1. Electronic Health Record
What is in it for you?

2. “For 8 minutes the computer and I were both functional today”
Randy Glasbergen

3. Worried? Dr. Sattenspiel:
"If we go to a system like this and begin to implement it, we may not be drowning in paper every day, but if we can’t get enough work done—if we can’t see enough patients in a reasonable amount of time to be able to generate the revenues that will support our office—then that could be a disaster."
Porter S; American Academy of Family Physicians Pilot project studies EHR implementation issues. Ann Fam Med Jul-Aug;2(4):377-8.

4. Central Concerns “More effort same output”
“Interferes with patient time”
Reduces quality of care

5. Other Concerns Pay for performance Anti-trust legal barriers
Privacy and security obligations
Liability exposure
Lack of interoperability

6. Lets focus on central problems that physicians express
Other Concerns
Pay for performance
Anti-trust legal barriers
Privacy and security obligations
Liability exposure
Lack of interoperability
Lets focus on central problems that physicians express

7. Worried about Effort
What if we have to maintain both paper and computer records?

8. “We back up our data on sticky notes because they do not crash”
Randy Glasbergen

9. Time saved because records are available on demand or remotely
Worried about Effort
Will it let me do what I am doing?
Do I have to spend more time at it?
I am not a typist
Will I have to redo
Is it fast?
Time saved because records are available on demand or remotely
Edsall RL, Adler KG. An EHR user-satisfaction survey: advice from 408 family physicians. Fam Pract Manag Oct;12(9):29-35

10. How much more time will it take?
Worried about Effort
Will it let me do what I am doing?
Do I have to spend more time at it?
I am not a typist
Will I have to redo
Is it fast?
How much more time will it take?
Edsall RL, Adler KG. An EHR user-satisfaction survey: advice from 408 family physicians. Fam Pract Manag Oct;12(9):29-35

11. Time Motion Studies of House Staff & Physician Offices
More Hype than Reality
1994: “Twice as long”
2001: “5% more time”
2006: “No difference”
Time Motion Studies of House Staff & Physician Offices
Bates DW, Boyle DL, Teich JM. Impact of computerized physician order entry on physician time. Proc Annu Symp Comput Appl Med Care. 1994;:996. Shu K, Boyle D, Spurr C, Horsky J, Heiman H, O'Connor P, Lepore J, Bates DW. Comparison of time spent writing orders on paper with computerized physician order entry. Medinfo. 2001;10(Pt 2): Lo H, Newmark LP, Yoon C, Volk LA, Carlson V, Kittler A, Lippincott M, Wang T, Bates DW. The electronic health record in specialty care: A Time motion study. AMIA Annu Symp Proc Nov 11;2006(CD):1014.

12. The Entire Industry is Changing
The 2005 CMS / Mathematica Hospital survey
83% used electronic lab results;
59% used electronic clinical notes;
50% had electronic images and lab orders;
24% used electronic reminders
21% used e-prescribing
What about CPOE?
Laschober M, Maxfield M, Lee M, K hober Kovac M, P ovac Potter F otter F, F , Felt- elt-Lisk S. Hospital ospital

13. Use of Computerized Physician Order Entry in Hospitals
Goal
Studies cited in Health Information Technology in the United States: The Information Base for Progress

14. Use of Computerized Physician Order Entry in Hospitals
In some areas, 80% of Urban Hospitals Use CPOE
Ward MM, Jaana M, Bahensky JA, Vartak S, Wakefield DS. Clinical information system availability and use in urban and rural hospitals. J Med Syst Dec;30(6):

15. Satisfaction with Order Entry
Earlier systems
Current systems
Murff HJ, Kannry J. Physician satisfaction with two order entry systems. J Am Med Inform Assoc Sep-Oct;8(5):

16. Much more complex than first imagined
Impact on Quality
Much more complex than first imagined

17. Long Term Impact Expected
Reduced medication errors
Reduced adverse sentinel events
Reduced liability & better reliance on guidelines
Reduced waste and duplicate testing

