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Disclosures
bull Co-Inventor
bull HughesRiskApps
ndash httpwwwHughesRiskAppsNet
bull Speaker
ndash Myriad Genetics
bull Breast Cancer Surgeon
Documentation in the Era of Pay-for-Performance Information Technology and EHR Update
EHRs are Document Management Systems
hellipa computer system used to track and store electronic documents
Definition From Wikipedia
The EHR organizes huge numbers of documents linked to individual patients and makes them accessible anywhere
EHR
Generic Interface Mostly a Glorified Filing Cabinet (Document Management System)
Minimal Database
Meds Allergies
Minimal Generic Clinical Decision
Support
EHR vendors have great expertise in Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
And yet the government has given EHR vendors full control of Health Information Technology
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Documentation in the Era of Pay-for-Performance Information Technology and EHR Update
EHRs are Document Management Systems
hellipa computer system used to track and store electronic documents
Definition From Wikipedia
The EHR organizes huge numbers of documents linked to individual patients and makes them accessible anywhere
EHR
Generic Interface Mostly a Glorified Filing Cabinet (Document Management System)
Minimal Database
Meds Allergies
Minimal Generic Clinical Decision
Support
EHR vendors have great expertise in Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
And yet the government has given EHR vendors full control of Health Information Technology
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHRs are Document Management Systems
hellipa computer system used to track and store electronic documents
Definition From Wikipedia
The EHR organizes huge numbers of documents linked to individual patients and makes them accessible anywhere
EHR
Generic Interface Mostly a Glorified Filing Cabinet (Document Management System)
Minimal Database
Meds Allergies
Minimal Generic Clinical Decision
Support
EHR vendors have great expertise in Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
And yet the government has given EHR vendors full control of Health Information Technology
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHR
Generic Interface Mostly a Glorified Filing Cabinet (Document Management System)
Minimal Database
Meds Allergies
Minimal Generic Clinical Decision
Support
EHR vendors have great expertise in Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
And yet the government has given EHR vendors full control of Health Information Technology
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
And yet the government has given EHR vendors full control of Health Information Technology
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHR vendors lack expertise inhellip bull Usability
ndash Context specific interfaces
bull Clinical Decision Support
bull Population Health
bull Workflow solutions
bull Interoperability
bull Structured data
bull And ndash hellipmost everything else except Document Management
And yet the government has given EHR vendors full control of Health Information Technology
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
ldquoMeaningfulrdquo Use bull $36000000000 of your and your
childrenrsquos money
ndash hellipto hospitals and eligible professionals to adopt and meaningfully use electronic health records
In defining who gets paid and who gets penalized the government is centrally dictating what functionality
EHRs will have
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Meaningful Use Objective Provide each patient with a visit summary that provides
relevant and actionable information and instructions Medication list allergies vitals reason(s) for visit procedures and other instructions
based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
If the certified EHR cannot populate all of these fields then at a minimum
Medication list allergies vitals reason(s) for visit procedures and other instructions based on clinical discussions that took place during the office visit problem list immunizations or medications administered during visit summary of topics coveredconsidered during visit time and location of next appointmenttesting if scheduled list of other appointments and tests that the patient needs to schedule with contact information recommended patient decision aids laboratory and other diagnostic test orders testlaboratory results and symptoms
Because EHRs certified by the government lack functionality a visit summary does not need to include a summary of the visit
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Too much hype and cheerleading from the government and administrators
A lot of wishful thinking bullEHRS willhellip bullEHRs shouldhellip bullWhen EHRs dohellip bullEHRs have tremendous potentialhellip
Reality check
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHRs
bull The Promise
ndash Increase efficiency
ndash Decrease MD workload
ndash Decrease staff workload
ndash Improve quality of care
ndash Decrease cost
ndash Share data with other hospitals
ndash See Notes anywhere
bull The reality EHRs
ndash Decrease efficiency
ndash Increase MD workload
ndash Decrease some staff
ndash Increase workload of remaining staff
ndash Quality decreased
ndash Increase cost
ndash Lack of interoperability or even intraoperability
ndash See Notes anywhere
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Decrease efficiency
bull Before using an EHR I routinely saw 30-32 patients a day Now I am exhausted at 20-25 because of the EHR
Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Increase cost
bull More complete coding means higher charges
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Increase cost
bull More complete coding means higher charges
ndash Office of the Inspector General report warns that electronic medical records could contribute to Medicare fraud
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Increase MD workload
ndash Shift work from lower paid employees to higher paid MDs
