Electronic Health Records:Electronic Health Records:

“อเมริกาเข้มแข็ง” สอนอะไรไทย?อเมรกาเขมแขง สอนอะไรไทย?

นพ นวนรรน ธีระอัมพรพันธ์ M S (Health Informatics)นพ.นวนรรน ธระอมพรพนธุ, M.S. (Health Informatics)

ฝ่ายเวชสารสนเทศ คณะแพทยศาสตร์ รพ.รามาธิบดี

11 พฤศจิกายน 2553

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Outline

• Electronic Health Records & Health IT

• HITECH Act

• Meaningful Use of EHRs

Lessons for Thailand• Lessons for Thailand

Electronic

H lth R dHealth Records

The Challenge - Knowing What It Means

Electronic Medical Computer-Based

Patient Records Electronic Medical

Records (EMRs)Patient Records

(CPRs)

Electronic Patient

Records (EPRs)Electronic Health

Records (EHRs)Records (EHRs) Personal Health

Records (PHRs)

Electronic Health Records (EHRs)

• Electronic documentation of patient care by providers

• Sometimes defined as a patient’s life-long records

Electronic Health Record (EHR) Systems

• Are they just electronic documentation?

Diag-nosis

History & PE

Treat-ments ...nosis& PE ments

• Or do they have some other values?

Common “Goals” for Adoption“Computerize”“Go paperless”

“Di it l H it l”“Get a HIS”

“Digital Hospital”

“Modernize”“Have EMRs”

“Sh d t ”“Share data”

Benefits of Health Information Technology

• Literature suggests improvement in health care through

– Guideline adherence (Shiffman et al, 1999;Chaudhry et al, 2006)

– Better documentation (Shiffman et al, 1999)

– Practitioner decision making or process of care (Balas et al, 1996;Kaushal et al, 2003;Garg et al, 2005)

– Medication safety (Kaushal et al, 2003;Chaudhry et al, 2006;van Rosse et al, 2009)

– Patient surveillance & monitoring (Chaudhry et al, 2006)

– Patient education/reminder (Balas et al, 1996)

– Cost savings and better financial performance Cost savings and better financial performance (Parente & Dunbar, 2001;Chaudhry et al, 2006;Amarasingham et al, 2009;Borzekowski, 2009)

Functions that Should be Part of EHR Systems

• Computerized Medication Order Entry (IOM, 2003; Blumenthal et al, 2006)

C t i d L b t O d E t • Computerized Laboratory Order Entry (IOM, 2003)

• Computerized Laboratory Results (IOM, 2003)

Ph i i N t • Physician Notes (IOM, 2003)

• Patient Demographics (Blumenthal et al, 2006)

P bl Li t • Problem Lists (Blumenthal et al, 2006)

• Medication Lists (Blumenthal et al, 2006)

Di h S i • Discharge Summaries (Blumenthal et al, 2006)

• Diagnostic Test Results (Blumenthal et al, 2006)

R di l i R t • Radiologic Reports (Blumenthal et al, 2006)

The Bigger Picture: Health Information Exchange

G t

Hospital A Hospital B

Government

p

Clinic CClinic CLab Patient at Home

Common Denominator

• Health Information TechnologyHealth Information Technology

• Electronic Health Records• Electronic Health Records

• Health Information Exchange• Health Information Exchange

Ultimate Goal = Health

• Don’t implement technology just for technology’s sake.(Yasnoff et al, 2001 and many others)

• “Don’t make use of excellent technology.

Make excellent use of technology.”(Tangwongsan, Supachai. Personal communication, 2005.)

U.S. Adoption of Health ITAmbulatory (Hsiao et al, 2009) Hospitals (Jha et al, 2009)

Basic EHRs w/ notes 7.6%

Comprehensive EHRs 1 5%Comprehensive EHRs 1.5%

CPOE 17%

U S l b hi d th W t t i • U.S. lags behind other Western countries (Schoen et al, 2006;Jha et al, 2008)

• Money and misalignment of benefits is the biggest reason

็“อเมริกาเขม้แขง็”

(ARRA/HITECH A t)(ARRA/HITECH Act)

American Recovery & Reinvestment Act

• Contains HITECH Act (Health Information Technology for

Economic and Clinical Health Act)

• ~ 20 billion dollars for Health IT investments

Goals:Goals:

