Andrew Burton-Jones - UQ Business School, The University of Queensland
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Transcript of Andrew Burton-Jones - UQ Business School, The University of Queensland
Andrew Burton-Jones
October 29, 2014 [email protected]
Using Integrated EHR/EMR Systems
Meaningfully
“Interoperability is the ability of
two or more systems to
exchange and subsequently use
that information.”
“Integration is … the process of
combining components into an
overall system.”
Where my talk fits in…
2
I focus on the role of users. You can’t really get interoperability or integration in reality, or leverage them, without “meaningful” use.
http://www.testingstandards.co.uk/interop_et_al.htm
Innovation process from an organisation/client perspective
(Cooper and Zmud, Management Science 1990)
Vendor side
Client side
Where my talk fits in…
3
Client side
Initiation: Scan the market and find initial matches
Adoption: Make investment decision
Adaptation: Get IT application ready for use
Acceptance: Organisational members use it
Routinisation: Use of the application is part of normal work
Infusion: The application is used to its fullest potential
Infusion, meaningful use, effective use – vs. adoption/use
Where my talk fits in…
4
http://www.healthit.gov/sites/default/files/rtc_adoption_and_exchange9302014.pdf
Examples…
5
US Approach – Meaningful Use
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf
6
Canada – Benefits Evaluation Framework
https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/544-benefits-evaluation-indicators-technical-report-version-2-0
Benefits Evaluation Framework –self-reported measures
7https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/544-benefits-evaluation-indicators-technical-report-version-2-0
Benefits Evaluation Framework –non-self-report measures
8https://www.infoway-inforoute.ca/index.php/component/docman/doc_download/544-benefits-evaluation-indicators-technical-report-version-2-0
Approaches like these are good for
getting adoption. They focus on…
9
Is the system used?
Is the system used often?
Are specific features used (often)?
But they don’t really focus on:
…is the system used well? i.e., meaningfully/effectively
Example from my researchin a community care setting
What does it take to use an integrated EHR
system truly meaningfully?
Canadian Regional Care Provider
Enabling
Community Electronic
Health Records
Integrated, Safe and High Quality
Care
+
Operational Efficiencies
11
• Over 5000 users, 100 sites
• Significant and continuing investment
Project Vision for HITS
A client centric electronic record for all community care
• Home Care
• Public Health
• Mental Health
• Addictions
• Communicable Disease
• Residential Care
• Transitional Care
• Palliative Care
Program F
Program A
Program B
Program E
Program D
Program C
Client’s Electronic Record
12
Case study design
13
Met ~150 staff
Level of data Relevant actor Relevant tasks Associated goal Workarounds
Administrative reports(classification of data)
Director/Manager
- Monitor operations
- Report data- Make
program/region-wide decisions
High-quality andcost-effective care the region
None available
Client trajectory(compilation of data)
Care team
Front-line staff
- Coordinate care- Make team-level
clinical decisions
- Make complex clinical decision
Continuity of care for whole person
High-quality care for whole person
Conversationswith clinicians and clients; shadow paper system
Individual record (original data)
Front-line staff - Input record- Access record- Make simple
clinical decision
High-quality care for client’s specific need
14
Three views on meaningful use
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Three views on meaningful use
View 1: Adaptation of Canadian
Benefits Evaluation Framework
16
B
A
Benefits evaluation approach
17
Quality of EHR System
Meaningful use
Quality of outcomes
Outcomes for staff
Outcomes for clients
Drivers of …
Quality EHR System
Meaningful use
+/-(vicious/virtuous)
+
+
+
+
+/-(corrective feedback)
External factors
C D
E
F
G
18
Construct Dimensions Example quotes for link A in the
model
Drivers of
the quality of
the EHR
system
- Investment in design and
implementation
Nobody had the appetite to
spend …what it would take,
because of cost resources.
- Investment in technical
infrastructure
…the upgrade [to] wireless
access, … it’s faster and it’s
more reliable … so it’s much
easier to use off-site.
- Investment in ongoing
maintenance
This immunization program…
would be awesome …but it isn’t,
because of the turnover in staff
maintaining this rules engine.
19
Construct Dimensions Example quotes for link B in the
model
Drivers of
meaningful
use
- Personal factors (framing,
knowledge, experience)
...an effective user is really good
at sort of filtering...prioritizing,
...They’ve got that clinical lens.
- Organizational factors
(organizational structure,
culture, roles)
...it’s effectively used because
...there’s been a structure and an
interest for several years to make
this work [including] a planning
team and the educators and
everybody....
- System factors (transparency) ...the idea that other people...
have...access to their record, I
think builds in a bit more of …an
internal check-and-balance.
High-level view
20
Construct Dimensions Example quotes for links C in the model
Quality of the
EHR system
- System quality (speed,
navigability, program
logic, ease of mistakes
and difficulty fixing
them)
- Information quality
(accuracy,
completeness,
relevance, clarity)
Vicious circle (i.e., poor system poor use
worse system)
...[HITS will ask] “why hasn’t [the referral
priority] been met?” …we have no idea. But
we have to enter something. So we
guess....So, there’s all this layer of inaccurate
information that is going to the Ministry,
…garbage in, garbage out.
Virtuous circle (i.e., good system good
use better system)
[over time] they’ve …done a much better
job of categorizing those clinical activities so
that it’s … aligned with what they’re actually
doing …. and so they just check them off …,
as opposed to having to write free-text
fields…. So, the design is helping the use of
it, and, … it sort of self-enforces.
