Practical Implementation: Lessons Learned from the Implementation of Electronic Health Records

1.  Practical Implementation: Lessons Learned from the Implementation of Electronic Health Records Peter Basch, MD Medical Director

2. Background and perspective General internist, office-based practice Capitol Hill, Washington, DC 6-MD practice (part of a 65-MD employed group) Implemented ambulatory EHR in 1997 (and an active EHR user) Medical Director, eHealth Initiatives, MedStar Health � 7-hospital system in Baltimore-Washington corridor Identify / develop, syndicate ehealth applications of value, primarily for the outpatient setting

3. Background - 2 My practice was to be the 1st of the practice group to implement an EHR Thus far, no other practices have followed Reasons No capital Lack of ROI � however, value of the EHR was evident to doctors and administration Why is it that something with clear benefit remains underutilized?

4. Lessons learned EHR � always on the verge of adoption EHRs typically don�t lead to sufficient enhanced throughput � as externally imposed process frictions remain, wasting time and effort. These �roadblocks� should be reduced before quality measures are added The expanded definition of quality redefines the electronic medical record as the electronic patient manager (or EPM) Use of EPMs (and not EHRs) will lead to healthcare transformation

5. Always on the verge of adoption� ~ 5-7% penetration in the outpatient setting Even at a time when� Networking became cheap Hardware costs were reduced 75-80% Performance was improving Procedural / imaging technology is fully adopted It is not about technology, but business case Practice view = added time/cost/complexity for same $ While a few are more efficient, most are not (but most all report that how they practice medicine has changed)

6. What are process frictions? Intended or unintended obstacles that separate decision making from action Specifically in healthcare delivery Certain managed care rules Certain regulatory mandates

7. Progress note + Now lets turn the clock forwards 20 years to the present, and add in coding and reimbursement rules and regulations (which we must follow to get paid and avoid incareration), and �Now lets turn the clock forwards 20 years to the present, and add in coding and reimbursement rules and regulations (which we must follow to get paid and avoid incareration), and �

8. Progress note + process frictions Now lets turn the clock forwards 20 years to the present, and add in coding and reimbursement rules and regulations (which we must follow to get paid and avoid incareration), and �Now lets turn the clock forwards 20 years to the present, and add in coding and reimbursement rules and regulations (which we must follow to get paid and avoid incareration), and �

9. = longwinded progress note Voila, a longwinded progress note that says nothing more than the brief one, but has redirected our time and focus away from the patient. In fact, creating this note took more time than seeing the patient.Voila, a longwinded progress note that says nothing more than the brief one, but has redirected our time and focus away from the patient. In fact, creating this note took more time than seeing the patient.

10. Rx + process friction

11. Lab order + process friction

12. Referral + process friction

13. Why are process frictions bad? Distraction of time

14. Distraction of time Progress note (+3min) ? long-winded note (no ? care) Prescription (+50 sec) ? same prescription formularies call backs Lab order (+50 sec) ? same order correct lab/book/form ABN Referral (+ ~ 2min + $$$) ? same referral correct book/form/authorization Total = +6.6min + $$$ ? no change in care The same is true for the other hoops we must jump thru for prescriptions, ordering labs, and writing referrals.The same is true for the other hoops we must jump thru for prescriptions, ordering labs, and writing referrals.

15. Why are process frictions bad? Distraction of time Distraction of focus

16. Distraction of focus Voila, a longwinded progress note that says nothing more than the brief one, but has redirected our time and focus away from the patient. In fact, creating this note took more time than seeing the patient.Voila, a longwinded progress note that says nothing more than the brief one, but has redirected our time and focus away from the patient. In fact, creating this note took more time than seeing the patient.

17. Why are process frictions bad? Distraction of time Distraction of focus Root cause of physician dissatisfaction

18. MD dissatisfaction � so what? Dissatisfaction levels > 50% First time in history that large #�s of physicians are retiring or leaving medicine in mid-career Physician shortage predicted by 2010 solely on demographics. Medical school applications down > 20% - have decreased 5 years in a row Applications by US med students for general IM / FP training programs ? ~50% past five years But I am afraid we will see it much sooner than predicted and for reasons other than demographics. Dissatisfaction is at an all time high. For the first time in history, physicians are leaving medicine in mid-career. And nobody is rushing in to replace us. Medical school applications continue to drop � what used to be a destination for the best and brightest is no longer. Internal medicine is suffering disproportionately � and is now able to fill just over � of its residency slots with US medical grads. And within internal medicine, general internal medicine and primary care are doing even worse.But I am afraid we will see it much sooner than predicted and for reasons other than demographics. Dissatisfaction is at an all time high. For the first time in history, physicians are leaving medicine in mid-career. And nobody is rushing in to replace us. Medical school applications continue to drop � what used to be a destination for the best and brightest is no longer. Internal medicine is suffering disproportionately � and is now able to fill just over � of its residency slots with US medical grads. And within internal medicine, general internal medicine and primary care are doing even worse.

