Title: Clinician Adoption: Physician Perspective Best Practice
1Clinician Adoption Physician Perspective
Best Practice Lessons Learned
- Dr. Mary Ellen Ehlers
- Dr. Ferdinand Venditti
2Background
- U.S. Healthcare System has
- High Costs,
- Variable Quality
- The adoption of information technology within
healthcare has been promoted as a way to reduce
costs and increase efficiencies as well as
improve quality. - Potential annual savings of billions by reducing
- Duplicate services caused by missing data
- Medical errors and adverse events
- Administrative costs
- The Federal Government is now driving the
adoption of Electronic Health Records via ARRA -
3Lack of Information when you need it.
- Clinicians reported missing clinical information
in 13.6 of visits - Missing information included laboratory results
(6.1), letters/dictation (5.4), radiology
results (3.8), history and physical examination
(3.7), and medications (3.2). - Missing information was reported to be somewhat
likely or very likely to adversely affect
patients (44), and to potentially result in
delayed care or additional services (59.5). - Significant time was reportedly spent
unsuccessfully searching for missing information
(5-10 minutes, 26 gt10 minutes, 10). - Missing clinical information was less likely
when individual clinicians reported having full
electronic records - Smith et al, JAMA. 2005293565-571
4ADEs in the Ambulatory Setting.
- Cohort study of 30,397 Medicare patients in a
single Multi-specialty group over 1 year - Collected all ADEs stemming from ambulatory
prescriptions - 1,523 adverse drug events were identified for an
overall rate of 50.1 per 1,000 person-years. - 28 were considered preventable
- 38 were serious or life-threatening and 42 of
these were deemed preventable - There were 11 deaths, 5 categorized as
preventable - Generalizing to entire Medicare population there
would be 1.9 Million ADEs with 685 deaths - Gurwitz et al, JAMA. 20032891107-1116
5EHR Adoption Survey
- National Survey of 2,758 physicians
- To determine the proportion of physicians who
were using such records in an office setting
DesRoches et al. NEJM 200835950-60
6EHR Adoption Survey
DesRoches et al NEJM 2008 35950-60
7Clinician Adoption of Available Functions
Simon et al. Arch Intern Med. 2007167507-512
8Factors Affecting Adoption
- Financial Systems are expensive
- 50-70,000 per MD to buy and implement
- Creates significant productivity decrease from
workflow redesign, training, site preparation,
and implementation - Disruption in the beginning
- Changes the way doctors and nurses practice
- Lack of perceived value
- Savings accrue to others payer and patients
- Lack of standards or guidance on systems
- Lack of IT expertise or knowledge
- Cultural barriers which are specific to a
Practice - Generational issues - often over-played
- Privacy concerns
- EHR adoption contingent on value creation,
somewhere...
9Factors Affecting Adoption Value Creation
- Most adopters have seen a business need
- Large practices, multi-site practices
- However, financial barriers critical for small
practices - Where most Americans receive healthcare
- Capturing and re-distributing value is critical
- Health Systems Hospitals
- Payers BC/BS MA, CDPHP
- Federal Government - ARRA
10Benefits Revenue Increase
Area/Benefit Description Range of Financial Benefits Basis Risk to Achieve
Coding Initiative EM Codes Electronic Health Record will offer system intelligence to assist with CPT4 and ICD9 coding. xxxx - xxxxx annually Detailed Analysis Moderate
Volume x increase on EM Codes Enhanced charge capture via efficiencies of an electronic venue for health records. xxxx - xxxxx annually Detailed Analysis Moderate
Volume x increase on Procedure codes Enhanced charge capture via efficiencies of an electronic venue for health records. xxxx - xxxxx annually Detailed Analysis Moderate
Revenue based on Quality Indicators EHR utilized to assist with insurance carrier based reward for quality measures. Est. xxxx - xxxxx annually P. Hildreth continuing to analyze and assess Moderate
11Benefits Expense Reduction
Area/Benefit Description Range of Financial Benefits Basis Risk to Achieve
FTE Reductions Salary expense of Practice staff performing duties related to hard copy medical records. xxxxx -xxxxx annually. Detailed Analysis Moderate
Transcription Expense Reduction of expenditure related to transcription services. xxxxxx - xxxxxx annually Detailed analysis to be completed based on Dept/Div implementation scheduled, and approval to use transcription in place of Elect Health Record. Moderate
Not why we moved forward with an Ambulatory EHR
12AMC Ambulatory EHR Vision
- Complete Information available on the right
patient, in the right place, at the right time. - To create a rich dataset to support Quality
Improvement efforts. - A Clinical Decision Support System to assist
Providers in reducing Medical Errors. - Enhance the Academic environment for our students
and trainees.
