the electronic medical record:the electronic medical ...3 today’s patient is demanding a similar...
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The Electronic Medical Record:The Electronic Medical Record: Is it the Holy Grail?
Jonathan L. Schaffer, MD MBAManaging Director
eClevelandClinic, Information Technology DivisionProgram Director
Advanced Operative Technology Group
DOS CME Course 20111 Oxtober 20101Confidential
Advanced Operative Technology GroupOrthopaedic and Rheumatologic Research CenterBiomedical Engineering, Lerner Research Institute
Staff Surgeon, Center for Joint ReconstructionDepartment of Orthopaedic Surgery, Orthopaedic and Rhuematologic Institute
Cleveland Clinic
Ermie Herring, MSN, PMPChief, Medical Informatics
The Office of Medical ServicesThe Department of State
© Cleveland Clinic 2011DOS CME Course 2011
The last time you needed cash, did you………..
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Wait in line at the bank? Stop at an ATM?
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The last time you needed information, did you…
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Use the card catalogue at the library?
Google it?
• Many daily tasks are easier and more convenient
• We save time
• We save money
Information Technology Benefits
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• We can’t remember what life was like before
• We rely on many of these services
• When applied to medical care– Increased patient safety and service
Increased physician productivity– Increased physician productivity
– Decreased transcription costs
– Improved billing cycles
– On demand information access
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Today’s patient is demanding a similar level of service from their health care providers.
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• Clinical, workflow, administrative, and revenue enhancement benefits of the EMR– Outweigh barriers and challenges– Only if healthcare organizations redesign work processes– Train and motivate users to navigate EMR systems
Analyzing EMRs
g y– Develop a common structured language
• Clinicians who use EMR– Electronic access to clinical information– Saves time– Provides a thorough and efficient way to manage patients
• ORGANIZED CLINICIANS ARE ORGANIZED !– And they will find the Holy Grail– Eventually– Maybe
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Computerized Physician Order Entry
• Streamlines entry of routine orders– Eliminates re-entry of data collected elsewhere – Monitors ‘completeness’ and accuracy of orders
• Facilitates ordering decisions– Drug interaction checking (drugs, food, allergies, labs)– Alerts physician to other contra-indications– Offers physicians a review of “Best Practice” guidelines– Checks for duplicate orders
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• Facilitates clinical follow-up– Offers overview of full patient list ‘at a glance’– Reports order status– Highlights overdue results and abnormal results– Offers ‘best practice’ guidelines re: next steps
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HiTech Act
Every Life Deserves World Class CareEvery Life Deserves World Class Care
EMR Political Landscape
• February 17, 2009 President Obama signed the $787 billion American Recovery and Reinvestment Act of 2009 (ARRA)
• Create jobs, restore economic growth and strengthen America's middle class through measures thatAmerica s middle class through measures that– Modernize the nation's infrastructure
– Enhance America's energy independence
– Preserve and improve affordable health care (28%)
– Expand educational opportunities
– Provide tax relief
Protect those in greatest need
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– Protect those in greatest need
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EMR Political Landscape
• $140 billion for “comprehensive healthcare reform” – $19.5 billion to promote HIT adoption and implementation
– Concern that system has flaws– Over-treatmentOver treatment
– Highly fragmented
– Uncoordinated care
• Physicians and hospitals are eligible to receive portions of these funds based on– Having an integrated EMR system in place by January 1, 2011
– Demonstrating EMR “meaningful use” as defined by a National
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– Demonstrating EMR meaningful use as defined by a National Coordinator for Health Information Technology committee
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Orientation to ARRA Structure
• Divided into two divisions– Healthcare and HIT are addressed throughout
• Division A: Appropriations Provisions– Title VII Dept. Labor, HHS, and Education
– Title XIII Health Information Technology for Economic and
Clinical Health (HITECH) Act
• Division B: Tax, Unemployment, Health, State Fiscal Relief, and Other Provisions– Title IV Medicare and Medicaid HIT (incentives
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(–A: Promotion of HIT (ONC)
–B: Testing of HIT
–C: Grants and Loans Funding
–D: Privacy
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Orientation to ARRA StructureDIVISION A: TITLE XIII—HEALTH INFORMATION TECHNOLOGY
• Subtitle A—Promotion of Health Information Technology– PART 1—IMPROVING HEALTH CARE QUALITY, SAFETY, AND EFFICIENCY
– 13101 ONCHIT; Standards Development and Adoption.– 13102 Technical Amendment.
