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The Cutting Edge: Health Information Technology Use in Greater Cleveland
David Kaelber, MD, PhD, MPHChief Medical Informatics Officer
Tom Swales, PhDAssociate Director of Medical Informatics
MetroHealth SystemCase Western Reserve University
Informatics and change (It never stops)
• Medical informatics is the field concerned with the optimal use of information, often aided by technology, to improve individual health
• Our Cleveland health information technology seems to be changing just as rapidly as our banks and airlines
Health Information Technology in Cleveland
• CareEverywhere• Cleveland Clinic Dr. Connect• Epicweb• Explorsys• Health Information Exchange (HIE)• MyChart• Knowledge Initiative
All functions should address five healthcare quality criteria
• Improve patient safety• Support delivery of effective patient care• Facilitate management of chronic
conditions• Improve efficiency• Have feasibility of implementation
Depression in Primary Care
– Despite depression is associated with poorer health outcomes among patients with chronic illnesses…
• Up to 50% of these patients are not currently being recognized due to a lack of systematic screening for depression
• 43% do not have sufficient staff resources to screen for depression
The Quality Chasm
Failure to detect, treat and collaborate in the care of co- occurring illnesses•Internal medicine physicians, family practice physicians, obstetrician/gynecologists and psychiatrists fail to detect alcohol/drug or mental illness (Friedmann et al, 2003; Miller et al., 2003; Saitz et al., 1997, 2002)•Mental health providers fail to screen and address co-occurring mental and substance-use conditions, or assess and address medical issues (Miller at al. 2003)
Poor quality in the delivery mental and substance use disorders•Only 27 percent of studies report adequate rates of physician adherence to established clinical guidelines for mental/substance use disorders (Bauer, 2002)•Low rates of adherence for treating depression in adults (Simon et al. 2001)
Why do we make diagnostic errors? (Hersh, 2010)
• Physicians fail to order or follow-up on test results in ambulatory care (Gandhi, 2006, Whals, 2007)– Physicians readily recall diagnostic errors
(failure to order or follow-up) (44%) but also clinician assessment errors (32%)
• Patients are not informed of clinically significant abnormal test results 7.1% of the time (Casalino, 2009)
• Half of specialist referrals are not completed (Weiner, 2010
• An important “next frontier” of patient safety (Newman-Toker, 2009)
Using EBM to assess questions about diagnosis
• Diagnostic process involves logical reasoning and pattern recognition
• Consists of two essential steps– Enumerate diagnostic possibilities and estimate their
relative likelihood, generating differential diagnosis– Incorporate new information from diagnostic tests to
change probabilities, rule out some possibilities, and chose the most likely diagnosis
• Screening tests help us recognize disease, especially in his case (depression)
BHGC endorses screening of all patients for depression
Patient Health Questionnaire (PHQ-9)
• A valid and reliable measure (Kroenke et al. 2001; Lowe et al. 2004)
• The PHQ-2/PHQ-9 have been validated in primary care settings (Arroll, 2010)
• Address variations in the diagnosis of MDD among psychiatrists (Kramer et al. 2000) and primary care physicians (Mojtabi, 2002)
http://www.thenationalcouncil.org/galleries/business-practice%20files/PHQ%20- %20Questions.pdf
Clinical effectiveness measures• Percent of patients whose symptoms are
reassessed by the use of a quantitative symptom assessment tool (e.g. PHQ-9) within 1 month, 4-8 weeks, 3 months, or 6 months of initiating treatment
• Remission: PHQ-9 score less than 5 at >= 4 months after a new episode
• Percent of patients with a 5 point reduction in PHQ-9 at 6 months
• Percent of patients with 50% reduction in PHQ-9 at >=4 months
• Patients who report an improvement in functioning on reassessment within 12 months (PHQ-9 item 10)
EHRs support clinical decision support
• Decision support uses EHR data to provide context-specific advice, alerts, and reminders, such as– Assisting with choices in diagnosis and therapy– Detecting problematic situations, such as
medication errors and drug-drug interactions• Is best delivered at the point of care,
especially when decisions are being made
Clinical practice guidelines are a type of decision support
• Paper guidelines are easy to use, if you can find one
• Guidelines are more likely to be followed, if part of the decision logic in the EHR
Resources for depression treatment in primary care
• NFP/OCHIN• ICSI Major Depression in Adults in Primary
Care algorithms • IMPACT treatment algorithms• Patient Educational Materials/MacArthur
Foundation Depression Toolkit
NFP PHQ-9 algorithms
Use the PHQ-9
• Can be used to screen for depression in primary care
• Can interface with primary care decision support– Measure severity of depression– Can monitor response to treatment
• The key challenge is workflow redesign (Unertl, 2009)
Medical informatics
• It’s nothing to be depressed about!