bull If you type your own notes you can get rdi of transcriptionists
bull If you enter your own billing information on each patient you can get rid of a billing data entry clerk
bull hellipSo if you clean your own exam rooms you can get rid of your houeskeepers
ndash Mouse clicking and data entry to no purpose
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Increase workload of remaining staff
bull Rooming a new patient helliptakes over 10 minutes because of all the data entry involved
ndash used to take 2-4 minutes
An Interview with Dr Nan Nuessle (DrNanN) ndash HITsm Spotlight Posted 31 Oct 2012 1002 AM PDT
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Lack of interoperability or even intraoperability
bull EHRs cannot share data outside of a hospital system ndash I have never received electronic EHR notes
bull How can EHRs share data between hospitals when EHRs canrsquot even talk to themselves ndash If path report in EHR says breast cancer 2 cm node
negative staging and problem list are blank bull Read report
bull Open staging section and enter stage 1
bull Open problem list and enter breast cancer
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
What do EHRs have to do with documentation for pay for performance Almost nothing
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Mastery of surgery
Courtesy of Matt Hutter
Outcomes databases Almost all data is manually entered
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
The Party Line How to increase EHR adoption
bull Regulations that require EHR use
bull Less pay for not using the EHR
bull Extra pay for using the EHR
In every other industry software is adopted voluntarily because it adds value
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Conclusion bull EHRs have value as Document Management
Systems
bull Good HIT can improve medical care
bull EHRs being sold for purposes beyond document management ndash Increase cost
ndash Increase workload
ndash Decrease efficiency
ndash Decrease quality of care
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Charles Babbagersquos Analytical Engine bull The British government
bull Began funding in 1823
bull Pulled the plug in 1842
ndash ₤17000 ($82151820 today)
bull Without receiving a working engine
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Charles Babbagersquos Analytical Engine
bull The British government
ndashBegan funding in 1823
ndashPulled the plug in 1842
bull ₤17000 ($82151820 today)
ndashWithout receiving a working engine
You could say it was the first failed government IT projectldquo (BBC)
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED
Robert G Hill Jr MD Lynn Marie Sears MBA Scott W Melanson MD
bull ER Docshellipspent 43 of their time entering data into a computer
bull Total mouse clicks approach 4000 during a busy 10-hour shift
Am J Emerg Med 201331(11)1591-4
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Medical interns spent
ndash 12 of their time talking to patients
ndash 40 of their time doing electronic paperwork
J Gen Intern Med 2013 28(8)1042-7
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Quality neutral to negative
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
The EHR has tremendous promise as a means of decreasing workload
decreasing cost and improving quality of care
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHR HIT has tremendous promise as
a means of decreasing workload decreasing cost and improving quality
of care
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
The original stethoscope was a short tube made of wood with a central channel not dissimilar to an empty toilet paper roll It had minimal functionality and was barely better than putting your ear on the patients chest httpwwwantiquescientificacomwebstethoscopemonaurallaennechtm
As such I think that it is a great analogy for todays EHRs They are barely better than paper Like an empty toilet paper roll they show teh promise of what might be by barely delivering that promise Had government gotten involved they may have created Meaningful use for the stethoscope telling the Doctor that everything must be done with the stethoscope and that no alternative instruments techniques or senses could be used (The way the administration often says that specialty specific software that has tremendous functionality must be replaced with the rudimentary or absent functionality of the EHR The equivalent is if some Office of the National Stethoscope Coordinator in the 1820s told Doctors to use stethoscope for everything Stopping them from using their nose (Smelling the urine) their eyes (Seeing skin lesions) or their hands (Feeling for an enlarged liver) Laennecs ides had promise as do EHRs But spending $40000000000 to mandate the use of empty toilet paper rolls seems like a bad idea
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
More Work More Patients Less Time
bull Strain on community oncologists working to overcome the barriers of poor usability of EHR with resultant reduced productivity coupled with the increased requirements for documentation for MU2 the cost of investment in the infrastructure and the inability to bill after 1012014 without implementation of ICD-10
Marilou Terpenning MD FACP
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Purpose of this Talk
bull What EHRs are
bull What EHRs can be
Using Hereditary Disease as an example
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Divine Intervention Saint Isidore of Seville (560-636 AD)
bull Named Patron Saint of the Internet and computer technicians in 1997 by Pope John Paul II
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
What is the future role of EHRs Dr Robert Rowley
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Therersquos a strong case to make that meaningful use forces a doctor to use an EHR inappropriately Every
person at ONC calls this blasphemous and every doctor is likely to agree that meaningful use causes more work
and does little to improve care
bull Meaningful Use Program a SuccesshellipDepending on How You Measure Success
