Electronic Medical Records: key implementation issues

C.T. Lin MD

Senior Medical Director, Informatics

University of Colorado Hospital

October, 2008

OutlinePaper Medical Records

– The burning platform

Electronic Medical Records– What and why – EMR usability– Physician Adoption

Substitution vs. Transformation

• Historical record of care

• Communication/continuity

• Preventive Care

• Quality assurance

• Legal record

• Financial record

• Research

Why keep medical records?

• can’t find the chart

• can’t find the result in the chart

• can’t read the chart

• can’t easily collate the data

• can’t compare across patients

• no analytic capacity

Paper disadvantages

PaperPaper

MedicalMedical

RecordsRecords

Paper records: Legibility?

One day’s worth of papers to One day’s worth of papers to be filed at UCHbe filed at UCH

by ctl

Quick!Quick!RecallRecall: Find all the patients : Find all the patients who take Vioxx!who take Vioxx!

P4PP4P: Prove that we give : Prove that we give Aspirin to all our CAD Aspirin to all our CAD patients!patients!

NQFNQF: Have all our diabetes : Have all our diabetes patients had a Pneumovax?patients had a Pneumovax?

VaccineVaccine: Call all high risk : Call all high risk patients to get flu vaccine patients to get flu vaccine now!now!

ScreeningScreening: We have free : We have free PFT screening next week! PFT screening next week! Who would benefit?Who would benefit?

Paper records: the Paper records: the burning platformburning platform

•Legibility suspectLegibility suspect

•Costly to maintainCostly to maintain

•Not disaster-proofNot disaster-proof

•Can’t qualify for Can’t qualify for pay-pay-for-performancefor-performance

•Population and quality Population and quality studies impracticalstudies impractical

Electronic Medical Records

Key elements of an EMR that support patient safety

• E-prescribing

• Computerized Provider Order Entry

• Automated reporting of test results

• Physician documentation

• only 9% of physicians in 2006 had this capability• HIMSS, Ambulatory Paperless Clinics Workgroup,

2007

Why must we have an EMR?

• Because the current system is inadequate

• Because expert bodies recommend it

• Because the government says so

• Because insurers are going to require it

• Because patients are going to demand it for better safety and improved service

“… information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade.”

– Institute of Medicine, 2001

Assembling an EMRSo, you have 2 EMR systems.

Well, can’t you just hook the 2 systems up?

What’s the big deal?

EMR Systems Map

IDX Visit Management, Patient Billing, & Scheduling

3M Clinical Workstation: integrated viewer, clinics + hospital

Provider Portal (MedXplore -> McKesson) Patient Portal

Lab RIS Path DictationIDX ADT

Allscripts: Deployed 20 of 40 Clinics

Em

erg

ency

McKessonRN docu, Bar Code,

Inpt Pharmacy, CPOE

Viewer

Interactive system

Infra-structure

GI pro

ced

CV

pro

ced

OB

GYN

Psy

ch

Peri

-Op

Onco

logy

Tra

nsp

lant

EMR usability

Don Norman

• Put the required knowledge in the world– Minimize training, make it obvious– Allow more efficiency for experts

• Use artificial and natural constraints– Forcing functions– Natural mappings

• Narrow the gulf of execution– Make things visible, obvious– Easy to do what user intends

• Narrow the gulf of evaluation– Make results of actions apparent– Immediate feedback on actions

Narrow the gulf of execution:

Make it easy to do what the user intends

Push this bar Push this bar to open doorto open door

Welcome, It is 11:15amThursday Oct, 19, 2007

Dr. Lin you have 2 messages and 2 alerts1. Check your messages2. Check your alerts3. Review a chart or test result4. Order a test5. Order a medication6. Order a consult7. Write a chart note8. Get help (x4302)

Nursing: Charting an Assessment

Blood panelAnalyte Lo Hi Unit Result Abnl

Na 135 145 mmol 143

K 3.5 4.8 mmol 5 H

Cl 95 115 mmol 101

CO2 19 29 mmol 22

BUN 3 17 mg/dl 18

Cr 0.2 1.2 mg/dl 0.7

Glu 90 124 mg/dl 83 L

Ca 8.2 10.1 mg/dl 9.1

Alb 3.8 4.5 mg/dl 4.1

ALT 0 45 mg/dl 40

AST 0 43 Mg/dl 37

Polar GraphNa

KCl

CO2

BUN

Cr

Glu

Ca

Alb

TIBC

MCV

ANC

PLTHCT

WBC

ALTAST

AlkP

TSH

O2sat

Temp

HRRR

SBP

Polar Graph

Data points: Last 3

Double click for details

BUN

Cr

Glu

Ca

AlkPSBP

NaK

Cl

CO2

Alb

TIBC

MCV

ANC

PLTHCT

WBC

ALTAST

TSH

O2sat

Temp

HRRR

Awarix(tm): Map based activity monitoring

Usability Conclusions

• The move to Electronic Medical Records not only improves information storage and flow, it could enhance safety and quality through information CLARITY

Physician adoption of EMR

Why EMR adoption is low nationally

• Costly: $40k per physician installation

• Only 11% of the benefit accrues to physicians; most goes to insurers and patients

• Non-standard EMR systems

• Change is hard! (non-computer users)

Principles of Organizational Change (John Kotter)

• Increase urgency

• Build the guiding team

• Get the vision right

• Communicate for buy-in

• Empower action

• Create short-term wins

• Don't let up

• Make change stick

The 80 - 20 rule

• In my opinion, the success of a project is perhaps 80 percent dependent on the development of the social and political interaction skills of the developer and 20 percent or less on the implementation of the hardware and software technology!

--Reed Gardner, LDS Hospital

A formula for adoption

+ Executive support and clear vision+ Physician champion(s) at executive and clinic levels+ Alignment of incentives for individual docs+ Adequate technical and workflow support+ Adequate time+ Robust hardware and software performance!

= Successful implementation

Photo apl

Adoption Stories

“Junior” physician championSurgery vs Medicine vs RheumatologyCounting clicks vs. fast systemsTablet PC and the medical assistantCINA story

“Culture eats technology for lunch”

EMR: Substitution

vs. Transformation

EMR: Substitution

• Its faster to create a new patient chart

• EMR charts can’t be misplaced

• Notes are LEGIBLE

• Prescriptions are LEGIBLE

• No more sticky notes

• 2 people can use the chart at a time

Transformation: Safety

• Electronic documentation instantly available, legible, longitudinal

• Safer prescribing (drug interactions, allergy check, formulary check)

• Vioxx recall: Patients identified, notified in 24 hours

Transformation: Quality

• Flu vaccine: identify highest risk patients to immunize first

• Diabetes: Track patients with highest Hemoglobin A1c’s

• Heart disease: monitor use of ACE-I, Aspirin, beta-blockers

Transformation: Patients• Patients and physicians both

contribute to a shared medical record

• Patients collaborate with providers to set their own treatment goals

• Patient can access, or give access, to their record anywhere in the world

Transformation: no EMR• Conversations between physicians,

nurses, and patients undergo:– Voice recognition– Natural language processing– Integrated, non-interruptive alerts based

on latest evidence

Substitution vs. Transformation Like improvements in transportation, EMR

developments generally are incremental at first…

Substitution vs. Transformation It was hard to foresee what the carriage could

become…

Substitution vs. Transformation And in the broader sense, what transportation

could become

Substitution vs. Transformation And we will always dream…