Physicians Adoption of Technology: A tale of two solutions

1. Physicians Adoption of Technology:A tale of two solutions Jerry Cade, MD, MBA Chief Medical Information Officer (CMIO) & Director, Viral Specialty Treatment Service, University Medical Center, Las Vegas, NV June 1, 2018 New Orleans, LA

2. The Challenge • Why has health care lagged behind other industries and institutions in adopting, adapting to, and embracing new technologies? • Are physicians particularly resistant to change?

3. The Answer: It Depends • By definition, healthcare is a cautious and conservative profession. Hippocrates most important entreaty was “primum non nocere”(first, do no harm). • Ironically, we healthcare providers eagerly embrace the latest, greatest technology in our respective fields of medicine--things such as robotic surgery; but, changes in how we organize and render that health care—changes underscored by an electronic health record (EHR)—provoke resistance and rebellion.

4. Medscape EHR Report 2016: Physicians Rate Top EHRs* *Peckham, Carol. “Medscape EHR Report 2016: Physicians Rate Top EHRs.” Medscape, Medscape%20EHR%20Report%202016_%20Physicians%20Rate%20Top%20EHRs.html. Accessed 16 May 2018.

5. Medscape EHR Report 2016: Physicians Rate Top EHRs* *Peckham, Carol. “Medscape EHR Report 2016: Physicians Rate Top EHRs.” Medscape, Medscape%20EHR%20Report%202016_%20Physicians%20Rate%20Top%20EHRs.html. Accessed 16 May 2018.

6. Medscape EHR Report 2016: Physicians Rate Top EHRs* *Peckham, Carol. “Medscape EHR Report 2016: Physicians Rate Top EHRs.” Medscape, Medscape%20EHR%20Report%202016_%20Physicians%20Rate%20Top%20EHRs.html. Accessed 16 May 2018.

7. University Medical Center (UMC)Las Vegas, NV • 564-bed tertiary hospital in Clark County (Las Vegas), Nevada • Only Level I Trauma Center in Nevada (catchment area includes Arizona, California, Nevada and Utah)* • Teaching hospital for the University of Nevada Las Vegas School of Medicine, whose inaugural class of 60 students matriculated on July 17, 2017 • In addition to the 564-bed inpatient facility, UMC includes various outpatient services *UMC treated the overwhelming majority of the victims from the October 1, 2017 shooting in Clark County in which 59 individuals lost their lives and 851 people were injured *UMC’s Trauma Center treated Tupac Shakur, who died on September 13, 1996, at age 25, of complications from gunshot wounds sustained in a drive-by shooting

8. University Medical CenterOutpatient Services • UMC Quick Care facilities are located throughout the Las Vegas Valley and provide urgent care • UMC Primary Care clinics are usually co-located with UMC Quick Cares and provide ongoing primary care for Southern Nevadans • UMC Wellness Center is the largest HIV clinic in the State of Nevada. In addition, to HIV/AIDS, the Wellness Center provides ongoing treatment for Hepatitis C, Hepatitis B and other viruses* * My life prior to health informatics. We started UMC’s Wellness Center in November 1986 with 5 patients. We now care for more than 3000 individuals and their families

9. OneUMCUMC’s Electronic Health Record (EHR) • OneUMC is the UMC-branded version of Epic • Implemented in the outpatient setting July 1, 2017 • Included the Quick Care & Primary Care facilities as well as in The Wellness Center • Initially, included 74 providers, 72 of whom are employed by UMC, 2 providers contract with UMC for their services • Also included ancillary services that are tied to outpatient medical care, i.e. finance • Implemented for the inpatient hospital and the remaining ancillary services on December 1, 2017 (at 0510 hours)

10. OneUMCOutpatient Implementation • All of UMC’s outpatient centers were still using paper charts—a legacy from a failed inpatient implementation of a previous EHR. • In February 2013, UMC endeavored to replace its antiquated paper medical record system with the EHR from McKesson Enterprise Information Solutions (EIS) • Part of the strategy underpinning UMC’s initial attempt at converting to an electronic health record included inpatient execution of the EHR followed by implementation of McKesson’s outpatient solutions

11. OneUMCOutpatient Implementation (cont.) • Inpatient go-live was planned in stages to take place over 10 months beginning in April 2013 • Outpatient go-live was planned for a few months after the final stage of inpatient EHR implementation • Within the first year, UMC began having challenges with the inpatient EHR* • Initial decision was to find an alternative EHR solution for UMC’s various outpatient settings. An interface would be built between this outpatient solution and McKesson’s (UMC’s inpatient) EHR *This should not be interpreted as a problem intrinsic to McKesson EIS. Simply, there was an incredible and insurmountable mismatch between the solutions offered by McKesson’s EHR and the solutions needed by UMC. Multiple mistakes—enough for everyone to share several times over—were made by both McKesson and UMC.

