2009 02 17 - introduction to ehrs for rehab providers

EvidenceforElectronicHealthRecordSystems

02.17.2009

DanielJ.Vreeman,PT,DPT,MScAssistantResearchProfessor|IndianaUniversitySchoolofMedicine

ResearchScientist|RegenstriefInstitute,Inc

Copyright©2008

T558|OTManagementinToday'sHealth&CommunitySystems

dvreeman@iupui.edu

Overview•  Overviewofnationalhealthinformation

technologyinitiatives•  Forcesdrivingadoptionofinformation

technologyinhealthcare•  Evidenceforcomputerizedrecommendations

changingbehavior•  EvidenceforEHRsinRehabilitation

ObjectivesUponparticipatinginthissession,youwillbeableto:

•  Explaintheforcesinthecurrenthealthcareenvironmentpromotingadoptionofinformationtechnology

•  Appreciatethetypesofproblemsinclinicalpracticeandhealthcaredeliverythatmaybeamenabletoimprovementwithmorejudicialuseofinformationtechnology

•  Discussthekeyfactorsforsuccessaswellasimportantbarrierstoimplementingelectronichealthrecordsystemsinrehabilitation

RequiredReadings:•  VreemanDJ,TaggardSL,RhineMD,WorrellTW.Evidenceforelectronichealth

recordsinphysicaltherapy.PhysTher.2006;86(3):434‐449.

WhyamIHere?

WidespreadRecognitionAbriefhistory

•  1960’s–Firststudiesofcomputersinhealthcare•  1991–IOMTaskForce•  2003–HHSbeginspromotingwidespreaduseofHIT•  2003–HHS,DoD,VAformConsolidatedHealthInformatics•  2004–PresidentBushmakesHITatopnationalpriority

–  StateoftheUnionAddress:“bycomputerizinghealthrecords,wecanavoiddangerousmedicalmistakes,reducecosts,andimprovecare”

–  CallsforEHRsformostAmericansin10years–  CreatestheOfficeoftheNationalHealthITCoordinator

•  2004–DHHSResponds–  SecretaryThompsonlaunchesthe“DecadeofHealthInformation

Technology”–  Createsastrategytodevelopanationalhealthinformationnetwork

•  Flurryoffederalactivity…•  2009–Stimuluspackage:$20billionforadoptingHIT

TheDecadeofHealthInformationTechnology

•  Thevision–  Complete,longitudinalhealthinformationfollowstheconsumer–  Healthdecisionsaremadewithinformationtoolstoassistandguide

•  The(envisioned)result–  Fewermedicalerrors–  Lesswastefulcare–  Fewervariationsincare–  Patient‐centeredcare–  Employerswithproductivityandcompetitiveedgefromreducedspending

BigPictureWhatistheRoleofElectronicHealthRecords?

•  EHRsaretheprimarybuildingblocks–  Deliveringinfotoclinicians–  Collectinginfofromclinicians(andinstruments)–  Repositoriesforstoringdata

•  Asuiteofapplicationsandprocesses–  Notjustone‘program’–  Farmorethanelectronicdocumentationsystems

•  Lotsofacronyms–  EHR,EMR,EPR,PHR,CPRS,DMR,etc…–  Noconsensusdefinition–  IOMconceptismostprevalent

TheEHRAnEHRIncludes:

1.  Longitudinalcollectionofelectronichealthinformationforandaboutpersons

2.  Immediateelectronicaccesstoperson‐andpopulationlevelinformationbyauthorized,andonlyauthorizedusers

3.  Provisionofknowledgeanddecision‐supportthatenhancethequality,safety,andefficiencyofpatientcare

4.  Supportofefficientprocessesforhealthcaredelivery

•  Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System. Washington, DC: National Academy Press; 2003.

•  A‘NetworkofNetworks’– Notacentraldatabase– Communicationviasharedsetoftechnicalandpolicyrequirements

–  Lotsofwaysunderlyingnetworkscanform• Geography• Affinity

•  Benefits–  Leverageexistingdatapools–  ‘Allhealthcareislocal’

BigPictureWhatWillThisLookLike?

