Ong approaching innovation with commercial ehrs

Innovation with Commercial EHRs

Ken Ong, MD, MPHCMIO, New York Hospital Queens

Queens is the most ethnically diverse urban area in the world with a population of over 2.2 million, 48% of whom are foreign‐born,representing over 100 different nations and speaking over 138 different languages.

Salvation Army opened the Rescue Home for Women in 1892 as a haven for unmarried mothers in a humble house on East 123rd Street in Manhattan.

During World War I, the facility opened a free medical service for the dependents of enlisted men.

In 1950’s, Salvation Army noticed a shortage of local general hospital facilities in the vast farmland communities located to the east of the East River: Queens.

In 1992, the hospital became an affiliate of the New York Hospital‐Cornell Medical Center, which merged with Presbyterian Hospital in 1997 to form the NYP Healthcare System.

New York Hospital Queens has grown to become a 519‐bed acute care hospital, that last year admitted more than 35,000 patients, had more than 139,000 outpatient visits, and treated 115,000 people through the emergency department.

New York Hospital Queens

What’s an Innovation?

Everett Rogers, Diffusion of Innovations

"an idea, practice, or object that is perceived as new by an individual or other unit of adoption".

Everett Rogers, Diffusion of Innovations

How Far Have We Come?

Office‐Based Physicians Are Responding To Incentives And Assistance By Adopting And Using Electronic Health RecordsBy Chun‐Ju Hsiao, Ashish K. Jha, Jennifer King, Vaishali Patel, Michael F. Furukawa, and Farzad Mostashari. HEALTH AFFAIRS 32, NO. 8 (2013): 1470–1477

Office‐Based Physicians Are Responding To Incentives And Assistance By Adopting And Using Electronic Health RecordsBy Chun‐Ju Hsiao, Ashish K. Jha, Jennifer King, Vaishali Patel, Michael F. Furukawa, and Farzad Mostashari. HEALTH AFFAIRS 32, NO. 8 (2013): 1470–1477

72 percent of physicians had adopted some type of system and that 40 percent had adopted capabilities required for a basic EHR system.

As of 2012, physicians in rural areas had higher rates of adoption than those in large urban areas, and physicians in counties with high rates of poverty had rates of adoption comparable to those in areas with less poverty.

However, small practices continued to lag behind larger practices.

Office‐Based Physicians Are Responding To Incentives And Assistance By Adopting And Using Electronic Health Records

By Chun‐Ju Hsiao, Ashish K. Jha, Jennifer King, Vaishali Patel, Michael F. Furukawa, and Farzad Mostashari. HEALTH AFFAIRS 32, NO. 8 (2013): 1470–1477

Adoption Of Electronic Health Records Grows Rapidly, But Fewer Than Half Of US Hospitals Had At Least A Basic System In 2012

By Catherine M. DesRoches, Dustin Charles, Michael F. Furukawa, Maulik S. Joshi, Peter Kralovec,Farzad Mostashari, Chantal Worzala, and Ashish K. Jha. HEALTH AFFAIRS 32. NO. 8 (2013): 1478–1485





The US health care system is in the midst of an enormous change in the way health care providers and hospitals document, monitor, and share information about health and care delivery. Part of this transition involves a wholesale, but currently uneven, shift from paper‐based records to electronic health record (EHR) systems. We used the most recent longitudinal survey of US hospitals to track how they are adopting and using EHR systems. Only 44 percent of hospitals report having and using what we define as at least a basic EHR system. And although 42.2 percent meet all of the federal stage 1 “meaningful‐use” criteria, only 5.1 percent could meet the broader set of stage 2 criteria. Large urban hospitals continue to outpace rural and nonteaching hospitals in adopting EHR systems. The increase in adoption overall suggests that the positive and negative financial incentives currently in place across the US health care system are working as intended. However, achieving a nationwide health information technology infrastructure may require efforts targeted at smaller and rural hospitals.



Some Hospitals Are Falling Behind In Meeting ‘Meaningful Use’ Criteria And Could Be Vulnerable To Penalties In 2015

By Catherine M. DesRoches, Chantal Worzala, and Scott Bates. HEALTH AFFAIRS 32, NO. 8 (2013): 1355

Some Hospitals Are Falling Behind In Meeting ‘Meaningful Use’ Criteria And Could Be Vulnerable To Penalties In 2015

By Catherine M. DesRoches, Chantal Worzala, and Scott Bates. HEALTH AFFAIRS 32, NO. 8 (2013): 1355

Our analysis of Medicare data found a substantial increase in the percentage of hospitals receiving EHR incentive payments between 2011 (17.4 percent) and 2012 (36.8 percent). However, this increase was not uniform across all hospitals, and the overall proportion of hospitals receiving a payment for meaningful use was low.