1. Boost economy (economic health)

2 Widespread adoption of Health IT (clinical health)2. Widespread adoption of Health IT (clinical health)

Quality Patient Safety Costs

National Leadership

• Office of the National Coordinator for Health Information

Technology (ONC -- formerly ONCHIT)

David Blumenthal, MD, MPP

National Coordinator for National Coordinator for

Health Information Technology

(2009 - Present)(2009 Present)

Photo courtesy of U.S. Department of Health & Human Services

Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

“Meaningful Use”Meaningful Use

“Meaningful Use” of A Pumpkin

“Meaningful Use”

of a PumpkinPumpkin

of a Pumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

Meaningful Use of EHRs: ONC’s 3-Stage Approach

Stage 1

- Electronic capture of

health information

Better

Healthhealth information

- Information sharing

- Data reportingStage 2

Stage 3

Use of

Health

pUse of EHRs

to improve

processes of

EHRs to

improve

outcomesprocesses of

care

outcomes

Blumenthal D, 2010

Components of Meaningful Use Regulations

• Medicare & Medicaid Incentives for Meaningful Use of EHRs– Centers for Medicare and Medicaid Services (CMS)

• Rule on Standards, Implementation Specifications &

Certification Criteria

• Certification Programsg– Office of the National Coordinator for Health IT (ONC)

Meaningful Use Incentives: Stage 1

Proposed Rule

• 23 Criteria for Hospitals to Pass

25 Criteria for Professionals (Clinics) to PassProposed Rule

(Jan. 2010)• 25 Criteria for Professionals (Clinics) to Pass

Public Hearing

• Pace & Scope: too ambitious, demanding, inflexible

• Few providers would likely qualify -> Little adoptiong

C Obj ti (15 it i i d)

Final Rule

• Core Objectives (15 criteria, required)

• Menu Set (10 criteria, pick 5)

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501-4.

Meaningful Use Final Rule: Core Objectives (Selected)

• Electronic capture of information– DemographicsDemographics

– Vital signs

– Medication listMedication list

– Allergies

– Problem listProblem list

– Smoking

• Medication order entry• Medication order entry

• Drug-allergy & drug-drug interaction checks

P ti t t / f h lth i f ti• Patient access to/copy of health information

Meaningful Use Final Rule: Menu Set (Selected)

• Drug formulary checks

• Lab results incorporation into EHRs• Lab results incorporation into EHRs

• Generate lists of patients by specific conditions

M di ti ili ti• Medication reconciliation

• Electronic reporting to governmental agencies

• Advanced directives for elderly patients

• Patient reminders for certain services (for clinics)

• Patient access to health information (for clinics)

Final Rule on Standards & Certification Criteria (Selected)

• Content Exchange Standards– HL7 CDA Release 2 & CCDHL7 CDA Release 2 & CCD

– NCPDP SCRIPT

• Vocabularies• Vocabularies• SNOMED CT

LOINC®– LOINC

– RxNorm ®

• Security• Security– NIST-certified encryption algorithms

Et• Etc.

Critique:q

L f Th il dLessons for Thailand

Disclaimer: Personal opinions. Supporting scientific evidence may not be available.

Lesson #1

Clear aim toward improved quality & Clear aim toward improved quality &

efficiency of health careefficiency of health care.

Lesson #2

Large health IT initiatives require Large health IT initiatives require

leadership from the highest levelleadership from the highest level

of governmentof government.

Lesson #3

To achieve widespread health IT To achieve widespread health IT

adoption substantial financial adoption, substantial financial

investment is necessaryinvestment is necessary.

Lesson #4

Leadership from a national Leadership from a national

organization with health informatics organization with health informatics

expertise is vital to successexpertise is vital to success.

Lesson #5

Criteria for “Meaningful Use” should Criteria for Meaningful Use should

be evidence based be evidence-based

to the extent possibleto the extent possible.

Lesson #6

Criteria for incentives should be Criteria for incentives should be

realistic and flexiblerealistic and flexible.

Lesson #7

Criteria for incentives should be Criteria for incentives should be

evolutionaryevolutionary.

Lesson #8

Accept local diversity in technologies Accept local diversity in technologies

& requirements & requirements.

Don’t aim for homogeneous Don t aim for homogeneous

environmentenvironment.

Lesson #9

Leverage existing standards Leverage existing standards

to the extent possibleto the extent possible.

Don’t reinvent the wheelDon t reinvent the wheel.

Lesson #10

Acknowledge that more than one Acknowledge that more than one

level of interoperability needs to be level of interoperability needs to be

achievedachieved.

