Electronic Medical Records: An Introductory Tutorial

1. Electronic Medical Records: An Introductory Tutorial William Tierney, MD Atif Zafar, MD AHRQ PBRN Resource Center

2. Outline of Presentation Introduction to EMRs (very basic information) Barriers to Adoption: Some Problems with Data Accessibility and Care Processes EMRs for Clinical Research EMRs and HIPAA Security No Nonsense Guide to Selecting an EMR Examples of EMRs OpenSource Commercial Lessons Learned

3. Introduction to EMRs

4. Introduction to EMRs Why do we need Electronic Medical Records (EMRs)? Many problems with the current healthcare system (underuse and overuse) 30% of children receive excessive antibiotics for otitis 20-50% of surgical procedures are not necessary 50% of back pain x-rays not necessary 50% of elderly patients don�t get a pneumovax

5. Introduction to EMRs Why do we need EMRs? Clinical practice is a data intensive operation a Inadequate data communication causes medical errors Human cognition is good at pattern recognition but not at remembering lists or evaluating multiple business rules.

6. Why do we need EMRs? Available 24 x 7 Can be viewed by more than one user at a time Is available from remote locations To covering MDs Others with appropriate needs Data can nearly always be found Is legible

7. Why do we need EMRs? Enhances Communication: Between providers--clinical messaging Can tag EMR location with message Referrals Half of specialists didn�t know what main question was A third of the time no information came back to PCP

8. Why do we need EMRs? Cost Savings: Dictation cost savings $170/FTE/month Chart pull savings $217/FTE/month Savings accrue to practice, apply to all payers

9. Why do we need EMRs? Assist with Decision Support: Many domains�cost and selection of: Drugs 18% reduction found by Overhage Lab tests 10-15% reduction in cost for charges, last result, probability of abnormal Radiological studies

10. Why do we need EMRs? Decision Support: In inpatients, computerizing ordering decreased Serious medication errors by 55% All medication errors by 81% EMR can help by Structuring medication orders 34% error rate with paper vs. 6% with electronic Alerting about Allergies Duplicate medications Many other issues

11. Introduction to EMRs Do EMRs make a difference? UNEQUIVOCALLY YES, BUT AT A COST! In multiple studies, EMRs have been shown to: Shorten Length of Stay in a Hospital setting Decrease Adverse Drug Events (ADEs) Improve Readability, Consistency and Content of the medical record Improve Continuity of Care Reduce practice variation Most benefits come from Decision Support.

12. EMR Use in the United States Even though the US Health Care system is the costliest in the world, its performance ranks 37th in the world according to the WHO! Only 5% of US primary care providers use EMRs (Bates et. Al., JAMIA 2003), 7% of all physicians (Wang, Bates, et. Al., American Journal of Medicine, April 2003)

13. EMR Use Around the World Use PCs Use EMR Australia 90% 53% Denmark 95% 62% Netherlands 95% 88% Sweden 95% 90% United Kingdom 95% 58% (c) 2001 Harris Interactive

14. Breakdown by Function - 2002 Australia UK Use EMR 90% 99% Of Those: Prescrip 100% 80% Notes Unknown 45% Reminders Unknown 70% Clin Vocab 15% (ICPC) 100% (Read) Paperless Unknown 45% $2B initiative by UK to get all physicians online

15. What is an EMR? At their heart, EMRs are just a database This database hold many kinds of information (coded and not coded) This database is organized by date, time, pat ID and contains: Patient registration data (name, contact info, DOB, SSN, etc.) Test results (laboratory, radiology, nuc med etc.) Medications (active, inactive) and Allergies Current list of diagnoses and problems Appointment Data Clinical Notes Billing Information

16. What is an EMR? So if an EMR is just a database, how is it different from other databases, and why is it so useful? Value Added: A Clinical Knowledge Heirarchy (term dictionary) How do clinical concepts work together Ex: Digoxin toxicity can occur with hypokalemia A List of Current Clinical Recommendations A List of Appropriate Medication Indications, Doses, Adverse Effects and Interactions and Cost Estimates Costs, Indications and Utility of Tests

17. What is an EMR? What are some typical EMR Components: Lab System: Contains all lab tests ordered and their results and stored as coded results (LOINC etc.) in many systems Radiology System: Stores test reports Pharmacy System:List of current medications, inactive meds and when they were last dispensed or ordered Billing System : A list of diagnostic codes used for billing (ICD9, CPT, etc.) Registration System: Names, Contact Info, Personal Info, etc. for patients

18. What is an EMR? Additionally, many EMRs have: An Order Entry System (where physicians enter orders, prescriptions, notes etc. online) A Decision Support System Often linked to the order entry system to provide guidance at the point of care Contains databases for clinical knowledge, guidelines, list of medication indications, doses etc.

