How electronic health records may influence behavior

1. How electronic health records may influence behavior George Hripcsak, MD, MS Department of Biomedical Informatics/ Medical Informatics Services Columbia University & NewYork-Presbyterian

2. Promise of clinical decision support • Long history of reminders • McDonald, NEJM 1976 • Barnett, Med Care 1978 • Computerized orders • Tierney, JAMA 1993 • Increase compliance with corollary orders • Overhage, JAMIA 1997 • Reduce maximum dosing errors • Teich, Archives Int Med 2000 • Improve prophylaxis • Kucher, N Engl J Med 2005

3. Institute of Medicine • To Err is Human: Building a Safer Health System (1999) • Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

4. Caveats • Many positive studies from 4 institutions • Chaudhry, Ann Int Med, 2006;144:E12-E22 • Unintended consequences of CPOE • Koppel, JAMA 2005 • Increased mortality after CPOE • Han, Pediatrics 2005 • CDSS improve process most of the time, but outcomes are understudied • Garg, JAMA, 2005

5. Documentation and Workflow Will we repeat the hype cycle?

7. 10/2/08 PGY1 Progress Note S: No events o/n. CXR yesterday showed lung still reexpanded while on water seal. Pt participated in physical therapy yesterday, felt weak afterwards. Still has transient cough. O: VS Tm 98.6 Tc 98.5 68-77 110-116/62-66 20-22 95%General NAD, sitting on edge of bed, with NC, appears improved HEENT PERLA, EOMI, no JVD CV RRR nml S1, S2 Pulm chest tube on R, dry crackles predominantly at the bases Abd soft, nt, nd, + BS, no HSM Ext trace ankle edema, no cords/calf tenderness Labs: see webcis ANA negative RF negative ESR 22 Hep B cAB/sAB positive, sAG negative, Hep C Ab negative stool O and P- negative Other Studies: 9/24 abd u/s Hepatomegaly. Increase in echogenicity and echotexture may be due to hepatic steatosis or a fibrotic process. TTE: Moderately limited study due to poor acoustic penetration. The left ventricle is mildly hypertrophied with normal systolic function. The left atrium is mildly dilated. The right ventricle is not optimally visuallized but overall right ventricular size and function are normal. No significant valvular abnormalities are seen on limited views. The measured peak right ventricular systolic pressure is approximately 40mmHg. A/P: 61 yo man with UIP vs. malignancy s/p VATS biopsy 2 wks ago at OSH, p/w worsening SOB found to have pneumothorax. Chest tube placed in ER, PTX now resolved on CXR. Pulm - likely HP, PTX s/p VATS biopsy and subsequent chest tube, now with reexpansion of lung. Hypersensitivity panel negative, though this does not r/o hypersensitivity pneumonitis. -f/u pulm recs -decrease O2 to maintain O2 sat of 95% -continue steroids -appreciate thoracic surgery consult - chest tube now on waterseal -PFTs when chest tube is out -daily CXR GI - LFT elevation, hepatomegaly of unclear source, hepatitis panels negative, TTE normal, LFTs have stabilized, relatively acute onset, possibly reactivation of Hep B vs. parasitic infection -appreciate GI consult - will repeat stool O and P/stool culture, f/u stronglyloidis and schistomiasis Ag, continue ivermectin, ANA, anti-sm Ab, quantitative immunoglobulins, alfa 1-antitrypsin, Ceruloplasmin, and GGT -MRCP if pt can have it with chest tube Heme - eosinophila, likely 2/2 parasitic infection -trend WBC count and eosinophila -Ivermectin FENGI -Cardiac diet PPX -sub q heparin FULL CODE

8. 10/2/08 PGY1 Progress Note S: No events o/n. CXR yesterday showed lung still reexpanded while on water seal. Pt participated in physical therapy yesterday, felt weak afterwards. Still has transient cough.O: VS Tm 98.6 Tc 98.5 68-77 110-116/62-66 20-22 95%General NAD, sitting on edge of bed, with NC, appears improved HEENT PERLA, EOMI, no JVD CV RRR nml S1, S2 Pulm chest tube on R, dry crackles predominantly at the basesAbd soft, nt, nd, + BS, no HSM Ext trace ankle edema, no cords/calf tenderness Labs: see webcis ANA negative RF negative ESR 22 Hep B cAB/sAB positive, sAG negative, Hep C Ab negative stool O and P- negative Other Studies: 9/24 abd u/s Hepatomegaly. Increase in echogenicity and echotexture may be due to hepatic steatosis or a fibrotic process. TTE: Moderately limited study due to poor acoustic penetration. The left ventricle is mildly hypertrophied with normal systolic function. The left atrium is mildly dilated. The right ventricle is not optimally visuallized but overall right ventricular size and function are normal. No significant valvular abnormalities are seen on limited views. The measured peak right ventricular systolic pressure is approximately 40mmHg. A/P: 61 yo man with UIP vs. malignancy s/p VATS biopsy 2 wks ago at OSH, p/w worsening SOB found to have pneumothorax. Chest tube placed in ER, PTX now resolved on CXR. Pulm - likely HP, PTX s/p VATS biopsy and subsequent chest tube, now with reexpansion of lung. Hypersensitivity panel negative, though this does not r/o hypersensitivity pneumonitis. -f/u pulm recs -decrease O2 to maintain O2 sat of 95% -continue steroids -appreciate thoracic surgery consult - chest tube now on waterseal -PFTs when chest tube is out -daily CXR GI - LFT elevation, hepatomegaly of unclear source, hepatitis panels negative, TTE normal, LFTs have stabilized, relatively acute onset, possibly reactivation of Hep B vs. parasitic infection -appreciate GI consult - will repeat stool O and P/stool culture, f/u stronglyloidis and schistomiasis Ag, continue ivermectin, ANA, anti-sm Ab, quantitative immunoglobulins, alfa 1-antitrypsin, Ceruloplasmin, and GGT -MRCP if pt can have it with chest tube Heme - eosinophila, likely 2/2 parasitic infection -trend WBC count and eosinophila -Ivermectin FENGI -Cardiac diet PPX -sub q heparin FULL CODE

