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Electronic Medical Records: key implementation issues

Electronic Medical Records: key implementation issues. C.T. Lin MD Senior Medical Director, Informatics University of Colorado Hospital October, 2008. Outline. Paper Medical Records The burning platform Electronic Medical Records What and why EMR usability Physician Adoption

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Electronic Medical Records: key implementation issues

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  1. Electronic Medical Records: key implementation issues C.T. Lin MD Senior Medical Director, Informatics University of Colorado Hospital October, 2008

  2. Outline Paper Medical Records • The burning platform Electronic Medical Records • What and why • EMR usability • Physician Adoption Substitution vs. Transformation

  3. Why keep medical records? • Historical record of care • Communication/continuity • Preventive Care • Quality assurance • Legal record • Financial record • Research

  4. Paper disadvantages • 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

  5. Paper Medical Records

  6. Paper records: Legibility?

  7. One day’s worth of papers to be filed at UCH

  8. Quick! Recall: Find all the patients who take Vioxx! P4P: Prove that we give Aspirin to all our CAD patients! NQF: Have all our diabetes patients had a Pneumovax? Vaccine: Call all high risk patients to get flu vaccine now! Screening: We have free PFT screening next week! Who would benefit? by ctl

  9. Paper records: the burning platform • Legibility suspect • Costly to maintain • Not disaster-proof • Can’t qualify for pay-for-performance • Population and quality studies impractical

  10. Electronic Medical Records

  11. 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

  12. 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

  13. “… 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

  14. Assembling an EMR So, you have 2 EMR systems. Well, can’t you just hook the 2 systems up? What’s the big deal?

  15. EMR Systems Map Provider Portal (MedXplore -> McKesson) Patient Portal McKesson RN docu, Bar Code, Inpt Pharmacy, CPOE GI proced CV proced Emergency Oncology Transplant OB GYN Psych Peri-Op Allscripts: Deployed 20 of 40 Clinics Interactive system 3M Clinical Workstation: integrated viewer, clinics + hospital Viewer IDX ADT Lab RIS Path Dictation Infra-structure IDX Visit Management, Patient Billing, & Scheduling

  16. EMR usability

  17. 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

  18. Push this bar to open door Narrow the gulf of execution: Make it easy to do what the user intends

  19. Welcome, It is 11:15amThursday Oct, 19, 2007 Dr. Lin you have 2 messages and 2 alerts • Check your messages • Check your alerts • Review a chart or test result • Order a test • Order a medication • Order a consult • Write a chart note • Get help (x4302)

  20. Nursing: Charting an Assessment

  21. Blood panel

  22. Polar Graph WBC Na HCT K Cl PLT ANC CO2 MCV BUN TIBC Cr Glu TSH Ca O2sat Alb Temp ALT HR AST RR SBP AlkP

  23. WBC Na HCT K Cl PLT ANC CO2 MCV BUN TIBC Cr Glu TSH Ca O2sat Alb Temp ALT HR AST RR SBP AlkP Polar Graph Data points:Last 3 Double click for details

  24. Awarix(tm): Map based activity monitoring

  25. Usability Conclusions • The move to Electronic Medical Records not only improves information storage and flow, it could enhance safety and quality through information CLARITY

  26. Physician adoption of EMR

  27. 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)

  28. 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

  29. 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

  30. 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

  31. Photo apl

  32. Adoption Stories “Junior” physician champion Surgery vs Medicine vs Rheumatology Counting clicks vs. fast systems Tablet PC and the medical assistant CINA story “Culture eats technology for lunch”

  33. EMR: Substitution vs. Transformation

  34. 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

  35. Transformation: Safety • Electronic documentation instantly available, legible, longitudinal • Safer prescribing (drug interactions, allergy check, formulary check) • Vioxx recall: Patients identified, notified in 24 hours

  36. 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

  37. 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

  38. Transformation: no EMR • Conversations between physicians, nurses, and patients undergo: • Voice recognition • Natural language processing • Integrated, non-interruptive alerts based on latest evidence

  39. Substitution vs. TransformationLike improvements in transportation, EMR developments generally are incremental at first…

  40. Substitution vs. TransformationIt was hard to foresee what the carriage could become…

  41. Substitution vs. TransformationAnd in the broader sense, what transportation could become

  42. Substitution vs. TransformationAnd we will always dream…

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