Electronic Health Record Features, Functions, Facts and Fallacies

Robert LigonSr. Health Information Technology Consultant

TMF Health Quality Institute

About Me

• Worked in HIT for over 25 years.• Most recently served as CIO to a large

cardiology practice in Illinois (44 physicians, 6 remote locations, 8 lab interfaces, 5 hospital document interfaces)

• Currently Sr. HIT Consultant for TMF Health Quality Institute (the QIO for the State of Texas)

TMF Health Quality Institute

TMF Health Quality Institute is an Austin, Texas-based nonprofit consulting company focused on promoting quality health and health care through contracts with federal, state and local governments, as well as private organizations.

TMF partners with health care providers in a variety of settings to ensure that every person receives the appropriate care, every time.

TMF is the designated Quality Improvement Organization (QIO) for the State of Texas

www.tmf.org

Experience with EHR

• Helped 300 physician practices evaluate readiness for an EHR and assisted with selection, adoption and implementation

(assessments and workflows) DOQ-IT, CMS QIO 8th Statement of Work (2005-2008)

• Currently working with 150 physician practices to improve EHR utilization, performance improvement and reporting. CMS QIO 9th Statement of Work (2008-2011)

Experience with EHR

• One of the most experienced consulting groups, outside of the vendor community, in EHR selection, adoption, implementation and optimization

• Private consulting with physician offices on EHR adoption, utilization and quality improvement

Objectives

• Provide overview of American Recovery and Reinvestment Act (ARRA) of 2009 stimulus incentives for Medicare and Medicaid

• Describe EHR terms, concepts and constructs

• Examine EHR functionality through the perspective of “meaningful use” criteria

Adoption of New Technology

“It will never come into general use, not withstanding its value, it is extremely

doubtful because its beneficial application requires too much time and gives a good bit of trouble both to the patient and the physician because its character is foreign and opposed to all of our habits and associations.”

Editorial in the London Times in 1834—regarding the stethoscope

American Recovery and Reinvestment Act 2009

“Stimulus Package”

American Recovery and Reinvestment Act*

• Provides 20 billion dollars for investment in HIT

• Creates incentives for adoption for Medicare and Medicaid providers

• Establishes HIT regional extension centers for resources and support

• Provides other money for national network standards and infrastructure

• Specifies changes in Health Insurance Portability and Accountability Act (HIPAA) – Security provisions now apply to business associates

*HITECH ACT, 2009

Medicare Incentives

Medicare IncentivesEligible Provider

“Meaningful Use” Defined

• Use of a “certified” EHR

• Ability to report on clinical measures

• Electronic exchange of patient health information

Medicare Incentive ScheduleYear First 2011 2012 2013 2014 2015 2016 Total

2011 $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000

2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000

2013 $15,000 $12,000 $8,000 $4,000 $39,000

2014 $12,000 $8,000 $4,000 $24,000

2015 +

$0 $0 $0

10% increase for providers in”healthcare professional shortage area”

Medicare Incentives

Medicare Incentives

If I already have an EHR can I qualify?

Yes, if the product is certified, you are using at “meaningful use,” and you are an eligible provider

Can I get both Medicare and Medicaid incentives?

No

Will the $44,000 be taxed?

Yes, probably

Are incentives per group or physician?

Payments are per physician (meets “meaningful use”)

Medicaid Incentives

Who qualifies• Not hospital-based• Demonstrates “meaningful use”• 30% or greater Medicaid patients

(20% if pediatrician)

Medicaid Incentives

Medicaid Incentives

• 85% of EHR cost, up to $25,000

• “Allowable” costs

• Up to $10,000 for each of the next 4 years

Medicaid Incentives

• Allowable costs

• “average costs for the purchase and initial implementation or upgrade of such technology (and support services including training that is for, or is necessary for the adoption and initial operation of, such technology)”

Medicaid Incentives for Ambulatory Care providers

• First year payment = $25,000 • Caps: following years at $10,000/year• First year cost no later than 2016• No payments made after 2021, or more than five years

from the first qualifying year

• Maximum Medicaid incentives = $63,750. vs. $44,000 maximum for Medicare incentives

EHR Concepts

EHR, EMR and PHR

• EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care

• EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.National Alliance for Health Information Technology (NAHIT)

EHR, EMR and PHR

• PHR: An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual.

