The Ambulatory EHR:

1
The Ambulatory EHR State of the
Industry Maryland HIMSS October 12,
2007 Peter Basch, MD, FACP Medical Director,
Ambulatory Clinical Systems MedStar Health
2
My perspective

• Practicing physician using EHR for more than a
  decade
• Medical Director Ambulatory Clinical Systems,
  MedStar Health
• Clinical leadership for our ambulatory EHR
  initiative
• 700 physicians in 49 specialties
• Member, HIMSS
• Chair, Maryland Task Force on EHRs
• Co-Chair, Physicians EHR Coalition
• Board Leadership Council member, eHealth
  Initiative

3
Washington Primary Care Physicians

• 1995
• 4-person internal medicine
• Two offices
• Washington, DC
• Maryland
• 13 support staff
• Drowning in paper
• Struggling to survive with declining
  reimbursements / increasing responsibilities

• Consensus decision to buy an EHR

4
3 months into implementation feeling the love
What am I, a f_at_ing secretary?
Was I supposed to be signing notes I think I
have been clicking delete by mistake.
Please dont tell me you spent our 401K on this!
5
Washington Primary Care Physicians

• 1995
• 4-person internal medicine
• Two offices
• Washington, DC
• Maryland
• 13 support staff
• Drowning in paper
• Struggling to survive with declining
  reimbursements / increasing responsibilities

• 2007
• 7-person internal medicine
• One office
• Washington, DC
• 14 support staff
• Drowning in information
• Surviving all enabled by an EHR

6
How is the ambulatory A-EHR doing?

• Adoption rate nationally 10 40
• Adoption regionally
• GWU implemented Allscripts
• Johns Hopkins implementing Centricity
• MedStar Health implementing Centricity
• University of Maryland implementing Epic

7
Outside of enterprises, progress is slower

• In solo / small practice

• In rural areas

• No concept of retained capital
• Lack of advice for purchase
• Dependent completely on vendor for training,
  implementation, post-implementation support
• Lack of ready IT support

• Lack of ready access to broadband

8
But help has been forthcoming - CCHIT
9
And from HIMSS, KLAS
10
And the eHealth Initiative
11
And HHS
12
And the CHcF and HITSP
13
And perhaps the economic barrier to MDs in small
practices has been overstated
14
State of the Industry Its all good
15
Or is it?
16
And the news on A-EHRs and quality has been
unsettling
17
And the news on A-EHRs and quality has been
unsettling

• No correlation between EHR use and improved
  outcomes in diabetes
• (OConnor, PJ et al., Ann Fam Med, 2004)
• No improvement in lipid management after 5 years
  of using an advanced EHR
• (Siemienczuk, J et al, Am J of Managed Care,
  2004)
• Negative correlation between diabetes measures
  and EHR use
  (Crosson, JC, Ann Fam
  Med, June 2007)

18
Have we all been profoundly wrong?

• Most current EHR research has looked at EHR
  technology pre-2004
• Without almost any decision support
• Most EHR research has looked at use of EHRs in
  fee-for-service settings
• Without incentives to use whatever decision
  support was present
• We are seeing exactly what should have been
  predicted EHRs used to support the business case
  of the IT purchaser
• EHRs with advanced CDS and used in settings where
  that use has been incentivized do show cost
  savings and quality improvement

19
Poor aim?
20
Unbelievably consistent?
21
Good aim wrong target!
22
Recasting the Bulls Eye from the EHR to
Enabling Infrastructure

• Goals EHR implementation

• Goals Infrastructure

• Have physicians use computers in practice
• Survive the implementation and get productivity
  back to baseline within 2-3 months

• Build a set of multidimensional goals based on
  patient / practice / enterprise needs
• Such asWith every use of the EHR (visits,
  calls, eCare, etc.) we will strive to make care
  better

23
Example Goals for EHR as enabling
infrastructure at MedStar Health

• Enhance our ability to honor our commitment to
  patient privacy and security
• Enhance our ability to measure quality and
  monitor safety in the ambulatory setting
• Help to achieve measurable improvements in
  quality of care and patient safety
• Reduce liability exposure, as defined and
  measured by Risk Management
• Enable successful participation in P4P programs
• Enable successful participation in other programs
  that advance quality and/or safety via
  transparency (internal or public reporting) of
  meaningful performance data
• Enhance the education of housestaff and students
  from multiple disciplines
• Support practice-based research
• Optimize physician / provider productivity
• Improve patient satisfaction
• Improve operational efficiency
• Enhance continuity of care and continuity of the
  record across the continuum

24
Choosing the right target is just the 1st step

• Aside from completion of work on standards (and
  their implementation), and developing privacy and
  security policies that lead to consumer trust
• Healthcare in the US most become defragmented
  stakeholders must work towards common goals
• Reimbursement reform must create a sustainable
  business case for information management and
  quality
• We will need clinical protocols and a new
  paradigm for duty / liability for interconnected
  healthcare

25
EHRs need to improve

• Even if all of the above were to happen tomorrow
• Most EHRs are built to document episodic care,
  and the best are built to suggest improvements to
  individual care episodes
• Organizations such as HIMSS need to challenge EHR
  vendors / developers to create and perfect
  software that supports the vision of HIT enabling
  healthcare transformation

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The EHR and new sources of error

• Alert fatigue / multi-tasking ? ignoring key
  alerts
• Pick-list errors (never misspelled but
  sometimes completely wrong)
• Faithful propagation of error
• Digital garbage ? screen fill and information
  overload ? missing salient points

28
Summary

• The State of the Industry is good, and there is
  every reason to expect widespread adoption of the
  A-EHR soon
• Adoption of the A-EHR is necessary but not
  sufficient to result in quality optimization
• The target for policy makers and HIT
  organizations should be healthcare transformation
  and reimbursement reform and not HIT adoption
  per se
• Work is needed on improving EHR functionality,
  and in anticipating and reducing / eliminating
  new errors from HIT