Critical‐access, smaller, and publicly owned or nonprofit hospitals appeared to be at particular risk for failing to meet Medicare’s meaningful‐use criteria, and the overall proportion of hospitals receiving a payment for meaningful use was low.

Starting in 2015, hospitals that fail to meet the criteria will be subject to financial penalties. To address the needs of institutions in danger of incurring these penalties, policy makers could implement targeted grant programs and provide additional information technology workforce support. In addition, the capacity of EHR system vendors should be carefully monitored to ensure that these institutions have access to the technology they need.

Meaningful Information ExchangeMeaningful Information Exchange

Operational Health Information Exchanges Show Substantial Growth, But Long‐Term Funding Remains A

ConcernBy Julia Adler‐Milstein, David W. Bates, and Ashish K. Jha. HEALTH AFFAIRS 32, NO. 8 (2013): 1486

30 percent of hospitals and 10 percent of ambulatory practices now participate in one of the 119 operational health information exchange effortsHowever, we also found that 74 percent of health information exchange efforts report struggling to develop a sustainable business model. Our findings suggest that despite progress, there is a substantial risk that many current efforts to promote health information exchange will fail when public funds supporting these initiatives are depleted.

Operational Health Information Exchanges Show Substantial Growth, But Long‐Term Funding Remains A Concern

By Julia Adler‐Milstein, David W. Bates, and Ashish K. Jha. HEALTH AFFAIRS 32, NO. 8 (2013): 1486

Innovation with a Commercial E.H.R.

NYHQ live with Eclipsys Sunrise CPOE in 2006

Attesting to Meaningful Use Stage 1, Year 2, in October 2013

Upgrading to 2014 certified Allscripts Sunrise in December 2013

E.H.R. Adoption at NYHQ

Order Sets

Clinical Documentation

Medical Logic Modules (MLMs)

Clinical Analytics

Clinical Decision Support Interventions to Improve Quality

Alert Physician that there are no allergies documented for Drugs or Drug Categories

Alerts clinician ‐when a hematocrit is falling rapidly, not when a hematocrit is low or falling slowly

Alerts clinician ‐when a high glucose result is received for a patient ‐ this can alert when an order for such medication is placed AND patient has recent high glucose.

Alerts clinician ‐when a high potassium result is received for a patient ‐when there is a high potassium AND patient is receiving medications that can continue to elevate potassium further ‐when an order for such medication is placed AND patient has recent high potassium.

Alerts clinician ‐when a high sodium result is received for a patient ‐ this can alert when an order for such medication is placed AND patient has recent high sodium.

Alerts clinician ‐when a low creatinine clearance result is received for a patient and the patient has current orders for conflicting medications ‐when an order for such medication is placed AND patient has recent low creatinine clearance

A Sample of Our 229 MLMs

Alerts clinician ‐when a low glucose result is received for a patient ‐ this can alert when an order for such medication is placed AND patient has recent low glucose, but default is set to NOT alert on order entry.

Alerts clinician ‐when a low potassium result is received for a patient ‐when a potassium is falling ‐when there is a low potassium AND patient is receiving medications that can continue to lower potassium further ‐when an order for such medication is placed AND patient has recent low potassium.

Alerts clinician ‐when a low sodium result is received for a patient ‐when a sodium is falling ‐ this can alert when an order for such medication is placed AND patient has recent low sodium.

Alerts clinician ‐when the platelets are falling AND patient is receiving medications that can continue to lower platelets further ‐when there are a low platelets AND patient is receiving medications that can continue to lower platelets further ‐when an order for such medication is placed AND patient has recent low or falling platelets.

Calculate ingredients for TPN Order Calculates Padua Model DVT risk assessment score


Chemical & mechanical restraints Create ED pediatric sepsis alert in ED Nursing Triage Note Critical lab values post a flag in the 'Unacknowledged Alerts' column. Clicking on the alert shows the lab result and provides an opportunity to document the response.

