2010 SAAS National Conference and NIATx Annual Summit Electronic Behavioral Medical Records: Improving your agency’s implementation Jay Ford, PhD Enid

2010SAAS National Conference and NIATx

Annual Summit

Electronic Behavioral Medical Records: Improving your agency’s implementation

Jay Ford, PhD

Enid Montague, PhD

Agenda

• Organizational readiness

• Meaningful use

• Business case for EBHR

• Impact on process workflow

• Trust in technology

Organizational Readiness

• Productivity & efficiencies

• Billing accuracy

• Regulatory compliance

• Patient safety & reduced errors

• Health information security

• Leverage data for dollars

Why Adopt EBHR?

Reason not to Adopt an EBHR

Source: www.satva.org

Why is readiness important?

It helps organizations detect potential obstacles to and identify opportunities to improve chances of successful implementation.

RIS Overall Score by Agency

RIS: Enhancing Organizational Readiness

Strategic Alignment

Leadership Support

Dedicated Resources

Impact on the Organization

Staff Acceptance

Organizational Motivation Meeting Needs & Usefulness Departmental Fit Implementation Promotion

Meaningful Use

What is meant by meaningful use

• Demonstrate use of certified EHR technology

• Use certified EHR to submit clinical quality measures

• Show that certified EHR is part of a network to promote exchange of health information

Stages of Incentive Rollout

Making Sense of a Certified Electronic Health Record

Meaningful Use Incentives

Medicare Medicaid

Allowable Costs/Charges

75% of allowable charges 85% of net avg. allowable costs (25K in Year 1)

($10K in subsequent 5 Yrs)

Incentive Level Year 1 - $18,000Decrease $4K next 4 Yrs

Year 1 - $21,250$8,500 next 5 Yrs

Total Incentive Level $44,000 per eligible professional $63,750 per eligible professional

Other Relevant Information

No payments after 2016Medicare Penalties if not Meaningful User by 2015

Eligible Professional must have 30% Medicaid Patient Volume or

30% of encounters if FQHC

H.R. 5040• Amends current meaningful use law to include

behavioral health providers• Extends eligibility for Medicaid/Medicare

implementation funds• Authorizes $15 million grant program to:

– Facilitate purchase of HIT– Train staff in HIT use– Improve secure electronic information exchange– Improve HIT adaptation to community BH– Assist with telemedicine implementation– Collaborate & integrate w/ HIT regional extension centers

Hospital CIO’s: Ready or NotReady

(More likely to apply for 2011 incentives)Or Not

(50% not ready: 1st Stage of Meaningful Use)

Involve customers in EHR Planning (74% of the 20% of CIO’s who have

involved customers will be ready in 2011)

Shortage of skilled staff

Collaborate with key stakeholders(3x more likely to involve patients)

(87% more likely to work w/health insurers)(63% more likely to assist MD’s with

meaningful use)

Lack of clarity or vendor readiness

Capacity of existing infrastructure

Meaningful use will increase physician involvement in quality initiatives

Not working with key customers (e.g., insurance companies)

Level of Implementation for Clinical Information System Components

ComponentDo not have

Available but not started yet

Initial Planning Stages

Partially Implemented

Fully Implemented

Scheduling 17.3% 10.4% 3.5% 21.1% 47.8%Intake 16.0% 4.5% 7.6% 21.9% 50.0%Billing 3.8% 2.1% 2.8% 14.9% 76.4%Clinical Assessment 19.2% 5.7% 12.5% 21.7% 40.9%Treatment Plan 18.9% 8.2% 12.9% 20.4% 39.6%E-Prescribing 51.6% 7.4% 12.7% 12.7% 15.5%Progress Notes 18.4% 7.0% 9.9% 18.4% 45.6%Quality Improvement/Outcomes 31.5% 9.0% 17.6% 28.7% 13.3%

Executive Dashboard (e.g. Balanced Scorecard) 52.1% 5.0% 19.6% 15.4% 7.9%

Source: www.satva.org

Impact on the Organization• Adapting to meaningful use may …

– Result in revised intake processes– Require changes in business practices– Foster and improve inter-agency collaboration

• Require an understanding of the business case for adoption

Business Case

Revenues, Costs, Cost Savings and Benefits

Revenues Costs and Cost Savings Benefits

Revenue Growth

Incentives for using certified EBHR

New Revenue PotentialEnhanced Cash Flow

Performance Incentives or New Grants

Implementation Costs:

