Why your EMR Sucks, and what you MIGHT be able to do about it

1. Why your EMR Sucks, and what you MIGHT be able to do about it Robert B Dunne MD Dept of Emergency Medicine

2. Terminology • EMR • EHR - Certified • CPOE • HITECH act • Meaningful use (Phase 1 and Now Phase 2) • HL7 • EDIS • Enterprise

3. History • “Developers stress that the issue most important for acceptance is whether the medical information system makes patient care easier to provide” Policy Implications of Medical Information Systems, December 1977

4. History • “Existing systems vary in scope, cost, and impact on the medical care system. Consensus has not been reached about the defining characteristics of a medical information system. “ Policy Implications of Medical Information Systems, December 1977

5. Who is using in the ED ACEP COUNCIL INFO DEMOGRAPHIC DATA 300 COUNCILORS 2011 ORDERS on the computer? • 1. REQUIRED FOR ALL 67% • 2. SOME 20% • 3. LAB ORDERS ONLY 6% • 4. PAPER ONLY 7%

6. Benefits of Electronic Records • Information that we need • Patient Tracking • No handwriting • Simultaneous use • Abbreviations/trailing zeros • Transcription error reduction • Correct ID of user • More integration with the record • Discharge instructions

7. Claimed benefits • Clinical Decision Support • Cost Savings • Correct doses/delivery/calculation • Reduction of duplicate tests • Improved Quality of Documentation

8. There are some frightening stories about the unintended consequences of CPOE

10. Unintended Consequences of Information Technologies • Aim • Determine the effect on mortality of introducing CPOE into Pittsburgh childrens hospital • Methods • Demography, clinical and mortality data collected on all children transported to a hospital where CPOE implemented institution-wide in 6 days. Trends for 13 months prior and 5 months after compared. Often delays in initial orders and loss of team members who had to be on the computer • Results • Mortality rate increased from 2.80% (39 of 1394) to 6.57% (36 of 548) • After adjustment for other covariables, CPOE independently associated with increased odds of mortality (odds ratio 3.28, 95% C.I. 1.94 – 5.55)

11. Unintended Consequences of Information Technologies • Conclusion • When implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates. • Often delays in initial orders and loss of team members who had to be on the computer reduced clinical communication and delayed orders • Importance • Received disproportionate media attention due to reactionary message • Follow-on study in Seattle, using same vendor system, also published in Pediatrics, showed no increase in mortality, BUT NO IMPROVEMENT EITHER • They listened to users and implemented with care

12. Another unintended consequence of CPOE • NHS UK

15. Unintended Consequences of Information Technologies • Reference • Linder et al., Arch Intern Med. 2007 Jul 9;167(13):1400-5. [Brigham & Women’s Hospital] • Aim • Assess effects of Electronic Health Records on quality of care delivered in ambulatory settings • Methods • Retrospective, cross-sectional analysis of 17 quality measures from 2003-2004 National Ambulatory Medical Care Survey, correlated with use of EHRs.

16. Unintended Consequences of Information Technologies • Results • EHRs used in 18% of 1.8 billion visits • For 14 of 17 quality measures, fraction of visits where recommended best practice occurred was no different in EHR settings than manual records settings. • 2 better with EHR: avoiding benzodiazepines in depression, avoiding routine urinalysis • 1 worse with EHR: prescribing statins for hypercholesteremia (33% vs. 47%, p=0.01) • Conclusion • As implemented, EHRs not associated with better quality ambulatory care

17. LA Article

18. Nine types of unintended adverse consequences • More/new work for clinicians • Workflow issues • Never ending system demands • Paper persistence • Changes in communication patterns • Emotions • New kinds of errors • Changes in the power structure • Overdependence on the technology *Campbell E, Sittig DF, Ash JS, Guappone K, Dykstra R. Types of unintended consequences related to computerized provider order entry. JAMIA 2006; 13:547-556. *Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. JAMIA 2007;14:415-23.

19. Workflow Issues • Mismatch between how work processes are intended to function and how they actually operate • Too much standardization • Confusion, duplication, misunderstanding across clinical role boundaries result • Prevention strategies include time, integration, meeting information needs, providing value • Need to continuously evaluate

20. CPOE alters communication among providers, ancillary services, and clinical departments Dykstra R. Computerized physician order entry and communication: Reciprocal impacts. Proceedings AMIA 2002:230-4. • Causes reductions in face-to-face communication • Causes “illusion of “communication, ” belief that the proper people will see it and act upon it • Causes depersonalization

21. CPOE causes changes in the power structure • Loss of clinician autonomy • Administration and I.T. gain power • Clinical decision support can “tell doctors how to practice” • Coalitions Ash JS, Sittig DF, Campbell E, Guappone K, Dykstra R. An unintended consequence of CPOE implementation: Shifts in power, control, and autonomy. Proceedings AMIA 2006:11-15.

22. Emotions run high • CPOE/Documentation evokes strong emotional responses • strongly negative • highly positive emotions • Strong positive correlation between time system is in place and positive emotions *Sittig DF, Krall M, Kaalaas-Sittig J, Ash JS. Emotional aspects of computer-based provider order entry: A qualitative study. Journal of the American Medical Informatics Association 2005; 12(5):561-7.

