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How electronic health records may influence behavior George Hripcsak, MD, MS Department of Biomedical Informatics/ Medical Informatics Services Columbia.

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Presentation on theme: "How electronic health records may influence behavior George Hripcsak, MD, MS Department of Biomedical Informatics/ Medical Informatics Services Columbia."— Presentation transcript:

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?

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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 / %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

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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

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26 Proposed addition for compliance Pain Smoke Pt edu Inform

27 PERRLA

28 Structured data entry general ofatigue fever or chills olumps or masses eyes wear glasses/contacts visual changes oeye pain oitchy/watery eyes nose and throat obloody nose congestion/runny nose osore throat hoarseness gastrointestinal odysphagia (trouble swallowing) heartburn onausea and vomiting oabdominal pain ojaundice odiarrhea constipation cardiovascular chest pain/tightness opalpitations ofainting spells edema or fluid retention ears ohearing aids oearache otinnitus (ringing in ears) ear drainage recurrent infections respiratory oshortness of breath cough/congestion owheezing productive of sputum/phlegm ohemoptysis (coughing up blood) dermatology oskin lesions/skin cancer rash …

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 2007October 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

34 UnitPatient s Med Rec OrdersHome Med List Both Med and Orders ##%#% #% Special9667%6 6 ICU10 100%10100% % ICU10 100%10100% % ICU99100%9 9 ICU15 100%1493% % Medsurg323197%32100% % Medsurg33 100%3297% % Medsurg201995%1995% % Medsurg24 100%24100% %... Medsurg18 100%18100% % Medsurg383797%3592% % Medsurg232087%2087% % Medsurg151280%1280% % TOTAL %56596%56495%

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

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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

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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”

51 Primary Care Information Project (PCIP) Public Health’s Role in Health Information Technology: The New York City Model Farzad Mostashari Mat Kendall New York City Department of Health and Mental Hygiene

52 PCIP 3000 Medicaid providers in NYC The following storyline illustrates the TCNY Clinical Decision Support System in action Jane Doe, a 48 year-old woman is cared for by her family practitioner, Dr. James Bear.

53 Dr. Bear wants to find out how he is performing compared to other physicians in his practice in controlling high blood pressure for his patients. Using the QUALITY MEASURE REPORTS FUNCTION, Dr. Bear is inspired by the performance of his peers in managing the blood pressure (BP) of their hypertensive patients; only one-third of his hypertensive patients have achieved good BP control. Dr. Bear queries the EHR to identify which of his patients have diabetes and an HbA1C > Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

54 Dr. Bear wants to improve his score on BP control and queries the EHR to identify patients with poorly controlled hypertension Using the ENHANCED REGISTRY FUNCTION, Dr. Bear identifies five patients with high blood pressure who do not have an appointment scheduled, and reaches out to each patient; he generates a letter scheduling a follow-up visit with patient Jane Doe. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

55 Jane Doe receives the letter and makes a f/u appointment During the visit, Dr. Bear’s assistant takes her history and vitals Jane mentions that she has had a few weeks of excessive thirst and fatigue Jane’s blood pressure is elevated (150/90) and highlighted in red by the AUTOMATIC VISUAL ALERT FUNCTION. Dr. Bear can trend her BP over time. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

56 Based on Jane’s chief complaint of excessive thirst, Dr. Bear performs a fingerstick test and confirms his suspicion that Jane has diabetes Dr. Bear enters a diagnosis of diabetes into the EHR Based on Jane’s new diagnosis of diabetes, the CLINICAL DECISION SUPPORT FUNCTION identifies four preventive care services that should be performed. This list of services is automatically populated in the CDSS panel. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

57 Dr. Bear agrees that these tests are appropriate and should be performed Dr. Bear uses the QUICK ORDER FUNCTION to order an HbA1C test for Jane, as well as a flu vaccine; the alerts disappear from the panel once they are ordered. Dr. Bear may also choose to suppress alerts, if he deems them unnecessary. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

58 Dr. Bear also selects the “LDL control (high risk)” alert, which displays the order set for high LDL levels The 1 st part of the COMPREHENSIVE ORDER SET displays a selected list of recommended medications (brand & generic) for lipid control. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

59 Dr. Bear views other order sets for high LDL levels The 2 nd part of the COMPREHENSIVE ORDER SET displays a selection of recommended labs, immunizations, follow-up appointments, referrals as well as printable physician and patient education materials. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

60 Dr. Bear wonders if he should change Jane’s medication regimen to better control her lipids and wants know what medications have been filled by her in the past 90 days Jane has signed a consent form to give the provider access to her medication history Since Jane is a Medicaid patient, Dr. Bear can use the eMedNY FUNCTION to view her 90-day medication history. He notices that Jane has not filled her lipid medication (simvastatin) for the past three months; she admits that she has stopped taking them because she wondered if her tiredness might have been due to these pills. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health

61 While she’s there, Jane asks Dr. Bear for a school health form for her 5 year- old (Tim) who is entering day care. Dr. Bear generates a preloaded NYC School Health form populated with Tim’s information for Jane to take with her. Tim’s information has already been automatically uploaded to the CITYWIDE IMMUNIZATION REGISTRY. The CIR will maintain a complete record of Tim’s immunizations which can be accessed by other providers as needed. 1. Measure Reports2. Enhanced Registry3. Automatic Visual Alerts4. CDSS 5. Quick Orders6. Comprehensive Order Sets7. eMedNY8. CIR and School Health Tim male 01/01/03 Mother

62 Quality initiatives improve quality, not EHRs Partnership among clinical leadership, quality, IS

63 Focus with clear goals

64 Slow, iterative process

65 Culture and buy in Need to pair bottom-up initiative with top-down, evidence-based approach

66 Research There is something there We need to find it


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