Using InformationInformation TechnologyTechnology to Drive Patient Care: Case Study in EHR Patient Care: Case Study in EHR

ImplementationImplementation

Tom Goodwin, MHAMIT MedicalCambridge, MAMarch 2007

With Help From Monkeys, Mice, and PenguinsWith Help From Monkeys, Mice, and Penguins

MIT MedicalStaff

122 Clinical Staff (Nearly all salaried)38 Administrative staff121 Support Staff

Scope of servicesInternal Medicine and SubspecialtiesCenter for Health Promotion and WellnessDental / Oral SurgeryGeneral Surgery and Subspecialties / Eye ServiceMental HealthNutritionObstetrics / GynecologyPediatrics / Adolescent medicineUrgent CareWorksite Health / Environmental Med / Health ScreenOn Site: •Laboratory •Radiology •Pharmacy

Demographics / VisitsTotal Population 20,259

23%

39%2%

36%

Graduate Students

UndergraduateStudentsAffiliates

Employees

131,670 Visits to MIT Medical 2006

47%

33%

4%

8% 8%MIT Health PlansStudentsPrimary Care BenefitMedicareOther

EMR Implementation:Major Goals

Improve Care

Control Costs

Increase Productivity

Increase clinician satisfaction

Increase patient satisfaction (Make clinical information available to

the patient)

Meet Compliance Guidelines

Interface With Practice Management System

Our Journey Began in Late 1997

Stages of Adopting to Technology

Duplication Phase Also Known as the Please Don’t Spank Me PhaseSubstitution PhaseInnovation PhaseTransformation Phase

Duplication Via Building a Repository (beginning Late 1999)

Stock the Water!Data Repository

DictationsLab / X-ray / Cytology Pharmacy Interface (Pharm -> EMR)Provider SchedulesPatient Demographics

Duplicate The Existing Paper Record

Duplication Phase at MIT Medical

Another Example of the Duplication Phase

Substitution Phase Begins Q1 2001

Phone Messages into the EMRNo paper messagesNo phone notes filed in the paper chartInteroffice communications

Referral NoteSpecialist ccFollow up from Urgent Care

E-mailCopy to EMR, no paper note

No Substitution without aPhysician Champion

Any organization that wants to implement an EHR needs a Physician ChampionPlus a strong Medical Director

A New Paradigm

Clinician Interacts With EMR

Need to look for TasksRetrieve clinical information here!Use EMR to communicateDocument all patient interactions in the EMR

AdoptionNo Choice

Medical Director Mandate

Took Some Getting Used ToNo RebellionSet A Path To Widespread EMR UseGrumpy Old Men Will Go For A Swim!

Our Medical Director meets with a reluctant clinician

An Opportunity to SweepAway Bad Habits

We Realized These Are Bad For Our Health

Deep fried outer shellLoaded with “trans” fatty acidsRed #5 DyeArtificial FlavoringLots of preservativesHigh in sodium

And…The Paper Charts WereVery Difficult To Transport

87% Reduction in Total Chart Pulls

Chart Pulls

150430

115332

75553

48323

19959

020000400006000080000

100000120000140000160000

2002 2003 2004 2005 2006

Year

Char

t Pul

ls

AppointmentChart Pulls

Non-AppointmentChart Pulls

Total Yearly

Innovation Phase BeginsMarch 2003

Laboratory and Radiology results electronically verified by clinician Electronic PrescriptionsBegan scanning outside consults, diagnostic test results, and older notes One electronically signed note per visit required without printing for the paper chart.Remote access added

Result Verification Made Easy

Annotate Here

Electronic Prescribing

Two Way Interface With MIT PharmacyThree-Click Refills

Time Saving for Provider, Pharmacy and PatientError Reduction

Formulary InformationCost Saving for Health Plan, Pharmacy and Patient

Information To Improve Health OutcomesDrug – Drug InteractionsDrug – Allergy InteractionsDrug – Disease Interactions

% Electronic PrescriptionsFilled at MIT Pharmacy

Electronic Prescriptions Filled at MIT Pharmacy

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-05Apr-05

Jul-05Oct-05

Jan-06Apr-06

Jul-06Oct-06

Jan-07

Scanning Items into our EHR

Implementation October 2003No New Papers Filed in Charts from October 15, 2003 ( →∞ )725,000+ Documents scanned in to dateNo New Paper ChartsEventually Reduced Staffing

5.5 FTE reduction in medical record staffing

Scanned Items Viewed from the EHR

The Remaining Paper ChartsAre Much Thinner

Note Types in MIT Medical EHR

299,535 Notes entered into MIT Medical EHR in 2006

27%

45%

1%

25%2% Transcription

ScannedPOLDirect EntryCopied

Remote Access Not Possiblewith 1980’s High Technology

Further Innovation 2005 Forward

Problem List becomes more important Orders go mainstream with the addition of Laboratory and Radiology interfaces. Patient Portal comes into operationSignificant improvements in dictation procedure Mental Health Department begins using the EHR

