R' Anne Webber, BSN, MHA, RN, CNN

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R. Anne Webber, BSN, MHA, RN, CNN

• Session 152
• Does Your Medical Record Support Evidenced-Based
  Care?

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Does Your Medical Record Support Evidence-Based
Care?

• R. Anne Webber, BSN, MHA, RN, CNN
• ANNA National Symposium
• April 3, 2006

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Conflict of Interest

• Employed by Health Informatics, Inc. a software
  vendor
• Presentation focus is broader than any one
  product and not vendor specific

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Session Objectives

• List the major forces to replace paper medical
  records with Electronic Health Records (EHRs)
• Describe the barriers to EHR adoption
• List the possible factors used to evaluate your
  current EHR or a proposed EHR
• Describe how future technology will assist
  clinicians to consistently apply evidenced-based
  care and improve outcomes
• Describe how nurses can influence future EHR
  design and adoption

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Definitions

• Electronic Medical Record (EMR)
• Replacement of traditional paper records
• Electronic Health Record (EHR)
• EMR with data from other sources (via interfaces)
• Interface - Electronic, automatic transfer of
  data from one database to another
• Personal Health Record or Information (PHI)
• Electronic, universally available, lifelong
  resource of health information maintained and
  owned by the individual (AHIMA)

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Overview

• What is driving the adoption of EHRs?
• What are the barriers to EHR adoption?
• How do we evaluate EHRs?
• What will the future EHR do to assist me and
  improve patient care?
• How can nurses influence EHR selection,
  implementation and future development?

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We are an information-based profession
Carolyn Headley, DNSc, MSN, RN, CNN April 2005
ANNA Symposium presentation entitled Closing the
Chasm between Evidence and Practice through
Research
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What is driving the adoption of EHRs?
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Medicine used to be simple, ineffective and
relatively safe. Now it is complex, effective
and potentially dangerous
Sir Cyril Chantler The Lancet, 1999
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What is driving adoption of EHRs? Government
President G. W. Bush 2005 State of the Union
Address
I ask Congress to move forward on a
comprehensive health care agenda.. with improved
information technology to prevent medical error
and needless costs
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EHR Adoption DriversPublic Access to Data

• CMS Dialysis Compare Facility level comparative
  data on
• Anemia
• Adequacy
• Mortality
• State-based administrative databases
• Incident reporting
• Outcome reporting

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EHR Adoption Drivers Outcomes-based reimbursement

• Self insured quality incentives
• Leapfrog Group
• Health Plans
• CMS Demonstration
• S 635 and HR 1298 establishes outcomes-based
  demonstration project linking payment to quality
  of care

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EHR Adoption Drivers Providers/Facilities

• Provider/Facility negotiation strategy based on
  internal outcome data
• Not much published so far - anecdotal
• Counter offer reimbursement rates based on
  internal outcome data not available to health
  plans

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It seems self-evident that many , perhaps most,
of the solutions to medical mistakes will
ultimately come through better information
technology.
Robert M. Wachter The End of The Beginning
Patient Safety Five Years After To Err is
Human Quality of Care, November 30, 2004
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What are the barriers to EHR adoption?
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EHR BarriersPerceived

• Healthcare Information Services implementation
  hurdles are more cultural than technical

Patient Safety Meeting San Diego, November
18-19, 2004
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EHR BarriersReal

• Cost
• Purchase
• Implementation
• Training
• Maintaining
• Fragmented Systems (No interfaces)
• Clinical
• Lab
• Billing
• Space

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How do we evaluate EHRs?
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EHR Evaluation

• Existing systems / Potential Systems
• Evaluation is the same

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EHR Evaluation

• Key Capabilities of an Electronic Health Record
  System (IOM, 2003)
• Health information and data
• Care management
• Order management
• Decision support
• Electronic communication and connectivity
• Patient support
• Administrative processes and reporting
• Reporting and population health

