Why your EMR Sucks, and what you Why your EMR Sucks, and what you MIGHT be able to do about itMIGHT be able to do about it

Robert B Dunne MDDept of Emergency Medicine

Terminology• EMR• EHR - Certified• CPOE• HITECH act• Meaningful use (Phase

1 and Now Phase 2)• HL7• EDIS• Enterprise

History

• “Developers stress that the issue most important for acceptance is whether the medical information system makes patient care easier to provide”

Policy Implications of Medical Information Systems, December 1977

History

• “Existing systems vary in scope, cost, and impact on the medical care system. Consensus has not been reached about the defining characteristics of a medical information system. “

Policy Implications of Medical Information Systems, December 1977

Who is using in the ED

ACEP COUNCIL INFO DEMOGRAPHIC DATA 300 COUNCILORS 2011

ORDERS on the computer?• 1. REQUIRED FOR ALL 67%• 2. SOME 20%• 3. LAB ORDERS ONLY 6%• 4. PAPER ONLY 7%

Benefits of Electronic Records• Information that we need• Patient Tracking• No handwriting• Simultaneous use• Abbreviations/trailing zeros• Transcription error reduction• Correct ID of user• More integration with the record• Discharge instructions

Claimed benefits• Clinical Decision Support• Cost Savings• Correct doses/delivery/calculation• Reduction of duplicate tests• Improved Quality of Documentation

There are some frightening stories about the unintended consequences of CPOE

Unintended Consequences of Information Technologies

• Aim– Determine the effect on mortality of introducing CPOE into Pittsburgh

childrens hospital• Methods

– Demography, clinical and mortality data collected on all children transported to a hospital where CPOE implemented institution-wide in 6 days. Trends for 13 months prior and 5 months after compared. Often delays in initial orders and loss of team members who had to be on the computer

• Results– Mortality rate increased from 2.80% (39 of 1394) to 6.57% (36 of 548)– After adjustment for other covariables, CPOE independently associated with

increased odds of mortality (odds ratio 3.28, 95% C.I. 1.94 – 5.55)

Unintended Consequences of Information Technologies

• Conclusion– When implementing CPOE systems, institutions should continue to

evaluate mortality effects, in addition to medication error rates.– Often delays in initial orders and loss of team members who had to be on

the computer reduced clinical communication and delayed orders• Importance

– Received disproportionate media attention due to reactionary message– Follow-on study in Seattle, using same vendor system, also published in

Pediatrics, showed no increase in mortality, BUT NO IMPROVEMENT EITHER

– They listened to users and implemented with care

• Another unintended consequence of CPOE

• NHS UK

Unintended Consequences of Information Technologies

• Reference– Linder et al., Arch Intern Med. 2007 Jul 9;167(13):1400-5.

[Brigham & Women’s Hospital]• Aim

– Assess effects of Electronic Health Records on quality of care delivered in ambulatory settings

• Methods– Retrospective, cross-sectional analysis of 17

quality measures from 2003-2004 National Ambulatory Medical Care Survey, correlated with use of EHRs.

Unintended Consequences of Information Technologies

• Results– EHRs used in 18% of 1.8 billion visits– For 14 of 17 quality measures, fraction of visits where

recommended best practice occurred was no different in EHR settings than manual records settings.

– 2 better with EHR: avoiding benzodiazepines in depression, avoiding routine urinalysis

– 1 worse with EHR: prescribing statins for hypercholesteremia (33% vs. 47%, p=0.01)

• Conclusion– As implemented, EHRs not associated with better quality ambulatory care

LA Article

Nine types of unintended adverse consequencesNine types of unintended adverse consequences

More/new work for clinicians Workflow issues Never ending system demands Paper persistence Changes in communication patterns Emotions New kinds of errors Changes in the power structure Overdependence on the technology

*Campbell E, Sittig DF, Ash JS, Guappone K, Dykstra R. Types of unintended consequences related to computerized provider order entry. JAMIA 2006; 13:547-556.**Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry.JAMIA 2007;14:415-23.

Workflow Issues

• Mismatch between how work processes are intended to function and how they actually operate

• Too much standardization• Confusion, duplication, misunderstanding across clinical

role boundaries result• Prevention strategies include time, integration, meeting

information needs, providing value• Need to continuously evaluate

CPOE alters communication among providers, ancillary services, and clinical departments

Causes reductions in face-to-face communication

Causes “illusion of “communication, ” belief that the proper people will see it and act upon it

Causes depersonalization

Dykstra R. Computerized physician order entry and communication: Reciprocal impacts. Proceedings AMIA 2002:230-4.

CPOE causes changes in the power structure

• Loss of clinician autonomy

• Administration and I.T. gain power

• Clinical decision support can “tell doctors how to practice”

• Coalitions

Ash JS, Sittig DF, Campbell E, Guappone K, Dykstra R. An unintended consequence of CPOE implementation: Shifts in power, control, and autonomy. Proceedings AMIA 2006:11-15.

Emotions run high • CPOE/Documentation evokes

strong emotional responses– strongly negative – highly positive emotions

• Strong positive correlation between time system is in place and positive emotions

*Sittig DF, Krall M, Kaalaas-Sittig J, Ash JS. Emotional aspects of

computer-based provider order entry: A qualitative study. Journal

of the American Medical Informatics Association 2005; 12(5):561-7.

EHR can cause insidious silent errors

• Problems with data presentation, selection, entry

• Pick lists for data entry promote juxtaposition errors Alpha vs Common lists

• If the correct data entry location is not found, busy providers tend to place data where they might fit

Information Entry

• What is good?