19. Why are process frictions bad? Distraction of time Distraction of focus Root cause of physician dissatisfaction Distraction of resources How many $10s or $100s of millions spent on the coding / compliance industry annually? Misdirected focus of EHR development �Saving Office Practice�

20. From EMR to EPM EPM = electronic patient management Vision - combines 2 interwoven processes Healthcare @ speed of thought Healthcare @> speed of thought Mechanisms Focus on quality / mindflow Reduction of process frictions Insertion of quality frictions To build that compelling story we need to start by changing our vocabulary. To many in Washington, the term �EMR� connotes a failed technology. CMS now prefers the term �EHR, or electronic health record.� I prefer the term EPM � electronic patient manager. The word �record� implies a static repository, not the functionality we want to highlight � which is that of an interactive toolset. EPM is based on two interwoven processes � healthcare @ speed of thought � which posits that decisions in healthcare should take effort, fulfillment should not; and healthcare @ >speed of thought � the embedding of real-time clinical decision support at the point-of-care. The EPM makes healthcare more affordable and hassle-free by enhancing throughput and reducing unnecessary process frictions, and then makes healthcare better by the insertion of quality enhancements. These are processes that will make what we do more relevant to us, our patients, and to those who we are asking to foot the bill. Recasting and retooling the EMR as an electronic patient manager is the requisite first step. But subsequent steps must also be taken in the right direction, such that widespread adoption of the EPM does not just add time, cost and complexity to our lives. These subsequent steps require our clarification of 4 misconceptions (widely held by policy makers) regarding the value of clinical IT. Misconception #1�To build that compelling story we need to start by changing our vocabulary. To many in Washington, the term �EMR� connotes a failed technology. CMS now prefers the term �EHR, or electronic health record.� I prefer the term EPM � electronic patient manager. The word �record� implies a static repository, not the functionality we want to highlight � which is that of an interactive toolset. EPM is based on two interwoven processes � healthcare @ speed of thought � which posits that decisions in healthcare should take effort, fulfillment should not; and healthcare @ >speed of thought � the embedding of real-time clinical decision support at the point-of-care. The EPM makes healthcare more affordable and hassle-free by enhancing throughput and reducing unnecessary process frictions, and then makes healthcare better by the insertion of quality enhancements. These are processes that will make what we do more relevant to us, our patients, and to those who we are asking to foot the bill. Recasting and retooling the EMR as an electronic patient manager is the requisite first step. But subsequent steps must also be taken in the right direction, such that widespread adoption of the EPM does not just add time, cost and complexity to our lives. These subsequent steps require our clarification of 4 misconceptions (widely held by policy makers) regarding the value of clinical IT. Misconception #1�

21. Healthcare @ speed of thought Decisions take effort Fulfillment does not Care processes are enhanced, such that throughput and output frictions are minimized Clinician experience - hassle-free, similar to FFS medicine. Practice becomes fun again. Patient experience - more time / relevant focus from provider

22. Healthcare @> speed of thought Decisions take effort; best-practice decisions take somewhat more effort, but not burdensome Fulfillment does not take extra effort Care processes are enhanced, such that throughput and output frictions are minimized, however, there are added insertions of knowledge �snippets� and decision support where appropriate Clinician experience - helpful, educational, not intrusive Patient experience - wow!!!

23. Key elements of EPM Time / focus / resources are devoted to quality, and meeting the expanded definition of care The seamless integration of quality, once a digital infrastructure is built, adds no time or cost to a visit. It does however always help us to do the right thing � appropriateness supercedes forms, formatting, and formularies.The seamless integration of quality, once a digital infrastructure is built, adds no time or cost to a visit. It does however always help us to do the right thing � appropriateness supercedes forms, formatting, and formularies.

24. Expanded definition of care Disease / population management Protocol adherence Error correction Best practices with: Medication Labs Specialty care Care delivery independent of setting and stated purpose of visit

25. Key elements of EPM Time / focus / resources are devoted to quality, and meeting the expanded definition of care Workflow enhancement (reducing process friction) is needed to make time / space for quality Documentation is not a driver, but a byproduct of appropriate care Quality is best enhanced when it is embedded into the care process, rather than as a post-hoc administrative burden The seamless integration of quality, once a digital infrastructure is built, adds no time or cost to a visit. It does however always help us to do the right thing � appropriateness supercedes forms, formatting, and formularies.The seamless integration of quality, once a digital infrastructure is built, adds no time or cost to a visit. It does however always help us to do the right thing � appropriateness supercedes forms, formatting, and formularies.

26. Healthcare transformation A sustainable business case for information management opens the door to widespread adoption of EPM The EHR must change to the EPM Its appropriate use must be incented

27. Healthcare transformation - 2 Tomorrow�s landscape Multi-stakeholder frictionless medicine Embedded error correction and quality enhancement eCare Proactive care True multi-contributor collaboration (which includes the patient) Basis for the revitalization / rebirth of primary care medicine

28. Summary As currently configured, EHRs will never (and should never) be widely adopted The first role of ehealth should be to achieve a reduction in process frictions (which will require providers, payers, and government working together) A sustainable business case for information management will open the door to the transformative benefits of electronic patient management (EPM)