1. How to Get Maximum Value from your EMR Dr. Alan Brookstone South Island Division of Family Practice January 30, 2012

2. Keys to Success Goals Expectations Leadership Foundational computer skills Practice, Practice, Practice Collaboration There are some things you cannot change, right now…

3. Focus of Today’s Presentation 1.Adoption & Current State 2.Data Quality 3.Change and Workflow 4.Training 5.Maximizing EMR Use 6.Sharing Knowledge & Skills

4. 1. Adoption & Current State International US vs. Canada South Island

5. Note: Multifunctional health IT capacity—uses electronic medical record and at least two electronic functions: for order entry management, generating patient information, generating panel information, and routine clinical decision support. Percent Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Doctors with Electronic Medical Records and Multifunctional Health IT Capacity

6. US – Regional Extension Center Program

7. National US Meaningful Use Data

8. EMR Adoption Journey – Level of Effort TIME Readiness Preparation Implementation Optimization + Ongoing Use Pre-EMR

9. Data Discipline Example - If you cannot identify your patients with bowel disease, how can you do colon cancer screening? Standardize – Coding – Diagnoses, Medications, Labs, History Clean – Coverage – all patients are in the system – Consistency – all data tells the same story – Completeness – all data is in the system – Correctness – right patients in, wrong patients out – Coded – all relevant data is coded or in a single format System thinking – Templates, reminders and searches work together Dr. Karim Keshavjee – Physician & Consultant – Mississauga, Ontario

10. Adoption ≠ Effective Use of EMR 16.1% of physicians report using Electronic Medical Records instead of paper charts. This compares to 9.8% in 2007 34.1% of physicians used combination of paper charts and EMR in 2010 vs. 26.1% in 2007. 2010 National Physician Survey - http://www.nationalphysiciansurvey.ca/nps/home-e.asp

11. 3. Change & Workflow Change is disruptive No disruption = Not sustainable How to manage the manage – Set clear direction, goals and objectives – Communicate regularly – Invite and acknowledge contributions and concerns – Address resistance by asking for input – Reward initiative – Build commitment

12. Workflow Workflow describes how a process takes place. The process is evaluated and improved to ‘flow’ more smoothly Optimizing workflow – Improve efficiency – Reduce redundancy (waste/duplication) – Identify gaps or areas of instability Plan on paper first – Office Visits – Chart Conversions – Allergy/Therapeutic injections

13. Chart is placed at vitals station Ht, Wt, BP Taken & recorded Patient is called to vitals station Patient is taken to exam room Chart is placed in sleeve on exam door Paper trigger Template needed How many vitals stations? How often do we see patient in room without vitals? Are cuffs and scales available in all rooms? How many BP’s do we miss? Ann Lefebvre MSW, CPHQ, Executive Director, NC Regional Extension Center Workflow – Vitals Collection

14. Workflow – Chart Conversion Stop Light System – Charts pulled for the next day and a GREEN dot is applied. The paper chart is for read only – everything is documented in the EMR – Additional information has been pre-loaded e.g. Meds, Allergies, Problem list, Recent vitals etc. – Physicians flag additional information in the chart they wanted preloaded or scanned – The next time the patient is seen, the chart gets a YELLOW dot, and a RED dot on the third visit – 4th visit – chart is not pulled because of RED dot – Goal: Everything in chart that is needed by 3 rd visit

15. Pearls Expect and manage disruption EMR implementation is just the beginning, not the destination Change is never complete – processes can always be improved

16. 4. Training Training not just for implementation and upgrades Should be ongoing and comprehensive - includes new learning and advanced functions As users get comfortable with a system, they learn new and faster ways to work using the EMR More complex features require more training

17. 17 5. Maximizing EMR Use Clinical decision support HIMSS Definition – Clinical Decision Support is a process for enhancing health- related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery – Made up of: Clinical elements e.g. reference information Administrative elements e.g. alerts or reminders

18. Types of Clinical Decision Support Drug-Drug Interactions Drug-Allergy interactions Dose Range Checking Pick lists Standardized evidence based order sets e.g. for CDM Rules (core measures, antibiotic usage, INR management) Links to knowledge references (in the EMR or Web-based) Alerts Templates Relevant data displays Point of care reference information Diagnostic decision support tools

19. 19 Evaluation Criteria – Data & Tools Relevance Efficiency Sensitivity Currency Usability

20. 20 Relevance General vs. specialty focused – Alerts, reminders, templates Is the tool primary care/internal medicine focused? – Chronic disease management How does it relate to your practice? – EMRs have their strengths and weaknesses

21. Does the tool slow you down or improve efficiency? – Speed of use (number of mouse-clicks) Does the benefit outweigh the cost in terms of the time it takes to use it? – Financial & time cost vs. clinical benefit 21 Efficiency

22. Does the tool provide the right amount of information to make the decision? – Too much or too little? – Who controls sensitivity settings? Individual user vs. practice level Need to ensure the right sensitivity settings – Alert sensitivity too high or low won’t provide the right information at the right time 22 Sensitivity

23. How timely is the information? Is it up-to-date? – Drug data – Clinical reference data – Out of date information loses relevance 23 Currency

24. How does the tool fit into your workflow? – If distracting or poorly designed, can increase risk of error What is the general satisfaction of users? – Speak with colleagues – Importance of user groups 24 Usability & Human Factors

25. Where Can CDS Add Value? Improved quality – By guiding users to best practices Increased safety – By verifying an action was the intended one Reduced cost – By identifying duplicate or unnecessary orders Improved documentation – Using templates or order sets for specific conditions Improved communication – Among clinicians regarding patient status – Between clinicians and patients Source: HIMSS

26. 5. Tips to Maximize EMR Use Set goals, personally, at the practice level Get complete buy-in from physicians and staff First, optimize your internal practice environment Hold regular practice meetings Make your data comparable and reproducible. Standardize on lists, codes, medications, order sets and templates Avoid short cuts in documentation. It may be tempting to enter certain data in narrative format – time pressured. To make data reproducible, it needs to be in a standard format Trust your gut. The EMR is a tool. Use clinical judgment when making decisions. Your EMR vendor is not infallible and needs your support and feedback Keep an open mind. What can your EMR do for you that you were never able to do before? Effective EMR Adoption and Use is about collaboration and the community in which you practice

27. Sharing Knowledge & Skills The skills and knowledge to be successful are right here in this room Mechanisms to support one another – Based upon common interests – Sustainable value Community level Goals – Improve health of CDM patients (e.g. recalls, alerts) – Information sharing – referrals & consultations (e.g. standardized South Island referral form, improve format of consultation reports User Groups – EMR based - share knowledge, develop super users