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EvidenceforElectronicHealthRecordSystems
02.17.2009
DanielJ.Vreeman,PT,DPT,MScAssistantResearchProfessor|IndianaUniversitySchoolofMedicine
ResearchScientist|RegenstriefInstitute,Inc
Copyright©2008
T558|OTManagementinToday'sHealth&CommunitySystems
Overview• Overviewofnationalhealthinformation
technologyinitiatives• Forcesdrivingadoptionofinformation
technologyinhealthcare• Evidenceforcomputerizedrecommendations
changingbehavior• EvidenceforEHRsinRehabilitation
ObjectivesUponparticipatinginthissession,youwillbeableto:
• Explaintheforcesinthecurrenthealthcareenvironmentpromotingadoptionofinformationtechnology
• Appreciatethetypesofproblemsinclinicalpracticeandhealthcaredeliverythatmaybeamenabletoimprovementwithmorejudicialuseofinformationtechnology
• Discussthekeyfactorsforsuccessaswellasimportantbarrierstoimplementingelectronichealthrecordsystemsinrehabilitation
RequiredReadings:• VreemanDJ,TaggardSL,RhineMD,WorrellTW.Evidenceforelectronichealth
recordsinphysicaltherapy.PhysTher.2006;86(3):434‐449.
WhyamIHere?
WidespreadRecognitionAbriefhistory
• 1960’s–Firststudiesofcomputersinhealthcare• 1991–IOMTaskForce• 2003–HHSbeginspromotingwidespreaduseofHIT• 2003–HHS,DoD,VAformConsolidatedHealthInformatics• 2004–PresidentBushmakesHITatopnationalpriority
– StateoftheUnionAddress:“bycomputerizinghealthrecords,wecanavoiddangerousmedicalmistakes,reducecosts,andimprovecare”
– CallsforEHRsformostAmericansin10years– CreatestheOfficeoftheNationalHealthITCoordinator
• 2004–DHHSResponds– SecretaryThompsonlaunchesthe“DecadeofHealthInformation
Technology”– Createsastrategytodevelopanationalhealthinformationnetwork
• Flurryoffederalactivity…• 2009–Stimuluspackage:$20billionforadoptingHIT
TheDecadeofHealthInformationTechnology
• Thevision– Complete,longitudinalhealthinformationfollowstheconsumer– Healthdecisionsaremadewithinformationtoolstoassistandguide
• The(envisioned)result– Fewermedicalerrors– Lesswastefulcare– Fewervariationsincare– Patient‐centeredcare– Employerswithproductivityandcompetitiveedgefromreducedspending
BigPictureWhatistheRoleofElectronicHealthRecords?
• EHRsaretheprimarybuildingblocks– Deliveringinfotoclinicians– Collectinginfofromclinicians(andinstruments)– Repositoriesforstoringdata
• Asuiteofapplicationsandprocesses– Notjustone‘program’– Farmorethanelectronicdocumentationsystems
• Lotsofacronyms– EHR,EMR,EPR,PHR,CPRS,DMR,etc…– Noconsensusdefinition– IOMconceptismostprevalent
TheEHRAnEHRIncludes:
1. Longitudinalcollectionofelectronichealthinformationforandaboutpersons
2. Immediateelectronicaccesstoperson‐andpopulationlevelinformationbyauthorized,andonlyauthorizedusers
3. Provisionofknowledgeanddecision‐supportthatenhancethequality,safety,andefficiencyofpatientcare
4. Supportofefficientprocessesforhealthcaredelivery
• Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System. Washington, DC: National Academy Press; 2003.
• A‘NetworkofNetworks’– Notacentraldatabase– Communicationviasharedsetoftechnicalandpolicyrequirements
– Lotsofwaysunderlyingnetworkscanform• Geography• Affinity
• Benefits– Leverageexistingdatapools– ‘Allhealthcareislocal’
BigPictureWhatWillThisLookLike?
