Clinician Adoption: Physician Perspective Best Practice

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Clinician Adoption Physician Perspective
Best Practice Lessons Learned

• Dr. Mary Ellen Ehlers
• Dr. Ferdinand Venditti

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Background

• U.S. Healthcare System has
• High Costs,
• Variable Quality
• The adoption of information technology within
  healthcare has been promoted as a way to reduce
  costs and increase efficiencies as well as
  improve quality.
• Potential annual savings of billions by reducing
• Duplicate services caused by missing data
• Medical errors and adverse events
• Administrative costs
• The Federal Government is now driving the
  adoption of Electronic Health Records via ARRA

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Lack of Information when you need it.

• Clinicians reported missing clinical information
  in 13.6 of visits
• Missing information included laboratory results
  (6.1), letters/dictation (5.4), radiology
  results (3.8), history and physical examination
  (3.7), and medications (3.2).
• Missing information was reported to be somewhat
  likely or very likely to adversely affect
  patients (44), and to potentially result in
  delayed care or additional services (59.5).
• Significant time was reportedly spent
  unsuccessfully searching for missing information
  (5-10 minutes, 26 gt10 minutes, 10).
• Missing clinical information was less likely
  when individual clinicians reported having full
  electronic records
• Smith et al, JAMA. 2005293565-571

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ADEs in the Ambulatory Setting.

• Cohort study of 30,397 Medicare patients in a
  single Multi-specialty group over 1 year
• Collected all ADEs stemming from ambulatory
  prescriptions
• 1,523 adverse drug events were identified for an
  overall rate of 50.1 per 1,000 person-years.
• 28 were considered preventable
• 38 were serious or life-threatening and 42 of
  these were deemed preventable
• There were 11 deaths, 5 categorized as
  preventable
• Generalizing to entire Medicare population there
  would be 1.9 Million ADEs with 685 deaths
• Gurwitz et al, JAMA. 20032891107-1116

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EHR Adoption Survey

• National Survey of 2,758 physicians
• To determine the proportion of physicians who
  were using such records in an office setting

DesRoches et al. NEJM 200835950-60
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EHR Adoption Survey
DesRoches et al NEJM 2008 35950-60
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Clinician Adoption of Available Functions
Simon et al. Arch Intern Med. 2007167507-512
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Factors Affecting Adoption

• Financial Systems are expensive
• 50-70,000 per MD to buy and implement
• Creates significant productivity decrease from
  workflow redesign, training, site preparation,
  and implementation
• Disruption in the beginning
• Changes the way doctors and nurses practice
• Lack of perceived value
• Savings accrue to others payer and patients
• Lack of standards or guidance on systems
• Lack of IT expertise or knowledge
• Cultural barriers which are specific to a
  Practice
• Generational issues - often over-played
• Privacy concerns
• EHR adoption contingent on value creation,
  somewhere...

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Factors Affecting Adoption Value Creation

• Most adopters have seen a business need
• Large practices, multi-site practices
• However, financial barriers critical for small
  practices
• Where most Americans receive healthcare
• Capturing and re-distributing value is critical
• Health Systems Hospitals
• Payers BC/BS MA, CDPHP
• Federal Government - ARRA

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Benefits Revenue Increase
Area/Benefit Description Range of Financial Benefits Basis Risk to Achieve
Coding Initiative EM Codes Electronic Health Record will offer system intelligence to assist with CPT4 and ICD9 coding. xxxx - xxxxx annually Detailed Analysis Moderate
Volume x increase on EM Codes Enhanced charge capture via efficiencies of an electronic venue for health records. xxxx - xxxxx annually Detailed Analysis Moderate
Volume x increase on Procedure codes Enhanced charge capture via efficiencies of an electronic venue for health records. xxxx - xxxxx annually Detailed Analysis Moderate
Revenue based on Quality Indicators EHR utilized to assist with insurance carrier based reward for quality measures. Est. xxxx - xxxxx annually P. Hildreth continuing to analyze and assess Moderate
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Benefits Expense Reduction
Area/Benefit Description Range of Financial Benefits Basis Risk to Achieve
FTE Reductions Salary expense of Practice staff performing duties related to hard copy medical records. xxxxx -xxxxx annually. Detailed Analysis Moderate
Transcription Expense Reduction of expenditure related to transcription services. xxxxxx - xxxxxx annually Detailed analysis to be completed based on Dept/Div implementation scheduled, and approval to use transcription in place of Elect Health Record. Moderate
Not why we moved forward with an Ambulatory EHR
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AMC Ambulatory EHR Vision

• Complete Information available on the right
  patient, in the right place, at the right time.
• To create a rich dataset to support Quality
  Improvement efforts.
• A Clinical Decision Support System to assist
  Providers in reducing Medical Errors.
• Enhance the Academic environment for our students
  and trainees.