12. Pre-OneUMCOutpatient EHR Implementation • Committee formed to look at various outpatient EHR solutions • Over next 12 months, committee narrowed down the possible choices to the 3 most promising solutions • Committee was in process of making final decision when “someone, somewhere” suggested that this dual EHR solution was fraught with potential problems • Committee disbanded with no final deliverable after decision made to look at possibility of replacing UMC’s inpatient EHR with an alternative that would serve both inpatients and outpatients

13. Pre-OneUMCOutpatient EHR Implementation (cont.) • However, this decision meant that the outpatient institutions would remain on paper medical records until a comprehensive EHR solution could be found for UMC

14. Implementing OneUMC in ourOutpatient Facilities • For the OneUMC (Epic) implementation, the strategy was to start with the outpatient clinics for multiple reasons, including the fact the providers in those areas had not yet had any experience with an EHR • There was a concern that this lack of previous EHR experience might mean that the outpatient areas would need more help making the transition from paper records to electronic ones* • Epic is replete with features, many of which we are still discovering and learning how to use, among these features are Epic’s mobile solutions—Haiku and Canto. For whatever reason, these were not on anybody’s radar as being particularly useful *This turned out to be unfounded

15. Implementing OneUMC in ourOutpatient Facilities (cont.) Haiku on iPhone X • Opens at In Basket, which is a shortcut to work that needs to be done • Can be customized to open wherever one chooses • You can REACT with Haiku, i.e. look at lab results, refill requested prescriptions, respond to messages—as in this example • Cannot (yet) ACT, i.e. write orders, order a new prescription, etc.

16. Implementing OneUMC in ourOutpatient Facilities (cont.) Canto on iPad 12.9” • More real estate so can open multiple activities simultaneously • This screenshot shows: • My inpatient hospital list • Today’s clinic appointments (although I can look at any appointments that I might have for any date in the past or in the future) • My In Basket, • My current dictations • Can be customized to open wherever one chooses • You can REACT with Haiku, i.e. look at lab results, refill requested prescriptions, respond to messages—as in this example • Cannot (yet) ACT, i.e. write orders, order a new prescription, etc.

17. Implementing OneUMC in ourOutpatient Facilities • Recall that the 74 outpatient providers had not used an EHR at UMC. Some of these providers (including me) had used an EHR in other environments • At the time of the outpatient go-live, UMC had 8 Quick Care centers (there are now 10 centers) • At the time of the outpatient go-live, UMC had 6 Primary Care clinics. All of the primary care clinics are co-located with a Quick Care (there are now 7 clinics) • The Wellness Center, UMC’s HIV/AIDS, hepatitis C, hepatitis B specialty clinic was also part of the July 1, 2017 go-live

18. Implementing OneUMC in ourOutpatient Facilities • Prior to and during go-live, I visited all 9 outpatient facilities • In addition to trying to prepare the providers for the changeover from paper charts to an electronic health record, I highlighted the features of Haiku and Canto and endeavored to persuade these clinicians how advantageous these two mobile solutions would be for helping to take care of their patients • The outpatient providers agreed that Haiku and Canto were “really cool;” however only 6 providers, other than me, committed to trying to use these mobile solutions as part of their new electronically-enhanced workflows* *Unfortunately, I was not clever enough to anticipate how eagerly the outpatient physicians/other providers would embrace Haiku and Canto, so I did not prospectively document this information

19. Implementing OneUMC in ourOutpatient Facilities • In less than one month, almost all of the outpatient clinicians were using, even becoming heavily dependent on, Haiku and Canto • Currently, the only questions I get asked about Haiku and Canto is when are they going to have more features • As mentioned, currently Haiku and Canto can react to medical data, a prescription request, a message. New messages CAN be sent de novo, but the clinician cannot (yet) write orders (there is some limited order writing capability in Canto, but it is not flexible), etc. Our providers have expressed a strong desire to have these features.

