i5021 Technology-Enabling Digital Documentation

Department of Veterans Affairs

i5021 Technology-Enabling Digital Documentation

i5021 Innovation: Technology-Enabling Digital Documentation (TEDD)

Jorge A. Ferrer M.D., M.B.A. | Informatician | Veterans Health Administration | Health Informatics-Knowledge Based Systems | E mail: [email protected]

Adjunct Assistant Professor School of Biomedical Informatics University of Texas Health Science Center at Houston

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VHA 2012 VAi2 Employee InnovationVoted 20 out of 3,841 innovation competition ideas

by VA employeesA HITIDE initiative within the VA portfolio • Innovation Lead: Jorge A. Ferrer MD, MBA• Innovation Vendor: Rover LLC

Focus: Clinical Data Entry & Documentation Innovation: Clinical Documentation Platform “Telling the Patient Story” Leverage VHA 2013-2018 Strategic Plan

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VHA 2012 VAi2 Employee InnovationA HITIDE initiative within the VA portfolio • Health Information Technology Innovation and

Development Environments (HITIDE): A Model for Health Information Technology Innovation

• HITIDE represents an “active innovation ecosystem that fosters collaboration of federal and private partners health IT-electronic health record innovations”.

http://www.nitrd.gov/nitrdgroups/index.php?title=Health_IT_R%26D_SSG/Health_Information_Technology_Innovation_and_Development_Environments_Subgroup_(HITIDE)#title

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Veterans Health Administration Strategic Plan FY 2013 – 2018

VHA Goals and Objectives: Provide Veterans Personalized, Proactive, Patient-Driven Health Care.

a. VA Health Care Delivery b. Communicationc. Awareness & Understanding d. Access to Information & Resources e. Quality & Equity f. Innovation & Improvement – VHA will drive an improvement culture by

advancing innovation trials, emerging health technologies, and experimentation, through exploration of both constructive failures and dynamic successes, adopting practices that improve care while minimizing and managing acceptable risk.

g. Collaboration – VHA will strengthen collaborations within communities, and with organizations such as the Department of Defense, the Department of Health and Human Services, academic affiliates, and other service organizations.

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Usability Present and Future Current Practice and Future Plans for Usability Experience: “Industry Perspective” for the Department of Veterans Affairs SHARPC AMIA Pre-Symposium Dec 2011 W. Paul Nichol, MD VHA Office of Informatics and Analytics

CURRENT VistA/CPRS USABILITY CHALLENGES• Electronic representation of paper chart • Dated infrastructure and technological

approach • Challenges in rapid change • Clinical practice

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SHARPC AMIA Pre-Symposium Dec 2011


CURRENT VistA/CPRS USABILITY CHALLENGESContinued:• Technology advances • User demands • Personalized care orientation – need

integration of data from multiple sources, not just VA

• Clinical decision support enhancements

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SHARPC AMIA Pre-Symposium Dec 2011


PRINCIPLES OF HEALTH INFORMATICS REDESIGN Robert L. Jesse, MD, PhD, Principal Deputy Under

Secretary for Health

1.If data is important enough that it is needed to manage the patient and/or the system, then it must be acquired as an integral part of the work process and not through retrospective data collection.

–Data should be acquired in real-time, and in concert with the documentation of clinical activities.

2.Solutions must make the work easier and not impose undue burden or re-work.

–Technology must facilitate the workflow, but not drive it. 3.Real-time visibility into the system must be available, and

it must be transparent across the enterprise. –Manage all patient-health system interactions (e.g. location and

times, waits and delays); manage patient staff relationship (e.g. handoffs); manage all tests and procedures in real-time (from scheduling to completion with concurrent documentation)

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PRINCIPLES OF HEALTH INFORMATICS REDESIGN Robert L. Jesse, MD, PhD, Principal Deputy Under

Secretary for Health

Continue:4.To deliver evidence-based care we must have

evidence-based management. –Clinical and Administrative processes support 5.To effectively manage the delivery of evidence-based

care we must manage complexity –Data>Information>Knowledge>Wisdom

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Disruptive InnovationDisruptive Innovation



AMIA’s Invitational Health Policy Meetings2006: Toward a National Framework for the

Secondary Use of Health Data 2007: Advancing the Framework: Use of Health Data2008: Informatics, Evidence-based Care, and

Research; Implications for National Policy2009: Anticipating and Addressing Unintended

Consequences of HIT and Policy 2010: Future of Health IT Innovation and Informatics2011: Future State of Clinical Data Capture and

Documentation

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AMIA’s 6thAnnual Policy MeetingThe Future State of Clinical Data Capture and DocumentationDecember 6-7, 2011, Washington, D.C.

AMIA’s 2011 Annual Health Policy Conference considered the future of clinical data capture, content and documentation with its challenges and opportunities. Because of the importance of high quality clinical documentation and data in supporting patient care, and given current initiatives encouraging the adoption of electronic health records (EHRs), it is crucial to understand how documentation and data capture processes and policies may be affected by “going electronic.”

