EMR IN PRIMARY CARE: HISTORY AND CURRENT PERSPECTIVES ON PATIENT CARE February 5, 2015 1
First, take a history. 1970 s Electronic innovations - primarily diagnostics Artificial heart 1973 Mammography 1974 CT scan 1975 Ultrasonography 1978 Glucometer 1978 Electronic documentation: Billing systems 2
First, take a history. 1970 S - 1980 s Clinical Data Management System/ El Camino Hospital (1971) Regenstreif Institute in Utah First Rudimentary EMR (1972) Computer Stored Data Ambulatory Record Project/ Massachusetts General (1980) Decentralized Hospital Computer Program / VA (early 1980 s) Dragon (1982) 3
First, take a history. Mid 1980 s PC revolution takes off IBM, Commodore, Compaq, Apple, TRS-80 Private office adoption climbs, but.. Billing Scheduling Word processing 4
Institute of Medicine 1991 To Err Is Human: Building a Safer Health System 1997 50,000 100,000 deaths per year attributed to medical error The Computer-based Patient Record: An Essential Technology for Healthcare there will be a steep learning curve to understanding the information needs of the ambulatory physician 5
1999 AHRQ Agency for Healthcare Research and Quality Prioritization of Evidence-based Medicine Medical best practices Identification of Quality Indicators 6
1999-2009: The Golden Years An EMR User Satisfaction Survey: Advice from 408 Family Physicians FPM 2005 80 systems 10% homegrown Epic, E-Clinical Works, Amazing Charts Alteer, Centricity, Healthmatics Recommendation: Proceed with Caution 7
2009: @%$# Gets Serious Hitech Act gets embedded in the ARRA Carrot: switching to EMR = $ Stick: not switching to EMR = $ 2010: Affordable Care Act Payment Reform Model: Quality bonuses, Pay for Performance, Accountable Care Organizations, etc. 8
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My Pictorial Journey into IT 11
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2009: @%$# Gets Serious Hitech Act gets embedded in the ARRA Carrot: switching to EMR = $ Stick: not switching to EMR = $ 2010: Affordable Care Act Payment Reform Model: Quality bonuses, Pay for Performance, Accountable Care Organizations, etc. 14
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EMR Promise and Reality Legibility The primary issue of IOM paper To Err is Human 17
EMR Promise and Reality Alerting (Legible means discrete, so ) (CPOE) system decreases the likelihood of medication errors by 48% Journal of the American Medical Informatics Association February 2013 Search is on to cure EHR alert fatigue AMA News 2013 X 18
EMR Promise and Reality Ease of Scheduling 19
EMR Promise and Reality Ease of Search Misfiling Lost Charts 20
EMR Promise and Reality Rapid, multiple site access to info Sharing Information X 21
EMR Promise and Reality Granularity of coding 22
EMR Promise and Reality Ease of use E-prescribing ICD-9/ICD-10 coding Billing functionality Built-in formularies X Dx related patient education 23
EMR Promise and Reality Justifying Billing Automatic audits Human audits Software Suggested Billing Inclusing of Dx s addressed at visit 24
EMR Promise and Reality CMS: Do EMR s Lead to Upcoding? AMANews May 2013 25
EMR Promise and Reality (UN)Justifying Billing Copy and Paste functionality X Note Macros X 26
EMR Promise and Reality Cost Record duplication Staff to assemble, file, retrieve record X Storage space Lost or missing test result 27
EMR Promise and Reality Security Physical risk of paper files Security advantage of automated backup Security X EMR is potentially hackable almost 21 million people have had their electronic medical records or electronic health records stolen or breached in the past three years. (Sec y HHS 2013) HIPAA audit violations possible 28
EMR Promise and Reality Legal Defense More complete chart Full audit function: what was changed and when Copy and Paste functionality X Macro templates X 29
EMR Promise and Reality Reminders Preventive Care Diagnosis related care Ad Hoc reminders Data for Research Aggregate data by Dx, test, finding, etc. (?) 30
EMR Promise and Reality Patient engagement/empowerment Portal functionality Scheduling Inquiries Bill payments Patient education E-Visits Health Maintenance/ BPA alerting Population Health management Longitudinal narrative 31
EMR: Promise and Reality What Does the Data Say? Patient Care Quality Availability of a basic EHR was associated with a significant increase in quality improvement for heart failure Am Journal Managed Care 2010 Dec large difference in care and outcomes among diabetics whose providers use EHRs compared with those using paper records NEJM Sept 2011 32
EMR: Promise and Reality What Does the Data Say? Patient Care Quality we did not observe similar improvement in AMI or pneumonia quality scores American Journal Managed Care 2010 Dec X there is little evidence that EMR adoption improves quality of diabetes care in the first 2 years post adoption American Journal Managed Care February 2013 X 33
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Conclusions health care IT has great potential to improve the quality of patient care, reduce medical errors, increase efficiency and access to care, and achieve substantial cost savings IF technology developers and policy makers can COLLABORATE with physicians and providers ACP e-health position paper 2009 36
Conclusions 8 in 10 physicians agree that the wave of the future in medicine in the next decade is interdisciplinary care teams and care coordinators 2013 Deloitte physician survey 37
Conclusions Successful HIT strategy focuses on the inclusion of physicians in organizational leadership and provision of structured training and experience based learning that facilitates understanding of the competitive, technological, and regulatory environment with carefully constructed (report cards) using valid and reliable measures appropriately communicated to physicians in a tools not rules strategy (Deloitte 2013 physician survey) 38