Primary Care Requirements for EHR

1. Primary Care Requirements for EHR AMIA Symposium 2017 Primary Care Informatics Workgroup Alan E Zuckerman MD FAAP aez@georgetown.edu Jeffrey Weinfeld MD MBI FAAFP weinfelj@georgetown.edu Georgetown University School of Medicine Washington DC 20007

2. Disclosure • Dr. Zuckerman discloses that he has no relationships with commercial interests. • Dr. Weinfeld discloses that he has no relationships with commercial interests. AMIA 2017 PCIWG Workshop

3. Learning Objectives • After participating in this activity, the learner should be better able to: • Define 8 key attributes of primary care and connect each of the attributes to functionality an EHR can provide • Identify at least three things are not working well with EHR support of primary care • Describe one or more use cases that illustrate what is required for an EHR to provide good primary care support • Explain one or more reasons why EHR is not meeting the needs of primary care • Identify one or more solutions that could improve EHR ability to support primary care and state it as a right for pc providers AMIA 2017 PCIWG Workshop

4. Overview • The attributes of Primary Care and their implications for EHR. • What is not not going well. • Primary Care use cases illustrate how an EHR can support primary care properly. • What went wrong and how can we fix it. • A primary care clinician’s Bill of Rights: What providers are entitled to expect from an EHR. • Next steps to get to where we want to go? AMIA 2017 PCIWG Workshop

5. The Attributes of Primary Care Help Shape the Requirements for EHR support of Primary Care Alan E Zuckerman MD We Need a Frame of Reference That Defines Our Values AMIA 2017 PCIWG Workshop

6. Sources of the IOM Definition of Primary Care • The IOM definition of Primary Care was first articulated in • Donaldson MS, Yordy KD, Lohr KN, et al. Primary Care: America’s Health in a New Era. Washington, DC: National Academy Press, 1996. • And was later summarized in • Krist AH, et al.: Electronic health record functionality needed to better support primary care. J Am Med Inform Assoc 2014;21:764–771 2014. AMIA 2017 PCIWG Workshop

7. Key Primary Care Attributes Defined by the Institute of Medicine (IOM) • Primary Care is … • Accessible • Coordinated • Sustained [or Continuous] • Comprehensive • A Partnership with Patients • Person-centered • Integrated • Accountable AMIA 2017 PCIWG Workshop

8. How Can an EHR Make Care Accessible? • Accessible means accessible in terms of patients both being able to have a primary care clinician and being able to receive care when needed and convenient. • An EHR can promote accessibility by: • Making primary care providers more efficient. • Allowing patients to book appointments. • Coordinating care with urgent care and emergency departments. • Preventing clinician burnout. AMIA 2017 PCIWG Workshop

9. How Can an EHR Make Care Coordinated? • Coordinated means across all services and settings, proactively providing all needed care and information in the right sequence, and appropriately using resources. • An EHR can promote coordinated care by: • Sharing data between primary care and specialists. • Improved communication within the office AMIA 2017 PCIWG Workshop

10. How Can an EHR Make Care Sustained? • Sustained means providing longitudinal care over a patient’s lifetime, as opposed to a single encounter or isolated exchange, and continuous care for events occurring is disparate settings over time. • An EHR can promote sustained care by: • Integrating information from all providers. • Visualizing data over a patient’s lifetime. • Transferring usable records to future new practices. • Efficiently visualizing a patient summary for a patient not seen before. • Providing reminders for tasks in preventive care and chronic care. AMIA 2017 PCIWG Workshop

11. How Can an EHR Make Care Comprehensive? • Comprehensivemeans addressing the entire scope of services (prevention, chronic care, acute care, and mental health) at any given Stage of a person’s life, and being delivered in all needed settings (office, home, emergency room, hospital, and nursing home). • An EHR can promote comprehensive care by: • Keeping preventive care needs visible at all times in all settings. • Brings needed medical information to the point of care. • Improving communication between different care settings. AMIA 2017 PCIWG Workshop

12. How Can an EHR Make Care A Partnership with Patients? • A Partnership with Patients means focusing on the therapeutic alliance and relationship-based approach to care to help advocate for and guide patients through the health system, seek agreement on health goals, and account for each individual’s values and preferences. • An EHR can promote a partnership with patients by: • Displaying patient preferences (beyond just advance directives) to all providers. • By visualizing the patient’s family, occupation, and home situation. • By accepting patient collected data. • By providing patients their data in usable and understandable form. AMIA 2017 PCIWG Workshop

