Special Project Report You should prepare a memorandum-type report that includes the following:  Situation Analysis. Describe the "real" or hypothetical work environment, provider objectives and current information systems configuration, as well as any unmet needs or issues.  Functional Requirements. List or otherwise characterize the key functional requirements to be met by a new or upgraded health information system.  Evaluate Vendor Alternatives. Describe and evaluate several vendor alternatives. Indicate pros, cons and unresolved issues for each alternative. Give special attention to the “human factor” considerations.  Provisional Recommendation. Given the admittedly incomplete information available to you, what would you recommend as next steps? Options include doing nothing, upgrading the current system, negotiating with one or more vendors, and evaluating other vendor alternatives. Be specific and indicate your rationales for each recommendation. Special Project Report

“…a health care information system (HCIS) is an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the health care organization.” definition

Health Care Information System Administrative Contains primarily administrative or financial data Used to support the management functions and general operations of the health care organization Clinical Contains clinical or health-related information relevant to the provider in diagnosing, treating and monitoring the patient’s care

Administrative Applications Patient administration systems Admission, Discharge, and Transfer Registration Scheduling Patient billing or accounts receivable Utilization management Financial management systems Accounts payable General ledger Personnel management Materials management Payroll Staff Scheduling

Clinical Applications Ancillary information systems Laboratory Radiology Pharmacy Other clinical information systems Nursing documentation Electronic medical record (EMR) Computerized provider order entry (CPOE) Telemedicine and telehealth Rehabilitation service documentation Medication administration

History and Evolution of Health Care Information Systems

Terminology changes HISTalk series

http://www.slideshare.net/histalk/104-cerner-part-1

Confidential - ICW America © 2007 Viewing Disk drive and disk pack 320K “floppy” Punch Card reader Line printer Starting at $?? In 19__ Confidential - ICW America © 2007

Confidential - ICW America © 2007 Key punch for cards Each line of code on the punch card to run the program, that needed to run sequenqually Confidential - ICW America © 2007

1960s “Billing Is the Center of the Universe” Health Care Environment Enactment of Medicare & Medicaid Cost-based reimbursement Building mode Focus on financial needs and capturing revenues State of Information Technology Mainframe computers Centralized processing Few vendor-developed products Needed to track costs to submit $ the need to track all of the costs needed to be computer based. Few commercial vendors at the times. Developed in house.

1960s HCIS Administrative and financial systems Used primarily in large hospitals and academic medical centers Developed and maintained in-house Data processing was primarily centralized on mainframe computers Technicon at El Camino Hospital Larry Weed and the POMR at UVM

“The Mainframe”

1970s “Clinical Departments Wake Up Debut of Minicomputer” Health Care Environment Time of hospital growth and expansion Medicare and Medicaid expenditures rising Need to contain health care costs State of Information Technology Mainframes still in use Minicomputers become available, smaller and more affordable

1970s HCIS “Turnkey” systems available through vendor community Increased interest in clinical applications (particularly in ancillary departments) Shared systems still used HBOC  McKesson SMS  Siemens Gerber Alley  AMEX  oblivion Many others

1980s “Computers for the Masses” Health Care Environment Medicare introduces prospective payment system for hospitals Medicaid and other private insurers follow suit Need for financial and clinical information State of Information Technology Unveiling of the microcomputer (PC) Advent of local area network Departmental System Journey Battle of the mini’s  LANs

1980s HCISs Distributed data processing Expansion of clinical information systems in hospitals Physician practices introduce billing systems Affordable, powerful computers now available to smaller organizations Ability to integrate financial and clinical information becomes increasingly important

1990s “Health Care Reform Advent of Internet” Health Care Environment Medicare changes in physician reimbursement Health care reform efforts of Clinton administration Growth of managed care and integrated delivery systems IOM calls for adoption of computer-based patient record

1990s continued State of Information Technology Unveiling of the Internet (World Wide Web) Internet revolutionizes how organizations communicate with each other, market services, conduct business Cost of hardware drops

1990s continued Health Care Information Systems Health care organizations take advantage of Internet Vendor community explodes Wide range of HCIS products/services available Growing interest in clinical applications Still relatively small growth in adoption of CPR/EMR systems

2000s “Health Care IT Arrives Patients Take Center Stage” Health Care Environment IOM reports on patient safety and medical errors HHS calls for standards for EHRs Spiraling health care costs Economic upheaval and growing number of uninsured Health care transparency and pay for performance New administration Federal stimulus money available for HIT

2000s continued State of Information Technology Internet use moves to new level Voice recognition rebounds Bar coding and RFID PDAs and multipurpose cell phones PHRs and consumers maintaining Web-based records Web 2.0 technologies

2000s continued Health Care Information Systems National call for EHR adoption Infusion of HIT funding Office of the National Coordinator for HIT (ONC) Regional health information organizations Health care organizations “struggle” with how to successfully implement point of care clinical systems CPOE EHR E-prescribing

2010 and Beyond An Era of Accountability, Transparency and Change--Affordable Care Act, Meaningful Use and ICD-10 All Kick In

2010+ Information Technologies Cloud computing Mobile applications Social Communication Next Generation Analytics

Key Technology Milestones 1960s: “Mainframes Roam the Planet” 1970s: “Debut of the Minicomputer” 1980s: “Computers for the Masses” 1990s: “Advent of the Internet” 2000s: “Health Care IT Arrives” 2000s: Mobile Technology Arrives 2010s: Watson Comes to Healthcare? Discussion and explanation of Watson Listening to medical interview and then preparing the EMR for the visit. The rise of NLP for documentation?

