Department of Veterans Affairs VHA VAi2 Employee Innovation VHA Innovation: Technology-Enabled Digital Documentation Jorge A. Ferrer M.D., M.B.A., LSA | Biomedical Informatician | Veterans Health Administration Office of Informatics and Analytics-Health Informatics | E mail: Adjunct Assistant Professor UTHealth School of Biomedical Informatics 1

Department of Veterans Affairs Technology-Enabled Digital Documentation The Technology-Enabled Digital Documentation (TEDD) innovation was voted number 20 out of 3,841 ideas by VA employees in the Innovation VAi2 VHA employee competition. VHA Strategic Plan FY 2013 – 2018 Innovation & Improvement – VHA will drive an improvement culture by advancing innovation trials, emerging health technologies, and experimentation, through exploration of both constructive failures and dynamic successes, adopting practices that improve care while minimizing and managing acceptable risk. Support Department of Veteran’s Affairs Blueprint for Excellence VHA theme three: Advance health care innovation for veterans and the country by leveraging successful VHA innovations. Innovation done thru a CRADA signed off by the USH in NIST Presentation: Building More Usable Electronic Health Records (EHRs) Supporting the Needs of Developers “Focus on Faster & Usable Clinical Documentation” FINAL-2.pdf FINAL-2.pdf 2

Department of Veterans Affairs Federal-Academia-Industry Innovation Advisory Team Dr. Clayton Curtis, VHA; Dr. Paul Nichol, VHA; Dr. Steve Brown, VHA; Dr. Murielle Beene, OHI; Dr. Neil Evans, VHA; Dr. Michael Weiner, VHA; Donna Harrigan-Thrailkill, VHA; Mike Davis, VA; Dr. Jonathan Nebeker, VHA; Dan Marsh, RN, VHA; Dr. Bill Rudman, AHIMA; Dr. Bria Bria, AMDIS; Dr. Caitlin Cusack, AMIA; Dr. Larry Ozeran, Clinical Informatics Inc; Dr. Doug Rosendale, CAIRNformatics; Dr. Jiajae Zhang, UT; Dr. Chris Gibbons, JHU; Marc Wynne, CMS; Dr. Jon White, AHRQ; Dr. Lana Lowry, NIST; Wei Ma, NLM; Dr. Suzie Burke-Bebee, ASPE; Dr. Alicia Morton, ONC; Dr. Ross Koppel, U of Penn; Matt Reid, AMA; Rocco Bagala, VHA; John Edge R.N., VHA; Angelica Midgett, VHA; Dr. Susan Woods, VHA; Teresa Paguio-Palarca R.N., VHA; Thomas Shelton R.N., VHA; Dr. Alan Calvitti, UCSD; Dr. Zia Agha, UCSD; Dale Marie Ryan, MS, RN, VHA; Dr. Debora Simmons, St. Luke's Health System. 3

Department of Veterans Affairs Technology-Enabling Digital Documentation Cooperative Research and Development Agreement (CRADA) The CRADA is one of the principal mechanisms used by federal labs to engage in collaborative efforts with non-federal partners to achieve goals of technology transfer. Intended to be a flexible mechanism that can be adapted to a variety of types of collaborative efforts between federal and non-federal organizations and that can be implemented relatively easily within a relatively short time. VAi2 Innovation Wiki Site 4

Department of Veterans Affairs VHA Strategic Plan FY 2013 – 2018 VHA Goals and Objectives: Provide Veterans Personalized, Proactive, Patient-Driven Health Care. a. VA Health Care Delivery b. Communication c. Awareness & Understanding d. Access to Information & Resources e. Quality & Equity f. Innovation & Improvement – VHA will drive an improvement culture by advancing innovation trials, emerging health technologies, and experimentation, through exploration of both constructive failures and dynamic successes, adopting practices that improve care while minimizing and managing acceptable risk. g. Collaboration – VHA will strengthen collaborations within communities, and with organizations such as the Department of Defense, the Department of Health and Human Services, academic affiliates, and other service organizations. 5

Department of Veterans Affairs Study: Physician Perceptions of Two Electronic Medical Records (EMRs): VistA (VA) and GE Centricity Lisa Grabenbauer, University of Nebraska Medical Center Research Objective: Examine physicians’ perspective on the objective benefits and limitations of current EMR Conclusions: Current EMR frustrates physician collection of data to improve patient care with cumbersome interfaces and processes Recommendations: EMR must provide seamless and flexible interfaces across system boundaries, for data input as well as data retrieval EMR should facilitate patient and team interactions, not inhibit them Research Study

