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Benefits (and Risks) of EHRs


Benefits (and Risks) of EHRs Georgetown University April 2, 2009 John K. Cuddeback, MD, PhD Chief Medical Informatics Officer Anceta AMGA s Collaborative Data ... – PowerPoint PPT presentation

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Title: Benefits (and Risks) of EHRs

Benefits (and Risks) of EHRs
  • Georgetown University
  • April 2, 2009
  • John K. Cuddeback, MD, PhD
  • Chief Medical Informatics Officer
  • Anceta AMGAs Collaborative Data Warehouse
  • American Medical Group Association

  • Background on AMGA
  • Multi-specialty medical group model of health
    care delivery systems thinking in a fragmented
  • History of IT in healthcare
  • Driving forces
  • Four eras
  • Goals for point-of-care systems
  • Reasons to be cautious about economic stimulus
  • Inferential gap in medicine
  • Other opportunities and ROI studies
  • Complementary tools Point-of-Care Systems and
    Retrospective Analytics
  • Substantial variation in practice
  • Unintended consequences of IT in healthcare
  • Recent research on adoption and effectiveness of
  • Discussion Policy implications

American Medical Group Association

AMGA improves health care for patientsby
supporting multispecialty medical groups and
other organized systems of care. Founded in 1949
  • 340 medical groups
  • 95,000 physicians
  • Delivering health care to more than 95 million
    patients each year, in 47 states
  • Average group size is 286 physicians, with 20
  • Median group size is 110 physicians, with 9 sites
  • Approximately one-third of members own one or
    more hospitals

2008 data
AMGA Values
  • Physician leadership
  • Fully integrated, efficient, patient-centered,
  • Team work across specialties
  • Continuous improvement of patient care systems
  • Total coordinated care through the use of
  • Interoperable electronic health records
  • Dedicated care managers or care coordinators
  • Evidence-based care guidelines
  • Systematic monitoring of quality and efficiency
  • Transparency and accountability for clinical care
    outcomes at the group level

2009 AMGA Board Members
  • Carilion Clinic (VA)
  • Carle Clinic Association (IL)
  • Cleveland Clinic
  • Franciscan Skemp Healthcare / Mayo Health System
  • Geisinger Health System (PA)
  • Henry Ford Health System (MI)
  • Intermountain Healthcare
  • The Iowa Clinic
  • The Jackson Clinic (TN)
  • Lahey Clinic (MA)
  • Mount Kisco Medical Group (NY)
  • Northwest Physicians Network (WA)
  • The Permanente Federation
  • St. Johns Clinic (MO)
  • University of Utah Hospitals Clinics
  • American Medical Group Association (ex officio)

Driving Forces for Development of Health IT
  • Parallels trends seen in other industries
  • Automate administrative functions (billing,
    financial management)
  • Automate core business processes ? access to
    information, greater consistency
  • Transform core business processes ? dramatic
    gains in quality and efficiency
  • Pre-2000 emphasis in health care systems
  • Administrativepatient management (registration,
    bed control) and patient billing
  • Systems for clinical departmentslaboratory,
    radiology, pharmacy, operating room, ED
  • Current emphasis, pre-stimulus package
  • Its not about technology, or even
    informationits about leveraging I as well as
    T to transform care
  • Automate risk-prone processesbarcode medication
  • Integrate data and systems around the patient,
    not hospital departments
  • And beyond the bedsideacross the continuum of
  • Integrate across institutionshealth information
    exchange (HIE), regional health information
    organization (RHIO)
  • Involve the patient and familypersonal health
    record (PHR)
  • Care coordinationPatient-Centered Medical Home
  • Comparative effectiveness research
  • Use real-world data to determine which treatments
    are most (cost-) effective
  • Economic stimulus packageAmerican Recovery and
    Reinvestment Act
  • 19 billion for Health ITcombination of grants
    and loans for purchase, incentives for
    meaningful use

Three Eras of IT in Health Care
Process IntegrationWorkflow Transformation
Data Integration Patient-Centric View Clinical
Decision Support CPOE
Technology Infusionfrom Other Industries
Implications for skill development ?
...for culture?
Goals for (Hospital) Point-of-Care Systems
  • Important twists in ambulatory care
  • Longitudinal perspectiveprevention
  • Fee-for-service paymentdocumentation
  • Enhance patient safety
  • Reduce unwarranted variation in practice
  • Smart resource utilization ? better outcomesat
    lower cost
  • Improve productivity and convenience for
  • Physician loyalty ? volume
  • Recruitment and retention for nurses and other
  • Competitive position of GME programs
  • Increase operational efficiency (workflow)
  • Eliminate rework and delay
  • Credibility for resource utilization efforts