– PART 2—Application and use of adopted health information technology standards; Reports
– 13111 Coordination of federal activities with adopted standards and implementation specifications.– 13112 Application to private entities.– 13113 Study and reports.
• Subtitle B—Testing of Health Information Technology – 13201 National Institute for Standards and Technology Testing. – 13202 Research and development programs.
• Subtitle C—Grants and Loans FundingSubtitle C—Grants and Loans Funding – 13301 Grant, loan, and demonstration programs.
• Subtitle D—Privacy – 13400 Definitions
– Breach Business Associate Covered Entity Disclose Electronic Health Record Health Care Operations Health Care Provider Health Plan National Coordinator Payment Personal Health Record Protected Health Information Secretary Security State Treatment Use Vendor of Personal Health Records
– PART 1—IMPROVED PRIVACY PROVISIONS AND SECURITY PROVISIONS
– 13401 Application of security provisions and penalties to business associates of covered entities; annual guidance on security provisions.– 13402 Notification in the case of breach.– 13403 Education on health information privacy.– 13404 Application of privacy provisions and penalties to business associates of covered entities.– 13405 Restrictions on certain disclosures and sales of health information; accounting of certain protected health information disclosures; access to certain information in electronic
format.– 13406 Conditions on certain contacts as part of health care operations.– 13407 Temporary breach notification requirement for vendors of personal health records and other non-HIPAA covered entities.– 13408 Business associate contracts required for certain entities.– 13409 Clarification of application of wrongful disclosures criminal penalties.– 13410 Improved enforcement.– 13411 Audits.
– PART 2—RELATIONSHIP TO OTHER LAWS; REGULATORY REFERENCES; EFFECTIVE DATE; REPORTS
– 13421 Relationship to other laws.– 13422 Regulatory references.
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g y– 13423 Effective date.– 13424 Studies, reports, guidance.
DIVISION B: TITLE IV—MEDICARE AND MEDICAID HEALTH INFORMATION TECHNOLOGY; MISCELLANEOUS MEDICARE PROVISIONS – 4001 Table of contents of title.
• Subtitle A—Medicare Incentives – 4101 Incentives for eligible professionals.– 4102 Incentives for hospitals.– 4103 Treatment of payments and savings; implementation funding.– 4104 Studies and reports on health information technology.
• Subtitle B—Medicaid Incentives – 4201 Medicaid provider HIT adoption and operation payments; implementation funding.
• Subtitle C—Miscellaneous Medicare Provisions – 4301 Moratoria on certain Medicare regulations.– 4302 Long-term care hospital technical corrections.
www.hipaasurvivalguide.com/hitech-act-text.php
Health Information Technology for Economic and Clinical Health Act (HITECH) Act
• Focus on funding for HIT– Promotion of HIT
– Incentives for EHR use
S ifi t i• Specific topics – EHR Terminology
– Immediate Funding for HIT Infrastructure and Implementation Assistance
– State Grants and Loan Programs
– HIT Education
M di I ti f M i f l U f EHR T h l
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– Medicare Incentives for Meaningful Use of EHR Technology–Eligible Professionals
–Eligible Hospitals
– Impact of Payment Incentives
– Medicaid Incentives
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HITECH Focus
• Enhancements that enable a nationwide health information network– Nationwide health information network
– Nationwide HIT infrastructureNationwide HIT infrastructure
– Health information exchanges (HIEs)
– Health information exchange organization (HIO)
– Regional health information organization (RHIO)
– E-prescribing gateway (e-Rx)
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HITECH Focus• Net opportunity of 19.5B investment in HIT systems
– Improve quality, safety, efficiency, care coordination, population and public health and value– Reduce health disparities– Engaging patients and families– Ensuring privacy and security– Authorizes CMS to provide financial incentives for eligible docs who meaningfully use EMR
• Use a certified EHR in a meaningful manner– Purchase certified EMR (www.cchit.org)– Demonstrate meaningful use of certified EMR (healthit.hhs.gov)
– 28 specific functions with EMR
– Submit 29 quality measures to CMS to qualify for payment #1– Bar raised in 2013 and 2015– Improved clinical performance on key health outcomes
– Payments up to $44,000 per physician over five years– Treat Medicare patients (Medicaid has different schedule)
– ePrescribing bonus available now– 2% of Medicare payments starting in 2010, decreasing thereafter, then penalties in 2012
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– 5% reduction in payment for those who do not use EMR– Hospitals $2M over four years
• Regional Extension Centers– Educational and technical assistance govt funded agencies– Priority are rural, poor urban area, small group, primary care docs
