R. Anne Webber, BSN, MHA, RN, CNN

Session #: 152

Does Your Medical Record Support Evidenced-Based Care?

Does Your Medical Record Support Evidence-Based

Care?

R. Anne Webber, BSN, MHA, RN, CNNANNA National Symposium

April 3, 2006

Conflict of Interest

Employed by Health Informatics, Inc. – a software vendor

Presentation focus is broader than any one product and not vendor specific

Session Objectives List the major forces to replace paper medical

records with Electronic Health Records (EHRs)

Describe the barriers to EHR adoption

List the possible factors used to evaluate your current EHR or a proposed EHR

Describe how future technology will assist clinicians to consistently apply evidenced-based care and improve outcomes

Describe how nurses can influence future EHR design and adoption

Definitions

Electronic Medical Record (EMR) Replacement of traditional paper records

Electronic Health Record (EHR) EMR with data from other sources (via interfaces)

Interface - Electronic, automatic transfer of data from one database to another

Personal Health Record or Information (PHI) Electronic, universally available, lifelong resource

of health information maintained and owned by the individual (AHIMA)

Overview

What is driving the adoption of EHRs? What are the barriers to EHR

adoption? How do we evaluate EHRs? What will the future EHR do to assist

me and improve patient care? How can nurses influence EHR

selection, implementation and future development?

“We are an information-based profession”

Carolyn Headley, DNSc, MSN, RN, CNNApril 2005 ANNA Symposium presentation entitled:

Closing the Chasm between Evidence and Practice through Research

What is driving the adoption of EHRs?

“Medicine used to be simple, ineffective and relatively safe.

Now it is complex, effective and potentially dangerous”

Sir Cyril Chantler The Lancet,

1999

What is driving adoption of EHRs? Government

IOM 2000

98,000 killed by medical errors

IOM 2001

54.9% receive appropriate care

IOM 2003

Data Standards required

President G. W. Bush

2005 State of the Union Address

“I ask Congress to move forward on a comprehensive health care agenda.. with improved information technology to prevent medical error and needless costs…”

EHR Adoption DriversPublic Access to Data

CMS Dialysis Compare – Facility level comparative data on: Anemia Adequacy Mortality

State-based administrative databases Incident reporting Outcome reporting

EHR Adoption Drivers Outcomes-based reimbursement Self insured quality incentives

Leapfrog Group Health Plans CMS Demonstration

S 635 and HR 1298 establishes outcomes-based demonstration project linking payment to quality of care

EHR Adoption Drivers Providers/Facilities Provider/Facility negotiation strategy

based on internal outcome data Not much published so far - anecdotal Counter offer reimbursement rates based

on internal outcome data not available to health plans

“It seems self-evident that many , perhaps most, of the

solutions to medical mistakes will ultimately come through

better information technology.”

Robert M. Wachter

The End of The Beginning: Patient Safety Five Years After ‘ To Err is Human’”

Quality of Care, November 30, 2004

What are the barriers to EHR adoption?

EHR BarriersPerceived

“Healthcare Information Services implementation hurdles are more

cultural than technical”

Patient Safety Meeting San Diego, November 18-

19, 2004

EHR BarriersReal Cost

Purchase Implementation Training Maintaining

Fragmented Systems (No interfaces) Clinical Lab Billing

Space

How do we evaluate EHRs?

EHR Evaluation

Existing systems / Potential Systems Evaluation is the same

EHR Evaluation

Key Capabilities of an Electronic Health Record System (IOM, 2003)

1. Health information and data2. Care management3. Order management4. Decision support5. Electronic communication and

connectivity6. Patient support7. Administrative processes and reporting8. Reporting and population health

EHR Evaluation What are your goals?

Improved care Increase patient safety Evidenced-based care Support for quality improvement

Increase staff/physician efficiency Opinion: EHR will NOT reduce chair-side

documentation time Can increase efficiency / power in reporting Can increase efficiency to locate and replicate

patient records Can increase availability of medical records

EHR Evaluation Decision Support (Evidenced-based care)

Computerized reminders prompts and alerts to improve compliance

with best practices ensure regular screenings identify possible adverse drug interactions facilitate diagnoses and treatments

Example: Does your EHR notify you when VP exceeds tolerance for 3 consecutive treatments with BFR at 200?

What will the future EHR do to assist me and improve

patient care?

“Who has time to sort through myriad references

and papers to look for evidence-based answers?”

Matt Lewis, MD Family Practice Management, May 2003

EHR Future

Technology advances Data integration

Transaction standards Integration

Hospital records Primary care Specialists Others

New technology

EHR Future – Handheld Devices Documentation options

Real-time EHR documentation Vitals, Services provided (medications administered,

dressing changes, etc.) E-prescribing, etc.)

Photos / Images Voice recordings Video recordings

EHR Future – Handheld Devices Communication options

Care Team and Patients e-mail Voice mail Page

Auto transfer to pharmacies (e-prescribing)

Auto transfer to/from labs

EHR Future – Handheld Devices Notifications and References

Evidence-based clinical items Safety warnings

Medication / allergy alerts Medication / medication interactions alerts

Reminders Ordered items due Preventive care

Test result alerts Reference databases

Drugs Protocols

EHR Future Radio frequency identification devices

(RFID) Identification and location

Patients Staff Equipment (Resources) Medication at dose level

Documentation Efficiency Right patient* Right medication* Right dose* Right time* Right route *(sort of)

* = validation / documentation at point of care possible

EHR Future

Patient access / entry into EHR Patient ‘ownership’ vs. Clinician ‘stewardship’

Asynchronous communication Physician / patient Patient initiated Physician and care team members Patient and care team members

EHR - Nurse Role

Get comfortable with change Review your nursing goals for EHR

adoption Take ‘ownership’ of EHR as an integral

part of your clinical processes Analyze current processes

How many steps? How many handoffs? How many opportunities for error?

How can nurses influence EHR selection,

implementation and future development?

Typical Clinical Processes

EHR -Nurse Role

Analyze current / proposed EHR system processes Does proposed/ current EHR support

desired (not current) processes? What are the cultural barriers for change?

Culture changes take time – may not match your implementation schedule

Design implementation plan for smooth transition from current processes to desired processes

Get expert help if needed – vendor assistance

EHR -Nurse Role

Leverage EHR efficiencies Implement improvement plan Implement CQI process:

Analyze results of change (outcomes analysis, chart audits, process analysis)

Plan

Analyze

Implement

EHR -Nurse Role

“Even if you’re on the right track, you’ll get run over if you just sit there.”

Review each upgrade to EHR Identify new functional efficiencies Determine desired changed to current

processes Plan and execute plan to implement

desired processes

Will Rodgers

Patient EHR ‘Rights’

Our patients have a right to have the: Right information Right place Right time Right interpretation

To assist the clinician to do the Right thing

Nurses EHR ‘Rights’

Right to significant input into EHR: Selection Implementation Ongoing evaluation New application design Enhancement ideas

Don’t settle for less!

“Let's make the right thing the

easiest thing to do.”

David Abelson MD,Park Nicollet