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Evaluating EHR at the Point of Care

Physicians’ Perspective, &Physicians’ Perspective, &

Perspective on Physicians Perspective on Physicians

Stephen R. Levinson, M.D.Stephen R. Levinson, M.D. (March 7, 2005)(March 7, 2005)

CMO, CMO, iMedXiMedXASA,LLC

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Attendee Demographics

PhysiciansPhysicians Solo private practiceSolo private practice Group practiceGroup practice Medical centerMedical center Organization Organization

AdministratorsAdministrators IT companiesIT companies Lab and RadiologyLab and Radiology

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Background: E/M coding trainerE/M coding trainer Medicare committeesMedicare committees TPA managementTPA management Spec soc. Quality and Spec soc. Quality and

insurance committees insurance committees Compliance expert for MDLCompliance expert for MDL AMA book on Practical E/M AMA book on Practical E/M

Coding and Documentation Coding and Documentation for Quality Carefor Quality Care

CMO for CMO for iMedXiMedX 26 yrs Medical Practice26 yrs Medical Practice

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Terminology of “Practical E/M” Measures Tools

Quality of CareQuality of Care E/M ComplianceE/M Compliance EfficiencyEfficiency ProductivityProductivity Physician usability Physician usability

(friendliness)(friendliness)

InterfaceInterface GraphicGraphic NarrativeNarrative

Data entry personnelData entry personnel PhysicianPhysician StaffStaff PatientPatient

Format **Format ** Data Storage/RetrievalData Storage/Retrieval Data EntryData Entry

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Questions for EHR Functionality

What digital data needs to be entered?What digital data needs to be entered? What digital data needs to be accessed?What digital data needs to be accessed?

Outcomes studies Outcomes studies EBMEBM Clinical Decision support Clinical Decision support

What studies have been done concerning What studies have been done concerning impact of EHR at the POC???impact of EHR at the POC???

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Format: Separate Consideration for Data Storage from Data Entry

Prior to EHR, regardless Prior to EHR, regardless of data entry format, the of data entry format, the only only data storagedata storage format format was Paper chartswas Paper charts

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For Hippocrates, Data Entry & data storage/retrieval, on papyrus

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Modern Medical Records Subbed Paper for Data Entry & Storage

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Pattern changed with Intro of Dictation for Data Entry

This did not change data This did not change data storage in paper chartsstorage in paper charts

Landmark of Landmark of data entrydata entry having different format from having different format from data storage & retrievaldata storage & retrieval

ALL discussion of advantages ALL discussion of advantages and disadvantages confined to and disadvantages confined to data entrydata entry LegibilityLegibility Turnaround speedTurnaround speed Cost $$$$Cost $$$$

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Introduction of E Health Records

First change in format for First change in format for data storage & retrievaldata storage & retrieval Dramatic reversal: now ALL discussion of Dramatic reversal: now ALL discussion of

advantages and disadvantages has been confined to advantages and disadvantages has been confined to enhancing benefits of enhancing benefits of data storage and retrieval data storage and retrieval

Total absence of assessment of Total absence of assessment of data entry data entry features features of Electronic Health Records of Electronic Health Records Analyze impact on MD & Pt at POCAnalyze impact on MD & Pt at POC Analyze impact on “measures” of medical recordsAnalyze impact on “measures” of medical records

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Data Storage/Retrieval Features Paper EHR StraightforwardStraightforward Access problemsAccess problems Cost problemsCost problems Features ??Features ??

SophisticatedSophisticated Access successAccess success Cost issuesCost issues FeaturesFeatures

SearchableSearchable InterconnectivityInterconnectivity InteroperabilityInteroperability CPOECPOE Data for EBMData for EBM Clinical decision Clinical decision

support at POCsupport at POCASA,LLC

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Examine Format for Data Entry Need to bring the same Need to bring the same

innovation, enthusiasm, innovation, enthusiasm, and commitment to EHR and commitment to EHR data entrydata entry design that design that developers are bringing to developers are bringing to data storagedata storage design design

Review must be fair and Review must be fair and honest, to stimulate honest, to stimulate optimal optimal data entrydata entry design design enhancements enhancements

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Fundamental Assumptions Incorporated in Existing EHRs

The physician is assigned as the data entry The physician is assigned as the data entry operator (‘DEO’)operator (‘DEO’)

Format for Format for data entrydata entry is the same as format for is the same as format for data storagedata storage (i.e., direct data entry into the (i.e., direct data entry into the computer)computer)

Cascade of consequences of these two Cascade of consequences of these two assumptions:assumptions: 1) For patient-physician interaction at POC1) For patient-physician interaction at POC 2) For quality of data entered into medical record2) For quality of data entered into medical record

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Consequence 1: Patient/Physician Interaction at

the Point Of Care

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Patients Want & Expect to See This (and so do Physicians)

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Patients Do NOT Want This

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Or This

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However, Everyone’s Happy with a Hybrid System!