• Care transformation is the goal with improved health system performance
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Meaningful Use
Every Life Deserves World Class CareEvery Life Deserves World Class Care
EHR Terminology
• Meaningful use of EHR:– Eligible professional demonstrates use of certified EHR
technology
• In a meaningful manner• In a meaningful manner– Definition to be determined but you had better be meaningful
– E-prescribing as determined to be appropriate by the Secretary
– Exchange of information to improve quality of health care and promoting care coordination
– Reporting of clinical quality measures and other measures selected by Secretaryy y
– Measures may become more stringent
– HHS may not require electronic reporting unless there is the capacity to accept data
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Meaningful Use of the EMR
• Hospitals and eligible professionals report that the EMR has been implemented in a meaningful way such that the quality of health care will be improved
• Five Health care outcomes policy priorities1. Improve quality, safety, efficiency and reduce health disparities
2. Engage patients and families
3. Improve care coordination
4. Improve population and public health
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p p p p
5. Ensure adequate privacy and security
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Modern Healthcare March 29, 2010 page 9
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Meaningful Use “Finalized” Q2 2010
Year Engagement Objectives Engagement Measures
2011 Provide clinical summaries for patients for each encounter, electronic copies, access to
ti t ifi d ti l
Percentage of patients with electronic access to clinical summaries, personal health i f ti d d ti lpatient specific educational
sourcesinformation and educational resources
2013 Offer secure patient – provider messaging; upload data from home monitoring devices
Percentage of patients with access to secure messaging and implemented ability to incorporate data uploaded from home devices
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2015 Access for all patients to PHRs populated in real time with data from EHR and electronic reporting on experience of care
National Priorities Partnership quality measures related to patient and family engagement and percentage of patients with access to real-time PHR
Adapted from Modern Healthcare June 22, 2009 page 6
Max Incentive Payments to Eligible Physicians
Year 2011 or 2012 2013 2014
1 $ 18,000 $ 15,000 $ 12,000
2 $ 12,000 $ 12,000 $ 8,000
3 $ 8,000 $ 8,000 $ 4,000
Orthopaedic surgeons will have great difficulty in meeting the current 25
4 $ 4,000 $ 4,000 $ 2,000
5 $ 2,000 $ 2,000 $ 0
Total $ 44,000 $ 41,000 $ 26,000
Orthopaedic surgeons will have great difficulty in meeting the current 25 Meaningful Use standards. Orthopaedics would derive greater benefits from standards promulgated by our medical specialty society rather than a set of
generic requirements that mostly do not apply to musculoskeletal patient care.
Thomas C. Barber MD, EMR Task Force team leader, AAOS NOW
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Reportable Quality Measures Round 1• % Diabetics with A1c under control
• % Hypertensives with BP under control
• % LDL under control
• % Smokers offered cessation counselingg
• % Patients with recorded BMI
• % Colorectal screening for 50+
• % Mammogramns for women 50+
• % Current pneumovax status
• % Annual flu vaccinations
• % Aspirin prophylaxis for patient at risk for cardiac event
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% Aspirin prophylaxis for patient at risk for cardiac event
• % Surgical patients receivng VTE prophylaxis
• Avoidance of high risk meds for elderly
• % Orders entered thru CPOE by physicians
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2011 Objectives
• Using CPOE for inpatient and outpatient
• Incorporating lab test into EMR for inpatient and outpatient
Mi i th d t f li t f ti t b diti f lit• Mining the data for lists of patients by condition for quality improvement and outreach
• Provide patients with PHR
• Provide patients with printed clinical summaries after an encounter
• Exchange data between providers (problems meds
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• Exchange data between providers (problems, meds, allergies, all tests
• Provide public health agencies with immunization data
• Comply with HIPPA privacy and security laws
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Cleveland Clinic’s Implementation of EMR
Every Life Deserves World Class CareEvery Life Deserves World Class Care
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Cleveland Clinic 1921
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• Group practice model– 2,700 physicians and researchers – 120 specialties and sub-specialties– 40,000 employees
