Life After “Go-Live”: True stories from five years of EMR use

1. Life After “Go-Live”:True stories from five years of EMR use Eric Rose, MD Associate Director for Clinical Informatics, Information Systems Department, University of Washington Physicians Network Clinical Assistant Professor, Department of Family Medicine and Division of Biomedical and Health Informatics, University of Washington http://faculty.washington.edu/momus/infodoc.htm

2. Eric Rose, MD

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4. Who are YOU? • How many have used EMR’s? • How many are considering EMR implementation? • Practice size Eric Rose, MD

5. Summary • Brief overview of EMR’s and UWPN • Description of some challenges faced in EMR implementation and our approaches to these • Suggestions for your own transition planning and implementation Eric Rose, MD

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7. EMR overview • Proposed as "The standard for medical and all other records related to patient care"—IOM 1997 • Universal adoption urged in “The next 5-10 years”—NCQA 1999 Eric Rose, MD

8. EMR overview-Basic Functions • Documentation of care • Order entry • Results notification & review • Inter-office and intra-office communication • Time management tools • Task management tools • Aggregate reporting for population management • Integration with practice management software Eric Rose, MD

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10. UWPN Overview • 8 primary care clinics, 76 providers (FP, Peds, IM, PA/NP, MH) • PLUS an two other multispecialty outpatient facilities with total of about 60 providers • Started from scratch in 1997 on EpicCare • PC workstations in all providers' offices, nurses' stations, & exam rooms • What I do Eric Rose, MD

11. EMR Challenges • Configuration is a BIG job • Requires rethinking of clinical workflows to take advantages of the capabilities of the EMR Eric Rose, MD

12. EMR Challenges Payoff is more than adequate: The EMR is easy to use 64% The EMR is worth the timeand effort to use 89% Eric Rose, MD

13. EMR Challenges “Although I'm spending more time at charting duties than in past practices, I am also accomplishing a lot more than in the past. I have never before had charts with such complete information.…It makes a doctor do a better job.” Eric Rose, MD

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15. EMR Challenges • Documentation of care • Handling flow of paper documents from outside the practice • Coding tasks • Clinical alerts & reminders • “Too good” information management • Asynchronous communication issues Eric Rose, MD

16. Documentation of Care • Typing is too slow • Voice recognition "not there yet" • Menu-driven templates-Limited applicability • Proliferation of templates • Modular keyboard macros helpful Eric Rose, MD

17. (Paper) Documents from Outside the EMR • Documents related to past care (old medical records) • “Working through outside records and deciding what to write a summary on and what to scan and what to shred is a pain. I'd rather take a quick look at them, then throw the whole thing into the back of the chart, and look at it closer when I need to.” Eric Rose, MD

18. (Paper) Documents from Outside the EMR • Documents related to ongoing care • Very time-intensive • Requires personnel with enough training to know "where" to enter the scanned image in the EMR Eric Rose, MD

19. Coding Tasks • EMR’s are designed for coding by provider, not billing personnel • Systems in greatest use, ICD-9-CM and CPT, often illogical & nonintuitive (asthma example) • The “right code” can be devilishly hard to find • Partial solutions = code selection tools (preferred subsets, synonyms) Eric Rose, MD

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21. Clinical Alerts & Reminders • At best, still interrupt the process of care • "Pop-up fatigue“ even for appropriate alerts • False-positives waste time and reduce providers’ overall responsiveness to alerts • Patient has received the intervention but the EMR can’t “see” it (done outside our system, not recorded appropriately, etc.) • Patient declines an intervention • Patient has left the practice • The intervention is not appropriate for the given patient Still, we've implemented many good alerts & reminders Eric Rose, MD

22. “So Good it’s Bad” Information Management • “Results Overdue” messages • Order cosigning • Clinical alerts, esp. trivial ones Eric Rose, MD

23. Asynchronous Communication Issues • Usually increases efficiency because don’t have to interrupt one another • However, repeated back-and-forth iterations are frequent • In some cases, face-to-face verbal communication is more efficient Eric Rose, MD

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25. EMR Successes • Better access to information • Population-level disease management and health promotion • Clinical QI • Clinicoadministrative QI • Billing QI Eric Rose, MD

26. Better access to information • Availability of the patient record • Easier retrieval of information for clinical care • Easier access by non-provider personnel outside the clinic Eric Rose, MD

27. Population-level disease management and health promotion • Disease-management programs • Automated mailings re: health-promotion services • Pharmaceutical recalls and safety alerts Eric Rose, MD

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29. Clinical Quality Improvement • Clinical alerts & reminders • Default prescription parameters Eric Rose, MD

30. Clinico-administrative Quality Improvement • Referral orders—Set up to reflect organization of specialty services @ UW • Integration of patient-ed materials with EMR • Tracking deferred immunizations • Flexible routing of results & messages Eric Rose, MD

31. Billing Quality Improvement • Immunizations • Med injections • Form completion • Wart/Skin tag destruction • etc. Eric Rose, MD

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33. Pending projects • Patient access to EMR • Formulary database integration • Statewide immunization registry integration • Direct transmission of prescriptions to pharmacies • Integration of complex guidelines • Clinical trial eligibility alerts Eric Rose, MD

34. Tips for success-Vendor Selection • Vendor stability • Customer service feedback • Adaptability to all settings where you'll use it • Scalability • Interoperability with other systems you are or will be using Eric Rose, MD

35. Tips for Success-Implementation • Put a lot of resources into the project up-front! • Involve all constituencies • Clinical personnel with "ownership“ • Listen, respond, be fair, BUT hold the line with prima donnas • Formalized, mandatory training of users • Responsive user support • Pay attention to workflow issues • Be conservative vis-a-vis configuration issues that imply a clinical standard of care • Careful documentation • Unambiguous delineation of roles & responsibilities Eric Rose, MD

36. Obligatory Weighty Quotation “Until EMR use becomes the norm for all practitioners, we will continue to lack the tools needed to manage the quality and costs of health care, the scientific basis for health care will continue to be undermined, and the dramatic transformation of healthcare so urgently required will be impeded.” Don Detmer, MD (Chair--IOM Committee on Improving the Patient Record) The Computer-Based Record: An Essential Technology for Health Care 1997 National Academy Press, Washington DC Eric Rose, MD

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38. Other Challenges • No perfect systems yet though progress is rapid • Cost can be a barrier (though maybe less than is commonly thought) • Interfacing with other systems (lab, scheduling, billing) is difficult & expensive • Communication between EMR systems is a LONG way off • Security issues are uncertain • Regulatory barriers (electronic signatures, prescription requirements varying by state) Eric Rose, MD

39. Sources for more information • FP Net http://www.aafp.org/fpnet/ • Family Practice Management http://www.aafp.org/fpm/ • KLAS-http://www.healthcomputing.com/klas/ • "Medical Software Reviews" newsletter http://www.crihealthcarepubs.com Eric Rose, MD

40. References Priebe, C. and Rose, E. Workflow Automation with Electronic Medical Records. In Norris, T.E. Informatics in Primary Care New York: Springer, 2002 Ahmad, A. et al. Key Attributes of a Successful Physician Order Entry System Implementation in a Multi-hospital Environment. JAMIA 9 (1): 16-24, 2002 Jan/Feb. Eric Rose, MD