Health IT Safety Webinar Series

1. Health IT Safety Webinar Series EHR Documentation and Health IT Safety July 30, 2015 1:00-2:30 pm EDT

2. Housekeeping • For any technical questions, please type your question into the Questions panel at lower right. • All telephone lines are muted. Due to the number of attendees, please use the Questions panel to ask any questions during the webinar. • Closed captioning for today’s session is available at http://www.captionedtext.com/ Event #: 2664368 • Q&A will take place at the conclusion of each presentation. Slides and a copy of the recording of this session will be posted at www.healthitsafety.org • For general questions about the webinar series, please contact healthitsafety@rti.org

3. Health IT Safety Webinar Series This series of 10 webinars focused on health IT and patient safety issues will occur monthly through September 2015. These webinars are funded by the Office of the National Coordinator for Health Information Technology (ONC) and are being conducted by RTI International, a non-profit research organization, as part of a year-long project to develop a road map for a Health IT Safety Center for ONC (contract HHSP23320095651WC). Additional information is available at: www.healthitsafety.org The views of the speakers are their own and do not represent the views of RTI or the ONC.

4. Jonathan S. Wald, MD, MPH, FACMI Today’s Presentations Gordon D. Schiff, MD, Associate Director, Center for Patient Safety Research and Practice, Brigham and Women’s Hospital Adam Wright, PhD, Senior Scientist in the Division of General Medicine at Brigham and Women’s Hospital, Boston, MA Anna Orlova, PhD, Senior Director for Standards at the American Health Information Management Association (Moderator) Mark Graber, MD, Senior Fellow at RTI International

5. Today’s Moderator • Mark Graber, MD, is a Senior Fellow at RTI International and an internationally recognized authority on diagnostic error in medicine. He founded the Diagnostic Error in Medicine conference series, the Society to Improve Diagnosis in Medicine, and the journal Diagnosis and has published widely.

6. Today’s Presenter • Brief Biography:Dr. Schiff is the Associate Director, Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, Associate Professor Harvard Medical School and Safety Director of the Harvard Center for Primary Care Academic Improvement Collaborative. He has recently completed a series of studies related to electronic prescribing errors and safety sponsored by the FDA and National Patient Safety Foundation. He is a practicing general internist and worked for more than three decade at Chicago’s Cook County Hospital. His specific areas of expertise include diagnostic errors and clinical documentation, medication prescribing safety and appropriateness, and malpractice issues in primary care. • Presentation: “Clinical documentation and Patient Safety- The next frontier for better diagnosis and treatment”

7. Clinical documentation and Patient SafetyThe next frontier for better diagnosis & treatmentONC Health IT Safety Webinar Series7/30/2015 Gordon Schiff MD Associate Director Center for Patient Safety Research and PracticeBrigham and Women's Hospital Div. General Medicine Safety Director – Harvard Center for Primary Care Academic Improvement Collaborative Associate Professor of Medicine Harvard Medical School

8. Outline: Chief Complaints, Assessment, Plan Personal background, perspectives New Epic user; prior Brigham LMR, Cook County Cerner HIT Safety Perspective Recent CPOE safety studies: can we transfer lessons Personal clinical note conceptual thoughts Issues & Ideas: Beyond usual issues to new paradigm Beyond Copy/paste, note bloat, distracts encounter, ↑work Failure to realize potential for quality, efficiency, safety, caring, communication, care redesign. Supporting diagnosis safety

9. Clinical Documentation • 1991 Landmark IOM Report • HITECH adoption tipping point • Central role in care; occupies much of MDs’, others’ time

11. Widespread frustrations about notes • “I just want to finish my note and move on to the next patient.” • “I want to come home at night and play with my kids and go to sleep (or maybe read some medicine), but instead I have to do my charting.” • “I am embarrassed to have others read my notes they are so bad, but I have to keep cutting more and more corners just to get them done.” • “ Meaningful use = meaningless notes

12. New, struggling EMR user • Just matter of time to: • Get trained and familiar • Enter backlog of meds, prior problems • Learn various tricks, shortcuts • Establish new workflows • Overcome “Trough of Disillusionment”

