Electronic Medical Records (EMRs) and e prescribing

1. Electronic Medical Records (EMRs)and e prescribing Dr Kithsiri Edirisinghe MBBS, MSc, MD ( Medical Administration)

2. Session outcomes • Benefits and functions of EMRs • Criteria for selecting and implementing an office EMR • ePrescribing: Standalone or Ambulatory EMR

3. EMR vs EHR vs CCR • EMR: electronic medical record • An electronic medical record for a patient at a particular site, providing such functionalities as e-prescribing, order/results management, work-flow tasking, communication and messaging • An EMR is NOT a paper record made electronic • EHR: electronic health record • The sum of a patient’s EMRs and other health- related information from multiple sites • CCR: Continuity of Care Record • Electronic core data set about a patient’s health- care status and treatment, current and historical

4. Patient safety? Quality improvement? Rising healthcare costs? Competitiveness? Consumer-driven care (participatory health)? Internet resources Personal health records Evolution not only toward electronic medical record but also to computer-guided and -supported healthcare What is Pushing You toward EMRs?

5. More timely, accurate, complete patient information No longer practicing blindly Point of care access to, capture of, transmission of patient information Real-time, remote access Improved patient care Improved patient safety Improved outcomes Reduced costs of healthcare Reduced wasteful duplication Improved efficiency Financial squeeze on physicians Reduced hassles Improved quality of life For yourselves For patients What Can You Gain from EMRs?

6. Critical Success Factors • Office workflow: Who does what, how, when, where, why? • Current practice management system? • Information capture preferences? • Staffing: Adequate? Ready? • Colleagues: Supportive? Ready? • Financial planning and expectations • Benefits: Hard, Soft, Stretch • Realistic timeline • What do you want/need from an EMR? • What features do you want? • What barriers do you face?

7. Increased revenues Improved reimbursement Increased patient volume Increased charge capture Decreased accounts receivable days Increased net collection rate Decreased denied claims Improved E&M compliance New business opportunities, clinical trials, data Improved competitiveness Improved quality of care Improved patient satisfaction Decreased costs Reduced chart filing costs Reduced transcription costs Decreased telephone calls, faxes from pharmacy Increased efficiencies, decreased hassles Improved quality of life Improved provider satisfaction Improved staff satisfaction Less time after hours What Outcomes Are You Seeking?

8. Clinical documentation Options Management Scanning CCR Clinical and administrative workflow tasking ePrescribing Drug interaction Formulary mgmt Refills Referrals Order entry Results management Abnormals Trends/graphs Summary lists Problems Allergies Medications Health maintenance reminders What Features Do You Want?

9. Charge capture & coding Medical necessity Automated coding E&M coding & compliance Decision support Clinical practice guidelines Practice messaging Internal External Population/disease management Patient portals Patient data entry Participatory health What Features Do You Want?

10. Expense Selection difficulties Staff resistance Time & effort required Incompatibility of hardware/software Ease of use Security Lack of technical expertise Obsolescence Ease of integration Concerns about ROI Solutions not right for you Lack of demonstration site Data/chart conversion Increase documentation Other? What Barriers Do You Face?

11. What Do You Want to Achieve? • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care When you are ready to look at systems What do you want to achieve?

12. Better Coding (not guaranteed) What Do You Want To Achieve? Savings from Transcription Patient Information Capture Speech Recognition System Efficiency Back-end Speech Recognition Front-end Speech Recognition • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care • Automated coding • Higher revenues from ‘lost’ charges and better coding • Success varies

13. Patient satisfaction Connectivity with Medical Community What Do You Want To Achieve? • Referrals • Reports • Labs • Hospital Communication • CCR • Communication by email • Refills • Trust • Efficiency/convenience • Less waiting time • Technology attraction • Computer-generated patient education • Guidance to websites • Web portals • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care

14. What Do You Want To Achieve? Remote Computing and Remote Documentation • Working at home or anywhere • Arranging your time accordingly • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care Better Quality of Life

15. What Do You Want To Achieve? Workflow Benefits • No waiting or searching for charts (for example, think of phone calls) • Easier refills • Easier results management • Signatures • Immediate availability of patient data • Point-of-care documentation • Better time management • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care

16. What Do You Want To Achieve? Computer and Internet Support for Decision Making • Formularies • Diagnostic information • Information about medications • Other decision support info • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care

17. What Do You Want To Achieve? Reports • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • 8. Improved quality of care • Query system by condition or medication • Follow-up and reminders • Standard reports • Ad hoc and other reports

18. What Do You Want To Achieve? Patient Information • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care • Receive patient information electronically • Integrate and create CCR • All insurance information • Health status from other providers

19. What Do You Want To Achieve? Improved Quality of Care • More money/savings/ROI • Better competitiveness • Remote working • Workflow benefits • Better decision support • Easier reporting • Better information about patients • Improved quality of care • Health maintenance • Disease monitoring • Practice guidelines • Patient education • Lab tables/interfaces • Data!!!

20. How Can You Use EMRs for Quality Improvement? • Templates with guideline prompts • Flow sheets, tables, summaries, etc. as decision aids • Internal messaging and flags for coordination, self-reminders, goal prompts • Personalized results letters or handouts for patient education • Lab interface for results reporting • Advance scheduling for followup • Queries to identify patients needing specific care leading to flags or outreach

21. How Can You Use EMRs for Quality Improvement? • Develop effective team communication • Measure for improvement and accountability • Incorporate performance and outcome data • Coordinate care and services across settings

22. What Should You Do? • Educate yourself and others on EMRs • Conferences, web, colleagues, experts, etc. • Prioritize goals and problems to solve • Narrow potential vendors: Determine • Cost • Features and functions • Usability • Set-up vendor demos • Include physicians, staff • Develop scenarios • Site visits to similar practices

23. How Can You Compare EMRs? • Practice size designed for, installed in? • IHN/hospital linked? • ASP-based? • Is system designed for and installed in endocrinology practices? • Costs? • Functionalities? • Usability?

