1. Department of Veterans Affairs 2012 VAi2 Innovation: i5021 https://vacloud.us/groups/5021/ https://vacloud.us/groups/5021/ Jorge A. Ferrer M.D., M.B.A | Medical Informatician | Veterans Health Administration OIA HI KBS | E mail: jorge.ferrer@va.govjorge.ferrer@va.gov Adjunct Assistant Professor UTHealth School of Biomedical Informatics 1

2. 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 2009. o Research Objective: Examine physicians’ perspective on the objective benefits and limitations of current EMR o Conclusions: Current EMR frustrates physician collection of data to improve patient care with cumbersome interfaces and processes o Recommendations: o EMR must provide seamless and flexible interfaces across system boundaries, for data input as well as data retrieval o EMR should facilitate patient and team interactions, not inhibit them

3. Department of Veterans Affairs Problem Statement The purpose of the innovation is to build a new clinical documentation platform including annotation and structured data capture that overcomes the major limitations and drawbacks of the traditional GUI workstation. o The primary design objectives are to provide tight integration with any defined workflow, improve usability with a new generation of technical solutions, enable portability of a familiar user experience (UX) across disparate EHR systems, and enhance the patient experience (PX) at the point of service. 3

4. Department of Veterans Affairs Project Goals and Design Principles Objective: Fundamentally improve clinical documentation at the point of service First Principles: o Tell the patient’s story o Fill in knowledge gaps o Minimize the intrusiveness of information technology in the exam room and points of care o Let the workflow process drive the technology – not the other way around 4

5. Department of Veterans Affairs Veterans Health Administration Strategic Plan FY 2013 – 2018 o VHA Goals and Objectives: Provide Veterans Personalized, Proactive, Patient-Driven Health Care. o a. VA Health Care Delivery o b. Communication o c. Awareness & Understanding o d. Access to Information & Resources o e. Quality & Equity o 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. o 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

6. Department of Veterans Affairs AMIA’s Invitational Health Policy Meetings o 2006: Toward a National Framework for the Secondary Use of Health Data o 2007: Advancing the Framework: Use of Health Data o 2008: Informatics, Evidence-based Care, and Research; Implications for National Policy o 2009: Anticipating and Addressing Unintended Consequences of HIT and Policy o 2010: Future of Health IT Innovation and Informatics o 2011: Future State of Clinical Data Capture and Documentation 6

7. 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. o 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.” 7

8. Department of Veterans Affairs AMIA’s 6thAnnual Policy Meeting (AMIA working definitions) o 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. o An individual’s health record is the repository of clinical information recorded about that person. The record has many functions. 8

9. 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 o 21% of time documenting o Annals Emergency Medicine. 1998;31:87-91 o 21% of time documenting o Annals Family Medicine. 2005;3(6):488-493 o 1.4 hour/day o Journal Clinical Oncology. 2002;20(24):4722-4726 o Up from 0.3 hours/day in 1976 9

10. Department of Veterans Affairs 10

11. Department of Veterans Affairs AMIA’s 6thAnnual Policy Meeting 2011 Meeting Assumptions o Need to transform the way we capture data and document clinical care o New technological and technical advances for clinical data capture and documentation o New and diverse data sources, health technologies and devices for data acquisition, collection and reporting, treatment support, and information dissemination o Blurring of lines between devices and applications intended primarily for use by providers, and those intended for patients o Dynamic environmental factors, trends and issues impacting clinical data capture and documentation 11

12. Department of Veterans Affairs 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 12

13. Department of Veterans Affairs Journal of 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 o Research Agenda Recommendations o 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. 13

14. Department of Veterans Affairs Journal of American Medical Informatics Association 2013: The wave has finally broken: now what? (Simborg) o Barriers to achieving the promise of improved quality and reduced cost remain, as well as some unintended negative consequences. o 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’ o 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. 14