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Consequence 2: Impact on Quality of Data Entered

It is critical to have It is critical to have optimal optimal data entrydata entry for for EHRs to achieve their EHRs to achieve their goals for quality & safetygoals for quality & safety

Loss of quality data entry Loss of quality data entry creates “GIGO”creates “GIGO”

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That is, Conclusions Are No Better Than the Data They are Based Upon

(Image from Google.com, from website: www.turkkupetcentre.fi/…/model_application.html)

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Effect on the Tools of Practical E/M

InterfaceInterface Graphic - maintainedGraphic - maintained Narrative - LOSTNarrative - LOST

Data entry personnelData entry personnel Physician - maintainedPhysician - maintained Staff – possible Staff – possible Patient - LOSTPatient - LOST

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Loss of the Narrative Interface Written narrative provides quality and Written narrative provides quality and

efficiency for multiple sections of med recordefficiency for multiple sections of med record HPIHPI Positive responses to ROS graphic interfacePositive responses to ROS graphic interface Abnormal exam findingsAbnormal exam findings Details of Medical Decision MakingDetails of Medical Decision Making

Keyboard entry could duplicate the enriched Keyboard entry could duplicate the enriched multilevel descriptions needed for Qualitymultilevel descriptions needed for Quality

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Loss of the Narrative Interface

How many physicians How many physicians can type while looking can type while looking at, and concentrating on, at, and concentrating on, patient at the same time? patient at the same time? NONENONE

Therefore, EHRs lose Therefore, EHRs lose narrative interface for narrative interface for data entry data entry due to due to fundamental assumptionsfundamental assumptions

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Evaluating EHR Alternatives to the Narrative (free text) Interface

Pick ListsPick Lists Generic templates containing general Generic templates containing general

descriptions related to patient’s chief descriptions related to patient’s chief complaint complaint Physician fills in a few variables through either Physician fills in a few variables through either

pick lists or limited keyboard entrypick lists or limited keyboard entry

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What Happens When We Force a Richly Descriptive Narrative Into a Graphic Format (Pick Lists or Templates)?

Let’s picture Will Let’s picture Will Shakespeare’s first effort Shakespeare’s first effort at writing Hamlet, using a at writing Hamlet, using a 200-phrase pick list:200-phrase pick list:

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““Hamlet comes home from school. Father died. Hamlet comes home from school. Father died. Mother married Father’s brother in one month. Mother married Father’s brother in one month.

Hamlet disturbed. Sees ghost. Hamlet more Hamlet disturbed. Sees ghost. Hamlet more disturbed.disturbed.

Hamlet acts crazy. Torments girlfriend (Ophelia); Hamlet acts crazy. Torments girlfriend (Ophelia); says become a nun. Ophelia disturbed, kills self. says become a nun. Ophelia disturbed, kills self.

Hamlet kills Polonius.Hamlet kills Polonius. Hamlet talks to a skull (Yorick). Skull doesn’t Hamlet talks to a skull (Yorick). Skull doesn’t

answer.answer. Rosencrantz and Gildenstern die.Rosencrantz and Gildenstern die.

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Actors visit castle. Hamlet chooses play and writes Actors visit castle. Hamlet chooses play and writes a new scene. a new scene.

Play disturbs Hamlet’s uncle. Play disturbs Play disturbs Hamlet’s uncle. Play disturbs Hamlet’s mother. Uncle kills Mother. Hamlet’s mother. Uncle kills Mother.

Big sword fight. Hamlet kills opponent. Hamlet Big sword fight. Hamlet kills opponent. Hamlet kills Uncle. Hamlet dies. kills Uncle. Hamlet dies.

