Jonathan E. Siff, MD, MBA, FACEP Director of Clinical Informatics The MetroHealth System Cleveland, Ohio

“You don’t know the power of the dark side” Darth Vader speaking to tech support after the death star implemented a new Electronic Health Record

I really do love electronic medical records and computers. However I’m realistic about the fact that they are not perfect and can introduce new risks along with their benefits. This talk will be vendor neutral Disclosures Put picture of me kissing computer here

Discuss some basic definitions related to Electronic Health Records (EHRs) List some of the reported benefits of electronic records systems Learn about some of the risks associated with electronic records in the ED Understand ways to mitigate the risk of EHRs to the ED Objectives

The promise of a better future through EHRs Publicity around medical errors created pressure to adopt EHRs as a solution American Recovery and Reinvestment Act provided $20 Billion for providers and hospitals to “meaningfully use” EHRs –Extra money now, penalties later End goal of increased safety and health at lower costs

The advertised benefits of EHRs Patient care benefits –Safety – error reduction, interaction checking, allergy checks –Computerized Physician Order Entry (CPOE) –Decision support –Legible and immediately available notes –No lost charts –Multiple users can access chart at once –Immediate access to past charts and data –Connection to Health Information Exchanges (HIE) or Regional Health Information Organizations (RHIOs)

Operational benefits –Streamlined workflows –Structured data for reporting –Increased productivity and throughput Revenue advantages –Cost savings –Better documentation leading to higher billings –Better reporting The advertised benefits of EHRs

The Reality Some benefits are undeniable –Legible charts, remote access But the biggest promises have yet to consistently materialize –Cost containment, improved efficiency, safety New risks due to complicated, difficult to use systems –Health IT and Patient Safety: Building Safer Systems for Better Care. IOM 2012

Operational Staff Liability Regulatory Patient Care EHR Risks

OPERATIONAL RISKS

Revised workflows and new responsibilities –Providers doing more than before –Initial unfamiliarity with system –Tasks in the EHR may take longer than before –Decreased provider productivity –Often never returns to baseline Biggest benefit where baseline operations poor Lower productivity leads to –Increased wait times and LWBS Operational Risk: Decreased Productivity and Turnaround Times

Revenue is always at risk –Lack of good checks and balances in new system –Fewer billed visits, lost encounters –Lower levels of service, missed procedures –Documentation may take longer –Charge capture can improve but it requires effort Operational Risk: Lower Revenue

Operational Risk: Downtime and Upgrades / Enhancements Computer systems go down - Always. –Scheduled vs. Unscheduled –Leads to operational inefficiencies and patient risk –The further from EHR implementation you are the greater these risks are likely to be Upgrades and system enhancements may lead to unintended consequences

Operational Risk: Increased cost of care Use of EHR’s has been shown to increase the cost of care in some studies –More imaging –Testing ordered to react to findings in chart Quality measures easier to report but do they really improve cost and care Other studies show no cost reduction eliminating promised ROI benefits

Operational Risk: Costs Electronic Health Records are not cheap –$700M reported for one major academic center “Going it alone” very difficult and expensive Departments part of an enterprise rollout will see increased costs too –Upstaffing, champions, paper Promised staff reductions often never materialize

Operational Suggestions: Champions Champions –One from each role –Not from traditional leadership positions –Get them involved on implementation committees and teams –Champions can engage staff and improve systems acceptance and use –This is a long term commitment as the need never ends

Operational Suggestions: Workflow analysis and review Review all workflows prior to EHR implementation Don’t try to reproduce the current state in the EHR Get your operations in order before go live –You can fix it later but its harder and more expensive

Operational Suggestions: Training and Build Training, Training, Training –Safety and efficiency issue –Don’t skimp – consider vendor recommendations –Role specific Content build should be done BEFORE go- live –Preference lists, order sets, D/C instructions –Optimization never ends

Operational Suggestions: IT issues Have adequate infrastructure –Enough devices of varying types –Fast enough network connections and servers Test interfaces between clinical systems Have downtime processes in place –Train these processes –Educate IT on the impact of ED downtime Participate in upgrade testing

Operational Suggestions: Staffing and Financial Up staff around go live if possible Adjust provider incentive plans Put billing and audit procedures in place to proactively catch issues –Involve your billing company or staff Have the right metrics Look at potential new or changed costs and get them in the EHR project budget