Take Home Message

• Adoption of health IT still work in progress, even

in developed countriesin developed countries

• We can learn something from other countries

• We need to do something, soon.

• Don’t forget to build the workforce!!• Don t forget to build the workforce!!

Useful Online Resources• healthit.hhs.gov

• www.himss.org/EconomicStimulus/

• www.amia.org/public-policy/testimony-www.amia.org/public policy/testimony

comments-reports

• www.nejm.org/doi/full/10.1056/NEJMp0912825

• www nejm org/doi/full/10 1056/NEJMp1006114• www.nejm.org/doi/full/10.1056/NEJMp1006114

References (1)• Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe NR. Clinical information technologies and

inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108-14.

• Balas EA, Austin SM, Mitchell JA, Ewigman BG, Bopp KD, Brown GD. The clinical value of computerized pp p

information services. A review of 98 randomized clinical trials. Arch Fam Med. 1996;5(5):271-8.

• Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

• Blumenthal D, DesRoches C, Donelan K, Ferris T, Jha A, Kaushal R, Rao S, Rosenbaum S. Health information , , , , , , ,

technology in the United States: the information base for progress [Internet]. Princeton (NJ): Robert Wood

Johnson Foundation; 2006 [cited 2010 Oct 14]. 81 p. Available from:

http://www.rwjf.org/files/publications/other/EHRReport0609.pdf

• Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010

Aug 5;363(6):501-4.

• Borzekowski R Measuring the cost impact of hospital information systems: 1987-1994 J Health Econ Borzekowski R. Measuring the cost impact of hospital information systems: 1987 1994. J Health Econ.

2009;28(5):939-49.

• Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG. Systematic review: impact

of health information technology on quality efficiency and costs of medical care Ann Intern Med of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med.

2006;144(10):742-52.

References (2)• Garg AX, Adhikari NKJ, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized

clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

JAMA. 2005;293(10):1223-38.

• Hsiao C, Beatty PC, Hing ES, Woodwell DA. Electronic medical record/electronic health record use by office-

based physicians: United States, 2008 and preliminary 2009 [Internet]. 2009 [cited 2010 Apr 12]; Available from:

http://www.cdc.gov/nchs/data/hestat/emr ehr/emr ehr.pdfp g _ _ p

• Institute of Medicine, Board on Health Care Services, Committee on Data Standards for Patient Safety. Key

Capabilities of an electronic health record system: letter report [Internet]. Washington, DC: National Academy

of Sciences; 2003 [cited 2010 Oct 14]. 31 p. Available from: http://www.nap.edu/catalog/10781.htmlof Sciences; 2003 [cited 2010 Oct 14]. 31 p. Available from: http://www.nap.edu/catalog/10781.html

• Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A, Rosenbaum S, Blumenthal D.

Use of electronic health records in U.S. hospitals. N Engl J Med. 2009;360(16):1628-38.

Jh AK D l D G dt D S tt T B t DW Th f h lth i f ti t h l i ti I t • Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int

J Med Inform. 2008;77(12):848-54.

• Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support

t di ti f t t ti i A h I t M d 2003 163(12) 1409 16systems on medication safety: a systematic review. Arch. Intern. Med. 2003;163(12):1409-16.

References (3)• Parente ST, Dunbar JL. Is health information technology investment related to the financial performance of US

hospitals? An exploratory analysis. Int J Healthc Technol Manag. 2001;3(1):48-58.

• Schoen C Osborn R Huynh PT Doty M Puegh J Zapert K On the front lines of care: primary care doctors’ Schoen C, Osborn R, Huynh PT, Doty M, Puegh J, Zapert K. On the front lines of care: primary care doctors

office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006;25(6):w555-71.

• Shiffman RN, Liaw Y, Brandt CA, Corb GJ. Computer-based guideline implementation systems: a systematic

review of functionality and effectiveness J Am Med Inform Assoc 1999;6(2):104-14review of functionality and effectiveness. J Am Med Inform Assoc. 1999;6(2):104-14.

• Van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG, Bollen CW. The effect of computerized

physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a

systematic review Pediatrics 2009;123(4):1184 90systematic review. Pediatrics. 2009;123(4):1184-90.

• Yasnoff WA, Overhage JM, Humphreys BL, LaVenture M. A national agenda for public health informatics:

summarized recommendations from the 2001 AMIA Spring Congress. J Am Med Inform Assoc. 2001

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