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Transcript of Electronic Medical Records: key implementation issues C.T. Lin MD Senior Medical Director,...
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…