19. What is an EMR? The spectrum of EMRs EMRs target specific user bases, from solo office-based practices to large, multispecialty tertiary care centers Many features are thus directed at managing workflows specifically to these user bases For example, large commercial EMRs unbundle services such as clinical documentation, results display etc. while office systems typically integrate all of these under the same interface.

20. How do Clinicians Interact with EMRs

21. Different Types of EMRs EMRs don�t necessarily need to be expensive and complicated or require that a computer be used to enter data Can have hybrid computer/paper based approaches Ex: In the CHICA� System, paper is used to interact with an electronic data repository Standardized paper forms are printed and then �scanned� Characters are recognized and the electronic data so generated interacts with the data repository

22. Different Types of EMRs At Indiana University, pediatric clinics use this system: A data repository was developed using Microsoft SQL Server A clinical guideline system was written in Arden Syntax An optical character recognition system called Cardiff Teleforms is used to process handwritten numerical data on preprinted scanned forms The data so generated is stored in the database and dynamic reminders are generated for the physician These are printed on the clinic computer The entire operation takes < 2-3 minutes!

23. Different Types of EMRs The Mosoriot Medical Record System� Indiana University has an HIV Effort in Kenya A Simple MS Access based database holds all patient records (3 years worth!) Provides forms for data entry, standard term dictionary, medication listings, registration system, clinical documentation system etc. Created by 1 programmer over 2-3 weeks! Highly effective, easy to maintain, inexpensive!

24. Data Sources So how can EMRs populate their databases? Data can come from many many sources: Admission/Discharge/Billing Anesthesia Systems Cytology Systems Diagnostic Imaging Management Systems EKG Carts Endoscopy Systems ER Systems

25. Data Sources More Data Sources: Home Care Systems ICU Monitoring Systems IV Fluid Infusion Control Systems Laboratory Systems Nurse Triage Order Entry Systems Pharmacy Systems (Inpatient/Outpatient) Pulmonary Function Systems

26. Data Sources More Data Sources Radiology systems Risk Management systems Registration Systems Scheduling and Clinic Charge Systems Transcription Systems Unit Dose Dispensing machines Ventilator Management systems

27. Data Sources So if there are so many data sources available and so many people are interested in using EMRs, why are they not more prevalent?

28. The Challenges of EMR Implementation

29. Problems with Electronic Data For the last 30 years the medical informatics community has struggled with how to architect the �vessel� that will hold patient data Problem is that they have focused on the wrong problem! We don�t just want to create a system that permits entry of data electronically, we want to create a system that can acquire this data automatically from other electronic data repositories and make it available at the time of service.

30. Problems with the Data Sources Too many repositories or �islands� of systems Difficult to �bridge� and combine in useful ways Contain different data at different levels of granularity Each uses a different code to identify the same information. Many institutions do not capture all of the data of interest to clinicians. Labs are sent to external reference laboratories Patients fill their scripts at community pharmacies As a result many implementations do not lead to satisfactory achievement of the intended quality assurance goals

31. Problems with Data Sources Another problem is that there are many many care providing sites in the United States: Hospitals 5000+ Nursing Homes 19000+ Pharmacies 59722+ Physician offices 200000+ Laboratories 63000 Emergency Rooms 4856 Hospice Care 2800 Home Care agencies 4258 All of these sites generate data that are not necessarily compatible.

32. Problems with Electronic Data Thus, the problem is not one of creating database fields de novo, it is one of merging existing fields from many different sources in meaningful ways When commercial and other EMR vendors create proprietary, closed, systems, with custom database architectures, they often worsen the problem and make it harder to populate the database with useful information, inexpensively

33. (1) The Role of Standards Fortunately, most of the informatics community has realized that the solution to the problem of merging data lies in the implementation of Standards for Data Communication. These standards permit data to be easily translated from one database system to another

34. (1) Standards There are many many standards, each for a different purpose Lab Data Communication General Clinical Messaging Radiology Image Transmittals Diagnostic Coding Procedure Coding Need to distinguish between coding standards and messaging standards.