13. How Can an EHR Make Care Person-centered? • Person-centered means addressing whole person care and delivered in the context of family (living conditions, family dynamics, and cultural background) and community (context for identity, source for social and psychological support, and determinant of the patient’s environment). • An EHR can promote person-centered care by: • Making the family context of care known to the current provider. • Clearly documenting patient values and preferences and retaining responses to experience with previous therapies • Accepting and using patient provided data particularly on “as needed” or “emergency” medications AMIA 2017 PCIWG Workshop

14. How Can an EHR Make Care Integrated? • Integrated means creating a system that allows all of the primary care attributes to function within practices, across the entire care delivery system, and throughout community population. • An EHR can promote integrated care by: • Sharing information between all of a patient’s providers and settings even if they are not on the same corporate vertically integrated system. • By importing discrete data by a patient summary, such as a new medication or a new lab result, into an EHR as computable data and not just human readable data. AMIA 2017 PCIWG Workshop

15. How Can an EHR Make Care Accountable? • Accountable means primary care clinicians and the systems in which they operate are responsible to their patients and communities for addressing a large majority of personal health needs through a sustained partnership with a patient in the context of a family and community and for (1) quality of care, (2) patient satisfaction, (3) efficient use of resources, and (4) ethical behavior. • An EHR can promote accountable care by: • Implement quality of care assessment and improvement projects. • Improve efficient use of resources. • Supporting good population medicine practices. AMIA 2017 PCIWG Workshop

16. AAFP Vision for a Principled Redesign OfHealth Information Technology • Envision a future state that involves the principled redesign and implementation of health information technology (IT) that optimally supports the health and health care of the US populace. • Move beyond present-day constraints to envision a future health care system where primary care has a central role in making meaningful improvements in the health of the individuals, communities, and populations that they serve, and in which health IT is a critical enabler of that work. • Technology was not “a fix” for what everyone took to be a “broken” health care system. • Technology will facilitate an ease of knowing, allowing individuals and their health care professionals to have a comprehensive view of their health, which includes individual, community, and environmental aspects of health, and to use this information in developing and executing personalized care plans. From: The American Academy of Family Physicians: Vision for a Principled Redesign of Health Information Technology. Ann Fam Med 2017;15(3):285-286. AMIA 2017 PCIWG Workshop

17. The Constraints of Primary Care Influence the Expectations and Need for EHR • Primary care clinicians have limited patient contact time so they must work efficiently to get everything done. • Primary care clinicians see a wide range of acute and chronic problems as well as provide comprehensive preventive care so they need reminders, point of care information access, and effective visualization of patient data. • Primary care providers have limited technical support in the patient care ambulatory setting. • Primary care providers have low budget priority in large organizations making system customization unlikely and slow. AMIA 2017 PCIWG Workshop

18. How What We are Doing Now is Not Working For Primary Care Jeffrey Weinfeld MD We Need to Align EHR with the Needs of Primary Care AMIA 2017 PCIWG Workshop

19. Outpatient EHR Adoption 2015 86.9% using any system, 77.9% certified systems, 53.9% basic system Office of the National Coordinator for Health Information Technology. 'Office-based Physician Electronic Health Record Adoption,' Health IT Quick-Stat #50. dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php . December 2016, accessed 10/16/17. AMIA 2017 PCIWG Workshop

20. PCMH Meaningful use ACOs QPP MIPS/MACRA Unrelenting change!

21. EHR AMIA 2017 PCIWG Workshop

22. The Computer Is Becoming a Barrier to Doctor Patient Communication Look at the patient not just at their labs Second opinion from the computer Refer patient to another doctor’s blog AMIA 2017 PCIWG Workshop

23. Pajama Time 1 – 2 hours per night on computer and clerical work (Sinsky C. Annals of Internal Medicine 2016) 48 minutes per day EHR-associated loss of free time (McDonald CJ. JAMA IM 2014)

24. Physician Burnout a Problem 54% of Physicians burnt out! Shanafelt. Mayo Clin Proc. 2015;90(12):1600-1613

25. Quadruple aim From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.(Bodenheimer T and Sinsky C. Ann Fam Med 2014;12:573-576. doi: 10.1370/afm.1713) AMIA 2017 PCIWG Workshop

26. Primary Care Challenges in Using EHRs Usability • Functionality Communication • Psychosocial Zhang J, et al. JAMIA 2016;23:137–143

27. There is a Need for Radical Revision of Billing / Coding Guidelines • Get rid of Review of Systems • Focus on Medical Decision Making AMIA 2017 PCIWG Workshop

28. Implementation Issues • Long training times • “How can we tailor this for you?” instead of “What do you want here?” • Unconfigured and Clinical Decision Support • We need to learn from each and share tools that work. • Start with a “best practices” set of content instead of a blank shell AMIA 2017 PCIWG Workshop

29. Important Primary Data is Missing from Many Records • Primary care provider/team • Patient generated data • Data from received patient summaries • Data from other organizations AMIA 2017 PCIWG Workshop

