Don’t be a Fish Out of Water Why We All Need to Care About Health Information Technology (HIT)

ACOEP Spring 2020

DISCLOSURES

• Nothing to disclose

OBJECTIVES

• Explain why HIT matters and what a powerful tool it can be –

for good or for evil

• Past – Catalog successes and failures of HIT to date

• Present – How to use HIT to help care for your patients today

• COVID Future – How to best utilize HIT in the post-COVID

world in your practice today and into the future

• Normal Future – The things that were already in the pipeline

You struggling to care for your

patient without HIT

HIT

infrastructure

AGENDA

The Past

PAPER CHARTS

• Pro:

– Quicker

– Unstructured orders give flexibility

• Con:

– Unstructured orders drive nurses crazy

– Illegible

– Very difficult to get longitudinal view of patient

– Very difficult to standardize care and perform QI monitoring

ADAPTATION

• Mutation produces variety and deviation

• Selection kills off the least functional mutations.

• Pre-computer– all mutation and no selection.

• Computerization – all selection and no mutation

ADAPTATION

• What we want and don’t have, however, is a system that

accommodates both mutation and selection to adapt

Stimulus

HITECH

Meaningful Use

The Present

Major EMR vendors hospital

market share in 2018.

1. Epic: 28 percent.

2. Cerner: 26 percent.

3. Meditech: 16 percent.

4. CPSI: 9 percent.

5. Allscripts: 6 percent.

7. Medhost: 4 percent.

8. athenahealth: 2 percent.

9. None/other: 9 percent.

The following four vendors provided service to hospitals

with more than 500 beds in 2018:

1. Epic (163 hospitals)

2. Cerner (77 hospitals)

3. Allscripts (16 hospitals)

4. Meditech (12 hospitals).

https://www.beckershospitalreview.com/ehrs/klas-epic-cerner-dominate-emr-market-share.html

ARE WE BETTER OFF?

• Definitely

– Reviewing data: recent lab trends, outpatient visits, hospitalizations

– CPOE: Decision support, Interaction checking, Standardization

– QI: Identify outliers, practice evidence based medicine

• But we have new problems to deal with

– Burnout

– Efficiency Loss

– Data Entry Monkey

– Regulations

• 4197 practicing physicians in Rhode Island surveyed in 2017– 43% (1792) responded and 26% reported burnout (low)

• HIT stress is common (70%), specialty related and independently predictive of burnout symptoms

• Poor/Marginal time for documentation = 2.8 OR

• Home use of EHR = 1.9 OR

• EHR adds to their daily frustration = 2.4 OR

• 1,400 char/note

• 275 words/note

• 0.5 page Notes

5.1 char/word

500 words/page

• 4,200 char/note

• 824 words/note

• 1.6 page notes

International U.S

The Present

The Future

The COVID

Future

DATA IS BEAUTIFUL VISUALIZATION

https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/

DATA IS BEAUTIFUL VISUALIZATION

https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/

DATA IS BEAUTIFUL VISUALIZATION

https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/

https://informationisbeautiful.net/visualizations/covid-19-coronavirus-infographic-datapack/

http://www.healthdata.org/research-article/forecasting-covid-19-impact-hospital-bed-days-icu-days-ventilator-days-and-deaths

http://www.healthdata.org/research-article/forecasting-covid-19-impact-hospital-bed-days-icu-days-ventilator-days-and-deaths

http://www.healthdata.org/research-article/forecasting-covid-19-impact-hospital-bed-days-icu-days-ventilator-days-and-deaths

http://www.healthdata.org/research-article/forecasting-covid-19-impact-hospital-bed-days-icu-days-ventilator-days-and-deaths

COVID-19

• Data visualization

• The world is interconnected and data sharing is critical to

public health efforts

• Lab management (testing availability) is a classic

application of informatics

•Telehealth

WHAT IS TELEHEALTH?