35. (1) Standards HL7 (Health Level 7) Most widely used standard General clinical messaging standard Communicates structured data Fields for: Diagnostic Results Notes Referrals Scheduling Information Nursing Notes Problems Clinical Trials data

36. (1) Standards Health Level 7 2000 hospitals, the CDC and most referral labs. Also used in Canada, Australia, New Zealand, Japan and extensively in Europe Bridges many systems, including laboratory, dictation, pharmacy, electronic patient records, performance databases, data repositories (cancer registries) etc. Web Site: http://www.mcis.duke.edu/standards/HL7/h17.htm

37. (1) Standards LOINC Logical Observations and Indicators Names and Codes A coding standard that is used for LAB data Used for representing laboratory observations and common clinical measurements At least 5 large commercial labs (Corning, MetPath, LabCorp, ARUP Labs and Life Chem) have adopted LOINC

38. (1) Standards DICOM Another messaging standard Standard of choice for transmitting diagnostic images Closely supported by all of the imaging vendors and is working with the HL7 group Web site: http://www.xray.hmc.psu.edu/dicom/dicom_home.html

39. (1) Some other coding standards ICD9/10 � Used to code diagnoses CPT � Used to code procedure data ISO+ - Used to code units of measure UMDNS � Device classification standard NDC � Drug entities classification SNOMED � organism names, topologies, symptoms and pathology HOI � Outcomes variables UMLS � Metathesaurus for clinical nomenclature Arden Syntax � Clinical knowledge

40. (2) Patient Identification How do we ensure that the information belongs to the correct person? Patients move and change addresses/tel#s Patients change names or use aliases Patients sometimes have multiple SSNs There are differences in patient, provider and place of service identifiers among data sources

41. (2) Patient Identification Solutions to this problem do exist but at a local institutional level at the moment Our institution uses a combination of mothers maiden name, SSN and DOB to uniquely identify the patient The Kassebaum-Kennedy Bill (PL 104-191) will make this into a national effort and standardize patient and provider identifiers

42. (3) Physician Data Capture The �ultimate EMR� promises to capture whatever data is needed to perform any EMR task � outcomes analysis, utilization review, profiling and cost estimation. This prospect excites many CEOs and CIOs However, much of the data needed for such functionalities comes from physicians (disease severity and clinical findings) and most of this data is recorded as un-coded free text.

43. (3) Physician Data Capture In order for physician generated data to be useful it needs to be in coded form so that algorithmic assertions can be made The problem of coding free text data is of paramount importance and information systems designers have struggled with this as long as the field of medical informatics has been in existence

44. (3) Physician Data Capture One approach we could take would be to translate existing free text dictations into coded, computer readable information, but: Human coding is error prone and expensive and is at too high a level of granularity to be useful Decades of research into computer based coding has still not yielded satisfactory results Or the physician could code the data themselves by entering structured notes but: This is costly in terms of time as it requires the user to map the terms into computer understandable words at a level of granularity which is useful

45. (3) Physician Data Capture Commercial EMR vendors bypass the problem and provide every mode of data entry possible: Direct keyboard entry Dictation with human transcription Voice Recognition Structured Data Entry Paper based data collection Web/PDA/Mobile devices Problem is that we don�t know which one is the most efficient so users have to think with their feet

46. (3) Physician Data Capture We did a study at Indiana University comparing voice recognition with typing and dictation/transcription and found that (at least for 1 user): Voice recognition almost doubled the note size as compared with typing It took longer to use voice recognition by 1.3 min as compared with typed notes Voice recognition was 30 fold less accurate than dictation/transcription During proofreading, the user missed 30% of errors 1.2% of errors changed the intended meaning Dictated note turnaround time was from 2-5 days!

47. (3) Physician Data Capture Managers and quality analysts want data that is often never captured Formal functional status Detailed Guideline criteria And we don�t even know how much of this kind of information is needed? For some disorders (angiography and knee surgery) data sets have been developed but we do not know the operating characteristics or predictive value of the data elements? How do we define and collect the �soft� data elements?

48. (3) Physician Data Capture We do have some instruments for some disorders (CAGE, Hamilton Scale, SF12/36 etc.) But we lack them for many other clinical entities and for much of specialty clinical care And checklist based symptom questionnaires as opposed to validated instruments elicit many more symptoms than open ended questions, so which of these are really important?