Hardware, Software, Infrastructure,

Implementation Labor or New Staff

Administrative Efficiencies

Reduce time to pull charts, improved billing

Cost Savings

Staffing, Elimination of Outside Services

Clinical Efficiencies(Less Paperwork,

Automatic order entry or group note generation)

Organizational Efficiencies• Administrative efficiencies

– Reduce staff and save on labor costs; – Use efficiencies to re-allocate responsibilities;– A combination of both

• Clinical efficiencies– Allow staff to spend more time with existing

clients or – Use efficiencies to increase capacity

Impact on Workflow

Impact of EBHR on Workflow

Impact of EBHR on Workflow

Impact on Intake

Oakwood’s eBilling Process

Key Implementation Messages

• Assess your technological infrastructure

• Evaluate organizational readiness

• Understand meaningful use

• Examine the business case

• Map current workflow

• Ensure adequate staff training

2010SAAS National Conference and NIATx

Annual Summit

Trust in Technology

Enid Montague, PhD Assistant Professor

Anna Julia Cooper FellowDirector: HCI lab

Industrial and Systems EngineeringUniversity of Wisconsin-Madison

enidmontague.com

Outline

• Why are we implementing new technologies?• Patient trust in care provider• Patient attitudes about technologies• Provider attitudes about technologies• Tips and considerations

28Enid Montague, PhD University of Wisconsin-Madison HCI Lab

Why are we using EMRs?

Image source: Laura Pedrick for The New York Times

Enid Montague, PhD University of Wisconsin-Madison HCI Lab 29

Why are we using EMRs?

Enid Montague, PhD University of Wisconsin-Madison HCI Lab 30

Nursing shortage

Year Supply Demand Shortage Percent

2000 1,890,700 2,001,500 -110,800 -6%

2005 1,942,500 2,161,300 -218,800 -10%

2010 1,941,200 2,347,000 -405,800 -17%

2015 1,886,100 2,569,800 -683,700 -27%

2020 1,808,000 2,824,900 -1,016,900 -36%

Source: Data from the Bureau of Health Professions. (2004)

US Supply versus Demand Projections for FTE Registered Nurses


Growth in medical technology industry

Enid Montague, PhD University of Wisconsin-Madison HCI Lab

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Growth in medical technology invention.


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Physician shortage


What is trust?

Trust is a person’s belief that a person or object will not fail them.

Enid Montague, PhD University of Wisconsin-Madison HCI Lab35

Trust is a popular topic in relation to the provision of health.

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Trust is a fundamental aspect of all relationships.

– Human- human• e.g. worker- worker, parent- child, doctor- patient,

– Human-organization• e.g. worker- company, patient- hospital

– Human- social institution• e.g. citizens- government, patient- health systems

– Human-technology• e.g. user- website, user- device, human- computer


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Trust triad model

Montague, E., Winchester, W.W. Kleiner, B.M. (in press). Trust in medical technology by patients and health care providers in obstetric work systems. Behaviour & Information Technology.

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Client- Provider Trust

Enid Montague, PhD University of Wisconsin-Madison HCI Lab39

Patient trust in care provider predicts… • Quality variables such as:

– adherence to medical advice – health service seeking behaviors – patient satisfaction– utilization of preventive services – malpractice litigation – health status – sustained enrollment in health plans

• Organizational and economic factors such as: – decreases in the possibility of a patient

leaving a care provider’s practice– withdrawing from a health plan


As trust declines…• The cost of providing care may increase. • Patients and care providers may engage in self-protection

– patients withhold information or avoid seeking care from sources they determine are untrustworthy and care providers practice defensive medicine.

• “People are increasingly unwilling to take risks, demand greater protection against the possibility of betrayal, and increasingly insist on costly sanctioning mechanisms to defend their interests” (p 13) (Tyler & Kramer, 1996).

• Distrust can “provoke feelings of anxiety and insecurity, causing people to feel uncomfortable and ill at ease and to expend energy on monitoring the behavior and possible motives of others” (p 1) (Fuller, 1996).

• When patients feel unsafe, energy that could be devoted to healing is expended on self-preservation.


Ideal environments for interpersonal communication

-Full view of the body-Full view of facial expressions-No limitations on making eye contact-Channels are free to focus on listening and responding


How does technology change interpersonal relationships?

Nonverbal cues are important for interpersonal communication and trust inclinical encounters

– Difficulty using multiple channels (i.e listening, while typing)

– Time utilizing technologies might affect total visit time

– Difficulty noticing the expressions of others– Difficulty showing appropriate expressions – Mistakes may cause stress and frustration– Time for social touch– Eye contact


Shared computer use can make interpersonal communication difficult.