STAFF RISKS

Staffing Risks “Implementation of an EHR is a complex social project that involves computers” Changing roles create uncertainty and pushback Decreased employee satisfaction –Increased stress, higher call off rates, turnover Increased post shift work Physical challenges

Staff suggestions Engage them in the process Place workstations with patient contact and staff safety in mind Ensure comfortable workstations with good mice and keyboards Show them you understand their pain Consider scribes

Liability Risks

Liability Risk Some systems make risk management a priority (ED specific, homegrown) Enterprise systems generally do not Liability Risks –Privacy and Security –Charting Liability –Alert fatigue / Ignored alerts –Failure to access available data –Metadata and audit trails

Privacy and Security Risks EHR information may be restricted from ED Providers leading to patient care risk Data loss is easier with EHRs than paper –Easy downloads, remote access Electronic greaseboards may create a risk HIPAA minimum necessary standard not met Inappropriate access easier

Charting Liability Documentation automation risks –Macros –Pre-populated exams –”All normal” buttons –Auto-population of data Cut and paste All charting shortcuts create some risk

Charting Liability System design risks Loss of calculated values Failure to use structured data fields Template risk Provider comments ending up in the chart Data validation risks Wrong patient entries

Alerts & Alert Fatigue Warnings presented to users based on conditions in the system If alerts are too frequent or not a high enough priority they create alert fatigue Ignored alerts increase risk Out of date or inaccurate alert databases Vital sign alerts can be very helpful but potentially deadly if ignored

Failure to access available data Electronic records make it much easier, but no less time consuming, for providers to review prior visits The extent to which ED providers will be expected to review internal records and to access external records is unclear at this point

Metadata and Audit Trails Information attached to each action taken (transaction) in the EHR –User, date / time stamps, edits, order origin Bypassed alerts and pathways evident Easy to see if providers altered history Timing of actions is evident –Time of attending note vs time of actual procedure

Liability and Risk Suggestions Train and re-train staff on correct workflows Encourage providers to ensure that times are of events are accurately entered in the system Educate staff on permitted access to charts Minimum necessary Limit use of cut and paste and optimize macros to reduce risk

Liability and Risk Suggestions Limit data on displays in public areas Lock down and secure computers –Physical security, limit ability to download data Optimize alerts –Work to limit alerts to only critical information –Keep underlying databases up to date –Make alerts easy to address for providers

Regulatory Risks

Template Risk –Medicare transmittal 438 > 453 > 455 –Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. Meaningful Use scrutiny

Regulatory Risks EHR built in coding tools / rules –“EHR vendors are deploying tools for clinicians to ensure their clinical documentation is complete. These tools may embed rules engines and other logic that is not transparent to the end user” (AHA to HHS) EHR Coaching to providers for E/M Level Teaching physician workflows –Consistently problematic Scope of practice

Regulatory Risk Suggestions Educate providers on billing rules Limit the use of cut and paste and copy forward Avoid macros or templates with infrequently used options pre-selected Make general charting tools available Avoid auto-coding and coaching tools in EHR Enforce scope of practice Teaching physician workflows

Patient Risks

Workflow changes –May delay patient care –Ordering issues Decreased communication with patients –Computers intrude on provider patient dynamic Increased distractions –Clinical alerts, other patient data

Don’t change it if it really works (and it’s important) If something is really important and the current system works you may not want to change it –X-ray reading changes –Critical lab results

You can never do enough training and you need to keep training because the system keeps changing Monitor your processes and “inspect what you expect” your users to do Never be afraid to admit something does not work and make it better Don’t assume your IT department knows or understands the risks discussed here today Final thoughts

The Final Truth There is no one solution Each organization will make choices that are right for it –May increase risk but deemed “worth it” Few problems have definitive solutions –Be sure the cure is not worse than the disease Everyone has to work together to address EHR risk

Remember this?

Suggested Reading The problem with EHR’s and coding. and-coding and-coding Institute of Medicine report: IT and Patient Safety: Building Safer Systems for Better Care, ED information systems primer – ACEP white paper. Systems-Primer---ACEP-White-Paper---April-2009/ Systems-Primer---ACEP-White-Paper---April-2009/ In development – ACEP Informatics section paper on EHR safety

Jonathan Siff, MD, MBA