• Main Campus– 17 Family Health Centers in Ohio
Cleveland Clinic 2010
17 Family Health Centers in Ohio
• Cleveland Clinic Health System– 9 Regional Hospitals– Children’s Hospital for Rehabilitation– 1 Affiliate hospital
• Nevada – Lou Ruvo Center for Brain Health, Las Vegas
• Florida– Weston Clinic and hospital
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• Canada– Toronto Health and Wellness Centre
• Cleveland Clinic Abu Dhabi
• Patients visit from 50 states and more than 80+ countries worldwide
Willoughby HillsFamily Health Center
FHCFHC
Ashtabula County Medical Center
HH
Euclid Hospital
HH
HHHH
FHCFHC
Elyria FamilyHealth Center
Westlake FamilyHealth Center
FHCFHC
FHCFHCLakewood
Family HealthCenter
FHCFHC
FHCFHC
Beachwood FamilyHealth and Surgery Center
FHCFHCLakewood Hospital
HH
Lutheran Hospital
HH
Huron Hospital
Hillcrest Hospital
HH
South PointeHospital
HH
Marymount Hospital
HH
ClevelandClinic
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Lorain Family HealthAnd Surgery Center
Strongsville Family Health and Surgery Center
FHCFHC
Brunswick FamilyHealth Center
FHCFHC
Wooster FamilyHealth Center
FHCFHC
Independence FamilyHealth Center
FHCFHCSolon FamilyHealth Center
Chagrin Falls FamilyHealth Center
FHCFHC
HHFairview Hospital
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Strategic Application of Information Technology
Value
Clinical Ops
Practice Transformation
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Infrastructure
Administrative Ops
• From a paper model
Moving the Practice of Medicine
• To a digital model
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Patients Providers
eHealth Services
Patients Providers
MyConsult:Your First Choice for
a Second Opinion
MyChart:Your Personal Health
Connection
MyPractice:Electronic Medical
Record System
MyPractice Community
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VirtualVisit:Patient/Physician
Interaction Globally
eResearch:Research
Standardization: Real Data; Real Results
DrConnect:Improved
Communication; Improved Care
MyMonitoring:Ongoing Condition
Reporting from Home
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Patients in MyPractice: 6.2 Million(Electronic Medical Record System)
ClevelandHH HH
HH
Hillcrest Hospital
HH
Euclid Hospital HH
Huron Hospital
HH
Ashtabula CountyMedical Center
FHCFHC
Willoughby Hills Family Health Center
FHCFHC
Avon Lake Family
Cleveland Clinic Canada
ClevelandClinic
HH
Fairview Hospital
HH
Lakewood Hospital
HH
Lutheran Hospital
HH
Marymount Hospital
HH
South Pointe Hospital
FHCFHC
Elyria FamilyHealth Center
FHCFHC
Westlake FamilyHealth Center FHCFHC
Lakewood FamilyHealth Center
FHCFHC
Strongsville FamilyH lth C t
FHCFHC
Independence FamilyHealth Center
FHCFHC
Solon FamilyHealth Center
FHCFHC
Beachwood FamilyHealth Center
Avon Lake FamilyHealth Center
FHCFHC
Avon FamilyHealth Center
FHCFHC
Lorain FamilyHealth Center
FHCFHC
FHCFHC
Chagrin FallsFamily Health
Center
FHCFHC
BainbridgeUrgent Care
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HH
Medina Hospital
Health Center FHCFHC
Brunswick FamilyHealth Center
FHCFHC
Wooster FamilyHealth Center
Twinsburg Medical OfficeFHCFHC
Broadview Heights Family Health Center
Lou Ruvo Center forBrain Health, Las Vegas Cleveland Clinic
Florida
Cleveland Clinic Abu Dhabi (2012)
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Current Processes, Work Flows• Practice Workflow
– Identify each step in process of care– Without complete understanding, transition to automation will fail
• Scheduling an appointment for the service– Registering a patient and obtaining payer-specific informationg g p g p y p– Verifying insurance coverage and eligibility for benefits – Requesting authorization from a payer for treatments or referrals
• Patient arrival, confirmation, visit– Interaction with clinical support staff– Interaction with provider– Formulation of impression and plan– Documentation of the services provided– Ordering treatment or diagnostic testing
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– Ordering treatment or diagnostic testing – Reviewing formulary limits of a payer or pharmacy benefits manager
– Implementation of the plan– Receiving test results and conveying them to patients
– Requesting follow-up care, such as return visits or referrals
• Billing and submitting claims to third-party payers
Clinician’s Roles
• Champions– Clinical team consisting of physician, PA / RNFA, secretary
• Guide adoptionGuide adoption– Timing– Strategies– Education
• Content determination– Define physician workflow
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p y– Display design
• Create and approve clinical decision support
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Drug Interaction Alert
DRUGS:COUMADIN TABLET 2 MG PO
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COUMADIN TABLET 2 MG POZOLOFT 50 MG POSIGNIFICANCE LEVEL. Very High Can override and
accept the interaction
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E-Prescribing