Meaningful use and the new “ARRA” of informatics
• Health Information Technology for Economic and Clinical Health (HITECH) Act of the American Recovery and Reinvestment Act (ARRA)– Incentives for adoption by physicians and
hospitals ($40B)– Direct grants administered by federal agencies
($2B)
Care EveryWhere
• Privacy, confidentiality, and security
• The era of HIPAA and HITECH
Last week… in <5 min I got the record, and identified the problem
Dr. Connect/Cleveland Clinic
• In Epic, see the EpicCare Link• Shared medical record for community
providers• Secure, Web-based access to the EHR for
referring providers• Secure messaging functions allow external
physicians to offer electronic consults
Epicweb• EpicWeb anytime/anyplace access to patient information• Login to the Epic system from any PC with a Web browser• Users can access major clinical features including care
documentation, chart review, order entry (with decision support) and secure messaging.
• EpicWeb allows physicians working from any location at home, in the office, and even on vacation to use the patient's entire medical record
• Users can also access provider schedules, benefit and eligibility information, referral authorizations and account balances
Explorys• A secure, cloud-computing
platform• Cleaned, normalized and
standardized data from participating health systems
• A tool for discovery of critical trends in treatments, costs, and outcomes
• Presents de-identified data either for your institution or for all health systems
• HIPAA compliant
Conclusion: 5,330 patients with diabetes are diagnosed with MDD
My last published study took 2 years for <50 patients now I get 2,320 patients in 5 minutes!
Observations of Explorys
• Metro patients with diabetes are twice as likely to be identified as depressed (5.6% vs. 2.4%)
• Nearly all of my patients with depression are on an antidepressant (92% vs. 75%)
• The power of Explorys to drill down to the heart of the problem is amazing
Cleveland Clinic Knowledge Program
• Tablet PC• 5-10 minutes at check-in• Core measures
– Patient Health Questionnaire (PHQ-9)– European Quality of Life Questionnaire
• Supplemental questionnaires based on patient’s specific condition– (i.e. epilepsy, sleep disorders, etc)
• Stored in the Knowledge Program database• Transferred to the patients EMR/Epic
Knowledge Initiative
• “The information collected provides updates in patient status and insight into clinically relevant issues that may be otherwise overlooked”
• “This initiative is also a useful tool when demonstrating treatment efficacy and outcomes to payors, government agencies, and the public. This is especially important as government and private insurers move toward value-based reimbursement.”
EHRs can enhance communication
• Medical records often serve as a means for providers to communicate
• Not only among physicians but also nurses, pharmacists and other ancillary staff
• Next logical step is health information exchange (HIE), where “data follows the patient” in care process
A growing number of EHRs are linked to PHRs, which allow patients to
• View their records• Communicate with their
providers• Access their health
system, e.g. fill prescriptions, schedule appointments, etc.
Epic MyChart• Integrated PHR that gives patients controlled
access to the same Epic medical records their doctors use
• Self-serve online functions allow patients to take an active role in their care– View test results – View upcoming & past appointments – Schedule appointments – Pay bills securely – Get automated health maintenance reminders – View problem-based education materials – Request refills – Send & receive secure messages with providers – View a child's records and print growth charts – Manage the care of elderly parents
Epic MyChart
• Cleveland Clinic (Miller, 2007)– Of 63,295 people registered for use, 51,194
used it– Users more likely to be married and Caucasian– Best predictors of system use were number of
diagnoses on the problem list and number of clinical encounters, i.e. those with more medical problems and usage of clinical services