49. (3) Physician Data Capture Coding of all medical information is unnecessary So where do we draw the line? (how much should be coded and how much can be stored as free text) in order to maximize the utility of the information. The other issue is with longevity of clinical notes. How often do you use a note from 2 years ago? How long do we need to keep the EMR data?

50. (4) Cost Cost is perhaps the biggest barrier to implementation Unfortunately there are few studies that have looked at the long term ROI with EMRs Most existing studies have been done by the system vendors and so the data should be examined with a cautious note However, the data that is available suggests that the ROI is excellent!

51. (4) EMR Cost Analysis Studies Several studies are worth mentioning (1) Renner et. Al. looked at implementing an EMR in 1996 in 40 primary care practices Its net present value (1996 dollars) was about $280,000 based on a 5-year model They found that reducing the cost of medications and preventing ADEs was of the greatest benefit in primary care

52. (4) EMR Cost Analysis Studies (2) Wang, Bates et. Al. looked at the cost of implementing a full EMR in primary care as compared with paper based chart systems Primary outcome was the cost benefit per provider over a 5-year period Used average statistics from their institution (Partners Healthcare, Boston), expert opinion and national data to estimate costs System Costs ($13,100 initial, $3100 each year + HW) Induced Costs ($11,200 in year 1)

53. (4) EMR Cost Analysis Studies (2) Wang, Bates et al. Benefits resulted from costs averted ($/year) Transcription savings ($2700) Reduction in need for chart pulls ($5/chart pulled) Drug cost savings and prevention of ADEs ($2200) Laboratory and Radiology cost savings ($10,700) Charge capture improvement ($7700) Decrease in Billing Errors ($7600) All benefits finally being realized in year 4

54. (4) EMR Cost Analysis Studies (2) Wang, Bates et. Al. Resulted in present value of net benefit (2002 dollars) to be $86,400/provider in year 5 Breaking down by EMR feature they got: Light EMR (net loss of $18,200/doc in year 5) Online patient charts only Medium EMR (net benefit of $44,600/doc in year 5) Adds an Electronic Prescribing Module Full EMR (net benefit of $86,400/doc in year 5) Adds Lab, Radiology and Charge Capture systems

55. (4) EMR Cost Analysis Studies (2) Wang, Bates et. Al. Conclusions: An Ambulatory EMR Resulted in net benefits across a range of assumptions, which increase as more features are added and as the time horizon lengthens Most benefit was derived from reductions in drug expenditures, improved test utilization, improved charge capture and reduced billing errors The greater the portion of capitated patients the greater the return, although benefits also accrue for fee-for-service patients (but mostly to payers and not health care institutions) Limitation: Did not consider malpractice reduction, increased provider productivity or decreased staffing requirements. Intangible benefits: Improved Quality and Decreased Errors

56. (5) Other Barriers (1) Physician reluctance and fear that their productivity may decline (which it does) (2) Unreliability of EMR Vendors in a volatile IT economy. Lack of adequate IT support from the vendors (3) Concerns over data security

57. Summary: Barriers to EMR Use Too many data sources, no simple way to coordinate and connect them except to use standards which are still evolving Unique patient identification still a problem � esp in large tertiary care centers Physician data capture inefficient and expensive

58. Summary: Barriers to EMR Use Startup costs can be prohibitive but long term benefits are clearly evident form pilot studies Physician reluctance a major barrier to use Concerns over security still an issue, eg: HIPAA System vendors are transient and fail to provide adequate support

59. EMRs for Clinical Research

60. EMRs for Research So what EMR functions do we need in order to effectively do clinical research? Answer: Depends on what you want to do However, to be able to ask questions of your practice, you need: Registration data (Registration system) Diagnoses (Billing data) Medications (Pharmacy data) Labs and other Test Results (Lab/Radiology data) AND A system to query these databases intelligently

61. EMRs for Research You don�t necessarily need a decision support or order entry system but if you want to intervene, you may want to include these systems as well

62. EMRs for Research Note that the registration, billing, pharmacy and lab/radiology data usually (but not always) exists, outside of the context of any specific EMR system These are just data repositories which need to be tapped into and queried So you need a system to access and query these databases, independent of any electronic medical record system.

63. EMRs for Research Alternatively, you could build a master repository which acquires and stores this information and permits intelligent queries to be performed This is exactly what we did in Kenya in the Mosoriot Medical Record System, although data is still hand-entered. Eventually it will be downloaded using HL7 messages.