30. Primary Care Use Cases Illustrate How an EHR Should Support Primary Care Jeffrey Weinfeld We Need a Model of Excellence AMIA 2017 PCIWG Workshop

31. What is a Primary Care Use Case? • A Use Case is a written description of how a user will perform specific tasks • It highlights • The goal of the task • The information requirements • The parties and stakeholders who participate in the task • The sequential exchange of information that is required • The displays and visualization of the task • How completing the task will satisfy goals and requirements • A primary care use case illustrates what is needed to deliver on the attributes From https://www.usability.gov/how-to-and-tools/methods/use-cases.html AMIA 2017 PCIWG Workshop

32. Primary Care Use Cases part 1 Jeffrey Weinfeld Components of a Patient Encounter AMIA 2017 PCIWG Workshop

33. Writing a Note • Use case – A note is generated during the visit with minimal effort from the physician. The note writing process does not impede doctor-patient communication. Editing is possible at any time and is fully versioned. • A critical part of the record • Varies from unstructured to partly structured by EHR • Should flow naturally from what is done in the record • Should not contain extra text that is unnecessary (note-bloat) AMIA 2017 PCIWG Workshop

34. Determining the Primary Care Provider • Continuous Care requires knowing if the person seeing the patient is the primary care provider, or if not, who is. • Residents as PCP vs attending vs billing provider. • Knowing the primary care provider enables the type of communication needed for coordinated care and integrated care. • Opportunity for targeted CDS AMIA 2017 PCIWG Workshop

35. Knowing Why the Patient Came to See You • Patient-centered care requires understanding why a patient came to see a provider at a given point in time. • Chief Complaint or reason for visit usually not coded and not always the same. • Integrating acute care with chronic care and preventive care is essential to provide comprehensive care. • Navigating a problem oriented medical record may require moving between data entry to assessment and plan for different problems as they come up in the course of an encounter rather than sequential movement from one section of the EHR to another. The agenda for a visit changes during the visit. AMIA 2017 PCIWG Workshop

36. Knowing About Other Recent Encounters and Tests and Who is Managing Which Problems • Integrated and Continuous care requires understanding all of a patient’s providers and events that have occurred since the last encounter with the primary care practice. • Encounter List vs Provider list vs Document List (with authors but no setting) • A primary care friendly EHR can sort out episodes of illness and episodes of care linking multiple phone messages and documents to an encounter for a specific problem. AMIA 2017 PCIWG Workshop

37. Transfer of Care After an ER Visit or Hospitalization • An interesting by-product (? Unintended consequence) of the Meaningful Use EHR Incentive Program is a proliferation of Patient Summary Documents (in CCD format). • Integrated care requires assimilation of key data in these transfer of care documents into the primary care record which requires reconciliation not just of medications, but also problems, immunizations, labs, and other data. • Some steps are mandated such as medication reconciliation at hospital admission, hospital discharge, and outpatient visits – many other steps seem to fall through the cracks. AMIA 2017 PCIWG Workshop

38. Chronic Disease Management using Quality Assurance (QA) and Clinical Decision Support(CDS) • A key challenge to both QA and CDS is having the right data to support guidelines. • An EHR can both re-use existing data and prompt for additional clinical data that needs to be structured and codes. • Often requires custom development. • Just-in-time reminders and prompts need to be intelligent to avoid alert fatigue and inappropriate recommendations. • The problem list alone may not be adequate to trigger correct chronic disease identification AMIA 2017 PCIWG Workshop

39. Use of Patient Generated Data • Part of building a Partnership with Patients requires that we use data that only a patient can provide to their primary care provider. • Patients are using apps and devices that capture important data on fitness, use of “as needed” medications, home monitoring of physiologic parameters and patients expect their doctor to be interested and able to use the information. • Most EHR are not yet equipped to handle this type of patient generated data and security fears and time constraints are rate limiting barriers that even many patient portals cannot overcome. AMIA 2017 PCIWG Workshop

40. Giving a Patient a Visit Summary at the end of the Visit • MU regulations are driving primary care clinicians to provide patient summaries. • What most EHR can generate is far from ideal, may rely too heavily on the provider to generate narrative text, and does not necessarily meet the patient’s needs to maintain a personal health record. • Better - maximize auto-population of data, set up tracking and notification for key tasks that both the provider and patient need to do after the encounter is over. AMIA 2017 PCIWG Workshop

