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Curtis L. Whitehair, MD, FAAPMR
Electronic Medical Record
March 27, 2009
Board Certified PhysiatristPhysical Medicine & Rehabilitation
Fellow American Academy of Physical Medicine & Rehabilitation• President – Maryland Society of PM&R
National Rehabilitation Hospital, Washington, DC Medical Director – Outpatient Center for
Orthopedic Rehabilitation Medical Director – Oncology Rehabilitation
Program, NRH/NRH Regional Rehab
Shepherd University, Shepherdstown WV◦ Major
Business Administration Information Systems & Computer Programming
◦ Minor Communications
CASE Consultant – Datatel, Inc.◦ 3 Books
ETK: Introduction to Screen Processing ETK: Introduction to Batch and Report Writing Managing Custom Source
Ross University School of Medicine, NY/Dominica
Internship – Family Medicine at Medical College of Virginia (VCU), Richmond VA
Residency – Physical Medicine & Rehabilitation at NRH/GTUH, Washington, DC
According to the IOM, an EHR system has several key capabilities:
◦ It’s a longitudinal collection of electronic health information for and about persons.
◦ It provides immediate electronic access to person- and population-level information by authorized users.
◦ It provides knowledge and decision-support systems that enhance the quality, safety, and efficiency of patient care.
◦ It supports efficient processes for health care delivery.
Physicians spend 38% of their time writing chart notes.
35-39% of total hospital operating cost are spent on patient and provider communication activates.
Medical records could not be located 30% of the time when needed.
Once found the volume of information in them was often so large that it became unmanageable.
It was shown that simply organizing information flow sheets accelerated retrieval of needed data at least 4-fold.
Top 10 Causes of Death in 1998
1 Heart Disease 724,269
2 Cancer 538,947
3 Stroke 158,060
4 Lung Disease 114,381
5 Medical Errors 98,000
6 Pneumonia 94,828
7 Diabetes 64,574
8 Motor Vehicle Accident 41,826
9 Suicide 29,264
10 Kidney Disease 26,295
Stage III, IV pressure ulcers Fall or trauma resulting in serious injury Vascular catheter-associated infection Catheter-associated urinary tract infection Foreign object retained after surgery Certain surgical site infections Air embolism Blood incompatibility Certain manifestations of poor blood sugar
control Certain deep vein thromboses or pulmonary
embolisms
> 50% of all healthcare expenditures in the US is on ambulatory care (rate of increase is greater for outpatient than inpatient services)
~80% of the nearly 1 billion annual outpatient visits take place in practices of 10 or fewer clinicians
~50% in practices with fewer than 5 clinicians
Practices between 1-9 physicians account for Practices between 1-9 physicians account for 88% of physicians88% of physicians
In practices larger than 9 physicians, adoption In practices larger than 9 physicians, adoption rates are significantly higher rates are significantly higher
Source: Burt and Sisk, 2005Source: Burt and Sisk, 2005
Practice Size
(# of Physicians)
% Using EHR % Distribution of Physicians in Sample (n=3,360)
1 13.0 35.3
2-4 16.2 39.9
5-9 19.9 12.8
10-19 28.7 7.1
20-above 38.9 4.9
88%
Reactive episodic visits
“Top-of-mind” decisions
Paper-based ad hoc prescribing
Non-interactive documentation
No news = good news
Reactive episodic visits
“Top-of-mind” decisions
Paper-based ad hoc prescribing
Non-interactive documentation
No news = good news
Reactive and proactive care
Embedded CDSS/guidelines
Knowledge based Medication Management (eRx)
Interactive documentation
Orders loop management
While promoting medical quality and E/M compliance, in 15 minutes a provider must be able to:◦ Perform and complete documentation of a
medically indicated, audit-proof, level 4 or level 5 patient visit with individualized narrative information in all
appropriate areas of the medical record including completion of counseling the patient ordering test ordering treatment charge entry
A value configuration describes how value is created in a company for its customers. It shows how the most important primary and secondary activates function to create value for customers.
It represents the way a particular organization conducts business.
The development of an Electronic Medical Record is not merely the construction of an IT system but a continual organizational improvement process aimed at bringing the healthcare organization to a higher achievement level through people, processes and technology.
The process changes with the users needs and requirements as they learn as well as technology and knowledge evolves.
