics Feb 10, 2014 26 Primary care practices in HealthTexas network Centricity EHR rolled out 2006-2008 wrvu intensity did not change wrvu per physician FTE: Lowest in first 6 months (-8%) Was not back to baseline at 12 months (-4.5%) Net revenue per physician FTE: -16.5 % at 6 months At baseline by 12 months Fleming NS, Becker ER, Culler SD, Cheng D, McCorkle R, da Graca B, Ballard DJ. Health Serv Res. 2014 Feb;49(1 Pt 2):405-20. doi: 10.1111/1475-6773.12133. Epub 2013 Dec 21. 4
~35,000 records examined 67.1% pre intervention 69% post intervention No follow up at 6 months: 10.1% vs 3.1% (statistically significant) 5
4 month study 18,529 patient encounters in ED 60 clinicians Consulted HIE 5.39% of the time Estimated cost savings: $283,477 The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 250 256, 2014 The Journal of Emergency Medicine, Vol. 46, No. 2, pp. 250 256, 2014 Key Question: Who benefits financially from a HIE? Who pays for a HIE? Estimates of $8,000,000/yr reduced cost in Memphis if full HIE in place 6
BUT NOT FOR PHYSICIANS! 7
Technical support increases quality of care Financial incentives increase compliance with quality measures Technical support increases quality of care Financial incentives increase compliance with quality measures BUT Financial incentives for certain measures dampens improvements for measures without incentives! 10 vendors = 90% of hospital market Only three vendors market share are growing: Epic Cerner McKesson Among academic medical centers: Allscripts, Epic, Cerner, McKesson and Quadramed are most popular >50% of new large hospital contracts in US Contains some piece of data on 51% of US population 8
Judy Faulkner BA in Mathematics MA in Computer Science Personally wrote a program to store patient data for department of psychiatry 1979 Borrowed $70,000 to buy computer and start company 2000 Still only 69 customers 2003 Kaiser Permanente contract $3 billion dollars Initially problematic installation cost the Kaiser CIO his job in 2006 MUMPS (Massachusetts General Hospital Utility Multi-Programming System) Contains a database structure based on multidimensional arrays Neil Pappalardo 9
*Others say the above criticism is inaccurate and unfair *The other side of the argument: this is perhaps a faster database structure than more traditional types. 10
Uncompromising standards for employees and aggressive recruiting campaign for high quality IT staff Stimulating work environment Careful selection of clients Attention to customer service Founded 1979 Neal Patterson Paul Gorup Cliff Illig 11
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Poor planning Incomplete/incorrect configuration Poor training Lack of clinician engagement PQRS Qualified Clinical Data Registry Medicare Part B Claims Direct EHR Reporting CEHRT via data submission vendor Qualified PQRS Registry 13
13 required, plus 5 menu EHR Reporting Period: full year reporting Meaningful Use Objectives and Measures: (1) protection of patient health information (2) electronic prescribing (3) clinical decision support (4) computerized provider order entry ( CPOE ) (5) patient electronic access to health information (6) coordination of care through patient engagement (7) health information exchange (8) public health and clinical data registry reporting. Each of these objectives has between one and six proposed measures. 2015 Edition Certified EHR Technology Required for 2018. No New Categories of Hardship Exceptions. 14
EHRs: Improve documentation quality Sometimes improve quality (sometimes worsen it) Improve staff efficiency Temporarily decrease physician efficiency Haven t yet demonstrated consistent improvements in quality of care or decrease in cost of care 15