Patient safety may be the main reason to adopt
point-of-care systems, but safety is only one of
many benefits.
Reasons to be Cautious
  • TechnologyEHR is far more than an electronic
  • Point-of-caredecision support, decision
    execution (workflow management/monitoring), team
  • Semantic interoperabilitymessaging standards,
    coding/content (information in computable form)
  • Use of data for improvementanalytical tools and
    skills, leading change
  • Workflow redesign
  • Never designed in the first place
  • Hospital ? Ambulatory
  • Payment incentives
  • System developers have focused on documentation
    and coding ? tangible ROI (pay-for-verbosity)
  • Fee-for-service encourages services if costs are
    to be controlled, the payment mechanism must
  • Culture of collaboration
  • Trust
  • Systems thinking
  • Data-driven QI

Electronic Medical Record
128-Slice CT Scanner, orRobotic Surgery System
  • New way of performing current functions
  • Soft benefits Quality, Safety, Efficiency
  • Little incremental revenue
  • Fundamental organizational change
  • Impacts everyonechange management, workflow
    redesign, device ergonomics
  • Requires culture, leadership commitment
  • Perceived as high-risk
  • Relatively immature technology
  • Still significant RD 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
  • Appliance
  • Few users, many beneficiaries
  • Sells itself
  • Risk is limited in scope
  • Mature technology
  • Development investment ? new product
  • Plug it in
  • Embedded algorithms
  • Benefits easily realized
  • ...but may be short-lived
  • Reliable win on traditional criteria

Rate of Absorption of Stimulus Funding
  • Informatics trainingAMIA 1010 initiative
  • Both practical skills (project management,
    workflow redesign) and theoretical work
    (knowledge representation)
  • Pace of cultural change
  • Organizational structures and governance
  • Clarify roles and expectations, build
    trustgenerational effects
  • Alignment of incentives (payment)
  • Realistic expectations
  • Care coordination in an open systemmany moving
    parts to the medical home
  • Many complex issuesare alerts and provider
    responses part of the legal medical record?
  • Current products and standards are still
    maturinglimited adoption, limited measurable
  • Stimulus includes 20 billion for health IT and
    comparative effectiveness
  • Entire US health IT industry was 26 billion in
  • Stimulus funding is a great deal, but it is also
    not enough to cover full implementation

  • Hypothetical 79-year-old woman with
  • chronic obstructive pulmonary disease,
  • type 2 diabetes mellitus,
  • hypertension,
  • osteoarthritis, and
  • osteoporosis,
  • all of moderate severity.
  • 12 separate medications
  • 19 doses per day
  • 05 separate dosing times/day
  • 4,877 medication cost/year (generics)

  • Alerts and reminders
  • Evidence-based care guidelines
  • Documentation standards
  • Potentially even more powerful customized care
  • Randomized controlled trials (RCTs) are regarded
    as the gold standard
  • Questions are narrow by design, relying on
    randomization to neutralize potentially
    confounding effects, in order to obtain
    definitive answers
  • RCTs typically involve younger patient
    populations, with single diagnoses, over brief
    study periods
  • Are the conclusions applicable to older
    patientsand those with multiple diseases?
  • RCTs are expensive and time-consuming
  • Typical drug trial may take 1015 years and cost
    10300 million
  • Cannot keep pace with development of new
    diagnostic and therapeutic modalities

No Safety Net for Medication Administration
Errors Resulting in Preventable and Potential
Adverse Drug Events
Bates et al., JAMA 199527429-34
Medication Management Cycle
  • Provide advice to prescriber
  • Protocols/algorithms
  • Check allergies, labs, diet
  • Drugdrug interactions
  • Drugdisease (w/ problem listor working
  • Antibiotic sensitivity data
  • Impose (friendly) constraints
  • Complete, formatted orders
  • Formulary, drug database(vs. reliance on memory)
  • Generic/ trade names
  • Typical doses
  • PO meds if on regular diet

  • order information to pharmacy
  • copy of order in chart (until full EMR)
  • copy of order onto Kardex