IndianaNetworkforPatientCare• Aworkinghealthinformationexchangefor13+years
– 100sourcesystems– 1billiondiscreteresults– CoreparticipantinNHINprototypeprojects
• 5majorIndianapolishealthcaresystems– 24hospitals(95%ofhospital/ERcareinIndy)– Hospital‐associatedgrouppractices
• CountyandStatehealthdepartments– Immunizationrecords,labresults,tumorregistry
• Nationalandregionallaboratories• Lotsmoreontheway…
– 18newhospitalswithinexistingsystems– 12newhospitalshavesignedagreements– 10newhospitalshaveverballycommitted
McDonaldCJ,OverhageJM,BarnesM,etal.TheIndiananetworkforpatientcare:aworkinglocalhealthinformationinfrastructure.HealthAffairs.1005;24(5):1214‐1220.
• LimitedadoptionofEHRs– Social/politicalchallengesoftenhardest– Unequaladoptionratesbypracticesize
• Financialrisk– UncertainROI– Unequalaccumulationofbenefits
• Threatstoprivacyandsecurity
KeyChallengestoCreatinganNHIN
• LackofStandards– Silosofinformation
• Exchanginghealthinformationrequires:– Vocabularystandards– Messagingstandards– Transmissionstandards
KeyChallengestoCreatinganNHIN
TheDecadeofHealthInformationTechnology
• RegionalHealthInformationOrganizations(RHIOs)• NationwideHealthInformationNetwork(NHIN)• DrivingEHRAdoption
– ReducetheriskofinvestinginEHRs– Developingacertificationprocess– Provideimplementationsupport
KeyFocusAreas
ForcesinHealthcareDrivingAdoptionofInformationTechnology
Consumerism
• Empoweredpatientswithchangingexpectations– Technology‐enabledexperiences
• Consumers(patients)aredemanding– Speed– Convenience– Customizedserviceandtools– Security,confidentiality
• Patientsmovefasterandfurtherthantheirhealthinformation
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
ConsumerismHowcaninformationtechnologyhelp?
• Consumersviewtechnologyas‘state‐of‐the‐art’– Canpromoteaperceptionofhighquality
• Integrateinformationfrommultiplesourcesacrossthelife‐span,butwithchallenges
• Repositoriescanbesubstratefor– Customizinghealthcaredeliveryandresource
distribution– Enablingprocess/systemintegrationtoimprove
consumerexperience
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
PersonalHealthRecords• Afastgrowingareaofinterest/activity
ExpandedUsesofHealthInformation
• JCAHO– Requiresdatatosupportmanagementops,
performanceimprovement,patientcare• HIPAA
– Adminprocedures,physicalsafeguards,security– Standardsforelectronicclaimsattachments
• PublicHealth• ClinicalResearch
– Clinicaldatarepositorieshavewelldocumentedresearchuses
ExpandedUsesofHealthInformation
• PracticeManagement– Exponentialincreasesindemandforvarioustypesofadministrativereports• Referralpatterns• Productivity• Lotsmore…
– Outcomestracking• Practice‐basedEvidence• Payforperformanceinitiatives
ExpandedUsesofHealthInformationHowcaninformationtechnologyhelp?
• Largepotentialefficienciesviaimproveddata– Storage– Processingandanalysis– Transmission– Monitoringandtracking(qualityassurance)
• Keyenabler:structureofunderlyingdata– Buildflexibleanalyticsontop
CostofCare
• USspends$1.7trillionannually– 16%ofGDP• 2xtheEUaverage
• Seriousproblemswith– Inefficiency– Poorquality– Lackofaccess
CostofCareHowcaninformationtechnologyhelp?
• Estimatesofsaving$140billionannually– CentralIndianaestimates$120million
• How?– Improvedinformationsharingandcarecoordination– Reducedredundancyandmedicalerrors
• Challenge:mereadoptionwon’tproducesavings– Realprocesschange(transformation)mustoccur
• Misalignedfinancialincentives
Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Affairs. 2005;24(5):1103-1117.
