1. Example: Improving Care by Design of an EHR Lecture by Farrokh Alemi, Ph.D. Narrated by Jonathan Duxbury

2. An Example Design an EHR that will reduce unnecessary visits while improving quality Assumptions  A staff model HMO  Both patients and providers have access to email and Internet  Informed consumers willing to take care of their own health (not for everyone but for a minority of patients)

3. An Example Design an EHR that will reduce unnecessary visits while improving quality Assumptions  A staff model HMO  Both patients and providers have access to email and Internet  Informed consumers willing to take care of their own health (not for everyone but for a minority of patients)

4. An Example Design an EHR that will reduce unnecessary visits while improving quality Assumptions  A staff model HMO  Both patients and providers have access to email and Internet  Informed consumers willing to take care of their own health (not for everyone but for a minority of patients)

5. An Example Design an EHR that will reduce unnecessary visits while improving quality Assumptions  A staff model HMO  Both patients and providers have access to email and Internet  Informed consumers willing to take care of their own health

6. An Example Design an EHR that will reduce unnecessary visits while improving quality Assumptions  A staff model HMO  Both patients and providers have access to email and Internet  Informed consumers willing to take care of their own health (not for everyone but for a minority of patients) Design an EHR to meet these assumptions

7. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant Neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

8. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant Neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

9. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant Neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

10. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant Neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

11. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

12. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant Neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122. 63 clusters of diagnoses explain 80% of primary care

13. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122. Each cluster is a use case, a scenario, under which we can examine impact of EHR

14. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122. In each cluster, ask internal & external experts how EHR will reduce visits

15. Describe the Content of Primary Care Visits 1. General medical examination 2. Acute upper respiratory infection 3. Pre- and postnatal care including complicated pregnancy and abortion 4. Hypertension 5. … 6. … 63. Malignant neoplasms of skin Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122. In each cluster, trace decisions and see what information is useful

16. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit.

17. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit.

18. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit.

19. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit.

20. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit. What impact will EHR have on our business objective in this use case?

21. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit. Experts: Reduces time for a well visit from 1 hour to ½ hour in 70% of the cases

22. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit. Given this use case what information is needed to carryout the necessary decisions?

23. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit. Information needed: exercise, weight, smoking, etc.

24. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit. Information needed: key findings and thoroughness of self exam

25. For General Medical Examination Cluster Patients will visit lab before scheduled appointment Patients will complete a health risk assessment online. Computer will provide feedback. Computer will guide patient in doing self examination. Computer will help patient plan questions they want to ask during the visit. Information needed: clients’ questions

26. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms Patient verification Permission to contact Preferred contact time Change in symptoms Protocol for triage to specialist Patient reported blood pressure Side effects of medication

27. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms Patient verification Permission to contact Preferred contact time Change in symptoms Protocol for triage to specialist Patient reported blood pressure Side effects of medication Lets’ look at Information needed in other use cases

28. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse

29. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse

30. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse

31. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse What impact will EHR have on our business objective in this use case?

32. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse Experts: Reduces visits in 60% of cases, where patient gets better after resting

33. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse Given this use case what information is needed to carryout the necessary decisions?

34. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse Information needed: patients signs and symptoms

35. For Acute Upper Respiratory Infection Cluster Patients contact clinicians by phone or email Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst System follows up with the patient to see if symptoms have gotten worse Information needed: Pt verification, permission to contact, preferred contact time, change in symptoms

36. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication  New information items added in

37. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication  Lets’ look at Information needed in other use cases

38. For Pre and Postnatal Care Cluster Some prenatal visits avoided for patients with positive laboratory tests Some post-partum visits avoided by the system triaging depressed patients to specialists

39. For Pre and Postnatal Care Cluster Some prenatal visits avoided for patients with positive laboratory tests Some post-partum visits avoided by the system triaging depressed patients to specialists

40. For Pre and Postnatal Care Cluster Some prenatal visits avoided for patients with positive laboratory tests Some post-partum visits avoided by the system triaging depressed patients to specialists What impact will EHR have on our business objective in this use case?

41. For Pre and Postnatal Care Cluster Some prenatal visits avoided for patients with positive laboratory tests Some post-partum visits avoided by the system triaging depressed patients to specialist Experts: Reduces visits in 10% of cases

42. For Pre and Postnatal Care Cluster Some prenatal visits avoided for patients with positive laboratory tests Some post-partum visits avoided by the system triaging depressed patients to specialist Given this use case what information is needed to carryout the necessary decisions?

43. For Pre and Postnatal Care Cluster Some prenatal visits avoided for patients with positive laboratory tests Some post-partum visits avoided by the system triaging depressed patients to specialist Information needed: items used in triage protocol

44. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication  New information added in

45. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication  Note that risk assessment was also needed in a previous use case

46. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication  Lets’ look at Information needed in other use cases

47. For Hypertension Cluster Patients measure blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition

48. For Hypertension Cluster Patients measure blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition

49. For Hypertension Cluster Patient measure blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition

50. For Hypertension Cluster Patient measures blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition What impact will EHR have on our business objective in this use case?

51. For Hypertension Cluster Patient measures blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition Experts: Reduces visits in 70% of cases, adds in cost of home equipment

52. For Hypertension Cluster Patient measures blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition Given this use case what information is needed to carryout the necessary decisions?

53. For Hypertension Cluster Patients measures blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition Information needed: patient reported BP

54. For Hypertension Cluster Patients measures blood pressure at home Patient calls in or is called by the system regarding control of their hypertension Clinician available by email to change prescription, explain progress and evaluate patient condition Information needed: patient verification, side effects, change in blood pressure

55. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication 

56. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication  As more use cases are examined more information items are added to the list.

57. List of Decisions & Information Items General medical exam Respiratory infection Pre and post natal careHypertension Health risks  Self exam results  Self exam thoroughness  Questions for the visit  Signs and symptoms  Patient verification  Permission to contact  Preferred contact time  Change in symptoms  Protocol for triage to specialist  Patient reported blood pressure  Side effects of medication 

58. Why Do This? Succeed by design  Design the improvements within the EHR system Specify functional information needs that correspond to real upcoming decisions

59. Why Do This? Succeed by design  Design the improvements within the EHR system Specify functional information needs that correspond to real upcoming decisions

60. Take Home Lesson Improve through design because what is not imagined is not done.