Department of Veterans Affairs Usability Framework for Innovation VHA Innovation Usability Framework We must produce faster and usable clinical documentation solutions which: Are easy to learn (and re-learn) Are efficient to use (performance) Are effective to use (completion) Prevent errors (not cause harm) Are satisfying to use (subjective impression) 7

Department of Veterans Affairs Usability Present and Future Current Practice and Future Plans for Usability Experience: “Industry Perspective” for the Department of Veterans Affairs SHARPC AMIA Pre-Symposium Dec 2011, W. Paul Nichol, MD, VHA Office of Informatics and Analytics CURRENT VistA/CPRS USABILITY CHALLENGES Electronic representation of paper chart Dated infrastructure and technological approach Challenges in rapid change Clinical practice 8

Department of Veterans Affairs Usability Present and Future Current Practice and Future Plans for Usability Experience: “Industry Perspective” for the Department of Veterans Affairs SHARPC AMIA Pre-Symposium Dec 2011, W. Paul Nichol, MD, VHA Office of Informatics and Analytics CURRENT VistA/CPRS USABILITY CHALLENGES Continue: Technology advances User demands Personalized care orientation – need integration of data from multiple sources, not just VA Clinical decision support enhancements 9

Department of Veterans Affairs PRINCIPLES OF HEALTH INFORMATICS REDESIGN Robert L. Jesse, MD, PhD, Principal Deputy Under Secretary for Health 1.If data is important enough that it is needed to manage the patient and/or the system, then it must be acquired as an integral part of the work process and not through retrospective data collection. –Data should be acquired in real-time, and in concert with the documentation of clinical activities. 2.Solutions must make the work easier and not impose undue burden or re-work. –Technology must facilitate the workflow, but not drive it. 3.Real-time visibility into the system must be available, and it must be transparent across the enterprise. –Manage all patient-health system interactions (e.g. location and times, waits and delays); manage patient staff relationship (e.g. handoffs); manage all tests and procedures in real-time (from scheduling to completion with concurrent documentation) 10

Department of Veterans Affairs PRINCIPLES OF HEALTH INFORMATICS REDESIGN Robert L. Jesse, MD, PhD, Principal Deputy Under Secretary for Health Continue: 4.To deliver evidence-based care we must have evidence-based management. –Clinical and Administrative processes support 5.To effectively manage the delivery of evidence-based care we must manage complexity –Data>Information>Knowledge>Wisdom 11

Department of Veterans Affairs Why Innovate? Innovation Project Goals and Design Principles Objective: Fundamentally improve clinical documentation at the point of service with the goal of the innovation is to improve clinicians' data-entry & documentation requirements with a focus on clinical reconciliation, structured data capture and semantic interoperability. First Principles: Tell the patient’s story Fill in knowledge gaps Minimize the intrusiveness of information technology in the exam room and points of care Let the workflow process drive the technology – not the other way around 12

Department of Veterans Affairs VHA Guiding Principles Veterans Health Administration Strategic Plan FY 2013 – 2018 VHA Goals and Objectives: Provide Veterans Personalized, Proactive, Patient-Driven Health Care. a. VA Health Care Delivery b. Communication c. Awareness & Understanding d. Access to Information & Resources e. Quality & Equity f. Innovation & Improvement – VHA will drive an improvement culture by advancing innovation trials, emerging health technologies, and experimentation, through exploration of both constructive failures and dynamic successes, adopting practices that improve care while minimizing and managing acceptable risk. g. Collaboration – VHA will strengthen collaborations within communities, and with organizations such as the Department of Defense, the Department of Health and Human Services, academic affiliates, and other service organizations. 13

Department of Veterans Affairs Health IT Policy Guidance AMIA’s Invitational Health Policy Meetings 2006: Toward a National Framework for the Secondary Use of Health Data 2007: Advancing the Framework: Use of Health Data 2008: Informatics, Evidence-based Care, and Research; Implications for National Policy 2009: Anticipating and Addressing Unintended Consequences of HIT and Policy 2010: Future of Health IT Innovation and Informatics 2011: Future State of Clinical Data Capture and Documentation 14