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E-Prescribing
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Age, Gender, Diagnosis Health Maintenance Alerts
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Patients Providers
eHealth Services
Patients Providers
MyConsult:Your First Choice for
a Second Opinion
MyChart:Your Personal Health
Connection
MyPractice:Electronic Medical
Record System
MyPractice Community
DOS CME Course 2011
VirtualVisit:Patient/Physician
Interaction Globally
eResearch:Research
Standardization: Real Data; Real Results
DrConnect:Improved
Communication; Improved Care
MyMonitoring:Ongoing Condition
Reporting from Home
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Willoughby HillsFamily Health Center
MyPractice Community
Total Users: 1135
Providers: 196
Residents / Fellows: 149
Ashtabula County Medical Center
Euclid Hospital
MPC
MPC
MPCMPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
Elyria FamilyHealth Center
Westlake FamilyHealth Center
LakewoodFamily Health
Center
Beachwood FamilyHealth and Surgery Center
Midwives: 12
Lakewood Hospital
Lutheran Hospital
Huron Hospital
Hillcrest Hospital
South PointeHospital
Marymount Hospital
MPC
MPC
MPC MPCMPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC MPCMPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
MPC
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Lorain Family HealthAnd Surgery Center
Strongsville Family Health and Surgery Center Brunswick Family
Health Center
Wooster FamilyHealth Center
Independence FamilyHealth Center
Solon FamilyHealth Center
Chagrin Falls FamilyHealth Center
Fairview Hospital
ClevelandClinic
FloridaMPC
MPC
MPC
MPC
MPC
MPC
MPC
MPCMPC
MPC
MPC
MPC
MPCMPC
MPC
CMPC
MPCMPC
MPC MPC
MPC
MPC
MPC
MPC
MPCMPC
MPC MPC MPCMPC
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Patients Providers
eHealth Services
Patients Providers
MyConsult:Your First Choice for
a Second Opinion
MyChart:Your Personal Health
Connection
MyPractice:Electronic Medical
Record System
MyPractice Community
DOS CME Course 2011
VirtualVisit:Patient/Physician
Interaction Globally
eResearch:Research
Standardization: Real Data; Real Results
DrConnect:Improved
Communication; Improved Care
MyMonitoring:Ongoing Condition
Reporting from Home
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Locate DrConnect by selecting either option
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• Objectives– Enhance communications
– Between Cleveland Clinic specialists and referring physicians– Create a user friendly system
– For non-CCF referring physicians to view patient EMR information securely
DrConnect
g p y p yover the internet
– Provide secure, monitored access to patient care records– Operative reports, discharge summaries, testing results, outpatient
documentation, problem lists
• Overview– Access for referring physicians to the records of their patient that has
been referred to CC– Limited to 185 days from the patient’s last appointment at CC
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– Have to sign up and enroll in order to participate– Referring physicians can request office staff to act as proxy– Access automatically triggered by encounter closure, admission– Manually triggered by signed ROI form and MyChart authorization
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New - Additional Resources for Physicians
Online Signup – Physician
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Online Signup – Non Physician
DrConnect Login
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DrConnect – What’s New
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DrConnect – Patient Lists
Patients Providers
eHealth Services
Cleveland Clinic’s Secure Online Services
Patients Providers
MyConsult:Your First Choice for
a Second Opinion
MyChart:Your secure, interactive
health record
MyPractice:Electronic Medical
Record System
MyPracticeCommunity:
EMR for Physicians in Private Practice
MyConsult:Your First Choice for
an Online Medical Second Opinion
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VirtualVisit:Patient/Physician
Interaction Globally
eResearch:Research
Standardization: Real Data; Real Results
Dr.Connect:Improved
Communication; Improved Care
MyMonitoring:Ongoing Condition
Reporting from Home
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• Increases access, quality and value– Formalize second opinion process and triage– Second opinion requires data from primary opinion– Removes the geographic barriers to care
MyConsult Online Medical Second Opinions
• Improves efficiency for patients, their doctors and consultants– Organizes staff functions for patient encounter– Consistent patient care with proactive nursing follow-up– Empower patients with convenient access to personalized information
• Receive the second opinion– From well-known physician and well known institution
