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Transcript of 2010 SAAS National Conference and NIATx Annual Summit Electronic Behavioral Medical Records:...
2010SAAS National Conference and NIATx
Annual Summit
Electronic Behavioral Medical Records: Improving your agency’s implementation
Jay Ford, PhD
Enid Montague, PhD
Agenda
• Organizational readiness
• Meaningful use
• Business case for EBHR
• Impact on process workflow
• Trust in technology
Organizational Readiness
• Productivity & efficiencies
• Billing accuracy
• Regulatory compliance
• Patient safety & reduced errors
• Health information security
• Leverage data for dollars
Why Adopt EBHR?
Reason not to Adopt an EBHR
Source: www.satva.org
Why is readiness important?
It helps organizations detect potential obstacles to and identify opportunities to improve chances of successful implementation.
RIS Overall Score by Agency
RIS: Enhancing Organizational Readiness
Strategic Alignment
Leadership Support
Dedicated Resources
Impact on the Organization
Staff Acceptance
Organizational Motivation Meeting Needs & Usefulness Departmental Fit Implementation Promotion
Meaningful Use
What is meant by meaningful use
• Demonstrate use of certified EHR technology
• Use certified EHR to submit clinical quality measures
• Show that certified EHR is part of a network to promote exchange of health information
Stages of Incentive Rollout
Making Sense of a Certified Electronic Health Record
Meaningful Use Incentives
Medicare Medicaid
Allowable Costs/Charges
75% of allowable charges 85% of net avg. allowable costs (25K in Year 1)
($10K in subsequent 5 Yrs)
Incentive Level Year 1 - $18,000Decrease $4K next 4 Yrs
Year 1 - $21,250$8,500 next 5 Yrs
Total Incentive Level $44,000 per eligible professional $63,750 per eligible professional
Other Relevant Information
No payments after 2016Medicare Penalties if not Meaningful User by 2015
Eligible Professional must have 30% Medicaid Patient Volume or
30% of encounters if FQHC
H.R. 5040• Amends current meaningful use law to include
behavioral health providers• Extends eligibility for Medicaid/Medicare
implementation funds• Authorizes $15 million grant program to:
– Facilitate purchase of HIT– Train staff in HIT use– Improve secure electronic information exchange– Improve HIT adaptation to community BH– Assist with telemedicine implementation– Collaborate & integrate w/ HIT regional extension centers
Hospital CIO’s: Ready or NotReady
(More likely to apply for 2011 incentives)Or Not
(50% not ready: 1st Stage of Meaningful Use)
Involve customers in EHR Planning (74% of the 20% of CIO’s who have
involved customers will be ready in 2011)
Shortage of skilled staff
Collaborate with key stakeholders(3x more likely to involve patients)
(87% more likely to work w/health insurers)(63% more likely to assist MD’s with
meaningful use)
Lack of clarity or vendor readiness
Capacity of existing infrastructure
Meaningful use will increase physician involvement in quality initiatives
Not working with key customers (e.g., insurance companies)
Level of Implementation for Clinical Information System Components
ComponentDo not have
Available but not started yet
Initial Planning Stages
Partially Implemented
Fully Implemented
Scheduling 17.3% 10.4% 3.5% 21.1% 47.8%Intake 16.0% 4.5% 7.6% 21.9% 50.0%Billing 3.8% 2.1% 2.8% 14.9% 76.4%Clinical Assessment 19.2% 5.7% 12.5% 21.7% 40.9%Treatment Plan 18.9% 8.2% 12.9% 20.4% 39.6%E-Prescribing 51.6% 7.4% 12.7% 12.7% 15.5%Progress Notes 18.4% 7.0% 9.9% 18.4% 45.6%Quality Improvement/Outcomes 31.5% 9.0% 17.6% 28.7% 13.3%
Executive Dashboard (e.g. Balanced Scorecard) 52.1% 5.0% 19.6% 15.4% 7.9%
Source: www.satva.org
Impact on the Organization• Adapting to meaningful use may …
– Result in revised intake processes– Require changes in business practices– Foster and improve inter-agency collaboration
• Require an understanding of the business case for adoption
Business Case
Revenues, Costs, Cost Savings and Benefits
Revenues Costs and Cost Savings Benefits
Revenue Growth
Incentives for using certified EBHR
New Revenue PotentialEnhanced Cash Flow
Performance Incentives or New Grants
Implementation Costs:
Hardware, Software, Infrastructure,
Implementation Labor or New Staff
Administrative Efficiencies
Reduce time to pull charts, improved billing
Cost Savings
Staffing, Elimination of Outside Services
Clinical Efficiencies(Less Paperwork,
Automatic order entry or group note generation)
Organizational Efficiencies• Administrative efficiencies
– Reduce staff and save on labor costs; – Use efficiencies to re-allocate responsibilities;– A combination of both
• Clinical efficiencies– Allow staff to spend more time with existing
clients or – Use efficiencies to increase capacity
Impact on Workflow
Impact of EBHR on Workflow
Impact of EBHR on Workflow
Impact on Intake
Oakwood’s eBilling Process
Key Implementation Messages
• Assess your technological infrastructure
• Evaluate organizational readiness
• Understand meaningful use
• Examine the business case
• Map current workflow
• Ensure adequate staff training
2010SAAS National Conference and NIATx
Annual Summit
Trust in Technology
Enid Montague, PhD Assistant Professor
Anna Julia Cooper FellowDirector: HCI lab
Industrial and Systems EngineeringUniversity of Wisconsin-Madison
enidmontague.com
Outline
• Why are we implementing new technologies?• Patient trust in care provider• Patient attitudes about technologies• Provider attitudes about technologies• Tips and considerations
28Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Why are we using EMRs?