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AMC Faculty Practice

• 240 MDs with 14 clinical sites spread through the
  region
• Vast majority in subspecialties - Primary Care
  sized for teaching
• 400 residents and fellows in 33 training programs
• The teaching faculty for 550 medical students
• Several hundred ongoing clinical research trials
• Award winning Clinical programs in Heart Failure,
  Heart Attack care, Diabetes, Stroke, Epilepsy,
  Renal Transplantation, HIV
• Though these programs are mostly islands when it
  comes to their medical information

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Baseline Where we started

• Lots lots of paper, but
• E-signature and storage of outpatient
  transcription for many years
• Soarian repository which includes
• Laboratories
• Radiology
• Other Ancillary data
• PACS for radiology images as well as other
  systems such and MUSE, Cardiac Echo, and
  Endoscopy

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Vision
Baseline
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AMC EHR Journey

• Made the decision at senior level to move forward
  with an ambulatory EHR in January 2005
• Started with a small circle of IT and Physician
  staff
• Site visits to educate and inform the group
• Widened the circle engaging the group that would
  become the champions for the project
• More site visits and education with ultimately 12
  physicians
• A guiding coalition

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AMC EHR Journey

• Developed an RFP for vendors with Physician
  involvement
• Went through a process for selection with
• presentations,
• demonstrations, and
• more site visits
• Simultaneously developed an internal business
  case for the project with Physician involvement
• Selected the Allscripts Touchworks product

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Allscripts Enterprise - Formerly known as
TouchWorks

• Base
• Scan
• Dictate
• Results
• E-prescribe
• Document

• Tasking
• Call processing
• Order
• Charge
• Note
• Analytics

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IMPLEMENTATION APPROACH
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Implementation Approach

• Close collaboration between IT and Practice
• Strong Physician Leadership and support
• Clinical Chairs involved through an Advisory
  Committee
• Physician Champion
• Physicians part of the Steering Committee
• Working Relationship with Vendor

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Implementation Approach

• Application delivered via Citrix
• Interfaces with practice management system and
  multiple ancillary systems for result reporting
• Preload of key information and electronic import
  of historic laboratory, radiology, and other
  ancillary data

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Baseline Data Preloaded

• 2 years of results - Labs, radiology, EKG,
  Endoscopy
• 2 years of Practice dictations including all
  consultations
• 2 years of Hospital dictations
• ED Visits
• Operative reports
• Discharge Summaries
• Scan documents decided by each site
• Outside consults
• Laboratories and other ancillaries
• Data more than 2 years old
• Dictations and Ancillary results from 2/09
  forward

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Implementation Approach

• 2 pilot sites of primary care providers
• Phased go-live with functionality rolled out in
  waves
• Subsequent sites brought live in small groups

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Change Management..
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Implementation Approach

• Incorporation of change management techniques to
  manage the process
• Coordination of technical operations, integration
  and build teams
• Careful Workflow analysis
• Customized development with significant user
  involvement and eye towards standardization

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Make sure you provide the right End use Devices.
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Implementation Approach

• Careful review and selection process for end use
  devices
• Different end use devices demonstrated at sites
  choices ranged from tablets to desktops to WOWs
• Hands-on sessions for providers
• Providers decided for their individual site

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Education, Education, Education
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Implementation Approach

• Extensive training and education for all users
• Role based
• Removed users from their clinical site for
  training
• Small group sessions
• One-on-one as needed
• Online materials, web-based training, reference
  materials available
• Trainers on site for Go-live and post go-live
  support
• Super-users at each clinical site

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APRIL FOOLS ?!?

• Go-Live
• April 1, 2009

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What is currently Live at AMC

• Patient Schedules
• History Builder
• Problem Lists
• Medication Lists
• Allergy Lists
• Dictation

• Results Reporting
• E-Prescribing
• Tasking
• Call Processing
• In-Office Orders

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Whos Live At AMC

• Medicine Pediatric group
• 8 MDs, 4 Nurses, 1PA,1 Pharm D, 16 Residents, 2-6
  students, 25 support staff
• General Pediatrics
• 8 MDs, 6 Nurses, 1NP, 30 Residents, 20 support
  staff
• ED, Billing, Peds Subspecialty MDs
• Approximately 80 View-Only Users

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How are we doing?
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September 2009

• All live modules are used
• Tasking most problematic
• E-prescribing well accepted by prescribers
• ? More work for nurses
• Both sites requested change in scanning to have
  less paper.
• DUR turned off

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Be careful what you wish for.
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Alert Fatigue
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Alert Fatigue
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Are Alert Overrides Appropriate?

• 7,761 drug-allergy alerts
• Alerts were overridden 80 of the time
• Review of 320 overrides, all deemed clinically
  justified, however
• 6 of patients experienced ADEs attributed to the
  overridden drug
• Only 6 of alerts triggered by exact match
  between drug ordered and drug allergy
• Evidence alerts are not specific enough

Hsieh et al JAMIA. 200411(6)482-491
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Challenges

• Software limitations
• Getting it right
• Task Views
• End use Devices
• Providers at multiple sites
• Faulty processes pre-EHR
• Balance
• Customize vs. Standardize
• Transition Electronic Paper

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From Our Users

• This saves me about an hour a day. We look
  much more professionalwe can answer questions
  about prescriptions right away
• We forget we can WRITE prescriptions
• "The EHR is life altering.for patients and
  physicians. Data is available in an organized
  way when and where you need itprescriptions are
  filled electronically (so handwriting is not a
  problem!) and the record is clear regarding the
  sequence of events in a patient's illness."

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Summary

• Careful planning
• Build a guiding coalition
• Teamwork (close collaboration)
• Involve the physicians
• Use feedback to alter the course
• Spend time in education