64. Mosoriot Medical Record System An example of an EMR that is inexpensive and functional and supports both clinical care and research in rural Kenya Built in 2-3 weeks by 1 programmer using Microsoft Access Consists of: Data dictionary tables which define test names, medications, diagnoses etc. Forms which are used for data entry Has tables for registration data, billing data, medication lists, lab and test results Currently running on Tablet PC devices in Kenya

65. Research Workflow Model

66. EMR Features Conducive to Research Reliance on Standards (HL7, LOINC, ICD9, CPT) Easy access to data repository, i.e. database structure is well documented Built-in Practice Profile Management systems Built-in decision support and order entry functionality Able to export data in a standard format (CSV, MDB etc.)

67. HIPAA Security

68. Introduction HIPAA = Heath Information Portability and Accountability Act Final Security Rule Published in the Federal Register on February 20, 2003 (effective 60 days) http://www.cms.hhs.gov/hipaa/hipaa2/regulations/security/default.asp Designation: 45 CFR 160, 162, 164 Compliance Dates: April 20, 2005 Covered Entities: 24 months after effective date Small Health Plans: 36 months after effective date

69. HIPAA Security Some excellent links: http://privacy.med.miami.edu/glossary/gt_security_rule.htm http://www.hipaadvisory.com/tech/wireless.htm http://www.hipaadvisory.com/regs/securityoverview.htm

70. HIPAA Security Security should not be confused with Privacy or Confidentiality Privacy: The rights of an individual to control his/her personal information without risk of divulging or misuse by others against his or her wishes Confidentiality only becomes an issue when the individuals personal information has been received by another entity. Confidentiality is then a means of protecting this information Security refers to the spectrum of physical, technical and administrative safeguards used for this protection

71. HIPAA Security Addresses 3 tiers of protection: Administrative Safeguards Physical Safeguards Technical Safeguards

72. Administrative Safeguards Institutional level Develop security management process where potential �threats� to PHI are determined Provide training to all employees about HIPAA Provides appropriate level of authorization based on a protocol for granting access Violations should be clearly documented and investigated A disaster recovery plan should be in place

73. Physical Safeguards Applies to 3 elements of the PHI data storage infrastruture: Facility where PHI data is stored Workstations on which it is stored Media on which it is stored

74. Physical Safeguards Require that the facility have access control Contingency plans need to be in place in case an intruder gains access Workstation security measures be in place Automatic logoff Screen is placed away from potential viewers PDAs should be password protected Devices and media should be appropriately disposed of in case they are no longer needed and data should be erased properly

75. Technical Safeguards Applies to how information is stored, verified, accessed and transmitted/received Access and audit controls Emergency access to information when needed Automatic logoff is enforced Data is encrypted and decrypted during transmission Verify integrity of the storage and transmission (digital signatures)

76. Am I HIPAA Compliant? Questions to ask yourself and your institution

77. Questions to ask your institution 1. Was a security audit done and if so what are the results? 2. Did I get the appropriate HIPAA training and do I have a certificate to prove this? 3. Are there procedures in place to grant access to PHI to authorized users? 4. What are the procedures in place in case of disaster, data loss or data theft? Are Backups made frequently?

78. Facility, Workstation, Media 1. What are the procedures in place to safeguard the facility from intruders? Are there contingency plans for dealing with intruders, data theft or other event? 2. How do protect the safety of workstations? Are they password protected? 3. Can bystanders view the screens on which PHI may potentially be displayed?

79. Facility, Workstation, Media 4. Is an automatic logoff mechanism enforced? What time limits are provided before this occurs? 5. What types of data are stored on PDA devices and if PHI is stored is it password protected or encrypted? 6. What procedures are used when disposing of, reusing or archiving data on hard disks, CDs, floppys and Zip disks? Are PHI data erased properly if the disks are to be disposed of or reused?

80. Data Level 1. Are there audit mechanisms for checking who is accessing the PHI data and is this done on a regular basis by authorized personnel? 2. Are there procedures in place to grant emergency access to information if needed? 3. Is data integrity checked when the data is transmitted or received? (digital signatures, digital certificates, checksums etc.) 4. Is the data encrypted and decrypted during the transmission process?