18. Reduced Duplicate Test
“There is delay in information flow from hospital to general practice”
Remote access could reduce the delay
Kljakovic M, Abernethy D, de Ruiter I. Quality of diagnostic coding and information flow from hospital to general practice. Inform Prim Care. 2004;12(4):

19. Less Medication Errors
Improves fidelity of exchanges among physicians, pharmacists and nurses
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc Jul-Aug;6(4):

20. Quality: Less Errors
Improves fidelity of exchanges among physicians, pharmacists and nurses
5 months after CPOE
Before CPOE
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc Jul-Aug;6(4):

21. Less Medication Errors
Improves fidelity of exchanges among physicians, pharmacists and nurses
5 months after CPOE
Allergy Warning System
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc Jul-Aug;6(4):

22. Less Medication Errors
Improves fidelity of exchanges among physicians, pharmacists and nurses
Allergy Warning System
Drug-Drug Interaction System
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc Jul-Aug;6(4):

23. Less Medication Errors
Just storing and retrieving data is not much of a benefit. To get more out of your investment, you need to analyze and use the stored data.
Improves fidelity of exchanges among physicians, pharmacists and nurses
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc Jul-Aug;6(4):

24. Less Medication Errors
Improves fidelity of exchanges among physicians, pharmacists and nurses
Shulman R, Singer M, Goldstone J, Bellingan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care Oct 5;9(5):R Epub 2005 Aug 8.

25. Less Medication Errors
Improves fidelity of exchanges among physicians, pharmacists and nurses
Why should errors go down?
Shulman R, Singer M, Goldstone J, Bellingan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care Oct 5;9(5):R Epub 2005 Aug 8.

26. Before EHR
WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N. MD, FAAFP; FERA, WILLIAM MD; McCORMICK, DONNA L. BS Community Hospital Successfully Implements eRecord and CPOE. Computers, Informatics, Nursing. 24(6): , November/December 200

27. WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N
WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N. MD, FAAFP; FERA, WILLIAM MD; McCORMICK, DONNA L. BS Community Hospital Successfully Implements eRecord and CPOE. Computers, Informatics, Nursing. 24(6): , November/December 200

28. EHR streamlines the process & reduces sources of error
WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N. MD, FAAFP; FERA, WILLIAM MD; McCORMICK, DONNA L. BS Community Hospital Successfully Implements eRecord and CPOE. Computers, Informatics, Nursing. 24(6): , November/December 200

29. Simple and straight forward
After EHR
Simple and straight forward
WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N. MD, FAAFP; FERA, WILLIAM MD; McCORMICK, DONNA L. BS Community Hospital Successfully Implements eRecord and CPOE. Computers, Informatics, Nursing. 24(6): , November/December 200

30. Timetable at a Community Hospital
How fast will
all of this
happen?
WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N. MD, FAAFP; FERA, WILLIAM MD; McCORMICK, DONNA L. BS Community Hospital Successfully Implements eRecord and CPOE. CIN: Computers, Informatics, Nursing. 24(6): , November/December 200

31. Timetable at a Community Hospital
Process improvement takes a lot longer
WOLF, DEBRA M. MSN, RN; GREENHOUSE, PAMELA K. MBA; DIAMOND, JOEL N. MD, FAAFP; FERA, WILLIAM MD; McCORMICK, DONNA L. BS Community Hospital Successfully Implements eRecord and CPOE. CIN: Computers, Informatics, Nursing. 24(6): , November/December 200

32. This is a quality improvement project
What next?
You get what you put in
The sooner the better
Success is more likely if you are involved
Quality of systems
Components included
Configuration decisions
This is a quality improvement project
and not an IT project

33. The Likely Impact Depends on the Details
What do you want it to be?
The Likely Impact Depends on the Details