Department of Veterans Affairs Health IT Policy Guidance AMIA’s 6thAnnual Policy Meeting The Future State of Clinical Data Capture and Documentation December 6-7, 2011, Washington, D.C. AMIA’s 2011 Annual Health Policy Conference considered the future of clinical data capture, content and documentation with its challenges and opportunities. Because of the importance of high quality clinical documentation and data in supporting patient care, and given current initiatives encouraging the adoption of electronic health records (EHRs), it is crucial to understand how documentation and data capture processes and policies may be affected by “going electronic.” 15

Department of Veterans Affairs Health IT Policy Guidance AMIA’s 6thAnnual Policy Meeting (AMIA working definitions) Clinical documentation [and data capture] refers to findings, observations, assessments, and care plans that are recorded in an individual's health record. It may include data entered using various methods, such as computer entry, document scanning, voice dictation, and automated acquisition from devices. An individual’s health record is the repository of clinical information recorded about that person. The record has many functions. 16

Department of Veterans Affairs AMIA’s 6thAnnual Policy Meeting The Future State of Clinical Data Capture and Documentation December 6-7, 2011, Washington, D.C. Time spent on documentation 21% of time documenting Annals Emergency Medicine. 1998;31: % of time documenting Annals Family Medicine. 2005;3(6): hour/day Journal Clinical Oncology. 2002;20(24): Up from 0.3 hours/day in Health IT Policy Guidance

Department of Veterans Affairs Health IT Policy Guidance AMIA’s 6thAnnual Policy Meeting 2011 Meeting Assumptions Need to transform the way we capture data and document clinical care New technological and technical advances for clinical data capture and documentation New and diverse data sources, health technologies and devices for data acquisition, collection and reporting, treatment support, and information dissemination Blurring of lines between devices and applications intended primarily for use by providers, and those intended for patients Dynamic environmental factors, trends and issues impacting clinical data capture and documentation 18

Department of Veterans Affairs Health IT Policy Guidance AMIA’s 6thAnnual Policy Meeting AMIA Guiding Principles Clinical data capture and documentation: 1. Be clinically driven and patient-centric –reflecting an individual’s longitudinal and lifetime health status 2. Be efficient –enhancing overall provider efficiency, effectiveness and productivity 3. Be accurate, reliable, valid and complete –enabling high quality care 4. Support multiple uses –including quality and performance measurement and improvement, population health, policymaking, research, education, and payment 5. Enable team collaboration and clinical decision making –including the patient as a member of the team 6. Reflect input from multiple sources –including nuanced medical discourse, structured items and data captured in other systems and devices 19

Department of Veterans Affairs Journal American Medical Informatics Association The Future State of Clinical Data Capture and Documentation: a report from AMIA’s 2011 Policy Meeting Caitlin M Cusack, George Hripcsak, Meryl Bloomrosen, S Trent Rosenbloom, Charlotte A Weaver, Adam Wright, David K Vawdrey, Jim Walker, Lena Mamykina Research Agenda Recommendations DHHS should fund the development of innovative automated documentation tools, including data input methods that accommodate entry by various methods such as dictation with or without voice recognition, digital handwriting, and document scanning with or without optical character recognition. 20

Department of Veterans Affairs Journal American Medical Informatics Association Journal of American Medical Informatics Association 2013: The wave has finally broken: now what? (Simborg) Barriers to achieving the promise of improved quality and reduced cost remain, as well as some unintended negative consequences. Poor usability of user interfaces: Both anecdotal and formal survey data continue to indicate that physician unhappiness with EHRs remains a problem. A HIMSS task force has described ‘usability’ as ‘possibly the most important factor hindering widespread adoption of EMRs’ Distrust of EHR-produced encounter notes: EHR vendors incorporate a number of tools in their products to speed up the process of recording a clinical encounter. These include problem templates, copy forward, and ‘singleclick’ entry of review of systems and physical examination components. 21

Department of Veterans Affairs Solutions Identified During Innovation Project Using computational resources to dynamically create scenario-specific, context specific user interfaces for patients and providers. Emphasis telling the patient's story rather than creating traditional progress notes. Support for an overarching documentation session that incorporates the entire health team and the patient. Support for multiple documentation modalities and paradigms to minimize the intrusiveness of the user interface. 22

Department of Veterans Affairs William Osler, M.D. “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” “There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” 23