Electronic health records Deploying knowledge at the Point of Care Andrew M. Wiesenthal, MD, SM Director, Deloitte Consulting, LLP May 29, 2014 NHS Scotland

The case for the EHR It’s just better, isn’t it obvious? If not, then make… All information about all patients available to appropriate care givers all of the time Care quality/value the best possible Care as safe as possible Care as seamless and pleasing as possible for patients Care delivery as efficient as possible Delivering care as smooth and pleasing as possible for health care workers

Core Principles Integrate care and the information that supports it across all sites and all levels of the care continuum Standardize wherever and whatever possible, balanced with the need for appropriate customization and continuous innovation

If Knowledge is Necessary, What are its Attributes? Science; or patient-derived intelligence Clear attribution Investigable Dynamic and Correctable Actionable Accessible at the right point in a Workflow Usable in a Reproducible Way “If you are going to make something the easiest thing to do, it better be the right thing.”

How is Knowledge Represented in an EHR? The data model The terminologies The user interface The core, frequent, repeatable, or dangerous clinical and business processes and workflows Privacy and security policies and techniques The technical approaches to information movement and exchange

Data Model What are the core data elements? What are their definitions? What are the rules for extending the model? What are the rules for altering the model (and then preserving history)? Addressing all of these questions will increase the value of the data collected by EHRs for patients and health system leaders and managers, and this in turn enhances new knowledge creation

Terminologies What are the core reference terminologies that populate the data model? What are characteristics of a good (not perfect) terminology? What is the difference between a reference terminology and an interface terminology? Why are both important, and why should they both be standardized? What are the downstream uses of the data (and who gets to use it, with what authority)? Selecting standard terminologies and implementing them in a standard manner will increase the reliability and value of data

User Interface There is emerging cognitive science about the way to organize the user interface of an EHR EHR vendors have not followed these developments, nor do they have formal approaches to interface design Designers of other high risk human-machine interactions (aircraft cockpits) follow a different design and implementation approach Common user interface characteristics would make movement between different systems simple for health care workers and safer for their patients Common user interface characteristics would make execution of represented knowledge more reliable

Processes and Workflows Processes are the steps we use to accomplish tasks Workflows are the subset of steps that occur through use of the EHR/computer/associated devices Health care settings are not factories, but They are dangerous They are complex There are many common processes within and among settings Standardizing processes and workflows will decrease risk, reduce complexity, and enable continuous quality improvement

The End Game Patients are cared for safely and effectively with the best possible outcomes and satisfaction with the process of care Health care workers feel that the system supports their ethical mission and optimizes the quality of their work life System leaders and managers have the tools to measure system performance and continuously improve it The EHRs enable this rather than getting in the way

Some Kaiser Permamente Examples First, what exactly is Kaiser Permanente? Registries and transition management decrease the post-AMI death rate Best cancer care anywhere and everywhere using care planning tools overlain with evidence-based protocols Total knee replacement: to glue, or not to glue, that is the question, using registries and data mining Making consent truly informed, using evidence-based videos and the patient portal Decreasing HAPU and eliminating catheter-related sepsis using real- time reporting integrated with nursing workflow

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