ClinicalDecisionMaking
• Makingsoundclinicaldecisionsrequires:– Rightinformation,righttime,rightformat• EBP(Patients+evidence+clinicalexpertise)– Lotsofhype– Clinicianswantit,butdon’thavetime
• Cliniciansfaceasurplusofinformation– ambiguous,incomplete,orpoorlyorganized
• Risingtideofinformation– Expandingknowledgesources– Improvedcommunicationmethods
Tierney WM. Improving clinical decisions and outcomes with information: a review. Int J Med Inf. 2001;62:1-9.
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
ClinicalDecisionMakingWhat’stheProblem?
• Manisanimperfectdataprocessor– Sensitivetoquantityandorganizationofinformation
• Decisionshurtbytoomany,toofew,orpoorlyorganizeddata
– Cliniciansaresusceptibletoerrorsofomission• Humansare“non‐perfectable”dataprocessors
– Betterperformancerequiresmoretimetoprocess– Irony
• Cliniciansincreasinglyfaceproductivityexpectations• Cliniciansfaceincreasingadministrativetasks
• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist’s role. Phys Ther. 1999;79(2) 171-185.
• American Physical Therapy Association. Reported Productivity Expectations of PTs 1999-2002. Available from http://apta.org
EBPandQualityofCareHowcaninformationtechnologyhelp?
• Eliminatethelogisticproblems• Efficientaccesstoprimaryliterature• Efficientaccesstoneededclinical
information• Toolstosupportimplementingthebest
evidenceatthepointofcare– Computersaretirelessdataprocessors
Vreeman DJ. Clinical prediction rules. Phys Ther 2006;86(5):761-762.
Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
WhatisaComputerizedReminder?
• Acomputer‐generatedsuggestionaboutclinicalcareforanindividualpatient– InformedbydatastoredinanEHR– SuggestionsbasedonprogramsthatoperationalizeEBPascomputablerules
• Oftenintegratedintoaclinicalapplication– E.g.Providerorderentryordocumentation
• Mostcommonformofcomputerizeddecisionsupport• Canbepresentedonpaperoraworkstation
CareReminders
ComputerizedReminder
EvidenceforComputerizedRemindersALongHistory
EvidenceforComputerizedReminders
EvidenceforComputerizedReminders
WhyInformationTechnology?
• Alloftheseforces– Clinicaldecisionmaking(EBP)– Qualityofcare– Consumerism– Expandedusesofhealthinformation
areconvergingontheneedtoeffectivelymanagehealthinformation
• Inadequacyofourcurrentpaper‐basedhealthinformationsystem
Whyaretherenoreminderstudiesinrehabilitation?
RemindersforRehabProvidersHowCanComputersHelp?
• Activity:Examplesfromclinicalpractice– Contentofthereminder– Whatdatawouldthecomputerneed?
ImplicationsforRehabilitation
EvidenceforEHRs
EvidenceforEHRsinRehabilitation• TheEHRsoperatedonallmajorhistoricalclassesofcomputers– 1968–2004
• Software– 12/13usedin‐housedeveloped– Only1usedcommercialsoftware
• Widevarietyofpracticesettings– Earlyintervention,outpatient,sub‐acute,actue
BenefitsofEHRs
BarrierstoImplementingEHRs
SuccessFactorsinImplementingEHRs
EvidenceforEHRsinRehabilitation
AdditionalRecommendationsMyOpinion
• AdoptEHRs,butbemindfulofthecomplexityinvolved– Clinicianworkflow(nothardware)isparamount
• MakeEHRpurchasedecisionswiththeNHINvisioninmind– Demandfeaturesofinteroperability
• HL7Messaging(import/export)essential– Whatfeatureswillhelpmemakebetterclinicaldecisions?
– Whatvocabularystandardsaresupported?
OtherQuestions?
