Improving Patient Outcomes through a More Effective Electronic Medical Record

Published by FierceHealthcare Custom Publishing Managing the Transition to the More Effective EMR Improving Patient Outcomes through a More Effective Electronic Medical Record sponsored by GE Centricity Practice Solution Arthur, a 66-year old-year retired electrician was diagnosed with Type 2 diabetes at age 62. Recently widowed, he s struggled to control his risk factors, keep track of multiple medications and arrange appointments with his primary care physician, endocrinologist, nutritionist and podiatrist. That all changed when Arthur s primary care physician installed an electronic medical record (EMR) system. For the first time, Arthur was able to access at least a portion of his personal health information, including demographics, progress notes, problems, and medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. As a result, Arthur can better manage his risk factors, short circuit complications and prevent trips to the hospital emergency room. Arthur isn t alone in experiencing dramatic changes in lifestyle and health through use of an EMR. Using EMRs instead of paper files has the potential to improve care for diabetic patients by boosting communication, according to a September 1, 2011 study in the New England Journal of Medicine. After analyzing the medical records of more than 27,000 adults who received care for diabetes at clinics in the Cleveland area, researchers determined that diabetic patients improved faster at medical clinics that had made the switch to e-records. Despite positive results related to EMR usage, questions remain. How can physician practices best use EMRs to focus business and clinical operations, improve outcomes and engage patients in healthcare decision making? Physician practices face multiple challenges ranging from the high costs of information technology (IT) maintenance and the data tidal wave, to reliance on EMRs as charts and siloed information repositories and incomplete clinical decision support (CDS). Truly effective EMRs offer physicians insight into how well a practice cares for its patients. Such insight calls for a blend of tools that inform diagnostic and treatment decisions at the point of care, facilitate collaboration among providers and between providers

and patients, achieve integration or remain integrated with a practice management solution, monitor and report safety and quality and engage patients and families. Effective EMRs also reach beyond information retrieval to intelligence grounded in information, according to Dr. Jon D. Morrow, Senior Medical Leader and Medical Quality Improvement Consortium (MQIC) Director, GE Healthcare. Instead of merely replacing paper, these EMRs leverage information to enhance knowledge through computer based intelligence and decision-making support, linking information from one EMR to the information in another. Clinical Intelligence and Insight via the EMR Clinical insight should come through dashboards that report performance on key metrics for Meaningful Use (MU), as well as real-time feedback on how physicians manage patients against guidelines, including those with chronic conditions like diabetes, chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF),. For example, if a guideline indicates that a diabetic patient needs a hemoglobin check every six months with a result no greater than one percent above the upper limit of normal, the dashboard should report how well each physician within the practice performs against that metric. Instead of functioning as a penalty, dashboard feedback should empower individual physicians to change their behavior, while prompting the sharing of best practices among physicians who are typically eager to learn how they stack up against their colleagues, says Mark A. Dente, MD., Chief Medical Officer, GE Healthcare IT. on whether or not patients had completed hemoglobin A1C tests within the last six months. Likewise, if a patient s blood pressure was too high, CDS within the EMR would recommend medications needed to manage blood pressure in the context of diabetes. When an EMR functions with a dashboard, physicians get specific, quantitative feedback on guideline use, says Dr. Dente. And that, in turn, makes it easier and more natural for physicians to integrate best practices into their workflow. Ideally, physicians want intelligence about the appropriateness of a medication in light of a patient s hypertension, COPD, diabetes or CHF, says Mark Blatt, M.D., Director of Global Healthcare Strategies, Digital Health Group, Intel. For example, if a physician decides to prescribe a hypertensive, she wants to know the best drug or cocktail of drugs to address a patient s condition. And she wants the information to emerge on a single screen, freeing her of the burden of flipping through multiple EMR screens or paper charts.. Dr. Morrow sees EMRs anchored in increasingly complex levels of clinical intelligence, including the following: Reactive intelligence and alerts: Alerts inform physicians that a patient is allergic to a medication or that the patient is already on a medication that would likely interact with a newly prescribed medication. With While the dashboard component of clinical insight functions is what Dr. Dente calls a speedometer for physician performance, clinical decision support (CDS) functions as a kind of global positioning system, providing day-to-day guidance on how a physician should diagnose and treat patients. Stated another way, the dashboard identifies areas and strategies for improvement, while CDS influences the interaction between the physician, patient and orders. For example, the dashboard might identify problems related to the hemoglobin A1C test for diabetics. Once a practice introduced a diabetic form with built in decision support, physicians could receive alerts