bull January 22 2014 I Written By John Lynn John Lynn is
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
bull Unlike the intuitive ease of touch-based smartphones and tablets electronic medical records are generally antiquated programs that are cumbersome to use Providers often spend more time checking boxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
bull For instance it takes me more than 50 mouse clicks all while scrolling through dozens of screens to document a straightforward office visit for a sinus infection Refilling a single prescription electronically which I do over a hundred times a day takes more than 10 clicks
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Stages of Meaningful Use
Stage 1
Data capture and sharing
Stage 2
Advanced clinical processes
Stage 3
Improved outcomes
1 Capturing health information in a coded format
2 Using the information to track key clinical conditions
3 Communicating captured information for care coordination purposes
4 Reporting of clinical quality measures and public health information
1 Disease management clinical decision support
2 Medication management
3 Support for patient access to their health information
4 Transitions in care
5 Quality measurement
6 Research
7 Bi-directional communication with public health agencies
1 Achieving improvements in quality safety and efficiency
2 Focusing on decision support for national high priority conditions
3 Patient access to self-management tools
4 Access to comprehensive patient data
5 Improving population health outcomes
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Outcomes DB
TRACS
STS
ACS-Bariatric Surgery Center Network
NSQIP
Cancer Registry
STS
TransplantUNOS
Emergency Surgery
VSGN
SVS Vascular Registry
Courtesy of Matt Hutter
Data Collection Efforts
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
But the most dramatic unanticipated costs were associated with the need to increase staff coupled with a loss in physician productivity ldquoWe used to see 32 patients a day with one tech and now we struggle to see 24 patients a day with four techs And we provide worse carerdquo said one survey respondent
ldquoPoor EHR usability time-consuming data entry interference with face-to-face patient care inefficient and less fulfilling work content inability to exchange health information between EHR products and degradation of clinical documentation were prominent sources of professional dissatisfactionrdquo the report says
Medical Economics EHR survey probes physician angst about adoption use of technology
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
are other key findings from the national survey 73 of the largest practices would not purchase their current EHR system The data show that 66 of internal medicine specialists would not purchase their current system About 60 of respondents in family medicine would also make another EHR choice 67 of physicians dislike the functionality of their EHR systems Nearly half of physicians believe the cost of these systems is too high 45 of respondents say patient care is worse since implementing an EHR Nearly 23 of internists say patient care is significantly worse 65 of respondents say their EHR systems result in financial losses for the practice About 43 of internists and other specialistssubspecialists outside of primary care characterized the losses as significant About 69 of respondents said that coordination of care with hospitals has not improved Nearly 38 of respondents doubt their system will be viable in five years
Medical Economics EHR survey probes physician angst about adoption use of technology
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Articles published on Breast Cancer
Genetics
Genetics amp family history
functionality in the EHR
4335 articles in 2012
Rudimentary family history No structured genetic test results pedigrees or CDS
Rudimentary family history No structured genetic test results pedigrees or CDS
Minimal knowledge Exponential knowledge growth
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
EHR
Breast MedOnc Interface
Breast Surgery Interface
Mammography Interface
Pathology Interface
RT Interface
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
Specialty Specific
CDS
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
bull This month an Office of the Inspector General report warned that electronic medical records could even contribute to Medicare fraud by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
Upcoding
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
4000 Clicks a productivity analysis of electronic medical records in a community hospital ED Robert G Hill Jr MD
Lynn Marie Sears MBA Scott W Melanson MD
bull An American Journal of Emergency Medicine study found that emergency physicians spent 43 of their time entering data into a computer compared with only 28 of their time spent talking to patients During a typical 10-hour shift a doctor would click a mouse almost 4000 times
bull The mean percentage of time spent on data entry was 43 (95 confidence interval 39-47) The mean percentage of time spent in direct contact with patients was 28 The pooled weighted average time allocations were 44 on data entry 28 in direct patient care 12 reviewing test results and records 13 in discussion with colleagues and 3 on other activities Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters Total mouse clicks approach 4000 during a busy 10-hour shift
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD
J Gen Intern Med 2013 Aug28(8)1042-7 doi 101007s11606-013-2376-6
In the wake of the 2003 and 2011 duty hours regulations how do internal medicine interns spend their time
Block L1 Habicht R Wu AW Desai SV Wang K Silva KN Niessen T Oliver N
Feldman L
bull Doctors in training have it worse Researchers at Johns Hopkins University School of Medicine found that medical interns spent 12 of their time talking to patients or about eight minutes a day per patient but more than 40 of their time on a computer filling out electronic paperwork
KevinMD Kevin Pho MD