National Alliance for Health Information Technology (NAHIT)

Rationale for EHR Adoption

• Improve quality, safety and efficiency

• Engage patients and their families

• Enhance coordination of care

• Improve population and public health; reduce disparities in care

• Ensure privacy and security

*Meaningful use preamble

Patient Safety• Error avoidance• Disease management• Wellness and a focus on prevention• Legible records• Guideline driven, evidence-based care• Population management

Improve Quality, Safety and Efficiency

• Use computerized physician order entry (CPOE) for all orders

• Implement drug-drug, drug-allergy checks

• Maintain up-to-date problem list, allergy list and medication list

• Transmit prescriptions electronically

• Use reminders for patient visits and testing

• Population managementONC, Health Policy Committee; Preamble to meaningful use

Improve Quality, Safety and Efficiency

Improve Quality of Care• Access to evidence-based guidelines• Rapid and remote access to patient information• Easier chronic disease management• Streamlined preventive care tracking• Safer medication management• Reminders and alerts for treatment/screening

Improve Quality, Safety and Efficiency

• 80% of U.S. adults take prescription medication, over-the-counter or dietary supplements

• 30% of U.S. adults take more than five medications

• Medication errors - 530,000 drug-related injuries in Medicare patients presenting to ambulatory care centers annually

Institute of Medicine of the National Academies report: Preventing Medication Errors 2006

Improve Quality, Safety and Efficiency

• Patients with diabetes– Only 50% receive adequate care for glycemic control, blood

pressure control and lipid management

• Patients with congestive heart failure– Only 70% of candidates receive ACE/ARB

• Preventive medicine– 40% of smokers do not get smoking cessation counseling– 47% of adults over 50 are not screened for colon cancer– 30% of women over 50 have not had a mammogram

Improve Quality, Safety and Efficiency

Saving Time and Money• Improved coding

– Most physicians• Meet the requirements for a level 4 visit

• Charge for a level 3 visit

• Document for a level 2 visit

• Medical Economics estimates a $40K loss to physicians down-coding one level

Improve Quality, Safety and Efficiency

Saving Time and Money• Improved coding

– Reimbursement for 99213 in Texas $60.76

– Reimbursement for 99214 in Texas $92.05

– Downcoding 3 patients a day = $93.87 per day

– $93.87 x 200 days = $18,774

Improve Quality, Safety and Efficiency

Saving Time and Money• Fewer chart pulls

– Cost of chart pull is $3-$5 per chart

• Improved efficiency of telephone refills – Cost to provider is $3-$5 per refill

• Reduced transcription – Cost to provider is $4-$7 per document

Engage Patients and their Families

Provide:• Patients with an electronic copy of medical record

• Clinical summaries to patients at each clinical encounter

• Patient-focused education material

Engage patients and their families

Patient satisfaction• Improved continuity of care with other providers

• Reduced time for call backs and medication refills

• Quick access to their records

• Perception of physician as “on the cutting edge”

Improve Coordination of Care

• Exchange key clinical information between providers

• Perform medication reconciliation at point-of-care

Improve Population and Public Health and Reduce Disparities in Care

• Submit electronic data to vaccination registries

• Transmit laboratory results to public health agencies electronically

• Provide electronic surveillance data to public health agencies according to legal requirements

Ensure Privacy and Security

• HIPAA

• Comply with national and state privacy and security laws

What do physicians want from an EHR?

• Ability to access charts remotely

• E-prescribing, management of formularies

• Better chart/document management

• Health maintenance reminders

• Results reporting

• Rx refill management

EHR Adoption by Physician Group Size

10.4

13.6 13.9

11

02468

10121416

% A

dopt

ion

1-5 6-10 11-20 >20

Practice Size

Medical Groups’ Adoption Of Electronic Health Records And Information Systems, Health Affairs, 2005

EHR Utilization

13

4

0

2

4

6

8

10

12

14

% A

dopt

ion

Bascic EHR Advanced Features

"Electronic Health Record Adoption in the Ambulatory Setting: Findings from a National Survey of Physicians,,NEJM

Why Don’t You Have an EHR Already?