Everyone dead. Everyone dead. Play endsPlay ends {Fortunately for world literature, Shakespeare did {Fortunately for world literature, Shakespeare did

not have to use a pick list to create Hamlet.} not have to use a pick list to create Hamlet.}

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Hypothesis: Effect of Lost Narrative on Diagnostic Paradigm

Optimal Paradigm: Good History Guides DxOptimal Paradigm: Good History Guides Dx With pick lists and generic templates, cascade With pick lists and generic templates, cascade

of:of: Limited history information (i.e., CC) guides Limited history information (i.e., CC) guides

selection of a non-specific historyselection of a non-specific history Record for 1 patient with a disease reads same Record for 1 patient with a disease reads same

as record for every other patient with that as record for every other patient with that diseasedisease

Non-specific history insufficient for precise DxNon-specific history insufficient for precise DxASA,LLC

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Effect on Diagnostic Paradigm

Increased reliance on Increased reliance on routineroutine laboratory and laboratory and radiographic testingradiographic testing

Increased costs and decreased efficiencyIncreased costs and decreased efficiency Increased “blanket” testingIncreased “blanket” testing Increased number follow-up visitsIncreased number follow-up visits

Decreased quality of careDecreased quality of care Lost ability to recognize when test results don’t Lost ability to recognize when test results don’t

fit the historyfit the history Physician “lost” when test results negative (no Physician “lost” when test results negative (no

basis to explain symptoms or guide future care)basis to explain symptoms or guide future care)ASA,LLC

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Effect of Lost Narrative on E/M Compliance Audit

Automatic defaults to Automatic defaults to negative or normal = failnegative or normal = fail

PFSH & ROS positive PFSH & ROS positive responses not documented responses not documented = fail= fail

Similar documentation Similar documentation visit after visit and case visit after visit and case after case shows only that after case shows only that EHR can enter the same EHR can enter the same template over & over template over & over = fail= fail

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Demo EHR Evaluation Protocol

Phase I: Enter complete detail of 4 – 5 Phase I: Enter complete detail of 4 – 5 charts into EHR demo. charts into EHR demo. Analyze usability and efficiency vs. usual Analyze usability and efficiency vs. usual

approachapproach Phase II: Repeat process with MD asking Phase II: Repeat process with MD asking

questions of spouse, acting as pretend questions of spouse, acting as pretend patient & reading chart responses while MD patient & reading chart responses while MD enters the data into the HERenters the data into the HER Analyze usability and efficiencyAnalyze usability and efficiency Have spouse analyze impact on the patientHave spouse analyze impact on the patient

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Hypothesis: Effect of Lost Narrative on Success of EHR Adoption

Efficiency of data entry Efficiency of data entry for 6 – 12 months for 6 – 12 months MDs then “master” the input into pick lists or MDs then “master” the input into pick lists or

pre-written templates for speedpre-written templates for speed What happens to bring about this change????What happens to bring about this change????

??MDs cease trying to input a customized ??MDs cease trying to input a customized narrative narrative

They can increase speed of data entry only by They can increase speed of data entry only by entering similar generic information on every entering similar generic information on every similar patient in order to ‘get the work done.’ similar patient in order to ‘get the work done.’

Those who refuse to adapt have system failureThose who refuse to adapt have system failureASA,LLC

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Effect of 2 EHR Assumptions on the Measures of “Practical E/M”

Efficiency Efficiency Reduced by loss of patient for data entryReduced by loss of patient for data entry

ProductivityProductivity Reduced by loss of efficiency, sub-optimal E/M codingReduced by loss of efficiency, sub-optimal E/M coding

E/M ComplianceE/M Compliance Reduced by similarity of descriptions among patientsReduced by similarity of descriptions among patients

Quality of CareQuality of Care Reduced by loss of narrative interfaceReduced by loss of narrative interface

Physician usability (friendliness)Physician usability (friendliness) Reduced by requirements for direct computer entryReduced by requirements for direct computer entry

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When Is a Doctor Too Old? Or Too Young?

By Abigail Zuger, M.D. New York Times February 8, 2005

The young doctor remembered little about each The young doctor remembered little about each patient from visit to visit, but typed volumes, patient from visit to visit, but typed volumes, and was a big fan of medical software that and was a big fan of medical software that supplies preformed phrases, sentences and supplies preformed phrases, sentences and paragraphs - paragraphs - the results of an entire physical the results of an entire physical exam, for instance - at the click of the mouseexam, for instance - at the click of the mouse. . Sometimes the mouse clicked just a little too Sometimes the mouse clicked just a little too quickly and erroneous information crept into the quickly and erroneous information crept into the charts.charts.

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When Is a Doctor Too Old? Or Too Young?

