Electronic Health Records vs. Niche Software that is actually useful for Family History

1. Electronic Health Records vs. Niche Software that is actually useful for Family History Kevin S. Hughes, MD, FACS Co-Director, Avon Comprehensive Breast Evaluation Center Massachusetts General Hospital Bruce Lin Project Director, Family History for Prenatal Providers Manager, Public Health Initiatives March of Dimes

2. The EHR has tremendous promise as a means of decreasing workload, decreasing cost and improving quality of care

3. The EHR has tremendous promise as a means of decreasing workload, decreasing cost and improving quality of care • Reality • EHRs decrease productivity or are neutral • EHRs have not been shown to increase quality • EHRs have not been shown to decrease cost • Consider what Jonathon Bush (AthenaHealth) calls the ‘Cash for Clunkers’ program. Doctors have to be paid to install these EHRs

4. EHR HIT has tremendous promise as a means of decreasing workload, decreasing cost and improving quality of care

5. Clinical Decision Support Apply Algorithms/Guidelines to patient data Identify best course of action Results displayed as intuitive Visualizations BRCAPRO Mutation Risk 25% Suggest Genetic Testing Facilitates best action as part of workflow

6. EHR Issues

7. “Computerization hasn't saved a dime, nor has it improved administrative efficiency” • 4,000 hospitals 2003 to 2007 • Computerization • Weak correlation • Quality for MI • No correlation • Cost savings • Improvements in administrative efficiency • Quality for pneumonia • Quality for heart failure • Overall quality (MI, heart failure, pneumonia) Himmelstein, The American Journal of Medicine (2010) 123, 40-46

8. EHR and productivity varies by specialty100 internists, pediatricians and family practitioners Hemant Bhargava, UC Davis Graduate School of Management • 25 to 33 percent drop in MD productivity • Over time • Internists slightly above original productivity • Pediatricians /family practitioners never recovered

9. Quote from a breast surgeon beginning EHR use • …our productivity is down 28% • I am the highest paid transcriptionist in the state • Each cancer patient chart takes me apprx 1 hour • For the first time in my career, I turned down an add-on patient

11. Currently: Paper + memory Patient completes paper form Reviews data using memory of guidelines Documents and Orders Orders Genetic Testing

12. EHR: Paper + extra work + memory Patient completes paper form Staff enters data into the EHR Reviews data using memory of guidelines Documents and Orders

14. EHR Same interface for every Specialty Small Database Meds Allergies Generic Interface Mostly Filing Cabinet Or Document Management System

15. EHR Cardiovascular Pathology Anesthesia Generic Mammography

16. IT ≠ EHR Role of the EHR in Family History …close to non-existent While EHRs do poorly for most aspects of medical care, they are worse relative to family history and genetics

17. Health IT EHR Designed to manage the entire spectrum of medical care Created by large corporations E.g., NextGen, Allscripts, eClinicalWorks, Misys, Centricity, Eclipse, LMR ‘Niche’ Software Designed for specialty areas Homegrown or developed by small vendors E.g., My Family Health Portrait, Jameslink, GREAT, Progeny, HughesRiskApps

18. Health IT EHR Designed to manage the entire spectrum of medical care Created by large corporations ‘Niche’ Software Designed for specialty areas Homegrown or developed by small vendors

19. Health IT and Clinical Care EHR ‘Niche’ Software

20. EHRs are limited to major areas Notes Allergies Path Reports Problem List Meds Lab

21. Adding new features for small markets is expensive ■ Notes Genetics ӨPedigree Allergies ΘFamily History Path Reports Risk ■ Problem List Meds Lab

22. Every EHR must rebuild the same basic route

23. EHRs have difficulty improving AHIC Core Data Set Published 2008 No EHR Vendor has adopted it HL7 Pedigree model for interoperability Approved 2006 No EHR Vendor has adopted it Family history upgrade to EHR at my institution submitted 2006 slated for analysis 2009 Implementation 2013 or later

24. The American Health Information Community (AHIC) Personalized Health Care Workgroup Recommendations to Secretary 2007 … Modular family history tool … collection of family health history within the EHR…messaging of … information to a variety of richer … tools that perform risk analyses… results of … calculations … returned to the EHR … for curation

25. Niche/Modular Software Innovative approaches to data entry Patient data entry Clinician data interface Innovative approaches to CDS Risk Algorithms/Guidelines Visualization appropriate to user Pedigree drawing EHR as a repository Core data set Interoperable Testing and iteration possible

26. EHRs and Niche Software • EHR vendors say: • Wait for the EHR to do this • Niche software is not needed • EHR should not exchange data with Niche Software

29. Hereditary Risk Identification CDS

30. Hereditary Risk Identification Click open 4 screens BRCA1+

31. Hereditary Risk Identification

32. Typical EHR HughesRiskApps

33. Better workflow Patient enters data Tablet PC iPad Website Patient educational materials Clinical Decision Support Reviews Report & Pedigree Reviews suggested management EHR Clinical Decision Support Documents and Orders

36. HughesRiskAppsBreast Surgery Module Kshughes@Partners.org www.HughesRiskApps.net