Exploring the Persistence of Paper with the Electronic Health Record (EHR)

1. Exploring the Persistence of Paper with the Electronic Health Record (EHR) International Journal of Medical Informatics 7 8 ( 2 0 0 9 ) 618–628 Presented by: Brooke Ethington BUS 550; 11/16/2010

2. Electronic Medical Records (EMR) • A database designed to enable medical care and long term treatment, improving storage, retrieval, and retention • Replaces a paper medical chart in full or in part • IDEALISTIC- still unable to deliver a product that fully meets caregiver’s needs • Predicative/Preventative Medicine • ‘Designer healthcare’ • Legibility • Increased efficiency, more effective use of physician time • Interoperability/Record Sharing • Secure and Private delivery of Insurance Services

3. HIPAA • Health Insurance Portability and Accountability Act (1996) • Title I: • Responsibility for maintenance of the original record lies with the creator • Responsibility for appropriate release to third parties lies with the creator • Title II: • Requires the Department of Health and Human Services to put rules into place to increase efficiency of dissemination of medical information • Privacy Rule: Mandatory disclosure of certain minimal information within 30 days; EDI to insurance and government

4. HITECH • Health Information Technology for Economic and Clinical Health (2009) • ARRA (American Recovery and Reinvestment Act, 2009) • $20 Billion dedicated to stimulating EMR technologies • $40,000 to $65,000 per physician award • $2+ M per hospital award • Goal: interoperability of health information • Extends HIPAA Privacy Rules (subtitle D) • Disclosure Accounting (effective 1/2011) • Breach Notifications (effective 8/2009) • Extension of responsibility to business associates (11/2009) • Up to $1.5M penalty for violations

5. EMR Technical Standards Most technical solutions only solve PART of the EMR problem. Is this question too complex to answer with one universal method? • HL7 - messages format for interchange between different record systems and practice management systems. • ANSI X12 (EDI) - A set of transaction protocols used in the US for transmitting virtually any aspect of patient data. • CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care. • CEN - EHRcom (EN 13606), a standard for the communication of information from EHR systems. • CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment. • DICOM - a standard for representing and communicating radiology images and reporting

6. General EMR Challenges • HERDING CATS! • Expense • Local Buy In • Technical Expertise • (Set up and Maintenance) • Stable Power Supply • Data Management/Entry • Security/Trust

7. Pros vs. Cons: Paperless CONS • Provider desensitivity to important information (cut & paste overload) • Too much time with the computer- less time with patients PROS • Availability of complete medical record • Portability • Graphing, charting, summary tools • “One Stop Shop”

8. Scope of VA Healthcare • ~$35 Billion budget • 155 Hospitals • 872+ ACC • 135+ Nursing Homes • 45+ Residential Treatment Centers • 209+ Vet Centers • 108+ Full home care programs • Serving 7.8+ Million enrollees annually

9. Scope of VA Healthcare • Medical Research • National Disaster Backup (Katrina) • Affiliations: • 107+ Medical Schools • 55 Dental Schools • 1200+ Ancillary Health Schools • Training of 90,000+ Health Care professionals annually

10. MUMPS • Massachusetts General Hospital Utility Multi-Programming System • Developed in 1960’s, adopted widely in 1970’s and 1980’s • Used in healthcare, finance, aerospace, and other applications • Hello World Example: • hello() write "Hello, World!",! quit • Command line: ‘do ^hello ()”

11. VistA • Veterans health Information Systems and Technology Architecture • An enterprise information system • Composed of100+integrated software modules (packages) • Awarded the Smithsonian Award for best use of Information Technology in Medicine,1995 • Awarded the Innovations in American Government Award by Harvard, 1996 • VistA Imaging, HealthEVet • FREE!! http://www.vistasoftware.org/

12. CPRS (Computerized Patient Record System) • GUI Interface of VistA • DEMO! (signing code: Doctor1)

13. Medical Records At VA; Case Study

14. Workarounds! (125 participants)

15. Lab IT Solutions • Data Innovations • Monarch • EP Evaluator • Autoverification • Orchard Software Products, Core Informatics, McKesson

16. Future of EMR at VA • Interface with Department of Defense • Barcode Expansion • Implementation of VBECS Blood Banking Software- 2010 • Integrated VA EMR; versus “Remote Data”

17. Val IT Weighs In… • Justifies the value of IT from the business perspective. “In October 2005 the U.S. Department of Veterans Affairs launched what many believe to be the most ambitious organizational information technology overhaul and consolidation ever to be attempted in the federal government.” “…the department has centralized all IT budgeting, planning and development, including putting full control of the department’s IT budget and staff under the VA’s Office of Information and Technology in Washington D.C., while placing a premium on encrypting, securing and accounting for every piece of computer hardware in the system.”