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AMIA’s 6thAnnual Policy Meeting (AMIA working definitions)

Clinical documentation [and data capture] refers to findings, observations, assessments, and care plans that are recorded in an individual's health record. It may include data entered using various methods, such as computer entry, document scanning, voice dictation, and automated acquisition from devices.

An individual’s health record is the repository of clinical information recorded about that person. The record has many functions.

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AMIA’s 6thAnnual Policy Meeting 2011 Meeting Assumptions

Need to transform the way we capture data and document clinical care

New technological and technical advances for clinical data capture and documentation

New and diverse data sources, health technologies and devices for data acquisition, collection and reporting, treatment support, and information dissemination

Blurring of lines between devices and applications intended primarily for use by providers, and those intended for patients

Dynamic environmental factors, trends and issues impacting clinical data capture and documentation

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AMIA’s 6thAnnual Policy Meeting AMIA Guiding Principles Clinical data capture and documentation: 1. Be clinically driven and patient-centric –reflecting an individual’s longitudinal and lifetime health status2. Be efficient –enhancing overall provider efficiency, effectiveness and productivity3. Be accurate, reliable, valid and complete –enabling high quality care4. Support multiple uses –including quality and performance measurement and improvement, population health, policymaking, research, education, and payment 5. Enable team collaboration and clinical decision making –including the patient as a member of the team6. Reflect input from multiple sources –including nuanced medical discourse, structured items and data captured in other systems and devices

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Journal of American Medical Informatics Association: The Future State of Clinical Data Capture and Documentation: a report from AMIA’s 2011 Policy Meeting Caitlin M Cusack, George Hripcsak, Meryl Bloomrosen, S Trent Rosenbloom, Charlotte A Weaver, Adam Wright, David K Vawdrey, Jim Walker, Lena Mamykina

Research Agenda Recommendations• DHHS should fund the development of innovative

automated documentation tools, including data input methods that accommodate entry by various methods such as dictation with or without voice recognition, digital handwriting, and document scanning with or without optical character recognition.

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Ben-Tzion Karsh, Matthew B Weinger, Patricia A Abbott, Health Information technology: fallacy and sober realities, Journal of American Medical Informatics Association 2010 17: 617-623.

“THE ‘WE COMPUTERIZED THE PAPER, SO WE CAN GO PAPERLESS’ FALLACY”

Taking the data elements in a paper-based healthcare system and computerizing them is unlikely to create an efficient and effective paperless system. This surprises and frustrates HIT designers and administrators.

The reason, however, is that the designers do not fully understand how the paper actually supports users’ cognitive needs. Moreover, computer displays are not yet as portable, flexible, or well-designed as paper.



Ben-Tzion Karsh, Matthew B Weinger, Patricia A Abbott, Health Information technology: fallacy and sober realities, Journal of American Medical Informatics Association 2010 17: 617-623.“THE ‘WE COMPUTERIZED THE PAPER, SO WE CAN GO PAPERLESS’ FALLACY”

The paper persistence problem was recently explored at a large Veterans Affairs Medical Center where EHRs have existed for 10 years. Paper continues to be used extensively. Why? The paper forms are not simple data repositories that, once computerized, could be eliminated.

Rather such ‘scraps’ of paper are sophisticated cognitive artifacts that support memory, forecasting and planning, communication, coordination, and education.

User-created paper artifacts typically support patient specific cognition, situational awareness, task and information communication, and coordination, all essential to safe, quality patient care. Paper will persist, and should persist, if HIT is not able to provide similar support.



Journal of American Medical Informatics Association 2013: The wave has finally broken: now what? (Simborg)

Barriers to achieving the promise of improved quality and reduced cost remain, as well as some unintended negative consequences.

• Poor usability of user interfaces: Both anecdotal and formal survey data continue to indicate that physician unhappiness with EHRs remains a problem. A HIMSS task force has described ‘usability’ as ‘possibly the most important factor hindering widespread adoption of EMRs’

• Distrust of EHR-produced encounter notes: EHR vendors incorporate a number of tools in their products to speed up the process of recording a clinical encounter. These include problem templates, copy forward, and ‘singleclick’ entry of review of systems and physical examination components.

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Cooperative Research and Development Agreement

Veterans Health Administration & Rover LLC.• The CRADA is one of the principal mechanisms used by

federal labs to engage in collaborative efforts with non-federal partners to achieve goals of technology transfer.

• Intended to be a flexible mechanism that can be adapted to a variety of types of collaborative efforts between federal and non-federal organizations and that can be implemented relatively easily within a relatively short time.

VAi2 Innovation Wiki Site• http://sandbox.vacloud.us/groups/5021/

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i5021 Technology-Enabling Digital Documentation