41. Primary Care Use Cases Part 2 Alan E Zuckerman MD Visualizing the Data AMIA 2017 PCIWG Workshop

42. What is Data Visualization? • Continuous Care requires effective data visualization • Every EHR will have a problem list, medication list, allergy list, immunization list, vitals signs, and lab results; but what we get is usually just the raw data. • Creative processing of the data, summarization over time, and graphical display enhance our ability to use large amounts of data that will accumulate over a patient’s lifetime of primary care. • The Pediatric Growth Chart is an excellent example of the need to creatively visualize data and a Boston Children’s app implemented using FHIR is a powerful demonstration of what can be done. AMIA 2017 PCIWG Workshop

43. Medication ReconciliationTwinList Demo Revisited • It is not surprising that this mandatory task has been called “Med-Wreck” as it is often not done very well and takes a lot of provider effort. • The 2011 University of Maryland Human Computer Interface Lab (HCIL) TwinList demos are a great example of what a computer can do to make the task easier and thrilled audiences at AMIA 2012. • It is open source code, yet who is using it? • A look at both demo1 and demo2 provides insight into how analysis of the task can help design a better EHR. AMIA 2017 PCIWG Workshop

44. TwinList DemoNovel Interfaces for Medication Reconciliation • Twinlist Demo (part1) Introduction to TwinList • https://www.youtube.com/watch?v=YoSxlKl0pCo • Twinlist Demo (part2) Advanced Features and Alternative Designs • https://www.youtube.com/watch?v=dABfksDvOiw • University of Maryland Human Computer Interaction Laboratory • www.cs.umd.edu/hcil/sharp/twinlist AMIA 2017 PCIWG Workshop

45. Comprehensive Lifetime Medication List • To support sustained care and comprehensive care, an EHR should support lifetime visualization of medications. • Most EHR focus on the active medication list based on recent prescriptions. • A comprehensive list should separate categories of medication by Acute, Chronic, As needed, and Emergency. • Some inactive medications have lifetime significance. • PRN or as needed medications need patient data on use to form an effective partnership with patients. • Chronic meds should be visualized to see start and end dates, changes in dosage over time, even changes in specific med within a class. • Refills need to be proactively monitored and may be needed for emergency meds even if never used. AMIA 2017 PCIWG Workshop

46. Comprehensive Lifetime Problem List • A dynamic problem list, visualized over time supports more effective comprehensive and continuous care. • Problems occur in episodes that can be visualized over time with start and end dates and numbers of visits both to primary care and to specialists. • Problems transition over time and the name or codes may change. • Status and severity of problems is an important item of data to capture and code as a guide to quality measurement. AMIA 2017 PCIWG Workshop

47. Comprehensive Lifetime Immunization History with Immunization Forecasting • Immunizations are a type of data in an EHR that must be viewed in a lifetime perspective and must be able to move between practices and providers. • Immunization data is an idea target to encapsulate in a portable data model that moves with the patient and preserves all coding for future use in the same or another EHR. This is one type of data that never should be stored in proprietary formats. • Encapsulated digitally signed data is never altered, but data imported and exported from immunization registries (IIS), needs reconciliation to correct small variations. • Harmonization of FDA NDC barcodes and CDC CVX codes is possible including group CVX mapping to components of multiple target vaccines. AMIA 2017 PCIWG Workshop

48. Transfer of Primary Care to or from Another Practice • It is inevitable that patients will move, practices will re-structure, and practices will sometimes need to change EHR vendor or system. • Sustained care for a patient requires us to deal with transitions of the primary care setting or record that is a more complex task than transfer of care after an ER visit, Hospitalization, or Specialist Visit. • Much of the data in a patient record is repetitive and may have limited value over time. • Transfer of active demographics, medications, allergies, problems, vital signs and immunizations is essential to continue to meet immediate care needs but more is need to preserve the rich person-centered history of previous providers. AMIA 2017 PCIWG Workshop

49. Can We Really Transfer a Complete Patient Record Between Two EHRs? • YES but we need to make a lot changes in our EHRs first. • The time to begin planning for conversion to another system is the day you install your current system. • We must divide our records into computable data and Human readable data that MUST be able to move with the patient. • We need to isolate administrative and operational overhead data. • All Human readable data (notes, documents, reports, etc.) must be in a “clinical document architecture” with a meta-data header and a body of structure content. • All computable data (vital signs, labs, medications, problems etc.) must be in well documented structured and coded standardized data objects. AMIA 2017 PCIWG Workshop

50. Newborn Hospital Discharge • There are few examples that involve as much “Mandatory Interoperability” between several partners and where the data has very time specific value and need to separate the patient specific exceptions from the sea of routine information. • Data is merged from the mother’s prenatal record, the mother’s delivery record, the infant’s nursery record, and newborn screening data and shared with the primary care provider, specialists, and public health. • ACOG has set excellent standards for maternal data, but we still lack comparable infant data standards from AAP. • Communication to public health on all point of care and laboratory newborn screening is essential to maintain quality of care. AMIA 2017 PCIWG Workshop