81. HIPAA Wireless Security

82. Before you Begin Do I really need to be wireless of can I get by with a wired connection? Is space limitation a problem? Is mobility absolutely necessary? Do I have the permission of my institution to install wireless networks? Do I have adequate IT support to do this?

83. 11 Steps to Wireless Security Wireless is inherently unsecure Many Many ways of hacking into wireless networks Technology base is there to make it secure Some simple steps can be taken to maximize the security of your wireless network

84. 11 Steps to Wireless Security 1. Change the default SSID (network name) on the router so that your name/location is kept secret 2. Disable the SSID broadcast, if your router supports it. This will prevent hackers from seeing you 3. Change the administrator�s password on your router.

85. 11 Steps to Wireless Security 4. Turn on the highest level of security supported by your hardware (i.e. Wireless Equivalent Privacy � WEP, which is older or WPA which is the latest and most secure) 5. Make sure you have the latest firmware updates. Implement MAC (media access control), which specifies exactly which WLAN PC cards can access the network and excludes others

86. 11 Steps to Wireless Security 6. Place the Wireless Access Point (WAP) towards the middle of the building, keeping the zone of potential access within the building. 7. Do your own security audit. Use Network Stumbler (www.netstumbler.com) on your Tablet PC, laptop of PDA and walk around the perimeter of your building to see where and what a would-be hacker may see

87. 11 Steps to Wireless Security 8. If you have a limited number of wireless clients (Tablet PC�s), provide them with static IP addresses, and disable DHCP on your router. This ensures that only �authorized� machines can �see� your network.

88. 11 Steps to Wireless Securit 9. If we are in an enterprise setting, use VPN�s (Virtual Private Networks). You can isolate your WLAN from the wired network using products such as the Netgear FVM318 or the SonicWall SOHO TZW. Then you can use the VPN to tunnel directly into the wired network securely

89. 11 Steps to Wireless Security 10. Avoid using public hotspots, areas that are insecure and open for general use. 11. Turn off file and print sharing on your Tablet PCs. Most devices do not prevent client-to-client traffic, so people sitting across the street from you can be looking at your shared directory remotely.

90. Guide to Selecting and Deploying an EMR

91. Selecting an EMR Award winning EMRs CPRI Davies Award Winners (1995-2000) Emphasis on successful implementation, not on technology that is behind the design Functional Requirements: Integrate data from multiple sources Provide decision support Used by caregivers as primary source of information Must enhance care, not just replace paper So who are there award winners and what are their strategies for success?

92. Davies Award Winners Intermountain Healthcare System, Salt Lake City Columbia Presbyterian Medical Center Department of Veteran Affairs CPRS (now open-source) Brigham and Women�s Hospital Kaiser Permanente, Cleveland OH Regenstrief Medical Record System North Mississippi Health Services Kaiser Permanente, Portland OR Northwest Memorial Hospital, Chicago Kaiser Permanente, Rocky Mtn. Region Harvard Vanguard System

93. Davies Award Winners Common Strategies and Attitudes towards implementing EMRs

94. Common Strategies Vision of healthcare as an information business Sustained leadership (5 years +) Run by project leaders and not CIOs Most projects had physician champions EMRs subjected not to a cost benefit ROI analysis but to an �unremitting pressure to show value�

95. Common Strategies Customer Service, Customer Service! Frequent, sustained, end-user orientations and feedback with demonstrated responsiveness to feedback! Weekly Regenstrief Pizza Meetings Kaiser physician focus groups Northwestern weekly feedback with �supplements� System developers were also the salespeople, troubleshooters, coaches and colleagues!

96. Common Strategies Plans in place for system evaluation and change management All winners had to re-engineer some workflow process � �don�t automate a manual process that occurs commonly but does not work�! Incremental deployment � don�t rush things Each increment overcame a specific barrier to care Systems were viewed as tools to enable care process improvement and were not an end to themselves

97. Common Strategies All resulted in a decreased reliance on paper-based sources of information Decision Support, Decision Support, Decision Support -> provides the largest value added compared to a paper system Focus on standards based data architecture rather than specific applications to do this or that FAST RESPONSE TIME! Flexible enough to adapt to organizational change

98. So what can I do to implement an EMR in my practice?

99. Can I implement an EMR? Depends on your size and your budget Solo practice -> yes, definitely Multispecialty group (2-100) -> probably (cost is around $4-20K per provider) Multispecialty, multisite groups � maybe Tertiary care centers with scattered secondary care sites -> probably need to be brave and wealthy!