IndianaNetworkforPatientCare•  Aworkinghealthinformationexchangefor13+years

–  100sourcesystems–  1billiondiscreteresults–  CoreparticipantinNHINprototypeprojects

•  5majorIndianapolishealthcaresystems–  24hospitals(95%ofhospital/ERcareinIndy)–  Hospital‐associatedgrouppractices

•  CountyandStatehealthdepartments–  Immunizationrecords,labresults,tumorregistry

•  Nationalandregionallaboratories•  Lotsmoreontheway…

–  18newhospitalswithinexistingsystems–  12newhospitalshavesignedagreements–  10newhospitalshaveverballycommitted

McDonaldCJ,OverhageJM,BarnesM,etal.TheIndiananetworkforpatientcare:aworkinglocalhealthinformationinfrastructure.HealthAffairs.1005;24(5):1214‐1220.

•  LimitedadoptionofEHRs–  Social/politicalchallengesoftenhardest–  Unequaladoptionratesbypracticesize

•  Financialrisk–  UncertainROI–  Unequalaccumulationofbenefits

•  Threatstoprivacyandsecurity

KeyChallengestoCreatinganNHIN

•  LackofStandards– Silosofinformation

• Exchanginghealthinformationrequires:– Vocabularystandards– Messagingstandards– Transmissionstandards

KeyChallengestoCreatinganNHIN

TheDecadeofHealthInformationTechnology

•  RegionalHealthInformationOrganizations(RHIOs)•  NationwideHealthInformationNetwork(NHIN)•  DrivingEHRAdoption

–  ReducetheriskofinvestinginEHRs–  Developingacertificationprocess–  Provideimplementationsupport

KeyFocusAreas

ForcesinHealthcareDrivingAdoptionofInformationTechnology

Consumerism

•  Empoweredpatientswithchangingexpectations–  Technology‐enabledexperiences

•  Consumers(patients)aredemanding–  Speed–  Convenience–  Customizedserviceandtools–  Security,confidentiality

•  Patientsmovefasterandfurtherthantheirhealthinformation

Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.

ConsumerismHowcaninformationtechnologyhelp?

•  Consumersviewtechnologyas‘state‐of‐the‐art’–  Canpromoteaperceptionofhighquality

•  Integrateinformationfrommultiplesourcesacrossthelife‐span,butwithchallenges

•  Repositoriescanbesubstratefor–  Customizinghealthcaredeliveryandresource

distribution–  Enablingprocess/systemintegrationtoimprove

consumerexperience

Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.

PersonalHealthRecords• Afastgrowingareaofinterest/activity

ExpandedUsesofHealthInformation

•  JCAHO–  Requiresdatatosupportmanagementops,

performanceimprovement,patientcare•  HIPAA

–  Adminprocedures,physicalsafeguards,security–  Standardsforelectronicclaimsattachments

•  PublicHealth•  ClinicalResearch

–  Clinicaldatarepositorieshavewelldocumentedresearchuses

ExpandedUsesofHealthInformation

• PracticeManagement– Exponentialincreasesindemandforvarioustypesofadministrativereports• Referralpatterns• Productivity• Lotsmore…

– Outcomestracking• Practice‐basedEvidence• Payforperformanceinitiatives

ExpandedUsesofHealthInformationHowcaninformationtechnologyhelp?

•  Largepotentialefficienciesviaimproveddata–  Storage–  Processingandanalysis–  Transmission–  Monitoringandtracking(qualityassurance)

•  Keyenabler:structureofunderlyingdata–  Buildflexibleanalyticsontop

CostofCare

• USspends$1.7trillionannually– 16%ofGDP• 2xtheEUaverage

•  Seriousproblemswith– Inefficiency– Poorquality– Lackofaccess

CostofCareHowcaninformationtechnologyhelp?

•  Estimatesofsaving$140billionannually–  CentralIndianaestimates$120million

•  How?–  Improvedinformationsharingandcarecoordination–  Reducedredundancyandmedicalerrors

•  Challenge:mereadoptionwon’tproducesavings–  Realprocesschange(transformation)mustoccur

•  Misalignedfinancialincentives

Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Affairs. 2005;24(5):1103-1117.