13. Adapting to the Suboptimal When told in late 1850’s by a recent visitor to the South that the slaves appeared to be happy and well adjusted,he is reported to have replied: “Then it’s even worse than I thought.” Frederick Douglass Abolitionist, ex slave

14. Malpractice Risk in Ambulatory CareOnly Small % related to Documentation??

15. Electronic Clinical Documentation- Failing in Myriad of Ways Failing in ways both apparent and less visible Most serious/sad is demoralization of primary care, other front line clinicians Added time for charting; subtracted time for caring Degrading pride in workmanship; my notes are a mess Clutter; Loss trust in quality and accuracy, ease to find info Scribes: solution or workaround? Need to move away from paper record conceptualization, toward integrated care process redesign/workflow tool

18. Our findings suggest that current CPD system design and usage is not optimally meeting the needs of users and appears to be based on an outdated paradigm. While there are clear benefits to CPD, the degree of angst and dissatisfaction with it speaks to a fundamental need for changes that probably reflect the need for a new paradigm governing how such systems should be built, implemented and used. Embi et al JAMIA 2013

19. Clinical Documentation- New Paradigm10 Functions Redesigned Documentation Needs to Fulfill Reflect, record, thinking Documentation should be interactive Info can input one way, display another Should be produced jointly and shared w/ pt Aid to synthesize, organize, history & course Identify, understand changes over time Support cognition, ↓memory burden Prevents overlooking problems, premature closure of dx Help overcome (rather than ↑) fragmentation Redesign for reliable communication, follow-up

20. Unmet Requirements/Wish List Prioritized/organized/integrated problem lists Reliable, continuously updated family hx; genetics Incorporation of patient sx questionnaires into history Enriched, omnipresent social hx Drive proactive, reliable plan and follow-up Visual affordances for cognitive support Rapid access to info while writing note Support my decision-making Real integration of voice recognition Take ½ time currently does Done by end of patient if not clinic session

21. Care Workflow Needs-Mostly Poorly Supported “Interval history” Review, record (prior to visit; w/ pt) Open-ended invitation/solicitation of how doing Eye contact; fingers (mostly) off keyboard “Review of problems” Prior description (pt/yours), status, assessment Not lose track of problems, issues, results Social history at forefront Visually, patient-centered interaction, updating kids ages Assessment Bury on bottom? ; need for narrative “voiced” in

22. COPY & PASTE – Disease or Symptom I have outlawed cutting and pasting. It is illegal and immoral and bad for both patient care and student/resident education. If I find a medical student in my ward team cutting and pasting anything in a note, they flunk the rotation • William Tierney President and CEO, Regenstrief Institute, Chief, Internal Medicine Service, Eskenazi Health. Indianapolis IN

24. Is Copy-Paste Billing Fraud? • In our view the federal government should not penalize physicians and hospitals for responsible use of tools in the electronic helath record that faciliate efficiency and the appropriate standardizationof the documentation of care -Sheehey et al JAMA Intern Med 2014

25. COPY & PASTE – Disease vs. Symptom? • Is Copy and Paste the cause of bloated, untrustworthy (even at times dishonest) notes? • Or is it a symptom of more fundamental design flaws? TWO CHEERS for COPY/PASTE • Copying forward existing history is not unreasonable starting point for today's note • Leg still amputated (tho David Bates case of how DKA turned into BKA), daughter still on drugs, still multiple warty lesions • Efficient way to avoid manual typing big blocks of text • How to minimize negatives, maximize +’s • A creative workaround, but bypasses real redesign needs

26. Scribes-Wonderful or Workaround? Assist in navigating EMR Enter data to allow more undivided attention to patient Help create more complete and timely notes Track down needed/missing information requested by provider Shown they can be cost effective and beneficial for restoring joy to practicing AHIMA . "Using Medical Scribes in a Physician Practice." Journal of AHIMA 83, no.11 (November 2012): 64-69 [

27. Scribes-Wonderful or Workaround? • Navigating EMR • Easier data entry • Less distraction from pt • More complete timely notes • Track down missing info • Restoring joy to work • Easing burden or working around poor design of EMR? 27

28. Realizing the potential of electronic clinical documentation to prevent, minimize, and mitigate diagnostic errors • Loss of safety for failure to fully leverage these potentials in these 15 areas.