As care processes become more dependent on IT clinical expectations of availability increasses.
Clinicians are used to high availability technical infrastructures.
Improve Quality Care
Avoid Adverse Drug Events
Improve Quality Measures
Enhance Patient Safety
Improve Operational Efficiencies and Reallocate Staff
Increase Reimbursements Decreased cost
Benefits of Implementing EMRs
DesRoches, et. al., NEJM, July3, 2008
Simultaneous 24/7 health record availability◦ Emergency/On Call physician
Improved chronic disease management◦ Prompts doctors and nurses whenever health
maintenance services are past due.◦ Prompts doctors and nurses to perform chronic
disease management services and identifies when parameters are not met.
Improved continuity of care and preventative care among different providers
Record is legible and timely
Record is more consistent across different providers
CPOE
eRX
eMAR
Standardize and integrate data capture for quality measurement into the normal documentation of care within the ambulatory EMR.
Reporting abilities of flow and process allow better understanding of process and procedures.◦ Data can flow into PI modules/software with import and
export
Implementation of an automated system for data extraction including valid, reliable reports that provide actionable insight for the measurement, analysis and improvement of care.
Increased safety in prescribing due to drug interactions and allergy alerts.
Ease of accessing patient prescription information in case of drug recall.
More efficient phone triage due to immediate access to patient records.
Consultant Reports and legible and timely.
Increased staff job satisfaction◦ Reduced staff stress related to failed searches for
paper records◦ Improved communication among staff
Staff to physician ratio decreased below national ratio average◦ FTE decrease 1 – 2.5 per physician.
Physical Plan reduction◦ Convert filing area to 3 exam rooms.
Better E/M documentation enhances provider confidence to code and bill appropriately for services rendered◦ It is common to down-code for fear of the audit or denials.◦ Service Notes are more defensible from a billing perspective
Transcription cost saved
Discounts from malpractice insurer◦ The malpractice insurer believes EMR greatly reduces
potential of drug errors / misunderstood notes
Improve charge capture◦ Reduction in delays in billing activities◦ Reduction in payer denials
Basic EHR Intermediate EHR Advanced EHR
On line chart with: - Clinical note
documentation - Results viewing
Basic plus:- Electronic
prescribing with: - Adverse drug
prevention capability - Alternative drug
suggestion
Intermediate plus:- Lab order entry with testing
guidance- Radiology order entry with
test guidance- Electronic Charge Capture
($18,200) Net Cost
$44,600 Net Benefit
$86,400 Net Benefit
Goshen, NY
520 Beds
4 Buildings
15 Units
– Sub-Acute Rehabilitation
– Long Term
– Dementia/Alzheimer's
– Palliative Care
Over 600 Employees
Valley View Case Study
Less time on resident care due to inefficiencies
Clinician and staff frustration high
In danger of losing reference lab
Inefficiencies resulted in an underlying concern for resident safety
Lost RevenueMedicare billing inefficiencies
Inaccurate data captureIncreasing CostsFormulary non-compliance was resulting in
escalating drug costs
Inefficient Work FlowRenewal process lengthy and error prone
Difficult to manage off-hour admissions
Cumbersome communication within facility
Nursing staff mired in paperwork
Resident Safety ConcernsDifficult to manage quality with paper and
retrospective MDS data
Incomplete or ambiguous orders
DUR alerts missed or late
Valley View’s Business Issues
Business Issues
Medication order renewal process
Formulary updates, communication and control
Facility communication and order data entry (telephone, ADT, etc.)
Pharmacy communication and order data entry
Resident identification, alert and room/bed assignment
* Through attrition
92% reduction in adverse drug events (from avg. of 2.81 per month to .23 per month)
9% additional time for over 200 employees (700 hours per week) to focus on direct resident care
Reporting (resident safety, quality indicators, DUR, shift productivity, census)
Compliance with State, Federal and accreditation audits, surveys and ad hoc requests
5 FTE Staff Reduction*Medication savings Renewal efficienciesEfficiencies in formulary trainingConsultation formsMedicare billing improvementLab billing improvement
$ 250,000$ 262,000$ 120,000$ 8,000
$ 20,000$ 15,000
$ 10,000
Valley View’s Return on Investment
Business ProcessAutomated
Direct Financial Benefit
AdditionalEfficiencies
Questions ?