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Clinician Adoption: Physician Perspective Best Practice

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Clinician Adoption: Physician Perspective Best Practice & Lessons Learned Dr. Mary Ellen Ehlers Dr. Ferdinand Venditti Implementation Approach Incorporation of change ... – PowerPoint PPT presentation

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Title: Clinician Adoption: Physician Perspective Best Practice


1
Clinician Adoption Physician Perspective
Best Practice Lessons Learned
  • Dr. Mary Ellen Ehlers
  • Dr. Ferdinand Venditti

2
Background
  • 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

3
Lack 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

4
ADEs 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

5
EHR 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
6
EHR Adoption Survey
DesRoches et al NEJM 2008 35950-60
7
Clinician Adoption of Available Functions
Simon et al. Arch Intern Med. 2007167507-512
8
Factors 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...

9
Factors 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

10
Benefits 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
11
Benefits 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
12
AMC 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.

13
AMC 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

14
Baseline 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

15
Vision
Baseline
16
AMC 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

17
AMC 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

18
Allscripts Enterprise - Formerly known as
TouchWorks
  • Base
  • Scan
  • Dictate
  • Results
  • E-prescribe
  • Document
  • Tasking
  • Call processing
  • Order
  • Charge
  • Note
  • Analytics

19
IMPLEMENTATION APPROACH
20
Implementation 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

21
Implementation 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

22
Baseline 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

23
Implementation Approach
  • 2 pilot sites of primary care providers
  • Phased go-live with functionality rolled out in
    waves
  • Subsequent sites brought live in small groups

24
Change Management..
25
Implementation 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

26
Make sure you provide the right End use Devices.
27
Implementation 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

28
Education, Education, Education
29
Implementation 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

30
APRIL FOOLS ?!?
  • Go-Live
  • April 1, 2009

31
What 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

32
Whos 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

33
How are we doing?
34
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35
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36
September 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

37
Be careful what you wish for.
38
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39
Alert Fatigue
40
Alert Fatigue
41
Are 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
42
Challenges
  • 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

43
From 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."

44
Summary
  • Careful planning
  • Build a guiding coalition
  • Teamwork (close collaboration)
  • Involve the physicians
  • Use feedback to alter the course
  • Spend time in education
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