History and Current use of Clinical Information Systems Lecture 2 History and Current use of Clinical Information Systems

CH 4 History and Evolution of Health Care Information Systems Definitions An Information System is an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the organization Information Technology describes the combination of computer technology (hardware and software) with data and telecommunications technology (data, image, and voice networks).

Types of Health Care Information Systems Administrative Information System Primarily administrative or financial information Used to support management functions and general operations Human Resource Management, Materials Management, Patient Accounting or Billing, Staff Scheduling Clinical Information System Contains clinical or health-related information used by providers in diagnosing, treating, and monitoring Department: radiology, pharmacy, laboratory systems Clinical decision support: medication admin, CPOE, EMR

History and Evolution

History and Evolution Policy and market innovations and correlations with IT Demand for IT driven largely by the market (follow the money). The dollar seems to be a better motivator than “doing the right thing” 1991 IOM report – The Computer-Based Patient Record: an Essential Technology for Health Care Called on the adoption of computer-based records by the year 2001 HIPAA in 1996 IOM: To Err is Human (2000) IOM Patient Safety: Achieving a New Standard for Care (2004)

Ch 5: Current and Emerging Use of Clinical Information Systems The systems The electronic medical record CPR(computer-based patient record)EMR An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff in one health care organization.

EMR Core Functions Health information and data (diagnoses, medications, allergies, demographics, narratives) Results management (test and procedure results) Order entry and support Decision support (computerized decision support capabilities such as reminders, alerts and diagnosing)

Practice Fusion EMR Demo www.Practicefusion.com

HIMSS EMR Adoption Model Stage Cumulative Capabilities Stage 0 Some clinical automation may exist Stage 1 All three major ancillaries installed – laboratory, pharmacy, and radiology Stage 2 Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results. CDR contains a controlled medical vocabulary (CMV) and the clinical decision support system and rules engine for rudimentary conflict checking The hospital may be health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.

HIMMS EMR Adoption Model Stage Cumulative Capabilities Stage 3 Clinical documentation installed (eg. Vital signs, flow sheets, nursing notes, care plan charting, eMAR) First level of clinician decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab) Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians via the intranet or other secure networks. Stage 4 CPOE for use by any clinician added to nursing and CDR environment Second level of decision support related to evidence-based medicine protocols implemented.

HIMMS EMR Adoption Model Stage Cumulative Capabilities Stage 5 The closed loop medication administration environment is fully implemented in at least one patient care service area. The eMAR and bar coding or RFID are implemented and integrated with CPOE and pharmacy to maximize point-of-care patient safety processes for medication administration The “five rights” of medication administration are verified at the bedside with scanning of the bar code on the unit does medication and the patient ID Stage 6 Full physician documentation/charting (structured templates) are implemented for at least one patient care service area for progress notes, consult notes, discharge summaries or problem list and diagnosis list maintenance. A full complement of radiology PACS is implemented and provides medical images to physicians via an intranet and displaces all film-based images

HIMMS EMR Adoption Model Stage Cumulative Capabilities Stage 7 The hospital no longer uses paper charts to deliver and manage patient care and has a mix of discrete data, document images, and medical images within its EMR environment Data warehousing is being used to analyze patterns of clinical data to improve quality of care and patient safety and care delivery efficiency Clinical information can be readily shared via standardized electronic transactions with all entities that are authorized to treat the patient or a HIE. The hospital demonstrates summary data continuity for all hospital services (e.g. inpatient, outpatient, ED, and with any owned or managed ambulatory clinics)

Stage 7 Hospitals in Texas Baylor Scott&White (3 Hospitals) Children’s Medical Center (2 Hospitals) Texas Health Resources (11 Hospitals) https://www.himssanalytics.org/emram/stage7 caseStudies.aspx

EHRs and Docs AMA: “The EHR has been reduced to a tool for billing, compliance and litigation that has sustained negative impacts on doctors’ productivity” Documenting a full clinical encounter is pure torment The government mandates that doctors use an EHR, the EHR vendors’ templates can create confusion and the appearance of fraud, which opens the door for payers to decline reimbursement.

EHRs and Docs Recent evidence that EHRs perpetuate fraud Easier to “upcode” EHRs produce more complete and accurate documentation, and this could be leading medical providers to seek reimbursement for services they have always been providing but weren’t properly documenting before. CMS has history of billing and so can look for trends in billing.

AHIMA American Health Information Management Association Recommendations: Code of ethics for both EHR vendors and Users to design and use the systems correctly and shared accountability for ensuring compliant documentation and coding practices

AHIMA American Health Information Management Association Recommendations: Organization guidelines to assure the features of an EHR are used correctly, addressing issues such as acceptable ways to capture information, limitations on certain features, and correct copy/paste procedures

AHIMA American Health Information Management Association Recommendations: National set of coding guidelines by CMS Education and training on EHR use for all who access it.

Adoption of EHR Meaningful Use of Electronic Health Records, April 2011 through May 2012.

Physician Adoption As of the end of 2012, 62,226 had attested to meaningful use under the Medicare program. Or about 12.5% of the 509,328 eligible physicians. 9.8% of specialists 17.8% of primary care providers 1.9% in Alaska to 24.2% in North Dakota Epic, Allscripts, eClinicalWorks, GE Healthcare, and NextGen accounted for almost 60%

Physician Adoption Barriers to Adoption Cost Lack of knowledge Workflow challenges Lack of interoperability

Hospital Adoption 44.4% of acute care hospitals had a basic EHR system in 2012. It was 12.2% in 2009.

