Electronic Health Records – Ready for Prime Time?

1. Electronic Health Records – Ready for Prime Time? James E. Tcheng, MD, FACC, FSCAI, FESC Professor of Medicine Professor of Community and Family Medicine (Informatics) Duke Clinical Research Institute Duke University Medical Center and Health System

2. EHR Transformation If you don’t know where you are going, chances are you will end up somewhere else. Yogi Berra If you don’t know where you are going, any road will get you there. Lewis Carroll

3. Evolution of Clinical & Research Infrastructures But still limited … Vestiges Desired State PLATFORM Electronic Health Records Paper Records Clinical databases - for transactions of patient-centriccare Researchdatabases - forvalidityand analysis Clinical Electronic DataCapture Paper CaseReportForm Clinical Research OWNERSHIP Controland dissemination of data is limitedbyowners, restrictingdevelopmentofa learninghealthcaresystem Practitioners Health Care Entities Clinical Clinical Research Academia/Industry

4. Cost – Value Tradeoff Optimum value Usefulness of data Adverse impact on usability Starting point Partially structured Paper Electronic free text Rigidly structured Adapted from B. Middleton

5. Semantics

6. Documentation Directions • Create structured documents where there is inherently structured content (e.g., procedure notes) • SPEED, completeness, accuracy, quality • Data as a byproduct of report creation • Workflow: technologist oriented • Create (only) elements of structure for documents that are inherently unstructured (e.g., clinic / hospital notes) • SPEED, usability, productivity, repetition • (Limited) creation of data • Workflow: clinician oriented

7. ACC “CardioEncounters” Project • Best of breed clinical cardiology encounter notes for CAD, HF, afib, HTN, HL … • LIMITED(and prompted) standardized data collection • Clinical focus – assessment and communication (APSO note, problem-oriented charting) • ACC PINNACLE Registry data elements within encounter note (eliminates paper registry form) • Satisfies EHR MU Stage 2 Registry participation 7

8. Cardiac Cath Structured ReportingACC/AHA/SCAI Health Policy Statement • “Standard” for data content, report format • Representation: ACC, SCAI, AHA, STS, SIR, SVS, ISACHD, IASC, CCS, APCS, HL7, IHE, DICOM, AACN • Clinician lens – integrating workflow with data capture and use • Parallel efforts: HRS (EP), ASE (echo), ASNC (nuclear), SCCT (cardiac CT), … Sanborn TA, Tcheng JE, et al. ACC/AHA/SCAI 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory. J Am CollCardiol 2014; 63:2591-2623. 8

9. Cardiovascular EndpointsACC/AHA Data Standards Task Force • Proposed controlled vocabulary (200+ concepts) • Death attribution, myocardial infarction, stroke / TIA, admit for unstable angina, heart failure event, PCI / PVI terms • Targeting regulatory submission – but intended to be generic across clinical care, patient-reported information, drugs & devices, all of medical science • Committee Chair: Karen Hicks, MD 9

10. The World is Changing …What Will IT Take? • EHR: still a long, long way to go • Meaningful Use not tuned to the MDEpiNet context • Philosophy: act once, use many, benefit all • Breaking down silos – think collectively, not independently • Operational: disruptive transformation • Clinician shift from (NOT “in addition to”) being historians (i.e., prosaic documentation) to assessment / communication • Societies: responsibility to lead transformation • Regulatory: needs to pull the appropriate levers • Informatics: key to coordination and data liberation • Woefully under-recognized, under-resourced