ClinicalDecisionMaking

•  Makingsoundclinicaldecisionsrequires:–  Rightinformation,righttime,rightformat•  EBP(Patients+evidence+clinicalexpertise)–  Lotsofhype–  Clinicianswantit,butdon’thavetime

•  Cliniciansfaceasurplusofinformation–  ambiguous,incomplete,orpoorlyorganized

•  Risingtideofinformation–  Expandingknowledgesources–  Improvedcommunicationmethods

Tierney WM. Improving clinical decisions and outcomes with information: a review. Int J Med Inf. 2001;62:1-9.

Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.

ClinicalDecisionMakingWhat’stheProblem?

•  Manisanimperfectdataprocessor–  Sensitivetoquantityandorganizationofinformation

•  Decisionshurtbytoomany,toofew,orpoorlyorganizeddata

–  Cliniciansaresusceptibletoerrorsofomission•  Humansare“non‐perfectable”dataprocessors

–  Betterperformancerequiresmoretimetoprocess–  Irony

•  Cliniciansincreasinglyfaceproductivityexpectations•  Cliniciansfaceincreasingadministrativetasks

•  McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.

•  Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist’s role. Phys Ther. 1999;79(2) 171-185.

•  American Physical Therapy Association. Reported Productivity Expectations of PTs 1999-2002. Available from http://apta.org

EBPandQualityofCareHowcaninformationtechnologyhelp?

•  Eliminatethelogisticproblems•  Efficientaccesstoprimaryliterature•  Efficientaccesstoneededclinical

information•  Toolstosupportimplementingthebest

evidenceatthepointofcare–  Computersaretirelessdataprocessors

Vreeman DJ. Clinical prediction rules. Phys Ther 2006;86(5):761-762.

Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72

Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.

WhatisaComputerizedReminder?

•  Acomputer‐generatedsuggestionaboutclinicalcareforanindividualpatient–  InformedbydatastoredinanEHR–  SuggestionsbasedonprogramsthatoperationalizeEBPascomputablerules

•  Oftenintegratedintoaclinicalapplication–  E.g.Providerorderentryordocumentation

•  Mostcommonformofcomputerizeddecisionsupport•  Canbepresentedonpaperoraworkstation

CareReminders

ComputerizedReminder

EvidenceforComputerizedRemindersALongHistory

EvidenceforComputerizedReminders

EvidenceforComputerizedReminders

WhyInformationTechnology?

•  Alloftheseforces–  Clinicaldecisionmaking(EBP)–  Qualityofcare–  Consumerism–  Expandedusesofhealthinformation

areconvergingontheneedtoeffectivelymanagehealthinformation

•  Inadequacyofourcurrentpaper‐basedhealthinformationsystem

Whyaretherenoreminderstudiesinrehabilitation?

RemindersforRehabProvidersHowCanComputersHelp?

•  Activity:Examplesfromclinicalpractice–  Contentofthereminder–  Whatdatawouldthecomputerneed?

ImplicationsforRehabilitation

EvidenceforEHRs

EvidenceforEHRsinRehabilitation•  TheEHRsoperatedonallmajorhistoricalclassesofcomputers–  1968–2004

•  Software–  12/13usedin‐housedeveloped–  Only1usedcommercialsoftware

•  Widevarietyofpracticesettings–  Earlyintervention,outpatient,sub‐acute,actue

BenefitsofEHRs

BarrierstoImplementingEHRs

SuccessFactorsinImplementingEHRs

EvidenceforEHRsinRehabilitation

AdditionalRecommendationsMyOpinion

•  AdoptEHRs,butbemindfulofthecomplexityinvolved– Clinicianworkflow(nothardware)isparamount

•  MakeEHRpurchasedecisionswiththeNHINvisioninmind– Demandfeaturesofinteroperability

• HL7Messaging(import/export)essential– Whatfeatureswillhelpmemakebetterclinicaldecisions?

– Whatvocabularystandardsaresupported?

OtherQuestions?