example: improving care by design of an ehr
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Example: Improving Care by Design of an EHR
Lecture by Farrokh Alemi, Ph.D.Narrated by Jonathan Duxbury
An Example
Design an EHR that will reduce unnecessary visits while improving quality
Assumptions A staff model HMO Both patients and providers have access to
email and Internet Informed consumers willing to take care of their
own health (not for everyone but for a minority of patients)
An Example
Design an EHR that will reduce unnecessary visits while improving quality
Assumptions A staff model HMO Both patients and providers have access to
email and Internet Informed consumers willing to take care of their
own health (not for everyone but for a minority of patients)
An Example
Design an EHR that will reduce unnecessary visits while improving quality
Assumptions A staff model HMO Both patients and providers have access to
email and Internet Informed consumers willing to take care of their
own health (not for everyone but for a minority of patients)
An Example
Design an EHR that will reduce unnecessary visits while improving quality
Assumptions A staff model HMO Both patients and providers have access to
email and Internet Informed consumers willing to take care of their
own health
An Example
Design an EHR that will reduce unnecessary visits while improving quality
Assumptions A staff model HMO Both patients and providers have access to
email and Internet Informed consumers willing to take care of their
own health (not for everyone but for a minority of patients)
Design an EHRto meet these assumptions
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant Neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant Neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant Neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant Neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant Neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
63 clusters of diagnoses explain 80% of primary care
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
Each cluster is ause case, a scenario,under which we can
examine impact of EHR
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
In each cluster, ask internal & external expertshow EHR will reduce visits
Describe the Content of Primary Care Visits
1. General medical examination2. Acute upper respiratory infection3. Pre- and postnatal care including
complicated pregnancy and abortion4. Hypertension5. …6. …63. Malignant neoplasms of skin
Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.
In each cluster, trace decisionsand see what information
is useful
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
What impact will EHRhave on our business
objective in this use case?
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
Experts: Reduces time for a well visit from 1 hour to ½
hour in 70% of the cases
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
Given this use casewhat information
is needed to carryout the necessary decisions?
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
Information needed:
exercise, weight,
smoking, etc.
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
Information needed:
key findings and
thoroughness of self
exam
For General Medical Examination Cluster
Patients will visit lab before scheduled appointment
Patients will complete a health risk assessment online. Computer will provide feedback.
Computer will guide patient in doing self examination.
Computer will help patient plan questions they want to ask during the visit.
Information needed:
clients’ questions
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptomsPatient verificationPermission to contactPreferred contact timeChange in symptomsProtocol for triage to specialistPatient reported blood pressureSide effects of medication
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptomsPatient verificationPermission to contactPreferred contact timeChange in symptomsProtocol for triage to specialistPatient reported blood pressureSide effects of medication
Lets’ look at Information needed in
other use cases
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
What impact will EHRhave on our business
objective in this use case?
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
Experts: Reduces visits in 60% of cases, where
patient gets better after resting
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
Given this use casewhat information
is needed to carryout the necessary decisions?
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
Information needed:
patients signs and
symptoms
For Acute Upper Respiratory Infection Cluster
Patients contact clinicians by phone or email
Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst
System follows up with the patient to see if symptoms have gotten worse
Information needed:
Pt verification,
permission to
contact, preferred
contact time,
change in symptom
s
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
New information
items added in
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
Lets’ look at Information needed in
other use cases
For Pre and Postnatal Care Cluster
Some prenatal visits avoided for patients with positive laboratory tests
Some post-partum visits avoided by the system triaging depressed patients to specialists
For Pre and Postnatal Care Cluster
Some prenatal visits avoided for patients with positive laboratory tests
Some post-partum visits avoided by the system triaging depressed patients to specialists
For Pre and Postnatal Care Cluster
Some prenatal visits avoided for patients with positive laboratory tests
Some post-partum visits avoided by the system triaging depressed patients to specialists What impact will EHR
have on our businessobjective in this use case?
For Pre and Postnatal Care Cluster
Some prenatal visits avoided for patients with positive laboratory tests
Some post-partum visits avoided by the system triaging depressed patients to specialist
Experts: Reduces visits in 10% of
cases
For Pre and Postnatal Care Cluster
Some prenatal visits avoided for patients with positive laboratory tests
Some post-partum visits avoided by the system triaging depressed patients to specialist
Given this use casewhat information
is needed to carryout the necessary decisions?
For Pre and Postnatal Care Cluster
Some prenatal visits avoided for patients with positive laboratory tests
Some post-partum visits avoided by the system triaging depressed patients to specialist
Informatio
n needed:
items u
sed in
triage
protocol
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
New information added in
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
Note that ri
sk asse
ssment
was also
needed
in a previous u
se ca
se
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
Lets’ look at Information needed in
other use cases
For Hypertension Cluster
Patients measure blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
For Hypertension Cluster
Patients measure blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
For Hypertension Cluster
Patient measure blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
For Hypertension Cluster
Patient measures blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
What impact will EHRhave on our business
objective in this use case?
For Hypertension Cluster
Patient measures blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
Experts: Reduces visits in 70% of cases, adds in cost of home equipment
For Hypertension Cluster
Patient measures blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
Given this use casewhat information
is needed to carryout the necessary decisions?
For Hypertension Cluster
Patients measures blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
Informatio
n needed:
patient re
ported BP
For Hypertension Cluster
Patients measures blood pressure at home
Patient calls in or is called by the system regarding control of their hypertension
Clinician available by email to change prescription, explain progress and evaluate patient condition
Information needed:
patient verification,
side effects, change
in blood pressure
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
As more use cases are
examined more information
items are added to the list.
List of Decisions & Information Items
General medical
examRespiratory
infectionPre and post
natal careHypertensio
nHealth risks
Self exam results
Self exam thoroughness
Questions for the visit
Signs and symptoms
Patient verification
Permission to contact
Preferred contact time
Change in symptoms
Protocol for triage to specialist
Patient reported blood pressure
Side effects of medication
Why Do This?
Succeed by design Design the improvements within the EHR
system Specify functional information needs
that correspond to real upcoming decisions
Why Do This?
Succeed by design Design the improvements within the EHR
system Specify functional information needs
that correspond to real upcoming decisions
Take Home Lesson
Improve through design because what is not imagined is not done.
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