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p y– Patient and family satisfaction high– Significant health care cost implications
• New way of requesting and receiving health-related services– Anytime, anywhere
Login, securelyRegisterBrowse website
MyConsult ProcessMyConsult ProcessMyConsult Online Second Medical Opinion Process1 Requestor 2 Patient 3 Diagnosis 4 Payment 5 Intake 6 Materials 7 Approval
Request opinion
Pathology review Deliver materials to Physician
Schedule patient
Triage Complete
Submit requested medical records
Complete clinical intake forms
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Assess Satisfaction
Publish opinionComplete opinion
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Brain Tumor
Select Diagnosisfrom Listfrom List
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Complete patient medical history
Identify the questions you would like your Cleveland Clinic physician specialist
to address
MyConsult Outcomes
• Diagnosis– Correct 75%– With changes 15%– Incorrect 10%
Additional diagnoses, further study to make best decision about intervention, i.e. spine standing or flexion/extension radiographs, pulmonary provocative testing
• Treatment recommendations– No changes 36%
– Everything that has been done or will be completed matches our recommendations
– Minor changes 22%– Repeat or additional imaging studies, provocative testing to differentiate spine vs. hip, surgical approach
(open vs. MIS), change in pharmacologic dosing or plan for changing agents
– Moderate changes 25%– Changes in invasive procedures or studies needed before proceeding, additional work-up needed to
confirm best approach, change in pharmacologic agents (or incorrect agent noted), change in treatment modalities
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– Major changes 17%– Disagree with current treatment plan. Current treatment path may lead to incorrect treatment often unless
further studies are completed.
• Significant health care cost implications
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Spine, Lumbar• 61yo F with back pain
– Trouble walking due to pain and polyneuropathy– Can’t stand straight– EMG with residual nerve damage from previous surgeries
• Multiple back surgeries since 2000– Fusion and then extension L1 to sacrum– Thoracic giant cell cystectomy– Residual motion at L1-L2
• Local MD recommendation– Extension of the fusion to T10
• Cleveland Clinic MyConsult second opinion– Dx is incorrect, Rx is incorrect– Pedical subtraction osteotomy
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ed ca subt act o osteoto y– Previous surgeries did not place spine in proper lordosis
• Financial impact modeling prediction– Over $155K in unnecessary future expenses
Crohn’s Disease• 55yo M with Crohn’s Disease, smoker
– 10 year history, using prednisone with some success– Failed Humira, MTX, imuran, Remicade, asacol and dapson– Diarrhea, rectal bleeding, mouth ulcers– Multiple colonoscopies and endoscopies (> 5), no granulomas– Limited to the colonLimited to the colon– ENT Dx was Behcets disease
• Local MD recommendation– Extension of the fusion to T10
• Cleveland Clinic MyConsult second opinion– Dx is incorrect, Rx is incorrect– CMV evaluation, serum and biopsy, if + antivirals– Eval for mycobacterium, stool cultures– Inflammatory bowel disease likely ulcerative colitis
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Inflammatory bowel disease likely ulcerative colitis– No gential involvement not Behcets– CRS evaluation for Eval for perianal fistulas Crohns– Appropriate med trials
• Financial impact modeling prediction– Over $75K in unnecessary future expenses
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Cardiology, CAD• 52yo F with DM, GERD, hyperlipidemia, CAD
– Palpitations and normal stress test– Cath with severe lesions leading to stents in LAD and RCA, 2005– Re-stented with DES in 2006 after repeat cath– Cath post procedure for recurrent symptoms with exertion– Diagonal pinched by more proximal of the LAD stents
• Local MD recommendation– CT angiography– CABG
• Cleveland Clinic MyConsult second opinion– Dx may be incorrect, Rx is incorrect– Studies in women could be misleading especially EKG findings
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– Cath needed, trial of NTG when symptoms recur– Further diagnostic eval for homocysteine, elevated LP(a), small vessel dx– DM under control (Hgb A1c under 6)
• Financial impact modeling prediction– Over $135K in unnecessary expenses
Travel Cost Comparison
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Cleveland Clinic Is Leading The Efficiency Charge
• The cost of delivering health care needs to decrease
• Cleveland Clinic is pioneering tactics to achieve this goalE l d h i i– Employed physicians
– Institute model
– EMR adoption
– Focus on efficiency
– Published outcomes
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State Department Specific Registration Form
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