13AMC Faculty Practice
- 240 MDs with 14 clinical sites spread through the
region - Vast majority in subspecialties - Primary Care
sized for teaching - 400 residents and fellows in 33 training programs
- The teaching faculty for 550 medical students
- Several hundred ongoing clinical research trials
- Award winning Clinical programs in Heart Failure,
Heart Attack care, Diabetes, Stroke, Epilepsy,
Renal Transplantation, HIV - Though these programs are mostly islands when it
comes to their medical information
14Baseline Where we started
- Lots lots of paper, but
- E-signature and storage of outpatient
transcription for many years - Soarian repository which includes
- Laboratories
- Radiology
- Other Ancillary data
- PACS for radiology images as well as other
systems such and MUSE, Cardiac Echo, and
Endoscopy
15Vision
Baseline
16AMC EHR Journey
- Made the decision at senior level to move forward
with an ambulatory EHR in January 2005 - Started with a small circle of IT and Physician
staff - Site visits to educate and inform the group
- Widened the circle engaging the group that would
become the champions for the project - More site visits and education with ultimately 12
physicians - A guiding coalition
17AMC EHR Journey
- Developed an RFP for vendors with Physician
involvement - Went through a process for selection with
- presentations,
- demonstrations, and
- more site visits
- Simultaneously developed an internal business
case for the project with Physician involvement - Selected the Allscripts Touchworks product
18Allscripts Enterprise - Formerly known as
TouchWorks
- Base
- Scan
- Dictate
- Results
- E-prescribe
- Document
- Tasking
- Call processing
- Order
- Charge
- Note
- Analytics
19IMPLEMENTATION APPROACH
20Implementation Approach
- Close collaboration between IT and Practice
- Strong Physician Leadership and support
- Clinical Chairs involved through an Advisory
Committee - Physician Champion
- Physicians part of the Steering Committee
- Working Relationship with Vendor
21Implementation Approach
- Application delivered via Citrix
- Interfaces with practice management system and
multiple ancillary systems for result reporting - Preload of key information and electronic import
of historic laboratory, radiology, and other
ancillary data
22Baseline Data Preloaded
- 2 years of results - Labs, radiology, EKG,
Endoscopy - 2 years of Practice dictations including all
consultations - 2 years of Hospital dictations
- ED Visits
- Operative reports
- Discharge Summaries
- Scan documents decided by each site
- Outside consults
- Laboratories and other ancillaries
- Data more than 2 years old
- Dictations and Ancillary results from 2/09
forward
23Implementation Approach
- 2 pilot sites of primary care providers
- Phased go-live with functionality rolled out in
waves - Subsequent sites brought live in small groups
24Change Management..
25Implementation Approach
- Incorporation of change management techniques to
manage the process - Coordination of technical operations, integration
and build teams - Careful Workflow analysis
- Customized development with significant user
involvement and eye towards standardization
26Make sure you provide the right End use Devices.
27Implementation Approach
- Careful review and selection process for end use
devices - Different end use devices demonstrated at sites
choices ranged from tablets to desktops to WOWs - Hands-on sessions for providers
- Providers decided for their individual site
28Education, Education, Education
29Implementation Approach
- Extensive training and education for all users
- Role based
- Removed users from their clinical site for
training - Small group sessions
- One-on-one as needed
- Online materials, web-based training, reference
materials available - Trainers on site for Go-live and post go-live
support - Super-users at each clinical site
30APRIL FOOLS ?!?
31What is currently Live at AMC
- Patient Schedules
- History Builder
- Problem Lists
- Medication Lists
- Allergy Lists
- Dictation
- Results Reporting
- E-Prescribing
- Tasking
- Call Processing
- In-Office Orders
32Whos Live At AMC
- Medicine Pediatric group
- 8 MDs, 4 Nurses, 1PA,1 Pharm D, 16 Residents, 2-6
students, 25 support staff - General Pediatrics
- 8 MDs, 6 Nurses, 1NP, 30 Residents, 20 support
staff - ED, Billing, Peds Subspecialty MDs
- Approximately 80 View-Only Users
-
33How are we doing?
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36September 2009
- All live modules are used
- Tasking most problematic
- E-prescribing well accepted by prescribers
- ? More work for nurses
- Both sites requested change in scanning to have
less paper. - DUR turned off
37Be careful what you wish for.
38(No Transcript)
39Alert Fatigue
40Alert Fatigue
41Are Alert Overrides Appropriate?
- 7,761 drug-allergy alerts
- Alerts were overridden 80 of the time
- Review of 320 overrides, all deemed clinically
justified, however - 6 of patients experienced ADEs attributed to the
overridden drug - Only 6 of alerts triggered by exact match
between drug ordered and drug allergy - Evidence alerts are not specific enough
Hsieh et al JAMIA. 200411(6)482-491
42Challenges
- Software limitations
- Getting it right
- Task Views
- End use Devices
- Providers at multiple sites
- Faulty processes pre-EHR
- Balance
- Customize vs. Standardize
- Transition Electronic Paper
43From Our Users
- This saves me about an hour a day. We look
much more professionalwe can answer questions
about prescriptions right away - We forget we can WRITE prescriptions
- "The EHR is life altering.for patients and
physicians. Data is available in an organized
way when and where you need itprescriptions are
filled electronically (so handwriting is not a
problem!) and the record is clear regarding the
sequence of events in a patient's illness."
44Summary
- Careful planning
- Build a guiding coalition
- Teamwork (close collaboration)
- Involve the physicians
- Use feedback to alter the course
- Spend time in education