Lies CMIOs Tell- Dr. David Allard, Henry Ford Health System

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  1. 1. EMR Innovation R. David Allard, MD Chief Medical Information Officer Henry Ford Health System mHealth Israel: January 10, 2018
  2. 2. Goals Discuss Why EMRs lag other innovation in Healthcare and other industries Propose an approach to innovation Discuss common issues with which CMIOs contend Give a few examples of why there is hope
  3. 3. Medicine is the Highest Tech Low Tech Industry Care techniques are advancing at a phenomenal rate Gamma knife Precision Medicine DaVinci Surgery Et Cetera The mechanisms we use to learn about these best practices and deliver the techniques have changed very slowly with healthcare and medicine still acting like a cottage industry
  4. 4. Cottage Industry vs. Standards Driven High Reliability Industry Cottage Industry Emphasis on craftsmanship Great doctor/provider Centers of Excellence Highly individualized care Highly variable in cost and outcome Optimized for the craftsman Hard to measure or predict outcomes levels Standards Driven Industry Emphasis on process and reliability Create processes that anyone (within reason) can do Consistency, highly reliable Transparency Optimized for the end recipient (consider the airline industry)
  5. 5. Medicine is the Highest Tech Low Tech Industry 13% of physicians in the USA are still on paper charts in 20171 53% of practices describe their EMR as basic 83% of residential care communities are on paper (2010) 32% of EHRs can exchange information with other providers systems (2014) 1https://www.cdc.gov/nchs/fastats/electronic-medical-records.htm
  6. 6. Medical Education and Dissemination of Clinical Innovation Today Medical Student learns from Senior Providers Becomes a Resident who goes to a new place to learn and get experience Sets up a practice as a senior provider and (sometimes) trains new medical students Ca. 650 AD Apprentice Learns from a Master Becomes a Journeyman who travels to learn more and get experience Sets up as new master, practices and starts training new apprentices
  7. 7. Why is This a Problem? CMIO Lie #1 Medicine is becoming a retail business Is medicine a service industry or a consulting industry at its heart? Service industry We certainly do things to and for people The literature is full of articles about the retailization of healthcare Consulting industry At the core of Medicine is knowing what to do Population Health, Big data, machine learning, The management of information such that it is represented of knowledge and applying that knowledge to benefit the health of populations and individual patients Bytes Data Information Knowledge Wisdom
  8. 8. Back to the antiquated system of sharing best practices and innovation Today Medical Student learns from Senior Providers Becomes a Resident who goes to a new place to learn and get experience Sets up a practice as a senior provider and (sometimes) trains new medical students Ca. 650 AD Apprentice Learns from a Master Becomes a Journeyman who travels to learn more and get experience Sets up as new master, practices and starts training new apprentices
  9. 9. If the Core of Medicine is Knowledge Management, Why Has That Been So Slow to Change? Technology capability Medical Records are more than a database Innovation requires facilitated workflow implies standardization, connectivity, data standards Information should feed Clinical Decision Support Technology availability The cost of devices to all required users was prohibitive Technology Utility Are there changes in outcomes to justify the cost (both IT cost and human cost?)
  10. 10. Why is EMR Innovation happening now? Ca. 1800 New England Pre-Industrial Revolution Demand exceeds supply Quality enormously variable given the cottage industry state of the operations New technology enabling greater supply and services with greater standardization US Statistics In 2016, median age is 37.9 years 29.5 in 1960 In 2016, total USA population 326.4 M 179.3 M in 1960 In 2016, Healthcare spending per capita $10,345 $146 in 1960 In 2007, physicians/1000 2.4 About 1 in 1960 Source: www.census.gov
  11. 11. Why is EMR Innovation Happening Now? Changes in the support for the hierarchy of information - EMR Utility catching up to the needs of a knowledge based industry Better connectivity with sources of information more availability of data Monitoring device integration with IT systems, wearables, HIEs Better codified standards to turn data into information Better reporting and data manipulation to turn information into better representations of reality (knowledge) Better graphing and visualization tools More availability of digitized algorithms for clinical decision support digital wisdom Guideline clearinghouses beginning to be codified
  12. 12. So Why do Doctors Hate EMRs?
  13. 13. So Why Do Doctors Hate EMRs Data Entry is burdensome New capabilities have created new work streams Regulatory requirements Expansion of the patient visit Incorporation of more data sources Redistribution of work Clerical perspective of the EMR Providers rarely view EMRs as a clinical competency neither does almost anyone else - but I would argue it is
  14. 14. Organization focus in change and innovation CMIO Lie #2 We want to be on the cutting edge of technology Organizations must decide who they want to be from a digital standpoint (and other innovations as well) Disruption Leading as a key differentiator Early adopter or follower Trailer Is technology who we are or a tool we use?
  15. 15. Organization Focus in Change More Ideas Than Time Device integration Data Mining New EMR modules Machine learning Enabling best practices (screening, risk scoring etc) Supply chain management Interaction with regulatory agencies Decision support tools Patient communication tools
  16. 16. Organization focus in change and innovation Problems with leading innovation/disruption Higher risk Labor intensive, iterative work Opportunity cost May require a high focus in a small area of change May be difficult to scale Most organization want to be leaders or adopters Allows scalability Predictability of future state
  17. 17. Value of a change based on many domains Domains of Value Safety and Quality User Experience Patient Experience System Stability ROI Information Portability Regulatory Compliance Domain relationships Improving one area often leads to a degradation in another The Net Total Experience needs to be positive Projects need to coexist peacefully and productively
  18. 18. Innovation in using tools vs. Innovation in making more tools New Tools May be easier to control or customize Often more industry friendly since each may represent separate products Creates new integration challenges from data to scale to workflow Using tools in new ways More integrated but harder to build Less highly customized to a specific use case Usually more cost controlled Often more scalable
  19. 19. Desirable Projects Highly defined scope Specific goals related to organizational strategy Fits into the landscape of the organization Includes longer term support and planning
  20. 20. Approach to Innovation Workflow integration Avoid creating separate parallel work streams Designs that are accessed when a clinician is already thinking about that patient and even better- that aspect of a patient Recognize the skills of the team Have all members of a team operate to the top of their abilities Data presentation Vetter visualization and digestion of data Data information knowledge wisdom Pay attention to User interfaces simple and in line with other work Pay attention to scalability -
  21. 21. Reasons for Hope Video visits from providers to smart phones Real time delivery of patient results increasing patient partnership in care Wearable monitors populating EMR data Consolidating data from multiple health systems Big data use in Sepsis prediction Readmission risk Assessing social determinants of care Decision Support Better imaging test ordering Drug-drug and drug-disease interaction