• It’s too expensive

• I’m not sure what I need. I might pick the wrong system.

• It’s too much work to redesign my office workflow to accommodate an EHR.

Picking the Right System

Do you want to replace your practicemanagement system with an integratedscheduling/PMS/EHR?

EHR vendor will usually migrate PMS data from current system. Financial data isproblematic.

Picking the Right System

Do you want to “host” the system in your office? (Servers, backups, UPS, etc)Software resides in your office on yourcomputers

Would you like someone else to host the system? (e.g., vendor, reseller, hospital)ASP or SAAS model

Picking the Right System

• Do you want to buy the system?• Do you want to lease the system?• Do you want to have hospital pay for system?

Picking the Right System

• Do you have multiple office locations?

• Do you want to access system from home?

• How much customization do YOU want to do yourself?

• What interfaces do you want (lab, radiology, select referrals)?

Committee on Certification of Healthcare Information Technology

• CCHIT

• Currently ~200 certified EHR products

• Establishing new certification criteria for “meaningful use”

• Uncertain if only recognized certification

Picking the Right SystemFinancing your system

• Leased– No down payment– Tax benefits – Immediate write-off– Less risk

• Purchase

Picking the Right System

ASP /SaaS Model (Hosted system)– Least hassle– Lower upfront cost– Less hardware maintenance– Interfaces can be more problematic– Make sure you maintain ownership of data– Make sure to address security issues with vendor

Picking the Right System

Host your own system– Higher hardware cost– You are responsible for backups and disaster

recovery– Need available resources for maintenance – Maybe more easily customized

Upfront Cost of EHR Financing your system

• EHR software—EHR+PMS ~$10,000 per provider

• Installation and training—$8,000-$24,000

• Server(s)—$8,000

• Network—$2,500

• Workstations (Tablet PC’s)—$2,500

• Peripherals (Scanners, Printers)—$3,500

• Interfaces, Migration of current PMS data—$3,000-$8,000

TOTAL ESTIMATE $40,000

Source of information?

Workflow Considerations

• Evaluate important workflows– Scheduling/Patient flow

– Laboratory results

– Medication refills

– Standing orders

– Scanned document management

• Who enters what data? – MA, RN and physician roles

• Messaging

Interfaces

• Existing PM system

• Laboratory Interface• Negotiate with Lab vendor(s) to cover cost of interface

• ePrescribing

• Documents from hospitals/referral physicians

• EKG

• Pulmonary functions

• Imaging

PMSEHR

Pharmacy

LAB

ClaimsClearinghouse

EKGPFT

Hospital

Health InformationExchange CCD

Referral

EHR Connectivity

Picking a vendor

• Narrow list to 2-3 vendors (AAFP, HIMSS) KLAS rating

• Seek out other users in your specialty/practice size• Have one demo with final 2-3 vendors• Don’t hesitate to bring back vendors• Most important question: Can you show me?

Keys to Success

• Build a “culture of quality” around EMR initiative• Evaluate workflow (patient flow, charting process,

refills, billing, etc)• Do not skimp on vendor education• Make sure vendor incorporates ALL of your

additional documentation (letters, procedure reports, education material, etc) before go-live phase

Examine EHR Functionality through the perspective of “meaningful use” criteria

“Meaningful Use”

• Current criteria may not be final criteria– Current criteria collaborative recommendations issued

by ONC HIT Policy Committee– Final criteria determined by CMS

• Final criteria due Nov-Dec 2009 with 60-day public comment period (Jan-March 2010)

• Escalating requirements from 2011 through 2015• “Qualifying year” vs “adoption year” expectations

“Meaningful Use”How an EHR stores Information

• Discrete data (blood pressure, age, diagnosis, medications)