• We can capture more patient information

• What is bad?

• Someone has to spend TIME entering that information

Information - Templates

And that’s just the HPI!(History of Present Illness)

Information

• There’s also the Physical Exam• On every patient…

Are we done yet???

The Most Expensive Data Entry Clerk

• CPOE = 6-8 min per patient• Documentation = another 6-8 min• Average ED Physician making $150/hr• $37.50/hr spent on charting• This just the professional rate• Other costs

– Lost Productivity– Time away from patient’s bedside≠satisfaction– 12 min x 200 patients per day = 3000 minutes

What Can you do

◦ Pre implementation evaluations (KLAS etc)◦ Push for evaluation do not get complacent◦ Participate in selection no matter how painful◦ Push for best work with vendors on own◦ Contract clauses – group expert◦ Do you’re own diligence◦ Show up, be clear on what you want◦ Persist/assign

Still a work in Progress

Can build useful orders

Highlighting key information

At a glance information• Pre-arrival• Affiliated Primary care• Chronic pain enrollees• Custom tailored• Can add anything

Documentation• Voice recognition• Scribes

– Personal Human Assistant

– Follow physicians and document at bedside

• Macros– Quicker documentation– Drop a normal macro

and change abnormals– Is this fraud?– Does this help patients??– What is put in the chart?

Scribe Programs• Increase physician direct patient care.

– Decrease the time a patient will wait to see a doctor– Increase the time the doctor can spend with the patient

• Enhance patient satisfaction. – Decrease the overall time a patient must spend in the ED

• Improve documentation. • Improve the working environment in the ED for all members. • Expedite patient flow through the ED• Need a credentialing plan• Need IT support, own sign in and QA program• Has to be clear who documented.

Communication tools Autofaxes/EMAIL

• Great Concept!• When patient leaves the Emergency

Department, automatically fax the chart to the Primary Care Doctor

• Seems beneficial. BUT.• Illusion of communication• Do they want it???

80/20 Rule

• You know this rule and it has many applications in the world

• 80% of programming needed for good patient care software is easier– The last 20% is much harder, takes into

consideration special circumstances, and takes much longer

– So it is often skipped

80/20 – Allergy Reactions80/20 – Allergy Reactions• Wait a minute!

Codeine has no real allergy reaction with benadryl.

• Codeine doesn’t interact with Tylenol either

• ALERT FATIGUE• This is where feedback

from clinicians and ED pharmacists can fix system problems

• We have to be the 20%

Downtime• We have become

dependent on EMR systems• Going to paper is an

internal disaster• Results can get lost, we

can’t track our patients as easily, communication breaks down

• This is one of the most dangerous times in the ED, even with good downtime procedures

Clinical care becomes overdependent on the computing infrastructure

• System failures wreak havoc unless good downtime procedures exist

• Reliance on clinical decision support may reduce learningReliance on clinical decision support may reduce learning

• ““If its in the computer it must be right!If its in the computer it must be right!””

System downtime, regardless of cause, can "create chaos" for users and organizations

"…[it can be] a real fight at times to get work done, because [people] are always in need of a computer."

"They use a white board screen saver in the ER that keeps track of people in the ER. When the hospital registry goes down, it can't provide the patient ID number, so we can't enter or find any information."

COMPUTER CO-DEPENDENCY

Not enoughhardware

Single systemcomponent

failure

Whole systemis down

"It's funny now. When the computer goes down, wedon't remember how to document on paper."

Training• The Best systems require

the least training• On paper there is minimal

training required• Most docs take 2-4 weeks• May have a greater effect

on nursing• Especially contingent/part

time/rotators• Costs of training

Med Cabinets RadiologyInfrastructureDocument Imaging

Med Cabinets RadiologyInfrastructureDocument Imaging

Alerts and monitoringAccess toolsLongitudinal Record (Data Repository)

Alerts and monitoringAccess toolsLongitudinal Record (Data Repository)

Progressively Introduce Technology

Full documentationEmergency DepartmentSurgical Services

Full documentationEmergency DepartmentSurgical Services

Bar Code Med AdminConnect Physician OfficesBar Code Med AdminConnect Physician Offices

Complex

Simple

Physician Order Entry, MD Documentation

Physician Order Entry, MD Documentation

Need for Real Evaluation of IT1.

Static IT attributes (hardware and software quality)

Static user attributes(computer knowledge)

2.Quality of interaction between

IT and user (e.g. usage patterns, user satisfaction, data quality)

3.Effects of IT on

process quality of care(efficiency, appropriatness,

organisational aspects)

4.Effects of IT on

outcome quality of care(quality of care, costs of care,

patient satisfaction)

Continuous Evaluation of the System

Develop contingency plans for continued operation during downtimes/disasters

Track system performance, network needs To get faster when you are busier Think ecommerce on cyber Monday

Create robust backup systems and test them with scheduled drills

Security Issues

• American National Standards Institute," whose "found that almost 60 percent of about 100 health-care executives surveyed cited lack of funding as the main reason for not securing digital records. Forty percent cited insufficient time, while 32 percent pointed to a lack of senior executive support.” AMS report 2012

Where we need to go

• Personal Health records• Interoperability• True linkage to the primary care world• Optimal Security• Non intrusive decision support• No training needed

Tools not Solutions

• EMR’s are often sold as “Solutions.”• This is sales..• EMR’s need another 10 years(?) until they are

truly mature and robust• Currently, they are tools slowly becoming

solutions• Physicians must get involved.

Paper persistence: Your hospital will be paperless, the same day my bathroom is…

Michael Shabot, M.D.