20. Another View—The Nevada Vital Records Registry (NVVRS): Birth/Death Vital Records

21. Another View—The Nevada Vital Records Registry (NVVRS): Birth/Death Vital Records

22. Another View—The Nevada Vital Records Registry (NVVRS): Birth/Death Vital Records

23. Another View—The Nevada Vital Records Registry (NVVRS): Birth/Death Vital Records(Current workarounds) • During the paper death certificate era, no problem getting physician signatures on a death certificate • With implementation of this electronic system, for the first time physicians began arguing over who needed to sign the death certificate • We had to create a policy mandating who was in responsible for signing the death certificate along with penalties for physicians who did not comply

24. Another View—The Nevada Vital Records Registry (NVVRS): Birth/Death Vital Records(Current workarounds) • To be fair and scientific, there are two possible reasons for this problem • First, we switched from paper death certificates to electronic death certificates, so one could argue that the difference we see was all secondary to this change • The second concern is that the software simply is not user friendly. Certainly, we have the evidence previously presented that if the solution is relatively straightforward, not overwhelmingly difficult to navigate, and provides clear value for and advantages to patient care, then physicians and other providers will embrace it.

25. What does this suggest to us about physicians (and other primary care providers) use of emerging technology? • The resistance of physicians (and others) to the adoption of emerging technologies is not absolute • When it becomes clear that the advantages of embracing new technologies are significant, at least our group of physicians eagerly adopted these mobile solutions, even though prospectively they did not think that Haiku and Canto would have any place in their daily practice of medicine

26. What does this suggest to us about physicians (and other primary care providers) use of emerging technology—additional thoughts and future inquiries • Our outpatient and quick care providers adopted Haiku and Canto because it helped them take better care of patients. Since they are employed by UMC, there were no financial advantages for them to do this. I would suspect that technological solutions, which increased revenue/income/bottom line, would also be more likely to be adopted • Technologies, which improve time and efficiency will probably be readily adopted, especially if the technology is easy to understand and use

27. Additional Thoughts & Future Inquiries • Dr. Eric Topol, Founder and Director of Scripps Translational Science Institute, cardiologist, geneticist, and digital medicine researcher, has argued that the smartphone represents the convergence of multiple, important health care and other technologies, which will lead to the democratization of health care. • Topol talks about his “Gutenberg moment,” in which he compares the evolution of the smartphone to the printing press in its ability to revolutionize society. It’s an interesting thought, with which I, respectfully, disagree, but such a contention stimulates many other interesting thoughts about the changing health care environment.

28. What does this suggest to us about physicians (and other primary care providers) use of emerging technology—additional thoughts and future inquiries (cont.) • Topol cites the rapidly declining cost of genomics and improving wireless technology as the beginnings of this revolution. This combined with biosensors, which feed real time data to smartphones, and which are continuously monitoring and recording vital signs, along with countless new smartphone applications, which perform the most common lab tests that we do in a doctor’s office today, have made the smartphone the symbol of this dramatic convergence of ideas.

29. Eric Topol’s Vision for the Future In addition to his academic positions at Scripps, Topol is the Editor-in-Chief of Medscape. Every couple of years, via Medscape, Topol offers his predictions for the new technologies that can change medicine.

30. Where do we go from here?—Challenges • Technological—Certainly, the last few years have seen major improvements in electronic health records; however, EHR and other health care software solutions are very much in their infancy, but we will get there • Need for change management, particularly among physicians. Everyone’s roles are evolving, but perhaps none more so than physicians, who were once the ship’s captain. That roll is rapidly becoming the patient’s, as it should be.

31. Where do we go from here?—Challenges • Technological—Certainly, the last few years have seen major improvements in electronic health records; however, EHR and other health care software solutions are very much in their infancy, but we will get there • Need for change management, particularly among physicians. Everyone’s roles are evolving, but perhaps none more so than physicians, who were once the ship’s captain. That roll is rapidly becoming the patient’s, as it should be.

32. ThankYou!