Image source: Laura Pedrick for The New York Times
Enid Montague, PhD University of Wisconsin-Madison HCI Lab 29
Why are we using EMRs?
Enid Montague, PhD University of Wisconsin-Madison HCI Lab 30
Nursing shortage
Year Supply Demand Shortage Percent
2000 1,890,700 2,001,500 -110,800 -6%
2005 1,942,500 2,161,300 -218,800 -10%
2010 1,941,200 2,347,000 -405,800 -17%
2015 1,886,100 2,569,800 -683,700 -27%
2020 1,808,000 2,824,900 -1,016,900 -36%
Source: Data from the Bureau of Health Professions. (2004)
US Supply versus Demand Projections for FTE Registered Nurses
31Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Growth in medical technology industry
Enid Montague, PhD University of Wisconsin-Madison HCI Lab
32
Growth in medical technology invention.
Enid Montague, PhD University of Wisconsin-Madison HCI Lab
33
Physician shortage
34Enid Montague, PhD University of Wisconsin-Madison HCI Lab
What is trust?
Trust is a person’s belief that a person or object will not fail them.
Enid Montague, PhD University of Wisconsin-Madison HCI Lab35
Trust is a popular topic in relation to the provision of health.
36
Trust is a fundamental aspect of all relationships.
– Human- human• e.g. worker- worker, parent- child, doctor- patient,
– Human-organization• e.g. worker- company, patient- hospital
– Human- social institution• e.g. citizens- government, patient- health systems
– Human-technology• e.g. user- website, user- device, human- computer
Enid Montague, PhD University of Wisconsin-Madison HCI Lab
37
Trust triad model
Montague, E., Winchester, W.W. Kleiner, B.M. (in press). Trust in medical technology by patients and health care providers in obstetric work systems. Behaviour & Information Technology.
38
Client- Provider Trust
Enid Montague, PhD University of Wisconsin-Madison HCI Lab39
Patient trust in care provider predicts… • Quality variables such as:
– adherence to medical advice – health service seeking behaviors – patient satisfaction– utilization of preventive services – malpractice litigation – health status – sustained enrollment in health plans
• Organizational and economic factors such as: – decreases in the possibility of a patient
leaving a care provider’s practice– withdrawing from a health plan
40Enid Montague, PhD University of Wisconsin-Madison HCI Lab
As trust declines…• The cost of providing care may increase. • Patients and care providers may engage in self-protection
– patients withhold information or avoid seeking care from sources they determine are untrustworthy and care providers practice defensive medicine.
• “People are increasingly unwilling to take risks, demand greater protection against the possibility of betrayal, and increasingly insist on costly sanctioning mechanisms to defend their interests” (p 13) (Tyler & Kramer, 1996).
• Distrust can “provoke feelings of anxiety and insecurity, causing people to feel uncomfortable and ill at ease and to expend energy on monitoring the behavior and possible motives of others” (p 1) (Fuller, 1996).
• When patients feel unsafe, energy that could be devoted to healing is expended on self-preservation.
41Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Ideal environments for interpersonal communication
-Full view of the body-Full view of facial expressions-No limitations on making eye contact-Channels are free to focus on listening and responding
42Enid Montague, PhD University of Wisconsin-Madison HCI Lab
How does technology change interpersonal relationships?
Nonverbal cues are important for interpersonal communication and trust inclinical encounters
– Difficulty using multiple channels (i.e listening, while typing)
– Time utilizing technologies might affect total visit time
– Difficulty noticing the expressions of others– Difficulty showing appropriate expressions – Mistakes may cause stress and frustration– Time for social touch– Eye contact
43Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Shared computer use can make interpersonal communication difficult.
44Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Typical sets ups that involve technologies can bring new communication challenges.
