electronic health record

Electronic Health RecordWhat is in it for you?

“For 8 minutes the computer and I were both functional today

”Randy Glasbergen

http://www.glasbergen.com/images/m008.gif

http://www.glasbergen.com/images/m008.gif

Porter S; American Academy of Family Physicians Pilot project studies EHR implementation issues. Ann Fam Med. 2004 Jul-Aug;2(4):377-8.

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."

Central Concerns

• “More effort same output”

• “Interferes with patient time”– Reduces quality of care

Other Concerns

• Pay for performance

• Anti-trust legal barriers

• Privacy and security obligations

• Liability exposure

• Lack of interoperability

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

Worried about Effort

• What if we have to maintain both paper and computer records?

“We back up our data on sticky notes because they do not crash”

Randy Glasbergen

http://www.glasbergen.com/images/k209.gif

http://www.glasbergen.com/images/k209.gif

Edsall RL, Adler KG. An EHR user-satisfaction survey: advice from 408 family physicians. Fam Pract Manag. 2005 Oct;12(9):29-35


• 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. 2005 Oct;12(9):29-35


• 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?

More Hype than Reality

• 1994: “Twice as long”

• 2001: “5% more time”

• 2006: “No difference”

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):1207-11. 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. 2006 Nov 11;2006(CD):1014.

Time Motion Studies of House Staff & Physician

Offices

Laschober M, Maxfield M, Lee M, K hober Kovac M, P ovac Potter F otter F, F , Felt- elt-Lisk S. Hospital ospital

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?

Studies cited in Health Information Technology in the United States: The Information Base for Progress

Use of Computerized Physician Order Entry in Hospitals

0

20

40

60

80

100

2002 2004 2006 2008 2010 2012 2014

Year

% H

os

pit

als

wit

h C

PO

E

Goal

Ward MM, Jaana M, Bahensky JA, Vartak S, Wakefield DS. Clinical information system availability and use in urban and rural hospitals. J Med Syst. 2006 Dec;30(6):429-38.

Use of Computerized Physician Order Entry in Hospitals

0

20

40

60

80

100

2002 2004 2006 2008 2010 2012 2014

Year

% H

os

pit

als

wit

h C

PO

E

In some areas,80% of Urban Hospitals

Use CPOE

Murff HJ, Kannry J. Physician satisfaction with two order entry systems. J Am Med Inform Assoc. 2001 Sep-Oct;8(5):499-509.

Satisfaction with Order EntryEarlier

systemsCurrentsystems

Impact on QualityMuch more complex than first imagined

Long Term Impact Expected

• Reduced medication errors

• Reduced adverse sentinel events

• Reduced liability & better reliance on guidelines

• Reduced waste and duplicate testing

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):227-34.

Reduced Duplicate Test

• “There is delay in information flow from hospital to general practice”

• Remote access could reduce the delay

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. 1999 Jul-Aug;6(4):313-21.

Less Medication Errors• Improves fidelity of exchanges among

physicians, pharmacists and nurses


Quality: Less Errors• Improves fidelity of exchanges among

physicians, pharmacists and nurses5 months

after CPOE

Before CPOE



physicians, pharmacists and nurses5 months

after CPOE

Allergy Warning System




Drug-Drug Interaction

System

Allergy Warning System




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.

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. 2005 Oct 5;9(5):R516-21. Epub 2005 Aug 8.

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. 2005 Oct 5;9(5):R516-21. Epub 2005 Aug 8.

Less Medication Errors• Improves fidelity of

exchanges among physicians, pharmacists and nurses

Why should errors go down?

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):307-316, November/December 200

Before EHR


EHR streamlines the

process & reduces

sources of error


Simple and straight forward

After 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. CIN: Computers, Informatics, Nursing. 24(6):307-316, November/December 200

Timetable at a Community Hospital

How fast willall 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):307-316, November/December 200

Timetable at a Community Hospital

Process improvement takes a lot

longer

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 projectand not an IT project

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

electronic health record

Documents

physician time

comparison of time

time motion study

electronic images

electronic reminders

electronic health recordwhat

electronic lab results

electronic clinical