Typical sets ups that involve technologies can bring new communication challenges.

Image source: Mayo SPARC


Patient trust in technology

Previous Experiences/ Attitudes

Previous Experiences/ Attitudes


The goal is appropriate trust in technology.


Using technologies to make decisions in the absence of additional information

Using technologies in ways they were not designed for

Using technologies to enhance human capabilities, while continuing to use medical knowledge

Refusing to use technologies that could enhance the provision of care and quality of work

Using technologies in lieu of medical care i.e. Google as a first or second opinion

Using technologies in a way they were not designed for

Using technologies appropriately to enhance health and care

Refusing to use technologies that could enhance the health and the care provision process

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Patient attitudes about technologies

• Concern over information security/ privacy• Lack of knowledge about technology (technology literacy)


Uncertainty about the health record can contribute to distrusting attitudes.

• Have you ever looked at your medical record?(52%) No, I have never looked at my medical record(39%) Yes, it was accurate(16%) Yes, it was inaccurate or incomplete


Beliefs can affect behaviors

• Do you believe the information in your medical record is kept secure?(70%) Yes(28%) No

• Have you ever avoided telling your doctor something about your health, because you did not want the information to appear in your medical record?(76%) No (20%) Yes


Which of the following would you not want to appear in your medical record?

• (43%) Number of sexual partners• (43%) Previous incarcerations• (26%) HIV/AIDS status • (24%) Sexually transmitted diseases• (22%) History of substance abuse• (20%) Prior use of illegal drugs• (20%) History of mental illness• ( 9%) Family history of genetic illness


There are different attitudes about information sharing with partners, friends, family.

• How many people would you like to have access to your medical record? and why?

Mixed results– Some said virtually everyone (doctors, nurses,

clinic staff, spouse, child, parent, emergency contact)

– Others said virtually no one (only doctor seeing them and only limited access to information involving the purpose of the visit)


Distrust in health system can affect attitudes about technologies.

• Studies have shown that certain populations are more distrusting of health care systems and providers– Racial/ethnic minorities (African American,

Hispanic American, Arab American)– Substance abusers– Those suffering from mental illness– Chronically homeless– Those with socially stigmatizing illnesses and

diseases


Differences can exist across age groups.

• Privacy literacy– Teens are aware of information privacy and

information sharing.• “I don’t know if the doctor is going to turn the screen off when they leave the room”• “I don’t know who else can see or access the

information they put it in the computer” • “I don’t know if my parents can see it” • “I don’t know what they are writing about me”


Differences can exist across age groups.

• Older clients might be more concerned about technology etiquette.• “I don’t think its polite when my doctor types while I’m

trying to talk to him”• “Its bad enough that my kids text message during dinner,

now I have to watch my doctor text during my check-ups”• “It took me two hours to get here, I only have 30 minutes

for the visit and they spent 10 minutes of my time trying to get the computer to work!”


Provider attitudes about technologies

• Provider distrust in technology can contribute to patient distrust in technology and the provider.

• Provider self-confidence can contribute to appropriate trust in the technology.



New technologies can be stressful for some care providers.

Techno-stress– “The negative psychological link between people and the introduction

of new technologies. “– Not unique to health care; educators have similar experiences

Causes of technostress– the quick pace of technological change– lack of proper training– increased workload as result of new technology– lack of standardization within technologies– the reliability of hardware and software– poor usability–

• Choose usable software that matches your organizations work flow is important!


Provider trust in technology


Things to consider.• Design of work stations

– Consider where and how you will introduce work stations into your practice

– Don’t be afraid to role play and try different set ups• User friendly solutions

– Develop a personal and organizational plan for addressing technology problems during client encounters.

• Flexible work flow- – Be able to treat each client as an individual

• You may not be able to type your notes during each visit• Communicate with clients about their ideas about

computer technologies– Develop a working plan together


Practical tips and considerations

• For the client– Be prepared to provide information about who has access to

their information and how it is kept confidential• For the clinician

– Consider the effects on your interpersonal relationships when choosing a system

• Training and be flexible… everyone may different• Allow for adequate time in visits to accompany additional

times or technology usage• Effective implementation plan• Match self trust/ self confidence with start times• Establish etiquette

– Communicate etiquette with other workers and clients


Thank you!

• For more information please,– See the NIAtx website– Contact Us:

Jay Ford, PhD [email protected] Montague, PhD [email protected]

(enidmontague.com)


Documents

2010 SAAS National Conference and NIATx Annual Summit Electronic Behavioral Medical Records: Improving your agency’s implementation Jay Ford, PhD Enid