1. Electronic Health Records vs
Electronic Health Records vs. Niche Software that is actually useful for Family History
Kevin S. Hughes, MD, FACS
Co-Director, Avon Comprehensive Breast Evaluation Center
Massachusetts General Hospital
Bruce Lin
Project Director, Family History for Prenatal Providers
Manager, Public Health Initiatives
March of Dimes

2. The EHR has tremendous promise as a means of decreasing workload, decreasing cost and improving quality of care

3. The EHR has tremendous promise as a means of decreasing workload, decreasing cost and improving quality of care
Reality
EHRs decrease productivity or are neutral
EHRs have not been shown to increase quality
EHRs have not been shown to decrease cost
Consider what Jonathon Bush (AthenaHealth) calls the ‘Cash for Clunkers’ program. Doctors have to be paid to install these EHRs

4. EHR HIT has tremendous promise as a means of decreasing workload, decreasing cost and improving quality of care

5. Clinical Decision Support
Apply Algorithms/Guidelines to patient data
Identify best course of action
Results displayed as intuitive Visualizations
BRCAPRO Mutation Risk 25%
Suggest Genetic Testing
Facilitates best action as part of workflow

6. EHR Issues

7. “Computerization hasn't saved a dime, nor has it improved administrative efficiency”
4,000 hospitals 2003 to 2007
Computerization
Weak correlation
Quality for MI
No correlation
Cost savings
Improvements in administrative efficiency
Quality for pneumonia
Quality for heart failure
Overall quality (MI, heart failure, pneumonia)
Himmelstein, The American Journal of Medicine (2010) 123, 40-46

8. EHR and productivity varies by specialty 100 internists, pediatricians and family practitioners
25 to 33 percent drop in MD productivity
Over time
Internists slightly above original productivity
Pediatricians /family practitioners never recovered
Hemant Bhargava, UC Davis Graduate School of Management

9. Quote from a breast surgeon beginning EHR use
…our productivity is down 28%
I am the highest paid transcriptionist in the state
Each cancer patient chart takes me apprx 1 hour
For the first time in my career, I turned down an add-on patient

11. Currently: Paper + memory
Patient completes paper form
Reviews data using memory of guidelines
Documents and Orders
Orders Genetic Testing

12. EHR: Paper + extra work + memory
Patient completes paper form
Staff enters data into the EHR
Reviews data using memory of guidelines
Documents and Orders

14. Document Management System
Same interface for every Specialty
EHR
Small
Database
Meds
Allergies
Generic Interface
Mostly
Filing Cabinet Or
Document Management System

15. Cardiovascular
Pathology
Anesthesia
Generic
Mammography
EHR

16. IT ≠ EHR Role of the EHR in Family History …close to non-existent
While EHRs do poorly for most aspects of medical care, they are worse relative to family history and genetics

17. Health IT EHR ‘Niche’ Software
Designed to manage the entire spectrum of medical care
Created by large corporations
E.g., NextGen, Allscripts, eClinicalWorks, Misys, Centricity, Eclipse, LMR
‘Niche’ Software
Designed for specialty areas
Homegrown or developed by small vendors
E.g., My Family Health Portrait, Jameslink, GREAT, Progeny, HughesRiskApps

18. Health IT EHR ‘Niche’ Software
Designed to manage the entire spectrum of medical care
Created by large corporations
‘Niche’ Software
Designed for specialty areas
Homegrown or developed by small vendors

19. Health IT and Clinical Care
EHR
‘Niche’ Software

20. EHRs are limited to major areas
Notes
Allergies
Path Reports
Problem
List
Meds
Lab

21. Adding new features for small markets is expensive
Notes ■
Genetics
Ө Pedigree
Allergies
Θ Family History
Path Reports
Risk ■
Problem
List
Meds
Lab

22. Every EHR must rebuild the same basic route

23. EHRs have difficulty improving
AHIC Core Data Set
Published 2008
No EHR Vendor has adopted it
HL7 Pedigree model for interoperability
Approved 2006
Family history upgrade to EHR at my institution
submitted 2006
slated for analysis 2009
Implementation 2013 or later

24. … Modular family history tool
The American Health Information Community (AHIC) Personalized Health Care Workgroup Recommendations to Secretary 2007
… Modular family history tool
… collection of family health history within the EHR…messaging of … information to a variety of richer … tools that perform risk analyses… results of … calculations … returned to the EHR … for curation

25. Testing and iteration possible
Niche/Modular Software
Innovative approaches to data entry
Patient data entry
Clinician data interface
Innovative approaches to CDS
Risk Algorithms/Guidelines
Visualization appropriate to user
Pedigree drawing
EHR as a repository
Core data set
Interoperable
Testing and iteration possible

26. EHRs and Niche Software
EHR vendors say:
Wait for the EHR to do this
Niche software is not needed
EHR should not exchange data with Niche Software

27. Current EHR Future EHR Monolithic
Interoperable with multiple ‘Specialty Specific’ systems

28. Current EHR Future EHR Monolithic
Interoperable with multiple ‘Specialty Specific’ systems

29. Hereditary Risk Identification
CDS

30. Hereditary Risk Identification
Click open 4 screens
BRCA1+

31. Hereditary Risk Identification

32. Typical EHR
HughesRiskApps

33. Better workflow EHR Patient enters data Tablet PC iPad Website
Patient educational materials
Clinical Decision Support
EHR
Reviews Report & Pedigree
Reviews suggested
management
Clinical Decision Support
Documents and Orders

34. Current EHR Future EHR Decrease productivity or neutral
Increase productivity
Mostly document repository
Database
Mostly free text
Structured data
Data entered by staff or provider
Data entered by patient, staff or provider
Generic interface
Specialty specific interfaces
Rudimentary CDS/Drug-Drug interactions
Effective CDS for multiple specialties
View isolated transactions
View consolidated information about a given problem
Proprietary hidden information
Open access to patient data
Monolithic, barely intraoperable
Interoperable with multiple ‘best of breed’ systems

35. Future EHR Interoperable with multiple ‘Specialty Specific’ systems
Current EHR
Future EHR
Monolithic
Interoperable with multiple ‘Specialty Specific’ systems

36. HughesRiskApps Breast Surgery Module