Basic vs. Comprehensive EHR Requirement Comprehensive Basic Clinical Documentation Demographic Characteristics of patients X Physicians’ notes Nursing Assessments Problem Lists Medication lists Discharge Summaries Advanced Directives

Basic vs. Comprehensive EHR Requirement Comprehensive Basic Tests and imaging Results Laboratory reports X Radiologic reports Radiologic images Diagnostic-test results Diagnostic-test images Consultant reports

Basic vs. Comprehensive EHR Requirement Comprehensive Basic CPOE Laboratory Tests X Radiologic Tests Medications Consultant Requests Nursing Orders

Basic vs. Comprehensive EHR Requirement Comprehensive Basic Decision Support Clinical Guidelines X Clinical Reminders Drug-Allergy Alerts Drug-Drug Interaction Alerts Drug-Lab interaction Alerts Drug-Dose Support x

Reasons for increases Demographics As older physicians retire and a new cohort enters, resistance lessens. Fear factor is dissipating – even among older physicians.

Reasons for increases Government incentives 2006 HHS granted Stark law exceptions and anti-kickback safe harbors to hospitals so they could help affiliated practices finance EMRs and other technology. About 1/3 of hospitals have offered financial assistance for EMRs and more than 60% offer physicians access to the hospital’s EMR HITECH

Value of EMR Improved Quality, Outcomes, and Safety Improved Efficiency, Productivity? Time Savings? Cost Reduction? Improved Service and Satisfaction?

Computerized Provider Order Entry (CPOE) Identified by the Leapfrog Group as one of the Four Leaps in Hospital Quality, Safety and Affordability (CPOE, Evidence-Based Referral, ICU “intensivist” staffing, Safe Practice Score). A CPOE accepts physician orders electronically, replacing handwritten or verbal orders

Computerized Provider Order Entry (CPOE) Also provides decision support at the point of ordering (duplicate test, drug-drug interactions, allergies, etc). Might also show the physician the cost of the drug Also called CPOM (management) to highlight that it is not just “entering orders” but more about managing orders.

Meditech CPOE Demo https://www.youtube.com/playlist?list=PL E05A6B2F84BB81E3

CPOE Adoption CPOE seen as a major obstacle to getting to Meaningful Use. For Stage 1: More than 30% of unique patients with at least one medication in their medication list have at least one medication entered using CPOE For Stage 2: More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP during the EHR reporting period are recorded using CPOE

CPOE Adoption Involves major change in workflow Most hospitals have named a Chief Medical Information Officer – physician champion. Cerner, Eclipsys and Epic are the biggest vendors in CPOE, with Cerner having the most live hospitals. (McKesson and MEDITECH also in game)

CPOE Resistance

CPOE and Workflow

Electronic Medication Administration System eMAR About half of medication errors occur during the ordering process (CPOE), but errors also occur in dispensing, administering, and monitoring medications. Bar-code-enabled point of care (BPOC) The five rights: The right drug to the right patient through the right route at the right dose at the right time.

eMAR http://www.chartmeds.com/Demos.aspx Patient wristband with barcode Provider identification band with barcode Bar-codes on the medication Linked to orders http://www.chartmeds.com/Demos.aspx

Telemedicine The use of medical information exchanged from one site to another via electronic communications to improve patients’ health. Specialist referral services Remote patient monitoring Two delivery methods Store and forward – digital images from one location to another. Teleradiology and teledermatology https://www.youtube.com/watch?v=UyoooVg0CJQ https://www.youtube.com/watch?v=mXgmX0k1se8

Telemedicine Interactive videoconferencing – face to face consultation. Urban to rural. Peripheral devices such as stethoscope eICU http://searchhealthit.techtarget.com/definition/Electronic -Intensive-Care-Unit-eICU Telesurgery

Telehealth Telehealth includes the use of technology to access remote health information, diagnostic images, and education Email communication Refilling prescriptions Registering patient Scheduling appointments

Personal Health Record An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be drawn from multiple sources while being managed, shared, and controlled by the individual Consumer-empowerment Comprehensive Longitudinal Individual controls

Putting IT Together

Top 10 Barriers to Implementation 10. Usability - products are hard to use and not well engineered for clinician workflow. 9. Politics/naysayers - every organization has a powerful clinician or administrator who is convinced that EHRs will cause harm, disruption, and budget disasters. 8. Fear of lost productivity - clinicians are concerned they will lose 25% of their productivity for 3 months after implementation. Administrators are worried that the clinicians are right. 7. Computer Illiteracy/training - many clinicians are not comfortable with technology. They are often reluctant to attend training sessions. 6. Interoperability - applications do not seamlessly exchange data for coordination of care, performance reporting, and public health.

Top 10 Barriers Continued 5. Privacy - there is significant local variation in privacy policy and consent management strategies/ 4. Infrastructure/IT reliability - many IT departments cannot provide reliable computing and storage support, leading to EHR downtime. 3. Vendor product selection/suitability - it's hard to know what product to choose, particularly for specialists who have unique workflow needs 2. Cost - the stimulus money does not flow until meaningful use is achieved. And it is generally not enough to cover the cost of implementation. Who will pay in the meantime? 1. People - it's hard to get sponsorship from senior leaders, find clinician champions, and hire the trained workers to get the EHR rollout done.