100. What EMR should I choose? Do not start in �product selection mode� Begin by identifying the practice processes that you wish to improve first Then search for the functions you need: Problem List Medications Clinical Encounters Lab/Xray/Pathology Telephone Calls Referrals Preventive Care Managed care

101. Which EMR should I choose? Anticipate primary and secondary users Primary Clinical decision making, Documentation Support for Billing Secondary Provider profiling and service utilization Quality report cards and outcomes analysis Regulatory reporting and justification for studies

102. What if I have a limited budget? Again, think of using selected modules to enhance parts of your practice Clinical Note Systems Prescription Writer Use one or more of the OpenSource EMRs Need some level of IT expertise to deploy No real support available from the developers

103. Examples of OpenSource EMRs a. OpenEMR (http://www.synitech.com/openemr/ <http://www.idltechnology.com/products/openemr/index.php>) b. Care2002 (<http://sourceforge.net/projects/care2002/>) c. Open Infrastructure for Outcomes � UCLA (<http://sourceforge.net/projects/open-outcomes/>) d. PatientRunner (<http://sourceforge.net/projects/patientrunner/>) � mental health record system e. OpenSDE (<http://sourceforge.net/projects/opensde/>) � structured note entry system f. MedSurvey (<http://sourceforge.net/projects/medsurvey/>) � clinical information system for Windows PCs g. OpenEMed (<http://sourceforge.net/projects/openmed/>) � Java based EMR h. Hardhats (VA�s VISTA software) � yes this IS open source now and available to EVERYONE (<http://www.hardhats.org/>), (<http://sourceforge.net/projects/hardhats/>)

104. EMRs for Primary Care Practice Recent survey done by the journal Family Practice Management (2001) Surveyed 28 vendors Price structure highly variable Found that the market is highly volatile and some vendors went out of business or merged with others during the time of the survey

105. EMRs for Primary Care Practice Five star systems: ChartWare HealthProbe Patient Information Manager EpicCare

106. EMRs for Primary Care Practice Four Star Systems Logician NextGen Pearl Physician Practice Solutions PowerMed EMR Practice Partner Patient Records QD Clinical

107. EMRs for Primary Care Practice Four Star Systems SOAPWare Welford Chart Notes Clinical Works Module (ASP) NextGen (ASP) Physician Practice Solution (ASP) topsChart (ASP)

108. EMRs for Primary Care Practice 4+ physician practices: ENTITY, Logician, NextGen, ClinicalWorks 10+ physician practices: EpicCare, PEARL, Physician Practice Solution All others can serve practices of any size

109. EMRs for Primary Care Practice Most allow ICD9 and CPT codes Many allow access from the web Most allow multiple modes of data entry (keyboard, mouse, touch-screen, light-pen, voice recognition etc.) Most permit integration of hospital data with a primary care database

110. Integration with Handhelds Some EMRs allow data access from PDAs and other handheld or laptop devices: ChartWare - O-HEAP DOCU*MENTOR - Partner ENTITY - PowerMed EpicCare - SOAPWare MedicWare - Welford ChartNotes NextGen - ClinicalWorks topsCHART

111. Other EMR Surveys/Resources HealthCare Informatics 2004 Resource Guide Comprehensive listing of EMRs, features, costs, contact information etc. $50 per copy Order from: http://www.healthcare-informatics.com

112. Some Lessons Learned

113. Lessons learned the hard way Well-designed renowned vendor products meet about 80% of your needs -> where will the other 20% come from? Poorly designed systems will be quickly abandoned by time-pressured end-users Caveat Emptor: �Total Solution�, �Turnkey solution�, esp if a proprietary black box

114. Lessons learned the hard way Clinical/Administrative information is inherently structured. Capturing it in unstructured ways (images) is a costly mistake Data acquisition costs may be more expensive than operational expense (I.e. keyboard entry time more costly than provider input)

115. Lessons learned the hard way Users will accept a tradeoff if there is a clear payback in functionality Attitudes towards computer use are not age dependent Be the 10th customer to a vendor, never the first! Beware of vendors who say �we can do that �what is it?�

116. Lessons learned the hard way The most important information a vendor will give you is the address of 2-3 sites where their system is currently in use

117. Acknowledgements David Bates, MD Daniel Masys, MD

118. DISCUSSION AND QUESTIONS