1. Peter Basch, MD Medical Director MedStar eHealth Initiative
Engaging Clinicians in Information Technology and Health Information Exchange
Peter Basch, MD
Medical Director
MedStar eHealth Initiative

2. The Value of Information Technology
Improving quality
Embedded care guidelines
Disease management
Reducing inappropriate variability
Improving safety
CPOE
ePrescribing
Reducing costs
Reducing unnecessary duplicative testing
Reducing hospitalizations, office visits, sequellae of chronic disease

3. And health information exchange
Improving quality
Fewer patients treated on limited information
Improving safety
Medications prescribed in fuller context
Reducing costs
Reducing unnecessary duplicative testing

4. The “stars” have aligned…
Strongly endorsed by Bush and Thompson
CMS demonstration projects
NHII
Medicare Modernization Act and eRx
Health IT coordinator
Multiple bills before Congress promoting IT

5. Clinician adoption of IT remains low
~3% of hospitals using CPOE
5-20% of clinicians using EHR
7-30% of clinicians using eRx
HIE used by <1% of clinicians
~ 100% of clinicians use procedural / imaging technology

6. Why do clinicians need to be engaged with HIT?
Hardware, software and networking costs
Bandwidth issues
Usability
“Technophobia”
Lack of standards / interoperability
“Cultural” issues
Business case

7. What can make care better…
Missing / relevant information

8. Can lead to unintended consequences
Care confusion
Expanded duty / liability
Missing / relevant information
Too much / irrelevant information

9. The consequences of having all information on all patients all the time…
Average generalist sees patients/day – gets labs on ~ ½ of them
Takes minutes a day to review, interpret, integrate, act on, communicate to patient
If all results “pushed” to all providers with relationship to patient…
Could increase work 6-fold ( to 2-6 hours a day!) – and if this is uncompensated, will either increase time in office or reduce “billable” time by 25-50% (enough to ruin most practices)

10. Expansion of duty / liability
Within the model of siloed care, duty is narrowly defined - only for what you do (or can be proved to have known, or should have known)
Once the information enters your record, you are responsible for it (even if you didn’t order it, or understand it)
And what if the information is not in the record, but could easily have been put in it (“reasonableness” may be redefined if information is just a “click away,” or could have been auto-pushed to the chart, if the clinician had “appropriately” set the default in the interconnected EHR)?
In the midst of a nationwide liability crisis, is this a welcome change?

11. Does more information to more providers improve care?
Meaningfulness of information to some providers
Does quality improve when multiple providers (who are informed, but “unqualified”) recommend a course of action?
Or when multiple informed (and qualified) providers chart reasonable, but different courses (unanticipated / unwanted second opinions)?

12. Despite challenges, change must occur
US leads the world in advanced procedures, imaging technology, and medication development – yet lags significantly behind many countries in many parameters of quality and safety
Growing expectations of patients and doctors
Increasing numbers of carrots and sticks

13. Change will occur thru…
Technologic advances
Policy / reimbursement changes
Clear understanding of duty / liability in an interconnected world
Clinicians helping to redesign workflow, such that connectivity = better care

14. Panelists Patricia Hale, PhD, MD, FACP Brian Keaton, MD, FACEP
Judy Murphy, RN, BSN
Tom Sullivan, MD
Steve Waldren, MD

15. Why do clinicians need to be engaged with HIT?
Hardware, software and networking costs
Bandwidth issues
Usability
Lack of standards / interoperability
“Technophobia”
“Cultural” issues
Business case

16. Physician culture – are there special challenges?
Judy
Steve
Pat – are physician naysayers more difficult to deal with than nonphysicians

17. Is the business case for IT the same for all clinicians in all settings?
Steve – what is the misalignment of costs and benefits – why don’t family doctors just buy IT and use it?
Judy – do physicians need to be paid to use HIT? How would you balance productivity against quality?
Brian – does IT require incentives for the emergency room – why or why not?
Tom – and is the business case for specialists the same as for generalists? Tom, you have been very active in the performance measures and pay-for-performance movements. Talk about some of the approaches and implications.

18. Success stories
Pat – importance of clinician leadership and senior administrative leadership. Cerner power chart results viewing, electronic review of dictation
Judy – documentation (multidisciplinary, ED, ICU), ambulatory CPOE. eRx
Tom – role of medical and professional societies

19. Baby steps or giant leaps – is incremental adoption the best way to succeed?
Insert Tom’s roadmap slide

20. It’s all about workflow, or is it
It’s all about workflow, or is it? When do you adjust the application, When do you change the workflow?

21. Health information exchange
Is it needed?
Aside from connectivity technology and data standards, what is needed to ensure that its use improves care?
Do clinicians need additional incentives to participate in health information exchanges?
Pat – you have attempted to implement a regional VPN. What were some of the issues in setting it up? Is it being successfully used?

22. Questions from the audience

23. Last words…
David Brailer has taken a temporary leave of absence, post, finding Washington DC summers just too hot! You are being considered by Secretary Thompson as the interim IT czar. You know that President Bush wants to have all clinicians using EHRs within 10 years, and Thompson, being less patient, wants it done this year. In 30 seconds or less, what is the most important thing that can be done to realize this objective.