Example: Improving Care by Design of an EHR

Example: Improving Care by Design of an EHR Lecture by Farrokh Alemi, Ph.D. Narrated by Jonathan Duxbury

An Example • Design an EHR that will reduce unnecessary visits while improving quality • Assumptions • A staff model HMO • Both patients and providers have access to email and Internet • Informed consumers willing to take care of their own health (not for everyone but for a minority of patients)

An Example • Design an EHR that will reduce unnecessary visits while improving quality • Assumptions • A staff model HMO • Both patients and providers have access to email and Internet • Informed consumers willing to take care of their own health

An Example • Design an EHR that will reduce unnecessary visits while improving quality • Assumptions • A staff model HMO • Both patients and providers have access to email and Internet • Informed consumers willing to take care of their own health (not for everyone but for a minority of patients) Design an EHR to meet these assumptions

Describe the Content of Primary Care Visits • General medical examination • Acute upper respiratory infection • Pre- and postnatal care including complicated pregnancy and abortion • Hypertension • … • … • Malignant Neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits • General medical examination • Acute upper respiratory infection • Pre- and postnatal care including complicated pregnancy and abortion • Hypertension • … • … • Malignant neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits • General medical examination • Acute upper respiratory infection • Pre- and postnatal care including complicated pregnancy and abortion • Hypertension • … • … • Malignant Neoplasms of skin 63 clusters of diagnoses explain 80% of primary care Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits • General medical examination • Acute upper respiratory infection • Pre- and postnatal care including complicated pregnancy and abortion • Hypertension • … • … • Malignant neoplasms of skin Each cluster is a use case, a scenario, under which we can examine impact of EHR Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits • General medical examination • Acute upper respiratory infection • Pre- and postnatal care including complicated pregnancy and abortion • Hypertension • … • … • Malignant neoplasms of skin In each cluster, ask internal & external experts how EHR will reduce visits Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits • General medical examination • Acute upper respiratory infection • Pre- and postnatal care including complicated pregnancy and abortion • Hypertension • … • … • Malignant neoplasms of skin In each cluster, trace decisions and see what information is useful Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

For General Medical Examination Cluster • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit. What impact will EHR have on our business objective in this use case?

For General Medical Examination Cluster • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit. Experts: Reduces time for a well visit from 1 hour to ½ hour in 70% of the cases

For General Medical Examination Cluster • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit. Given this use case what information is needed to carryout the necessary decisions?

For General Medical Examination Cluster Information needed: exercise, weight, smoking, etc. • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster Information needed: key findings and thoroughness of self exam • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster • Patients will visit lab before scheduled appointment • Patients will complete a health risk assessment online. Computer will provide feedback. • Computer will guide patient in doing self examination. • Computer will help patient plan questions they want to ask during the visit. Information needed: clients’ questions

List of Decisions & Information Items

List of Decisions & Information Items Lets’ look at Information needed in other use cases

For Acute Upper Respiratory Infection Cluster • Patients contact clinicians by phone or email • Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst • System follows up with the patient to see if symptoms have gotten worse

For Acute Upper Respiratory Infection Cluster • Patients contact clinicians by phone or email • Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst • System follows up with the patient to see if symptoms have gotten worse What impact will EHR have on our business objective in this use case?

For Acute Upper Respiratory Infection Cluster • Patients contact clinicians by phone or email • Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst • System follows up with the patient to see if symptoms have gotten worse Experts: Reduces visits in 60% of cases, where patient gets better after resting

For Acute Upper Respiratory Infection Cluster • Patients contact clinicians by phone or email • Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst • System follows up with the patient to see if symptoms have gotten worse Given this use case what information is needed to carryout the necessary decisions?

For Acute Upper Respiratory Infection Cluster Information needed: patients signs and symptoms • Patients contact clinicians by phone or email • Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst • System follows up with the patient to see if symptoms have gotten worse

For Acute Upper Respiratory Infection Cluster Information needed: Pt verification, permission to contact, preferred contact time, change in symptoms • Patients contact clinicians by phone or email • Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst • System follows up with the patient to see if symptoms have gotten worse

List of Decisions & Information Items New information items added in

For Pre and Postnatal Care Cluster • Some prenatal visits avoided for patients with positive laboratory tests • Some post-partum visits avoided by the system triaging depressed patients to specialists

For Pre and Postnatal Care Cluster • Some prenatal visits avoided for patients with positive laboratory tests • Some post-partum visits avoided by the system triaging depressed patients to specialists What impact will EHR have on our business objective in this use case?

For Pre and Postnatal Care Cluster • Some prenatal visits avoided for patients with positive laboratory tests • Some post-partum visits avoided by the system triaging depressed patients to specialist Experts: Reduces visits in 10% of cases

For Pre and Postnatal Care Cluster • Some prenatal visits avoided for patients with positive laboratory tests • Some post-partum visits avoided by the system triaging depressed patients to specialist Given this use case what information is needed to carryout the necessary decisions?

For Pre and Postnatal Care Cluster • Some prenatal visits avoided for patients with positive laboratory tests • Some post-partum visits avoided by the system triaging depressed patients to specialist Information needed: items used in triage protocol

List of Decisions & Information Items New information added in

List of Decisions & Information Items Note that risk assessment was also needed in a previous use case

For Hypertension Cluster • Patients measure blood pressure at home • Patient calls in or is called by the system regarding control of their hypertension • Clinician available by email to change prescription, explain progress and evaluate patient condition

For Hypertension Cluster • Patient measure blood pressure at home • Patient calls in or is called by the system regarding control of their hypertension • Clinician available by email to change prescription, explain progress and evaluate patient condition

For Hypertension Cluster • Patient measures blood pressure at home • Patient calls in or is called by the system regarding control of their hypertension • Clinician available by email to change prescription, explain progress and evaluate patient condition What impact will EHR have on our business objective in this use case?

Example: Improving Care by Design of an EHR