this level of intelligence physicians can easily determine if their decision conflicts with information found within a patient s records whether they re found in the current setting or elsewhere, says Dr. Morrow. Proactive reminders: The effective EMR also offers physicians patient-specific recommendations. For example, instead of waiting for the physician to take action before making a recommendation, the effective EMR would share these insights on a patient: The patient is 68 years old. This patient should have an annual flu shot based on national guidelines. The flu season has already begun and flu is highly prevalent in the patient s location. Please arrange for this patient to get a flu shot. In an effective EMR, results are actionable. The system alerts the physician of a patient s need and provides an alert along with a button that says: It s recommended that your patient get a flu shot. Would you like me to order the test for you? If the physician responds to the query in the affirmative, the EMR would send a prescription for a flu shot to the patient s pharmacy. Retrospective, big picture system review: At this level, the effective EMR examines the quality of care a physician rendered to patients and then rates the physician against national guidelines. As a result, the physician can verify if care meets national guidelines on specific criteria, identify patients who may have experienced gaps in care, and discover how his personal clinical performance compares with the performance of colleagues. This kind of information is useful within accountable care organizations (ACOs). Because physicians are competitive, practices can easily drive improvement by informing physicians of their deficits, says Dr. Morrow. Learning where they may have missed the mark and where they tend to excel motivates physicians to read up and apply standards to improve practice. Equally critical, is how such information appears to physicians. Every level of clinical intelligence calls for a graphical interface, according to Dr. Blatt. Text provides too much information for physicians to observe and it s not the way physicians think. Physicians want data presented succinctly, preferably with overlapping pictures, icons and diagrams that offer insight into a patient s health status along with follow-up recommendations.. If physicians are to fully integrate an EMR into their practice, they need an EMR that makes them smart and facilitates decision making in real time by presenting massive amounts of data in real time, adds Dr. Blatt. That s the EMR of the future. Clinical Collaboration and Integrated Practice Management via the EMR An effective EMR should also facilitate clinical collaboration through communication and accountability, according to Dr. Dente. That s because decision support has the power to create a set of tasks for a population of patients, communicate with members of the care team and close the loop so the responsible team member usually a care manager follows up with patients even if they haven t been seen by clinicians. Hospitalized patients are often cared for by multiple ologists while an internist struggles to manage the case through an EMR that Dr. Blatt calls an electronic record of disparate thoughts. The answer, he believes, rests in an EMR that offers a collaboration platform with the power to coordinate live telemetry and remote monitoring data with text-based and Picture Archiving and Communication System (PACS) information. Dr. Blatt is convinced that collaborative workflow environments will grow in importance as EMRs evolve into registries and tools for documentation and chronic disease management. The key, he says, is giving

physicians the opportunity to perform meaningful collaborative work synchronously or asynchronously. whichever makes most sense in diagnosing and treating a patient. Real-time collaboration is also likely to benefit patients who may turn to a collaborative platform to hold conferences with primary care and specialist physicians. Instead of phoning a patient prior to surgery, practices may host video conferences within the EMR to verify receipt of information related to medications, demographics, insurance and registration. If patients need additional information, they ll be able to connect with physician office staff via the EMR. The best EMRs also help practices monitor what Dr. Dente calls the vital signs of healthcare : quality, cost, access and reimbursement. Healthcare needs to be able to balance all four of those at the same time, he says. If physicians focus only on the cost of healthcare, quality suffers. If they focus on quality with no consideration of cost, they reduce the number of patients they can treat and the quality experience of society suffers. To provide quality care to patients in need and still maintain financial viability, practices need insights from integrated practice management and clinical systems, according to Dr. Blatt. In an ideal scenario, integrated practice management and clinical systems may lead to features like open scheduling, where physicians have the capacity to book appointments with specialty facilities like MD Anderson or Memorial Sloan Kettering. Population Health Management and the Effective EMR Equally important is the power of EMRs to facilitate population health management. While EMRs previously focused on digitizing data capture and collection, effective EMRs will focus on the choices physicians make in using and acting upon data, according to Joann Kern, R.N., Director of Product Management, Electronic Health Records, GE Healthcare. Physicians realize they can no longer manage patients, populations and outcomes without a healthy technology backbone, she says. The goal is not simply ensuring that physicians document patient visits, but that a population of diabetic, CHF or COPD patients complies with a recommended treatment. Achieving population health management will require a more intense focus on usability turning data points into meaningful information, according to Kern. As healthcare works to help physicians make more accurate, timely, evidence-based decisions, EMRs must inform and illuminate the decision-making process. The last thing providers need is a cluster of individual data points, devoid of any explanation of how the data points connect. Kern champions EMRs that rely on sophisticated CDS rather than streams of data points, control information saturation and pull data points together to inform workflow. That, in turn, means that EMR systems must reach beyond clinical workflow to outcomes management and predictive modeling. Knowing if a patient is more or less likely to develop a co-morbidity is based on large, analytic data sets, says Kern. This means moving beyond transactional CDS toward harnessing the collective intelligence of patients and ensuring that a physician recommends the same treatments for patient 1,000 as she did for patient number one. Ensuring Patient Safety and Quality via the EMR EMRs have the power to promote patient safety and minimize medical errors through dashboards that offer insight into how well a practice performs from a safety perspective.