9. Cut and paste • Once entered, a mistake lasts forever … 36 year old man … 27 year old woman … • Doctors are telling us not everything needs to be restated every time

10. Sublanguage • Misspellings and interesting abbreviations • text messaging s/p LURT 1998 c/b 1A rejection 7/07 back on HD pHtn 2/2 ASD w L->R shunt p/w abd pain x 3 • Doctors are telling us data entry and review must be made more efficient

11. Medicine resident daily progress note:Events overnight

12. Medicine resident daily progress note:Subjective

13. Medicine resident daily progress note:Vital sign flowsheet

14. Medicine resident daily progress note:Vital signs by physician

15. Medicine resident daily progress note:Medications

16. Medicine resident daily progress note:Physical exam

17. Medicine resident daily progress note:Laboratory

18. Medicine resident daily progress note:Radiology

19. Medicine resident daily progress note:EKG and telemetry

20. Medicine resident daily progress note:Assessment

21. Medicine resident daily progress note:Problem list

22. Medicine resident daily progress note:Plan

26. Proposed addition for compliance Inform Pt edu Smoke Pain

27. PERRLA

28. general fatigue fever or chills lumps or masses eyes wear glasses/contacts visual changes eye pain itchy/watery eyes nose and throat bloody nose congestion/runny nose sore throat hoarseness gastrointestinal dysphagia (trouble swallowing) heartburn nausea and vomiting abdominal pain jaundice diarrhea constipation cardiovascular chest pain/tightness palpitations fainting spells edema or fluid retention ears hearing aids earache tinnitus (ringing in ears) ear drainage recurrent infections respiratory shortness of breath cough/congestion wheezing productive of sputum/phlegm hemoptysis (coughing up blood) dermatology skin lesions/skin cancer rash … Structured data entry

29. Cost per click • $16M nationally per checkbox • # doctors, # notes per year, time on checkbox • Should do cost benefit

30. Weekly Notes Written in Eclipsys XA:Inpatient Providers 17,991 8,227 October 2007 October 2008

31. “I don’t read notes anymore; I just write them.There is no information in them. I do look at vital signs, labs, and resident signout notes.”

32. Medication reconciliation Review of eight medical centers: • ED enters meds on paper, review and edit on floor, no other med list allowed in chart; await better software • Nurse enters meds on paper, doctor reviews; await better software • Nurse enters meds on paper, doctor reviews, doctor attests electronically c hard stop on meds at 6 hours; await better software • Nurse enters meds electronically (some from insurer), prints for doctor; await better software • Pharm tech enters meds electronically, prints for doctor; await better software • Pharm tech enters meds electronically • All paper; await better software • Failed attempts at nurse and doctor entry; await better software NYPH: • Doctor (or nurse) enters meds electronically, doctor attests c hard stop at 18 hours; look forward to better software

33. Reconciliation and attestation

35. Lessons • Quality initiatives improve quality, not EHRs • Why home-grown systems succeed • EHR is an infrastructure, not an intervention

36. Lessons • Focus with clear goals • If the goal is only Leapfrog, that is all that will be achieved

37. Lessons • Slow, iterative process • What does not kill the patient makes the system stronger

38. Lessons • Culture and buy in • May get away with strong arm

39. Lessons • Research • Basic research: we don’t yet know how to do this right • HSR: evidence-based EHRs or at least better art

40. Focused initiatives • Focused initiatives with clear goals • Measure process and outcomes • Discharge summary writer

41. DSUM Writer vs. Dictation(focused intervention)

42. DSUM Writer vs. Dictation

44. Next generation documentation • What would really support both individual and team care • Past medical history as a central resource • vs. cut and paste • Document only current thoughts & actions • review everything else • Merge intern progress and signout notes • Improved user interface technology • natural language processing, speech

45. Data entry technology • Natural language processing • Convert narrative text to encoded form • Natural interface for MD • Computable for use in databases

49. Clinical data warehouse 2,500,000 patient records 62,000,000 laboratory test batteries 6,000,000 clinical notes: discharge summary, admission, progress, signout, and visit notes 34,000,000 narrative reports from 40 ancillary departments, including radiology, pathology, cardiology, pulmonary 20,000,000 inpatient orders, outpatient orders Flowsheeted nursing documentation c VS

50. Micro-consults • Anticoagulation • evidence for dosing, genetics, contraindications • variable practice • Reminders are insufficient • Order a micro-consult • Advise on dosing based on EHR (automated to human review) • Primary MD gets order set • Consult tracks in a registry (with automated surveillance) • Escalate to consult as needed • Bill for micro-consult? • “Mega-reminders”