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EHR Evaluation

• What are your goals?
• Improved care
• Increase patient safety
• Evidenced-based care
• Support for quality improvement
• Increase staff/physician efficiency
• Opinion EHR will NOT reduce chair-side
  documentation time
• Can increase efficiency / power in reporting
• Can increase efficiency to locate and replicate
  patient records
• Can increase availability of medical records

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EHR Evaluation

• Decision Support (Evidenced-based care)
• Computerized reminders
• prompts and alerts to improve compliance with
  best practices
• ensure regular screenings
• identify possible adverse drug interactions
• facilitate diagnoses and treatments
• Example Does your EHR notify you when VP exceeds
  tolerance for 3 consecutive treatments with BFR
  at 200?

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What will the future EHR do to assist me and
improve patient care?
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Who has time to sort through myriad references
and papers to look for evidence-based answers?
Matt Lewis, MD Family Practice Management, May
2003
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EHR Future

• Technology advances
• Data integration
• Transaction standards
• Integration
• Hospital records
• Primary care
• Specialists
• Others
• New technology

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EHR Future Handheld Devices

• Documentation options
• Real-time EHR documentation
• Vitals,
• Services provided (medications administered,
  dressing changes, etc.)
• E-prescribing, etc.)
• Photos / Images
• Voice recordings
• Video recordings

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EHR Future Handheld Devices

• Communication options
• Care Team and Patients
• e-mail
• Voice mail
• Page
• Auto transfer to pharmacies (e-prescribing)
• Auto transfer to/from labs

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EHR Future Handheld Devices

• Notifications and References
• Evidence-based clinical items
• Safety warnings
• Medication / allergy alerts
• Medication / medication interactions alerts
• Reminders
• Ordered items due
• Preventive care
• Test result alerts
• Reference databases
• Drugs
• Protocols

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EHR Future

• Radio frequency identification devices (RFID)
• Identification and location
• Patients
• Staff
• Equipment (Resources)
• Medication at dose level
• Documentation Efficiency
• Right patient
• Right medication
• Right dose
• Right time
• Right route (sort of)
• validation / documentation at point of care
  possible

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EHR Future

• Patient access / entry into EHR
• Patient ownership vs.
• Clinician stewardship
• Asynchronous communication
• Physician / patient
• Patient initiated
• Physician and care team members
• Patient and care team members

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EHR - Nurse Role

• Get comfortable with change
• Review your nursing goals for EHR adoption
• Take ownership of EHR as an integral part of
  your clinical processes
• Analyze current processes
• How many steps?
• How many handoffs?
• How many opportunities for error?

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How can nurses influence EHR selection,
implementation and future development?
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Typical Clinical Processes
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EHR -Nurse Role

• Analyze current / proposed EHR system processes
• Does proposed/ current EHR support desired (not
  current) processes?
• What are the cultural barriers for change?
• Culture changes take time may not match your
  implementation schedule
• Design implementation plan for smooth transition
  from current processes to desired processes
• Get expert help if needed vendor assistance

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EHR -Nurse Role

• Leverage EHR efficiencies
• Implement improvement plan
• Implement CQI process
• Analyze results of change (outcomes analysis,
  chart audits, process analysis)

Implement
Plan
Analyze
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EHR -Nurse Role

• Even if youre on the right track, youll get
  run over if you just sit there.
• Review each upgrade to EHR
• Identify new functional efficiencies
• Determine desired changed to current processes
• Plan and execute plan to implement desired
  processes

Will Rodgers
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Patient EHR Rights

• Our patients have a right to have the
• Right information
• Right place
• Right time
• Right interpretation
• To assist the clinician to do the Right thing

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Nurses EHR Rights

• Right to significant input into EHR
• Selection
• Implementation
• Ongoing evaluation
• New application design
• Enhancement ideas
• Dont settle for less!

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Let's make the right thing theeasiest thing to
do.
David Abelson MD, Park Nicollet