Department of Veterans Affairs VHA Employee Innovation VHA Innovation: Technology-Enabled Digital Documentation (TEDD) i5021 Innovation Use Case: Clinical

Department of Veterans Affairs

VHA Employee Innovation

VHA Innovation: Technology-Enabled Digital Documentation (TEDD) i5021

•Innovation Use Case: Clinical Reconciliation Servicee.g.-Medication Reconciliation Write-back functionality innovation to enhance clinical performance of clinical documenters at the point of service.

Jorge A. Ferrer M.D., M.B.A | Medical Informatician OIA HI KBS | Veterans Health Administration | E mail: [email protected]

Adjunct Assistant Professor UTHealth School of Biomedical Informatics

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Technology-Enabled Digital Documentation (TEDD)

• The Technology-Enabled Digital Documentation (TEDD) innovation was voted number 20 out of 3,841 ideas by VA employees in the Innovation VAi2 VHA employee competition.

• Write-back functionality innovation to enhance clinical performance of clinical documenters at the point of service.

• This innovation is one of Veterans Affairs outfacing testbeds environments in Health Information Technology Innovation and Development Environments (HITIDE).

• HITIDE represents an “Active Innovation Ecosystem” that fosters collaboration of federal and private partner Health IT (HIT)/Electronic Health Record (EHR) innovations, leveraging the use of in-kind development testbeds, which simulate a federated environment of disparate information technology systems. 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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Study: Physician Perceptions of Two Electronic Medical Records (EMRs): VistA (VA) and GE Centricity Lisa

Grabenbauer, University of Nebraska Medical Center 2009.http://www.academyhealth.org/files/2009/sunday/murphyk.pdfResearch Objective: Examine physicians’ perspective on the objective benefits and limitations of current EMRConclusions: Current EMR frustrates physician collection of data to improve patient care with cumbersome interfaces and processesRecommendations: EMR must provide seamless and flexible interfaces across system boundaries, for data input as well as data retrievalEMR should facilitate patient and team interactions, not inhibit them

Research Study


Usability Framework for Innovation

VHA i5021 Innovation Usability Framework

We must produce faster and usable clinical documentation solutions which:

• Are easy to learn (and re-learn)• Are efficient to use (performance)• Are effective to use (completion)• Prevent errors (not cause harm)• Are satisfying to use (subjective impression)

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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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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 CHALLENGESContinue:

• 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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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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What Problem Are We Solving?

Innovation Problem Statement

The purpose of the outcome-driven innovation is to build a Technology-Enabled Digital Documentation (TEDD) platform to enhance the award-winning VHA's CPRS to overcome the major limitations and drawbacks of the traditional graphic user interface workstation. The primary design objectives are to provide tight integration with any defined workflow, improve usability with a new generation of technical solutions, enable portability of a familiar user experience (UX) across disparate EHR systems, and enhance the patient experience (PX) at the point of service.

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Why Innovate?

Innovation Project Goals and Design Principles

Objective: Fundamentally improve clinical documentation at the point of service with the goal of the innovation is to improve clinicians' data-entry & documentation requirements with a focus on clinical reconciliation, structured data capture and semantic interoperability.First Principles:•Tell the patient’s story•Fill in knowledge gaps•Minimize the intrusiveness of information technology in the exam room and points of care•Let the workflow process drive the technology – not the other way around

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VHA Guiding Principles

Veterans Health Administration Strategic Plan FY 2013 – 2018VHA 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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Health IT Policy Guidance

AMIA’s Invitational Health Policy Meetings

2006: 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 Meeting The 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 The Future State of Clinical Data Capture and Documentation December 6-7, 2011, Washington, D.C.

Time spent on documentation21% of time documenting

Annals Emergency Medicine. 1998;31:87-9121% of time documenting

Annals Family Medicine. 2005;3(6):488-4931.4 hour/day

Journal Clinical Oncology. 2002;20(24):4722-4726Up from 0.3 hours/day in 1976

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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 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 RecommendationsDHHS 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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Journal American Medical Informatics Association

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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Solutions Identified During Innovation Project

• Using computational resources to dynamically create scenario-specific, context specific user interfaces for patients and providers.

• Emphasis telling the patient's story rather than creating traditional progress notes.

• Support for an overarching documentation session that incorporates the entire health team and the patient.

• Support for multiple documentation modalities and paradigms to minimize the intrusiveness of the user interface.

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William Osler, M.D.

• “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.”

• “There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.”

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Documents

Department of Veterans Affairs VHA Employee Innovation VHA Innovation: Technology-Enabled Digital Documentation (TEDD) i5021 Innovation Use Case: Clinical