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
“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
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
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?
“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?
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!