29. Schiff & Bates NEJM 2010

30. Schiff & Bates NEJM 2010

31. Schiff & Bates NEJM 2010

32. Clinical Documentation CYA

33. Canvass for Your Assessment Van Gogh: Self-Portrait in Front of the Easel

34. -Differential Diagnosis-Weighing Likelihoods -Etiology -Urgency -Degree of certainty Canvass forYour Assessment

35. What is an Assessment -5 D’s • Definingthe problem(s)-describe, justify, group • Diagnosis–DD, etiology, cause of exacerbation • Doing– how is patient doing?: time course, response to rx, interpretation of response • Do -- what needs to be done, and why • Don’t Know– what are uncertainties, need to f/up

36. Summary: Practical Next StepsBuilding Better Clinical Documentation Better integration of problems/list into note workflow Realizing role for voice recognition Real time support High level just-in time-support Coupled with advanced learning from users Pro-active error, problem reporting ↑ Vendor transparency, accountability Better learning from observations, testing Learn from documentation practices Measure “S:S ratio” (sailing vs. stuck) (also for Help Desk) Re-conception, design, evaluation, metrics to support needed redesign functions.

37. End of Dr. Schiff’s presentation (4 additional slides, for reference, follow)

38. Clear Complete Concise Current Organized Prioritized Burke et al JAMIA 2014 High Sensitivity High Specificity Cogency Actionable AMIA Future of High Quality Clinical Information 2011 Note Quality Attributes

39. What belongs in notes? Meds? Allergies? Labs? Next appointment? Preventive medicine data/schedule

40. Who Does What, and How they Like it • Home grown EMR- 1088 physicians • 85% used a single method to document majority of visits • PCPs predominantly used templates (60%) vs. specialists (34%) • 38% of specialists predominantly dictated. • Survey: 383 responders most satisfied w/notes module, regardless documentation method. Pollard et al Int Jl Med Inform 2013

41. Note Quality & Chronic Disease Quality Scores • Evaluated 239 DM, CAD notes written by 111 physicians • 110 notes written by PCPs, 52 cardiologists, 77 endocrinologists. • Reason for visit absent in 10% of notes • Medication list not present in note in 19.7% • Timing for follow-up absent in 18.0% • Laboratory quality indicators were more often found in other EHR sections than in physician note. • Clinical quality scores for DM & CAD showed no significant association with subjective note quality • Overall note quality did not correlate w/clinical quality scores, suggesting writing high-quality notes and meeting quality measures are not mutually reinforcing activities Edwards et al BMJ QSHC 2014

42. Today’s Presenter • Brief Biography:Dr. Wright is an Associate Professor of Medicine at Harvard Medical School and a researcher in biomedical informatics at Harvard Medical School. Dr. Wright studies clinical decision support and data mining in electronic health records. His specific areas of research include problem lists, using EHRs to reduce medical errors and malpractice and learning from large clinical databases. • Presentation: “Making more accurate problem lists—challenges and recommendations.”

43. Making More Accurate Problem Lists:Challenges and Recommendations Adam Wright, Ph.D. 43

44. The Problem List 44

46. The Problem List An accurate, complete problem list is important Used for decision support Used in medical decision making Some evidence that patients with complete problem lists have better outcomes A communication tool for providers 46

47. The Problem List A good problem list is challenging Who owns the problem list? What is a problem? What is the role for the patient? Problem lists are often inaccurate or incomplete 47

48. Problem List Completeness 48

49. The Problem List and P4P / MU • Total at risk for BWPO is $735,000 • BCBS: 75% complete for DM, HTN and CVD (combined) • HPHC: 70% complete for DM, HTN and CVD (must clear 70% for each problem) • 80% problem list completeness is also a requirement for meaningful use 49

50. Problem List Completeness 50