23. EHR can cause insidious silent errors • Problems with data presentation, selection, entry • Pick lists for data entry promote juxtaposition errors Alpha vs Common lists • If the correct data entry location is not found, busy providers tend to place data where they might fit

24. Information Entry • What is good? • We can capture more patient information • What is bad? • Someone has to spend TIME entering that information

25. Information - Templates And that’s just the HPI! (History of Present Illness)

26. Information • There’s also the Physical Exam • On every patient… Are we done yet???

27. The Most Expensive Data Entry Clerk • CPOE = 6-8 min per patient • Documentation = another 6-8 min • Average ED Physician making $150/hr • $37.50/hr spent on charting • This just the professional rate • Other costs • Lost Productivity • Time away from patient’s bedside≠satisfaction • 12 min x 200 patients per day = 3000 minutes

28. What Can you do • Pre implementation evaluations (KLAS etc) • Push for evaluation do not get complacent • Participate in selection no matter how painful • Push for best work with vendors on own • Contract clauses – group expert • Do you’re own diligence • Show up, be clear on what you want • Persist/assign

29. Still a work in Progress

30. Can build useful orders

31. Highlighting key information At a glance information • Pre-arrival • Affiliated Primary care • Chronic pain enrollees • Custom tailored • Can add anything

32. Documentation • Voice recognition • Scribes • Personal Human Assistant • Follow physicians and document at bedside • Macros • Quicker documentation • Drop a normal macro and change abnormals • Is this fraud? • Does this help patients?? • What is put in the chart?

33. Scribe Programs • Increase physician direct patient care. • Decrease the time a patient will wait to see a doctor • Increase the time the doctor can spend with the patient • Enhance patient satisfaction. • Decrease the overall time a patient must spend in the ED • Improve documentation. • Improve the working environment in the ED for all members. • Expedite patient flow through the ED • Need a credentialing plan • Need IT support, own sign in and QA program • Has to be clear who documented.

34. Communication tools Autofaxes/EMAIL • Great Concept! • When patient leaves the Emergency Department, automatically fax the chart to the Primary Care Doctor • Seems beneficial. BUT. • Illusion of communication • Do they want it???

35. 80/20 Rule • You know this rule and it has many applications in the world • 80% of programming needed for good patient care software is easier • The last 20% is much harder, takes into consideration special circumstances, and takes much longer • So it is often skipped

36. 80/20 – Allergy Reactions • Wait a minute! Codeine has no real allergy reaction with benadryl. • Codeine doesn’t interact with Tylenol either • ALERT FATIGUE • This is where feedback from clinicians and ED pharmacists can fix system problems • We have to be the 20%

37. Downtime • We have become dependent on EMR systems • Going to paper is an internal disaster • Results can get lost, we can’t track our patients as easily, communication breaks down • This is one of the most dangerous times in the ED, even with good downtime procedures

38. Clinical care becomes overdependent on the computing infrastructure • System failures wreak havoc unless good downtime procedures exist • Reliance on clinical decision support may reduce learning • “If its in the computer it must be right!”

39. System downtime, regardless of cause, can "create chaos" for users and organizations COMPUTER CO-DEPENDENCY Not enough hardware "…[it can be] a real fight at times to get work done, because [people] are always in need of a computer." Single system component failure "They use a white board screen saver in the ER that keeps track of people in the ER. When the hospital registry goes down, it can't provide the patient ID number, so we can't enter or find any information." Whole system is down "It's funny now. When the computer goes down, we don't remember how to document on paper."

40. Training • The Best systems require the least training • On paper there is minimal training required • Most docs take 2-4 weeks • May have a greater effect on nursing • Especially contingent/part time/rotators • Costs of training

41. Complex Bar Code Med Admin Connect Physician Offices Simple Med Cabinets Radiology Infrastructure Document Imaging Progressively Introduce Technology Physician Order Entry, MD Documentation Full documentation Emergency Department Surgical Services Alerts and monitoring Access tools Longitudinal Record (Data Repository)

42. Need for Real Evaluation of IT 1. Static IT attributes (hardware and software quality) Static user attributes (computer knowledge) 2. Quality of interaction between IT and user (e.g. usage patterns, user satisfaction, data quality) 3. Effects of IT on process quality of care (efficiency, appropriatness, organisational aspects) 4. Effects of IT on outcome quality of care (quality of care, costs of care, patient satisfaction)

43. Continuous Evaluation of the System Track system performance, network needs To get faster when you are busier Think ecommerce on cyber Monday Develop contingency plans for continued operation during downtimes/disasters Create robust backup systems and test them with scheduled drills

44. Security Issues • American National Standards Institute," whose "found that almost 60 percent of about 100 health-care executives surveyed cited lack of funding as the main reason for not securing digital records. Forty percent cited insufficient time, while 32 percent pointed to a lack of senior executive support.” AMS report 2012

45. Where we need to go • Personal Health records • Interoperability • True linkage to the primary care world • Optimal Security • Non intrusive decision support • No training needed

46. Tools not Solutions • EMR’s are often sold as “Solutions.” • This is sales.. • EMR’s need another 10 years(?) until they are truly mature and robust • Currently, they are tools slowly becoming solutions • Physicians must get involved.

47. Paper persistence: Your hospital will be paperless, the same day my bathroom is… Michael Shabot, M.D.