• “Free text” (HPI, narrative, procedure description)• Documents (Text, MS Word, PDF)• Images (radiology, echocardiography, EKG)• Combination (PFT results + graphs)• Reference tables (CPT, SNOMED, medications)

EHR Note: Only discrete data can be queried for reporting (So discrete data from consult must be entered in EHR)

EHR

DiscreteData BP

HistoryDatesMedications

Documents

DC SummaryClinic NoteProcedure NotePhone NoteScanned Document

Reporting and Outcomes MeasuresCan Only be Done on Discrete Data

Discrete vs Object vs “Free Text”

Data Integration

One data-entry point should result order, clear alert and beavailable for performance reporting.

This lab result •Satisfies order•Cancels alert•Is available for reporting

Data Integration

How an EHR Exchanges Information

• HL7-text data (labs, dc summaries, documents)• Continuity of care document (CCD)• “Free text” (HPI, narrative, procedure description)• Documents (Text, MS Word, PDF)• Images (Radiology, Echocardiography, EKG)• Combination (PFT results + graphs)• Reference tables (CPT, SNOMED, Medications) EHR Note: Only discrete data can be queried for reporting

(So discrete data from consult must be entered in EHR)

“Meaningful Use”CPOE

• Computerized Physician Order Entry– ALL orders(medication, laboratory, procedure, imaging,

immunization, referrals) require an EHR order beginning in 2011.

• Interfaces for orders not required until 2013• Benefit is order tracking EHR note: Orders should be linked to alerts and documents

so when you receive a document it should be easy to result the order or when an alert is satisfied it should result an order

“Meaningful Use”Drug Safety

• Maintain current medication list• Drug-drug interaction• Drug-allergy interaction• Formulary checking• E-prescribing• Medication reconciliationEHR Note: Medication reconciliation requires

interoperability

Domestic airline flight fatality rate

Anesthesia during surgery

Prescriptions written by doctors

44,000 - 98,000 preventable hospital deaths

Airline baggage handling

Inpatient medication accuracy

Mammography screening

Antibiotic overuse

Post-heart attack medications

Acute low back pain

IRS Tax Advice (phone – in)

1

10

1,000

100

1,000,000

100,000

10,000

DPMO

SIGMA

1 2 3 4 5 6

Source: GE medical SystemSource: GE medical System

Selected Six Sigma Performance

“Meaningful Use”Reporting of Quality Measures

• Outcome measures– BP at goal– LDL at goal– HgbA1C under control

• Process measures– Mammography screening– CRC screening– Vaccinations– Smoking cessation

“Meaningful Use”Reporting of Quality Measures

Process measures (continued)– High risk medications in elderly (Beers criteria)– Prophylactic ASA therapy

• System measures– % of all orders documented in CPOE– % of all prescriptions that are generic– % of lab results incorporated electronically– % of encounters where med reconciliation performed

“Meaningful Use”Reporting of Quality Measures

• Details of reporting mechanism unknown• Details of any performance improvement goals are

unknown• Lack of measures for many specialties• Make sure you are entering data so it is reportable• Run reports by race and gender to identify disparities EHR Note: Evaluate EHR software product carefully for

reporting capabilities. Many EHR products do not allow you to easily create your own reports but require third party software development (Crystal Reports)

“Meaningful Use”Other General Requirements

• Provide patient with electronic version of EHR• Record advance directives• Maintain up to date problem list (CPT or

SNOMED)• Record vital signs, BMI, allergies, demographics• Meet HIPAA privacy and security rules

“Meaningful Use”Other General Requirements

Capability:• To submit clinical data through health

information exchange• To submit vaccination data to state registry• To submit surveillance data to public health

Concluding Thoughts

• Start EHR selection & adoption process as soon as possible

• Regional Extension center help available after Jan 1…..

• Carefully integrated EHR will save time, money and provide better patient care

73

Bob LigonTMF Health Quality Institute

Bridgepoint I, Suite 3005918 West Courtyard Drive

Austin, TX 78730-5036512-334-1707

bligon@txqio.sdps.org

Contact Information