Centricity solutions. Because the Centricity EMR is a locally implemented solution, participating providers have easy access to a server that strips out identifying, protected health information with the exception of patient age and approximate geographical location. Once the MQIC system de-identifies, extracts and aggregates data from EMRs, it creates special reports that physicians view on EMR screens under a tab called quality. Physicians who require more detail, or who are users of older versions of the Centricity EMR, can access reports through a separate portal. Reports reveal how well physicians and practices are performing, as well as how well they ve performed against peers and competitors, says Dr. Morrow. Physicians, who are competitive by nature, learn that even though they may have fulfilled 70 percent of government recommendations, other practices have fulfilled 80 percent. Effective EMRs create a learning environment for understanding how safe patients are, while providing physicians with a toolset to improve how they manage patients and protect safety, says Dr. Dente. That s the difference between EMRs implemented for the purposes of digitization and EMRs implemented for the purpose of quality improvement. EMRs will be invaluable in helping physicians fulfill Meaningful Use (MU) requirements. MU has already driven community hospitals to adopt clinical information systems, including EMRs, according to a November 2011 report from KLAS. Among the predictions: The number of community hospitals that have yet to develop clinical information system will drop as organizations ramp up to meet MU requirements and mandates like the transition to ICD-10 code sets. While physicians are required to simply report on quality measures in the early phases of MU, Dr. Dente believes that the government will ultimately hold physicians accountable for the quality of these measures. While traditional EMRs will report on quality, learning EMRs will provide physicians with the tools to improve quality, he says. Quality reporting is the essence of Medical Quality Improvement Consortium (MQIC), a proprietary system that collects data from more than 500 facilities and 25,000 users of the EMR software from GE With the permission of participating providers, GE Healthcare also licenses MQIC data, which represents the records of nearly 30 million patients, to large organizations, including universities, government agencies and pharmaceutical companies that are involved in population-based health research or assessment, benchmarking and reporting of quality. And what of the future? MQIC has the capacity to receive data from varied sources, including inpatient EMRs and EMRs from other vendors. This would enhance the value of the database as well as the type and level of quality reports offered to physicians, according to Dr. Morrow. Also possible is the creation of more granular and frequent reports biweekly, weekly or even daily. While MQIC involves retrospective analysis, Dr. Morrow is convinced that physicians will ultimately use MQIC prospectively and proactively to improve the quality of care. The goal, he says, is to use published, shared measures as clinical intelligence and practice guides, applying retrospective reports from one group of patients to a second group of patients. However, instead of examining measures retrospectively, physicians would view these measures as recommendation for improving a patient s care while care delivery is still taking place. Information will flow within the practice as well as beyond the practice, embracing communities,

states and regions, predicts Dr. Morrow. Physicians will have the ability to access and review all information, which will feed into CDS systems, he says. EMRs will have an impact on individual patients and entire communities in terms of outcomes and health economics. Engaging Patients and Families via the EMR Tighter relationships between patients and physician practices mean that practices will increasingly tap technology to facilitate simple transactions, initiate shared decision making and offer patients access to test results, disease and condition information, and lists of problems under the management of a specific physician, according to Dr. Dente. Patient portals connected through a communications platform offer patients the tools they need to look within a practice and make more informed decisions. But engagement is a multi-phase process begins with awareness and extends through engagement and activation. Patients may view a portal or even register with a portal during the early awareness phase. However, it s not until patients use and rely on a portal as a primary source of communication with a practice that engagement truly occurs. Activation reaches beyond engagement as patients increasingly depend on digital tools to reduce health risks and improve chronic conditions. Guidelines for Changing EMR/ Practice Management Systems Dr. Blatt offers these recommendations to practices looking to upgrade or replace their EMR and practice management system in the years ahead: Information exchange: How well does the EMR/PM system facilitate interoperability and data exchange? Visualization: Does the system use easyto-read graphical interfaces to present data more clearly than in text-based systems? Training: Does the EMR/PM system require minimal training much like an ipad? Does the vendor offer multiple training options both on site and online? Collaboration: Does the system offers collaboration spaces and support synchronous and asynchronous decision making About GE Healthcare Centricity Practice Solution: GE Healthcare brings over 20 years of successful EMR implementations in settings ranging from solo practitioners to some of the nation s largest healthcare organizations. GE s Centricity Practice Solution, an integrated EMR and practice management system, delivers critical information right to the point of care, enabling primary care and specialty practices to manage millions of patient records, securely exchange clinical data, and benchmark outcomes for quality improvement initiatives. Designed with extensive input from users, this intuitive software is backed by GE Healthcare s world-class customer service, support, professional services, and Six Sigma processes. In addition, we partner with healthcare leaders, striving to leverage the global policy change necessary to implement a successful shift to sustainable healthcare systems. For more information, contact us at emr.cps@ge.com or visit www.gehealthcare.com/cps