Image source: Mayo SPARC
45Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Patient trust in technology
Previous Experiences/ Attitudes
Previous Experiences/ Attitudes
46Enid Montague, PhD University of Wisconsin-Madison HCI Lab
The goal is appropriate trust in technology.
Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Using technologies to make decisions in the absence of additional information
Using technologies in ways they were not designed for
Using technologies to enhance human capabilities, while continuing to use medical knowledge
Refusing to use technologies that could enhance the provision of care and quality of work
Using technologies in lieu of medical care i.e. Google as a first or second opinion
Using technologies in a way they were not designed for
Using technologies appropriately to enhance health and care
Refusing to use technologies that could enhance the health and the care provision process
47
Patient attitudes about technologies
• Concern over information security/ privacy• Lack of knowledge about technology (technology literacy)
48Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Uncertainty about the health record can contribute to distrusting attitudes.
• Have you ever looked at your medical record?(52%) No, I have never looked at my medical record(39%) Yes, it was accurate(16%) Yes, it was inaccurate or incomplete
49Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Beliefs can affect behaviors
• Do you believe the information in your medical record is kept secure?(70%) Yes(28%) No
• Have you ever avoided telling your doctor something about your health, because you did not want the information to appear in your medical record?(76%) No (20%) Yes
50Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Which of the following would you not want to appear in your medical record?
• (43%) Number of sexual partners• (43%) Previous incarcerations• (26%) HIV/AIDS status • (24%) Sexually transmitted diseases• (22%) History of substance abuse• (20%) Prior use of illegal drugs• (20%) History of mental illness• ( 9%) Family history of genetic illness
51Enid Montague, PhD University of Wisconsin-Madison HCI Lab
There are different attitudes about information sharing with partners, friends, family.
• How many people would you like to have access to your medical record? and why?
Mixed results– Some said virtually everyone (doctors, nurses,
clinic staff, spouse, child, parent, emergency contact)
– Others said virtually no one (only doctor seeing them and only limited access to information involving the purpose of the visit)
52Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Distrust in health system can affect attitudes about technologies.
• Studies have shown that certain populations are more distrusting of health care systems and providers– Racial/ethnic minorities (African American,
Hispanic American, Arab American)– Substance abusers– Those suffering from mental illness– Chronically homeless– Those with socially stigmatizing illnesses and
diseases
53Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Differences can exist across age groups.
• Privacy literacy– Teens are aware of information privacy and
information sharing.• “I don’t know if the doctor is going to turn the screen off when they leave the room”• “I don’t know who else can see or access the
information they put it in the computer” • “I don’t know if my parents can see it” • “I don’t know what they are writing about me”
54Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Differences can exist across age groups.
• Older clients might be more concerned about technology etiquette.• “I don’t think its polite when my doctor types while I’m
trying to talk to him”• “Its bad enough that my kids text message during dinner,
now I have to watch my doctor text during my check-ups”• “It took me two hours to get here, I only have 30 minutes
for the visit and they spent 10 minutes of my time trying to get the computer to work!”
55Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Provider attitudes about technologies
• Provider distrust in technology can contribute to patient distrust in technology and the provider.
• Provider self-confidence can contribute to appropriate trust in the technology.
56Enid Montague, PhD University of Wisconsin-Madison HCI Lab
57Enid Montague, PhD University of Wisconsin-Madison HCI Lab
New technologies can be stressful for some care providers.
Techno-stress– “The negative psychological link between people and the introduction
of new technologies. “– Not unique to health care; educators have similar experiences
Causes of technostress– the quick pace of technological change– lack of proper training– increased workload as result of new technology– lack of standardization within technologies– the reliability of hardware and software– poor usability–
• Choose usable software that matches your organizations work flow is important!
58Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Provider trust in technology
59Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Things to consider.• Design of work stations
– Consider where and how you will introduce work stations into your practice
– Don’t be afraid to role play and try different set ups• User friendly solutions
– Develop a personal and organizational plan for addressing technology problems during client encounters.
• Flexible work flow- – Be able to treat each client as an individual
• You may not be able to type your notes during each visit• Communicate with clients about their ideas about
computer technologies– Develop a working plan together
60Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Practical tips and considerations
• For the client– Be prepared to provide information about who has access to
their information and how it is kept confidential• For the clinician
– Consider the effects on your interpersonal relationships when choosing a system
• Training and be flexible… everyone may different• Allow for adequate time in visits to accompany additional
times or technology usage• Effective implementation plan• Match self trust/ self confidence with start times• Establish etiquette
– Communicate etiquette with other workers and clients
61Enid Montague, PhD University of Wisconsin-Madison HCI Lab
Thank you!
• For more information please,– See the NIAtx website– Contact Us:
Jay Ford, PhD [email protected] Montague, PhD [email protected]
(enidmontague.com)
62Enid Montague, PhD University of Wisconsin-Madison HCI Lab