Patient Monitoring
Medication Administration Record (MAR)
Quality Control
Symbol PPT 2740ruggedized, pen/touch input PDA
w/ laser barcode reader and WiFi
Critical Success Factors for Clinical Systems
  • Clinical and operations leadership (1)
  • Strategic commitmentbeyond the IT project
  • Clinical and operational improvement initiative
    that leverages information technology, not a
    technology initiative
  • Focus on realizing clinical and operational
    benefit, rather than vendor selection
  • Knowledge managementclinical content
  • Outcomes dataanalytical skills
  • Understand processoutcome relationships
  • Process redesign skills
  • Technical supportavailability/reliability
  • User support, device ergonomics
  • Tracking ROI ? on-going reinvestment

Incremental or Big Bang?
Estimated ROI for Full Ambulatory EHR
  • Estimated cost savings
  • Save 28,000 per average provider per year
  • Revenue enhancement
  • Eliminate more than 10 in rejected claims per
    outpatient visit
  • Address drug, procedure and coding issues through
    advanced clinical decision support
  • Productivity Gains
  • Neutral effect on provider time with improved
    staff productivity

2004 study by Center for IT Leadership Partners
Healthcare, Boston, MA
Even Greater Potential ROI from Interoperability
External Data
Concept or reality?
New Approach to Quality Management
Traditional Quality Assurance
Bad Apples
Hypothetical distribution of patients treated,
showing how often various levels of quality are
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
LOS for Kidney Transplant
Hosp A, B
Hosp A
Percent of Cases
Length of Stay (LOS)
1991 UHC data
Differences in Rates of Hospital Admission
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.
Small-area analysis
Childrens Hospital of Pittsburgh
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 patients 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 departments 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. 15081509) Yong
Y. Han et al. Unexpected Increased Mortality
After Implementation of a Commercially Sold
Computerized Physician Order Entry System.
Pediatrics 2005 116 15061512.
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
  • Rather than framing the problem as not
    developing the systems right, these failures
    demonstrate not developing the right systems
    due to widespread but misleading theories about
    both technology and clinical work.
  • The misleading theory about technology is that
    technical problems require technical solutions
    i.e., a narrowly technical view of the important
    issues involved that leads to a focus on
    optimizing the technology. In contrast, a more
    useful approach views the clinical workplace as a
    complex system in which technologies, people, and
    organizational routines dynamically interact....
  • There is quite a large mismatch between the
    implicit theories embedded in these computer
    systems and the real world of clinical work.
    Clinical work, especially in hospitals, is
    fundamentally interpretative, interruptive,
    multitasking, collaborative, distributed,
    opportunistic, and reactive. In contrast, CPOE
    systems and decision support systems are based on
    a different model of work one that is objective,
    rationalized, linear, normative, localized (in
    the clinicians mind), solitary, and
    single-minded. Such models tend to reflect the
    implicit theories of managers and designers, not
    of frontline workers.
  • Introduction of computerized tools into health
    care should not be viewed as a problem in
    technology but rather a problem in organizational
    change, in particular, one of guiding
    organizational change by a process of
    experimentation and mutual learning rather than
    one of planning, command, and control.
  • This implies that any IT acquisition or
    implementation trajectory should, first and
    foremost, be an organizational change trajectory.

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January 9, 2009
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 3595060, July 3, 2008
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Prospects for the Future
  • Growing public expectationssafety and quality
    are no longer taken for granted
  • Providers face increasing pressures on cost, as
    well as quality
  • Weve done all the easy stuffunit cost,
    straightforward utilization management
  • Were forced to address the higher level
    issuesworkflow, process integration, over-use,
    access to care
  • Growing willingness to learn from real-world
    experiencedata warehouses, analytics
  • We are beginning to see realistic incentives
    pay-for-performance programs (P4P)
  • Incent improved care enabled by IT, not HIT
    adoption per se
  • Still need more fundamental payment reform
  • EHR designs have responded to payment pressures
    volume (piecework orientation),
  • Align economic benefits with investment
  • Still too optimistic about interoperable IT as
    a solution for a fragmented care system
  • Gaining a critical mass of health care workers
    who demand, rather than reject, technology
  • Learning to distinguish clinical content and
    systems thinking from techno-gadgetry
  • Recognizing the possibility of making things
    worse (negative unintended consequences) and
    learning how to avoid doing so

We tend to underestimate the long-term impact of
technology,but we invariably overestimate the
pace of adoption.
Bill Gates
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