Direct Order Interface with MIT Laboratory

Electronic Laboratory Orders

0%10%20%30%40%50%60%70%80%90%

100%

M-0

5

M-0

5

J-05

S-0

5

N-0

5

J-06

M-0

6

M-0

6

J-06

S-0

6

N-0

6

J-07

Direct Order Interface to MIT Medical Radiology System

Electronic Radiology Orders

60%72%

83%90% 91% 93% 95% 96% 97% 95% 97% 97% 98% 99% 99%

0%

20%

40%

60%

80%

100%

120%

Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07

MIT Medical Patient Portal

Using our portal patients are able to:Exchange secure, encrypted messages with their providersRequest new appointments, view past and upcoming appointmentsReceive automated appointment remindersRequest updates to personal informationView certain clinical information including: Allergies, Immunization History and Medications

Introducing the “Talking Mouse”

Desktop Dictation has improved clinician satisfaction

No longer chained to a telephone.No need to identify yourself, dictate patient demographics, or punch in work types.Can easily pause for interruptions.Saves about 30 seconds per dictation over using the telephone. Learning is a snap!

A Video Representation of Our Dictation System

Drastic Improvement in Transcription Turnaround Time

Mean Turnaround Time

30 31.5 31

8.15.47 3.54

7.111.26 10.26 10.1

05

101520253035

Oct

-03

Nov

-03

Dec

-03

Jun-

05

Jul-0

5

Aug-

05

Sep

-05

Oct

-05

Nov

-05

Dec

-05

Hou

rs

Mice can keep secrets!MIT Medical requires all 27 Mental Health clinicians to put their notes into TouchWorks as of September 2005.Ability to segregate Mental Health notes with added security.7 of 27 Mental Health clinicians use dictate, the rest use direct note entry.

MIT Medical has saved a lot of cheese.

Dictation Charges

$0.00$5,000.00

$10,000.00$15,000.00

$20,000.00$25,000.00

$30,000.00

Jul-0

3

Sep-

03

Nov

-03

Jan-

04

Mar

-04

May

-04

Jul-0

4

Sep-

04

Nov

-04

Jan-

05

Mar

-05

May

-05

Jul-0

5

Sep-

05

Nov

-05

Jan-

06

Clinicians Dictating at MIT

01020304050607080

Aug-

04

Oct-0

4

Dec

-04

Feb-

05

Apr

-05

Jun-

05

Aug-

05

Oct-0

5

Dec

-05

Num

ber o

f Clin

icia

n

Transformation Sneaks Up On You

Anticoagulation ClinicDiabetes Care GroupReferrals entered into EHRDisease ManagementEnhanced role of Triage NursesFantastic reporting capacityAnd we got a grant to look at potential safety issues with electronic prescribing!

Anticoagulation Clinic

120 patients taking coumadin are managed via protocol by triage nursesNurses verify PT / INR results, contact patient, change dosage if necessary, and inform Attending MD.Within the first 3 months a much higher percentage of patients are within therapeutic range than before.

Diabetes Care Group

Triage Nurses also participate in the care of approximately 550 Diabetic patientsMonitor orders and results of HBA1C, ensure that patient has had yearly eye and foot exams, and is scheduled to see Attending MD.All functions done through the EHR

Flow Sheets Allow for Better Disease Management

Reporting Allows Us To Know Our Patients and Clinicians

Medication Safety Grant

MIT Pharmacy error rate is well below the industry average of 1.6%Electronic Prescribing poses new opportunities for errors.We are using a Human Factors Engineer to review the whole process

Lots of Interest In EHRs But…

Slow EHR Adoption Rate in U.S.

EHR Adoption Among U.S. Physicians and Health Centers (2005 - 2006)

11.2% 12.7%

76.1%

8.6%15.9%

75.5%

0.0%

20.0%

40.0%

60.0%

80.0%

Full EMR Partial EMR None

EMR Adoption Status

Prop

ortio

n of

Res

pons

esin

Per

cent

PhysiciansCHCs

Health Information Technology in the United States: The information Base for Progress, Robert Wood Johnson Foundation, 2006

Benefits of the EHR at MIT

Patient care has improved with the availability of information.Reduction of 5.5 FTE in Medical RecordsCredit from Medical Liability Insurance CarrierTime savings for ancillary staffExpanded role for Triage NursesClinicians are more satisfiedPatients like the availability of information in our portalImproved HIPAA and JCAHO compliance

Specific positive feedback from reviewersA collection of solo clinicians becomes a Group Practice