Evolution of the CIO TITLES REPORT Data Processing Manager VP (administration) IS/IT Manager or Director CFO CIO SVP “Super” CIO (with CTO & CMIO) CEO or COO

Health Information Technology Jobs What did you learn? Health Information Technology Jobs

Chapter 5 Clinical Information Systems Less than Comprehensive E-Prescribing, lab, PACS and many other clinical information systems omitted Not Current E.g., newly-reported EMR problems Overly Positive E.g., Cedar-Sinai case study Insufficient focus on research bias Challenges Understated Adoption Rates Misleading Security/Privacy concerns minimized

Various terms used over time CPR Computer-Based Patient Record EMR Electronic Medical Record PHR Personal Health Record EHR Electronic Health Record

PHR vs. EHR vs. EMR “The Conceptual Ideal” EMR EHR PHR (includes clinic records only) PHR vision thing. PHR a super set as a tethered to EHR EHR (also includes other provider records) PHR (also includes personal health information)

Core Functions

EHR Adoption in US Hospitals

2012 Physician Adoption of EHRs

EHR Use in Other Post Acute and LTC Settings Extremely low 6%--Long term care 4%--Rehabilitation 2%--Psychiatric Source: Health Affairs, 2012

Value of EHR Improved quality, outcomes and safety Computerized reminders and alerts Improved compliance with practice guidelines Reduction in medical errors Improved efficiency, productivity, and cost reduction Improved service and satisfaction

CPOE Driven by need to improve patient safety Automates the ordering process Accepts orders electronically, provides decision support, may aid in diagnosis and treatment

Use and Status of CPOE Estimates vary up to 77% Historically teaching hospitals more likely to use Many organizations are in various stages of implementation Required for achieving meaningful use

Historical Barriers to CPOE Use Complexity of ordering process Physician entry an issue Takes longer to place order; many systems are ‘cumbersome’, take too many steps Incentives may not be aligned with use Lack of confidence in system reliability Insufficient training Mandating use – should you?

CPOE Implementation at Cedars-Sinai Medical Center perspective

Medication Administration Use of barcoding becoming more widespread Aids in correctly identifying patient, drug, dose, etc. HIMSS implementation guide—good resource More widely accepted Has been used successfully by many health care organizations Again, has potential to aid in making sure the right meds, get to the right patient, at the right dose…

Pharmacy Purchasing and Practice Aug 2013

Telemedicine Use of telecommunciations for the direct provision of care to patients at a distance Over 200 telemedicine programs involving over 3500 health care institutions Store and forward Two-way interactive TV Funding an issue Cost effectiveness not established

Telehealth Using telecommunications to communicate with patients and deliver services Electronic consultations (e-consultations) Patient portals Refilling prescriptions Registering patient Scheduling appointments

Telehealth Current use of email communication between patients and physicians Value to patients and providers Issues Complexity of infrastructure Degree of integration Message structure Cost Security Reimbursement

Personal Health Record & Patient Portals Managed by consumer May include both health and wellness information Patient portal—secure web site through which patients can access PHR or EHR Approximately 7% of consumers have PHR

Barriers to Adoption & Strategies for Overcoming Them Financial Organizational or Behavioral Technical Barriers Privacy and Security Barriers

Fitting Pieces Together

Case Study Acquiring an EHR System How Realistic Is the Valley Practice Scenario? How Well Do You Think the Indicated System Acquisition Approach Would Work? What Are the Problems or Risks? What Would You Have Done Differently?

Wager’s System Acquisition Process Establish a Project Steering Committee Define Project Objectives and Scope of Analysis Screen the Marketplace and Review Vendor Profiles Determine System Goals Determine and Prioritize System Requirements

Wager’s System Acquisition Process (cont.) Develop and Distribute the Request for Proposal or Request for Information Explore Other Options for Acquiring System Evaluate Vendor Proposals Conduct a Cost-Benefit Analysis Prepare a Ratings Matrix Prepare a Summary Report and Recommendations Conduct Contract Negotiations

SDLC

Assess Usability

Despite the best made plans, things can and do go wrong… Failure to manage vendor access to organization leadership Failure to keep the process objectives (getting caught up in the vendor razzle-dazzle) Overdoing or under-doing the RFP Failure to involve the leadership team and users extensively during the system selection Turning negotiations into a blood sport 20% of the people will claim…….

Executives Sharing With Executives IT Purchasing Strategies