Benefits (and Risks) of EHRs. Georgetown University April 2, 2009 John K. Cuddeback , MD, PhD Chief Medical Informatics Officer Anceta • AMGA’s Collaborative Data Warehouse American Medical Group Association [email protected] Agenda. Background on AMGA
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AMGA improves health care for patientsby supporting multispecialty medical groups and other organized systems of care.
Founded in 1949
2009 AMGA Board Members
Patient Financial SystemsDepartmental Clinical Systems
Institute of Medicine (IOM) reportsThree Eras of IT in Health Care
COLLABORATION CONTINUOUS IMPROVEMENT
Process IntegrationWorkflow Transformation
Data Integration: Patient-Centric View
Clinical Decision Support – CPOE
Technology Infusionfrom Other Industries
Implications for skill development?
Recruitmentand RetentionGoals for (Hospital) Point-of-Care Systems
Patient safety may be the main reason to adopt point-of-care systems, but safety is only one of many benefits.
“Soft” benefits: Quality, Safety, Efficiency
Little incremental revenue
Fundamental organizational change
Impacts everyone—change management, workflow redesign, device ergonomics
Requires culture, leadership commitment
Perceived as high-risk
Relatively immature technology
Still significant R&D on basic components
Complex, expensive implementation
Organizational knowledge management
Benefits have many dependencies
...but are likely to be sustained
High-stakes career move
Completely new capability
Direct reimbursement for new service
Also drives volume
Few users, many beneficiaries
Risk is limited in scope
Development investment new product
Plug it in
Benefits easily realized
...but may be short-lived
Reliable win on “traditional” criteria
Electronic Medical Record
128-Slice CT Scanner, orRobotic Surgery System
chronic obstructive pulmonary disease,
type 2 diabetes mellitus,
all of moderate severity.
12 separate medications
19 doses per day
05 separate dosing times/day
$4,877 medication cost/year (generics)
48% of errors intercepted
37% of errors intercepted
23% of errors interceptedNo “Safety Net” for Medication Administration
Errors Resulting in Preventable and Potential Adverse Drug Events
Bates et al., JAMA 1995;274:29-34
Medication Administration Record (MAR)
Symbol PPT 2740ruggedized, pen/touch input PDA
w/ laser barcode reader and WiFi
Business Process Reengineering
2004 study by Center for IT Leadership
Partners Healthcare, Boston, MA
Analytical systems are essential for integration and transformation.
Deploy improved practice
Develop improved practice
CLINICAL DATA REPOSITORY
Concept or reality?
Traditional Quality Assurance
Hypothetical distribution of patients treated, showing
how often various levels of quality are attained.
Level of Quality
Continuous Quality Improvement
For these distributions, better quality is on the right-
hand side. CQI both raises the overall level of quality
and reduces variation from case to case (indicated
by a narrower distribution).
Level of Quality
0%LOS for Kidney Transplant
Hosp A, B
Percent of Cases
Length of Stay (LOS)
1991 UHC data
Wennberg JE, Series Ed. The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth Atlas of Health Care 1999. AHA Press, 1999. pp. 74-75.
“The usual ‘chain of events’ that occurred when a patient was admitted through our transport system was altered after CPOE implementation. Before implementation of CPOE, after radio contact with the transport team, the ICU fellow was allowed to order critical medications/drips, which then were prepared by the bedside ICU nurse in anticipation of patient arrival. When needed, the ICU fellow could also make arrangements for the patient to receive an emergent diagnostic imaging study before coming into the ICU. A full set of admission orders could be written and ready before patient arrival. After CPOE implementation, order entry was not allowed until after the patient had physically arrived to the hospital and been fully registered into the system, leading to potential delays in new therapies and diagnostic testing (this policy later was rectified). The physical process of entering stabilization orders often required an average of ten ‘clicks’ on the computer mouse per order, which translated to ~1 to 2 minutes per single order as compared with a few seconds previously needed to place the same order by written form. Because the vast majority of computer terminals were linked to the hospital computer system via wireless signal, communication bandwidth was often exceeded during peak operational periods, which created additional delays between each click on the computer mouse. Sometimes the computer screen seemed ‘frozen.’
“This initial time burden seemed to change the organization of bedside care. Before CPOE implementation, physicians and nurses converged at the patient’s bedside to stabilize the patient. After CPOE implementation, while 1 physician continued to direct medical management, a second physician was often needed solely to enter orders into the computer during the first 15 minutes to 1 hour if a patient arrived in extremis. Downstream from order entry, bedside nurses were no longer allowed to grab critical medications from a satellite medication dispenser located in the ICU because as part of CPOE implementation, all medications, including vasoactive agents and antibiotics, became centrally located within the pharmacy department. The priority to fill a medication order was assigned by the pharmacy department’s algorithm. Furthermore, because pharmacy could not process medication orders until they had been activated, ICU nurses also spent significant amounts of time at a separate computer terminal and away from the bedside. When the pharmacist accessed the patient CPOE to process an order, the physician and the nurse were ‘locked out,’ further delaying additional order entry.” (pp. 1508–1509)
Yong Y. Han et al. Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System. Pediatrics 2005; 116: 1506–1512.
Computer Technology and Clinical WorkRobert L. Wears, MD, MS, and Marc Berg, MA, MD, PhDJAMA, March 9, 2005 — Vol. 293, No. 10, pp. 1261-1263
IT-related activities of health professionals observed by the committee in these institutions were rarely well integrated into clinical practice. Health care IT was rarely used to provide clinicians with evidence-based decision support and feedback; to support data-driven process improvement; or to link clinical care and research. Health care IT rarely provided an integrative view of patient data. Care providers spent a great deal of time in electronically documenting what they did for patients, but these providers often said that they were entering the information to comply with regulations or to defend against lawsuits, rather than because they expected someone to use it to improve clinical care. Health care IT implementation time lines were often measured in decades, and most systems were poorly or incompletely integrated into practice.
“Although the use of health care IT is an integral element of health care in the 21st century, the current focus of the health care IT efforts that the committee observed is not sufficient to drive the kind of change in health care that is truly needed. The nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade….”
N Engl J Med 359:50–60,
July 3, 2008
We tend to underestimate the long-term impact of technology,but we invariably overestimate the pace of adoption.
— Bill Gates