By Abigail Zuger, M.D. New York Times February 8, 2005

Insurance reviewers occasionally confused the Insurance reviewers occasionally confused the old doctor's terse notes with incompetence. old doctor's terse notes with incompetence. Patients occasionally complained bitterly about Patients occasionally complained bitterly about the young doctor, deploring that habit of the young doctor, deploring that habit of pounding the computer keyboard for the pounding the computer keyboard for the duration of their visit and never once looking duration of their visit and never once looking them in the eyethem in the eye. Both doctors, learning of these . Both doctors, learning of these misunderstandings, were mortified and furious. misunderstandings, were mortified and furious. Colleagues who had to wade through charts Colleagues who had to wade through charts belonging to either one just tore their hairbelonging to either one just tore their hair. .

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A Patient’s Perspective ““If I wanted to have a visit If I wanted to have a visit

with a keyboard, I’d sit at with a keyboard, I’d sit at home and surf the Internethome and surf the Internet

Something else is Something else is supposed to happen in the supposed to happen in the doctor’s officedoctor’s office

You don’t need 10 years You don’t need 10 years & $250,000 of education & $250,000 of education to be spent on typing to be spent on typing

Perhaps keyboard input Perhaps keyboard input should be banned from the should be banned from the exam room” exam room”

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It’s Time to Re-examine the 2 Data Entry Fundamental Assumptions

The physician must record data,The physician must record data, But must the physician be the individual But must the physician be the individual

entering that data directly into the computer?entering that data directly into the computer? Who does the CEO of a company appoint to Who does the CEO of a company appoint to

enter information into their computer system?enter information into their computer system? CEOCEO Senior ManagementSenior Management AdministratorsAdministrators Clerical staffClerical staff

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Shipping your luggage to S.F. – What’s the Most Effective Option?

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What Happens When We Change the Data Entry Assumptions?

Hybrid I: At least one company has opened Hybrid I: At least one company has opened this door by allowing the option of MD this door by allowing the option of MD dictationdictation

DEOs or voice recognition software enter DEOs or voice recognition software enter the narrative datathe narrative data

Innovative first stepInnovative first step Requires further examination of structure Requires further examination of structure

and function of data entry format to satisfy and function of data entry format to satisfy all medical record measuresall medical record measures

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Possible Solution: Hybrid System II

Professional DEOs enter Professional DEOs enter medical information into medical information into EHR EHR

Physician has full Physician has full flexibility for a “data flexibility for a “data transfer medium”transfer medium”

Achieves compliance, Achieves compliance, efficiency, quality, efficiency, quality, usabilityusability

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Data Transfer Medium Options

Structured paper Structured paper templates (IMR) templates (IMR) Narrative interface Narrative interface

options options Patient data entry PFSH & Patient data entry PFSH &

ROS graphic interface ROS graphic interface templatestemplates

Complete E/M Complete E/M compliance compliance documentation and documentation and guidanceguidance

DictationDictation Tablet PC written entryTablet PC written entry

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Additional EHR Issues

What should we measure for quality, What should we measure for quality, including “pay for performance”?including “pay for performance”?

How will “clinical decision support” How will “clinical decision support” function and be received?function and be received?

What about physician training?What about physician training?

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Issue 1:Data for “Pay for Performance”?

Management of chronic illnesses (e.g., DM, Management of chronic illnesses (e.g., DM, CHF)CHF)

Preventative care (e.g., mammography, Preventative care (e.g., mammography, colonoscopy, PSA)colonoscopy, PSA)

??? Diagnostic insight??? Diagnostic insight Number of visits prior to establishing a diagnosis Number of visits prior to establishing a diagnosis

for a given symptomfor a given symptom Appropriateness of testingAppropriateness of testing Appropriateness and timeliness of referralsAppropriateness and timeliness of referrals

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Issue 2: Response to Clinical Decision Support?

In the journal/DVD/Internet In the journal/DVD/Internet era,era,

IOM reports: It takes about 17 IOM reports: It takes about 17 years for a proven new years for a proven new therapy to be adopted into therapy to be adopted into standard carestandard care

WHY ???WHY ???

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½ Life of MD Practice = 17 Yrs! ““I finished my training in 1976”I finished my training in 1976” Not trained for changeNot trained for change Not trained for E/M codingNot trained for E/M coding Not trained for EHRNot trained for EHR Not trained for InterconnectivityNot trained for Interconnectivity Financial constriction has destroyed Financial constriction has destroyed

physician time for creative improvementphysician time for creative improvement When an electronic message arrives in an When an electronic message arrives in an

empty forest, is there a change in behavior?empty forest, is there a change in behavior?ASA,LLC

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How Effective is the Telephone - If No One’s Listening

on the Other End??

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Issue 3:To Digitize the Healthcare Environment, We Must Include Physician Training

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Questions?? Answers????

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