Fires 'Name Alert' in 'Similar Name' column of patient list Generate an alert to prevent duplicate diet order Heparin dosing related If a previous echocardiogram was ordered, the following alert is given: "Please note: a previous transthoracic echocardiogram was ordered on [date]".


If carboplatin is selected, the following alert is given: "AUC Cockgraft‐Gault calculator is defaulted to utilize IDEAL body weight. Choices for ACTUAL and ADJUSTED body weight are available by changing the default in the dose calculator. Please utilize 'AUC (Cockgraft‐Gault actual)' when a patient's actual body weight is LESS than their ideal body weight to ensure appropriate dose."

Insulin dose calculated Place an CDiff +ve result comment in the header at the time of result posting.

Provide INR Lab Results and Prior Dosing History on the Order Set Form

Pulls in any infection control precautions into the radiology requisition order form


Pulls in current insulin dose into a new Endocrinology consult or progress note.

Pulls urine or blood HCG results into the radiology order form for women between the ages of 9 and 55. If the HCG is positive, an alert is tiggered: "WARNING: Patient with positive HCG on [date]. This may indicate pregnancy. Please be aware when ordering radiographic studies." If the pregnancy status is unknown, the following alert is given: "NOTE: No pregnancy test is charted on this patient. Please indicate the pregnancy status and consider pregnancy testing if appropriate."

Requires reasons for omission if no DVT prophylaxis is ordered Retrieves hemoglobin and platelet results when either a blood or

platelet transfusion is ordered. RxWriter (discharge medication app): Alert to user when dosage

amount is zero or missing Alert to user when Frequency is zero or missing Alert to user when Quantity is zero or missing


Start ExitCare application from a document list radio button. The ED Nurse Triage assessment places a flag on the ED display board

and fires an alert ("This patient has met modified SIRS criteria and may be at risk for serious infection.") if the temperature, pulse, respirations or blood pressure are more or less than defined parameters for children for particular ages.

This MLM will create C‐Diff infection alert header when patient readmitted and he had that infection in most recent visit.

To pull active DNR order list and insert in DNR order section of Summary of Care|Discharge|Transfer Note

To warn the person ordering NPO or dc tube feeding, that the patient is on hypoglycemic drug(s) and may require supplementation.

tPA dose calculation Warn user that concurrent use of anticoagulants, antiplatelets, and

thrombolytic medications are prohibited with indwelling neuraxial catheters


NYHQ’s New York City Designated Stroke Center

Stroke P.I. Initiative 2012‐2013

From paper to electronic documentation, i.e., NIH Stroke Scale

Stroke coordinator hired Modified Rankin Scale added to nursing note VTE prophylaxis order set improved Branching logic added to core measure section in Summary of Care note

Summary of Care Note:Branching Logic to Capture Hospital Inpatient Quality

Reporting Core Measures

NIH Stroke ScaleTotal Score Automatically Calculated

DVT Risk Assessment: Padua ModelTotal Score Automatically Calculated

Stroke Measures ImprovedMeasure Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 4 Months Pre 4 Months Post ChangeModified Rankin Scale at Discharge 17.9% 18.9% 37.5% 10.5% 22.8% 43.0% 72.1% 76.7% 21.2% 53.7% 153.1%VTE Prophylaxis 62.5% 71.9% 59.5% 72.9% 90.7% 93.4% 91.1% 100.0% 66.7% 93.8% 40.6%Dysphagia Screen 52.6% 38.1% 52.9% 41.3% 39.1% 58.0% 63.5% 64.9% 46.2% 56.4% 22.0%Stroke Education 89.7% 78.9% 100.0% 82.6% 95.2% 100.0% 95.9% 100.0% 87.8% 97.8% 11.4%

Protected Health

Information Redacted

Adopting MU2 Innovations: Inpatient

View, Download, & Transmit (VDT)Medication Reconciliation ApplicationBar Code Medication Administration Electronic Transmission of Summary of Care to HIE (Healthix)

Reporting MU2 compliant Syndromic Surveillance & Reportable Diseases

Adopting MU2 Innovations: Ambulatory

View, Download, & Transmit (VDT)Expanding Patient EngagementPatient‐Provider Secure Health Messaging

Appointment requestsMedication refill requests

Ken Ong, MD, MPHe‐mail = [email protected] = @kenongmdURL = kenongmd.com

Health & Medicine

Ong approaching innovation with commercial ehrs