Doctor ready for a true virtual visit in the era of COVD

TELEHEALTH

https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth

TELEHEALTH—CMS

• Virtual Check-In Visits – Telephone only visits

• eVisits – Patient Portal online digital visits

• Telehealth – Audio/visual technology to engage with a

patient (commonly Telemedicine/Telehealth)

TELEHEALTH – ED CODES

HCPCS Code Description

G0425 Inpt/ed teleconsult30 (min)

G0426 Inpt/ed teleconsult50 (min)

G0427 Inpt/ed teleconsult70 (min)

TELEHEALTH – CMS REGULATIONS

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

TELEHEALTH

https://www.beckershospitalreview.com/lists/275-telehealth-companies-to-know-2019.html

TELEHEALTH – CMS REGULATIONS

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

TELEHEALTH

TELEHEALTH

• Radiologists have been doing this

for decades

• How can you use this in your ED

tomorrow?

TELEHEALTH

https://www.beckershospitalreview.com/lists/275-telehealth-companies-to-know-2019.html

KEEP IT SIMPLE

• Tablet device or laptop with a generic log-in:

– HospitalTeleMedicine@gmail.com

• Tablet in patient’s room to tablet outside patient’s room

• Tablet in hospital to patient at home (many have devices)

• There are a million use cases for this. Here are a few:

MSE BY TELEHEALTH???

https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/emergency-

medical-treatment-and-labor-act-emtala-requirements-and-implications-related-covid19

VIRTUAL URGENT CARE

• Hospital-wide phone triage system

– This might be better with full system (waiting room etc)

• Could save a visit to the ED from a nervous individual

• Could save PPE/Exposure for a patient already in ED

CONSULTS/TRANSFERS

• Rural ED specialty consults and transfers between

hospitals

• Consults within same hospital to reduce PPE/exposure

– Tablets in all COVID units

– ED mainly for consultants

– ICU for intensivist attending overnight or staffing multiple

hospitals

– Floor for monitoring borderline patients more frequently

PATIENT TO FAMILY COMMUNICATION

• Patient’s are terrified

• No one should die alone

REGISTRATION STAFF

• Reg staff sit at their station and patients hold ID up to

camera on tablet

F/U WITH DISCHARGED PATIENTS

• Most patients have video enabled phone

• Load some common apps and connect in the ED before

discharge

The Normal

Future

HOW DO WE EVALUATE PERFORMANCE?

• PPH

• RVU/Hr or RVU/Pt

• Press Ganey

• Total Admit or D/C LOS

• Door to Doc

• Doc to Dispo– Admit vs Discharge

– Process issues affects this but we own it

• Admit percentage– e.g. Global, Chest Pain

• Imaging rates per chief complaint– e.g. CT for abd pain,

– Dimer/ CTA for Chest Pain

• Efficiency in the EHR, “Pajama Time”

HOW DO WE EVALUATE PERFORMANCE?

• Know how these are calculated at your shop

• Which of these can you take action on?

• Which of these are system issues?

• Private vs Public internal data reporting

– We made some metrics public with good results

– PPH, RVU/Hr, Admit %, Chest Pain Admit %

VALUE BASED CARE/QUALITY METRICS

• Door to Admit – Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.

• Door to Discharge – Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.

• Boarding Time – Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/eCQM_EH_Table_April2014.pdf

https://cmit.cms.gov/CMIT_public/ListMeasures

THESE THINGS ARE NOT GOING AWAY

• Medicare is trying to reduce burden

• Value based payment means we have to measure value

somehow

APPROPRIATE USE CRITERIA

• 2021 penalties begin if ED’s don’t adopt a decision

support tool for advanced imaging (CT/MRI/Nuc/PET)

APPROPRIATE USE CRITERIA

PREDICTIVE ANALYTICS/MACHINE LEARNING

• Non-interventional radiology most at risk of replacement

• 48 FDA Approved algorithms so far

– Lung nodules on XR

– Intracranial Hemorrhage on CT

• For now they are adjuncts

PREDICTIVE ANALYTICS/MACHINE LEARNING

• ED Bounceback risk scores

• Admission likelihood scores

• Notify you when turnaround times go up automatically, tell

you why and what to do about it

• Sepsis predictive algorithms

• MEWS patient deterioration scores

• Decision support that is actually helpful

THE CLICKLESS PATIENT VISIT

INFORMATION EXCHANGE

• Technology is no longer the (biggest) barrier

Don’t be a Fish Out of Water!

JUMP IN, THE WATER FEELS FINE!