24. What else? Interfaces and conversion costs including mapping data fields License fees One-time or annual Implementation Training Travel costs Support and upgrades Backup: where and when Other? What isn’t included? What does pricing include? Hardware Data center only Peripherals Software Templates CPT codes E-prescribing CCR integration PHR integration What recurring costs? Software/hardware maintenance Upfront or annual license fees Comparing Costs

25. Comparing Functionalities Functionalities • Certification? • Continuity of Care Record or Document (CCR/CCD) capability? • Other criteria…

26. Functionalities:Information Capture • What modes of information capture does it offer? • Transcription • Speech recognition: front-end, back-end • Keyboard entry • Digital pen and paper • Handwriting recognition • Point and click • Pull-down menus • Templates, custom or standard • Home monitoring devices • Data entry by patient • Direct from mobile devices (mDevices) • HYBRIDS

27. Integration Functionalities • Integration with • Practice management system • ePrescribing • Labs • Payers • Other?

28. Payer-related Functionalities • Real-time eligibility determination? • With which payers? • Real-time charge capture? • With which payers?

29. Interoperability Functionalities • Is system interoperable with • Local hospital systems? • Personal health records? • Patient portals? • Patient data entry systems? • Other?

30. Comparing Usability Usability • Demonstrations essential • How does one navigate in the system • Easy • Intuitiveness • Suitable to your preferences/style • How long does it take to do the same documentation in the EMR vs without the EMR • How easy is it to query internal data or data from the system or other systems with which it is integrated • Follow up standard demos with hands-on try-outs

31. Is version demonstrated the one you would be purchasing? Downtime? Interoperability? With what and how? Interfaces What data fields are included? E-prescribing Definition? Transaction cost? Reports Required? Custom? ???? to Ask

32. Hardware/software needs ASP? Hard-wired, wireless, both? Devices Data submission What/how, e.g., data to payers? Pay for performance data? Scanning Speed? Double-sided? Quality Implementation time Definition? Does it include installation, training, loading your data? What else? ???? to Ask

33. Contract Considerations • Exercise due diligence • Consult IT contract attorney • Establish payment milestones • Do not pay in full upfront • Address response time • How do they prioritize? • What about mergers? • Rights to your data • Escrow clause for source code

34. Implementation • Different implementation paths for different practice sizes and specialties • Realistic timeframes • Staff involvement • Workflow changes • Data conversion: scanning, CCR • Support and maintenance • Backups and recovery

35. Implementation • Plan and test, plan and test • Policies & procedures • Privacy, confidentiality, security • Medicolegal requirements • Backups and disaster recovery • Support and maintenance • Modular or “Big Bang” • Have flexible timetables • Appoint a project manager • Assign responsibilities • Modify schedules • Start immediately following training • Implementation never ends

36. All EMRs Are Not Equal • Price range is enormous • $1000 to $50,000+/physician • No best of breed • Features vary • Not easy to change • Not just system but also workflow makes difference between failure and success

37. Remember! • EMRs differ for each application • Different needs, benefits, and implementation paths for different domains/practices/individuals • Sharing all information is not the goal • Ask questions! Don’t assume!

38. Remember! • Making paper documents electronic does not achieve potential of EMRs • Not easy • Spend resources to find out • Develop a strategy • Get buy-in • Not just EMRs, also computer-guided, computer-supported healthcare

39. ePrescribing Systems • Standalone ePrescribing or integrated within Ambulatory EMR? • Both addressed by CCHIT (certification body)

40. Time Line for Certifying Standalone ePrescribing Systems • Public comment periods (ended in April) • Publish final 09 Criteria, roadmap, and test scripts: mid-May • Certification Begins: July 1

41. Certification: Capabilities for Qualifying ePrescribing Systems Same for standalone and ambulatory EMR Generate a medication list Select medications Print prescriptions Transmit prescriptions electronically Conduct safety checks • Drug information, Inappropriate dose, Inappropriate route. Drug-to-drug interaction, Allergy concerns, Warnings/cautions Provide information on lower cost alternatives Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from patient’s drug plan Comply with Part D standards for interoperability

42. 2009 Unique Characteristics of Standalone vs Ambulatory EMR • Focus on core ePrescribing of medications (vs. EHR) • Problem list management proposed for future years • Technical criteria geared to align with scope and architecture of ePrescribing standalone solutions • Criteria included to provide following in an exportable format for migration to other systems • medication list • allergy list • prescription history data

43. Identify and maintain a patient record Manage patient demographics Manage medication list Manage allergy, intolerance and adverse reaction list Order medications Eligibility and formulary Manage medication orders Support for drug interaction and error checking Provider demographics eRx interoperability Concurrent use Access control Audit Authentication Data retention, availability, and destruction Technical services Backup/recovery ePrescribing – draft standalone certification criteria

44. Standalone ePrescribing or Integrated within Ambulatory EMR? • Your choice • Assess what makes sense for your practice • Consider the timeline • Interoperability essential

45. THANK YOU!