Meaningful use - Inputting record
- Accessing record
- Coordinating care
- Monitoring operations
- Decision-making
21
Construct Dimensions Example quotes for links D, E, F, in the model
Quality of
outcomes
- Client outcomes
(client care, client
coordination, client
satisfaction)
...[If] a client is struggling…I can access their
notes ...see the client, make sense, put [the plan]
in place ...And...part of the plan may be … that he
see his GP …and then boom – we can notify the GP
– there’s … a loop of communication, and the
client is served.
- Staff outcomes
(satisfaction,
efficiency,
teamwork,
professional
readiness, culture
change)
...we can catch errors better ...we can audit and
say, “OK, who booked it? …And it’s not about
going back and finger wagging, it’s about saying,
“Well how do we educate that person?” “Oh, it
was a casual, what are we doing wrong in our
education of casuals? How do we support them
better, you know?”
- Corrective feedback
back to the drivers
of quality (e.g.,
informing users’
knowledge/
experience)
… if they do not see the motivation of putting
some data there… they don’t do it. …if that data is
needed, we go back to them with a report … and
then they see the reason for which we’re asking,
and it improves. So it’s a …back-and-forth process.
22
Construct Dimensions Example quote for link G in the
model
External
factors
- Factors outside the authority’s
control
...you never know what the
ministry wants, or how they’re
going to change their programs,
or when, … so it’s difficult.
Three views on meaningful use
View 2: A closer look at meaningful
use
23
A closer look at meaningful use…
24
forms
part of
Meaningful use
Accuracy
- Truth
- Whole truth
- Nothing but
the truth
Reflective practice
- Client
- Clinical and co-
worker workflow
- System workflow
forms
part of
forms
part of
influencesinfluencesinfluences
Consistency
- Utilization
- Place
- Form
- Amount
- Meaning
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Sub-dimension Quote
Truth … when it comes to an area that I can see that when you look at
the numbers and you just compare it to the work that they’re
doing, it just doesn’t match up, is child and youth. …it looks like
they’ve only seen two or three people [which isn’t true].
Whole truth … some of their counselling team will just write one or two lines …
and it’s really quite cryptic, and you just have no idea what was
discussed, whereas I find at this site there’s more robust meat of,
“These are the challenges…, this is the plan.” …for
multidisciplinary team working together [my other site’s practice]
is not the ideal.
Nothing but the
truth
[Case notes should be] clear…, pithy …to the point [and] there
shouldn’t be any writing that people could misconstrue
Dimensions - Accuracy
Dimensions - Consistency
26
Sub-dimension Quote
Utilization In HITS there’s a form in the central index module, where you can collect a
person’s ethnicity…some programs do it, some don’t. Some staff do it, some
don’t. … So you really need …to inform the staff, “we need this information
to be captured so that we can actually report it.”
Place …some nurses are … putting ...the information where it’s supposed to go…
Other nurses… don’t get the information where it is [supposed to go], or it
can be in two places or even three places, and they’re still phoning,… and
leaving sticky notes….
Form …different people chart differently, so … you have to read the whole case
note to get what you’re looking for … so you’re flipping through just to see if
they happen to mention it, ‘cause it’s not highlighted.
Amount I know there’s tons of variance out there in …what they document and how
much they document. And in some cases, I think some nurses are over-
documenting and in some cases they are under-documenting.
Meaning …because that form is accessible to multiple people from multiple programs,
one will put it in, someone else will come along, will change it to something
different. Because their interpretation could be different.
Dimensions - Reflective practice
27
Sub-dimension Quote
Client [Using HITS effectively is] thinking clinically and saying, “OK,
what’s, what’s important,” … you want to communicate the
important things [about the client].
Clinical and
co-worker
workflow
I put information that I know will be relevant for that person
[taking over]. I know to do that from experience, from
feedback [from the person taking over] and because I've
worked on that side of healthcare and I know [it] would be
relevant for me....
HITS
workflow
…a good use of HITS is using the proper …grids, making sure
that if I’m going to put [data] in …, it may take longer to initially
put it in, but it saves time in the long-run because then it
carries over to all the screens [and] reports.
Importance of reflective practice
28
…as professionals, we meet regularly. … Where is that information going? Are you putting that information in the case note …or … the plan…? I’ve heard [people ask], “Do your managers give you time for things,” and my immediate professional response is, “we don’t ask for that time, we make that time,” because … to provide good care …we are ethically bound to spend time with our colleagues making sure our education [and] standards are good.”
Three views on meaningful use
View 3: Mapping out meaningful use
across the organisation
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Process view
30
Relevant
functionality offered
by the EHRMeaningful use
Achievement of
immediate goal
Data input
functionality
Meaningful use
(Accuracy, consistency,
reflective practice)
Relevant data input
…By mapping functionality to work processes, we can map out meaningful use across the organisation
Example Map
What did we learn from the three
views?
32
Lessons learned
• For the organisation we studied:
– An integrated/interoperable system is not really integrated or
interoperable if different users/units are using it inconsistently
– Mapping out more meaningful use across the organisation
provided a road-map to get more value
– Helped guide new interventions and funding
33
Lessons learned
• In general:
– A mindset for getting value from more meaningful use of IT
• What does meaningful use of your system involve?
• Is your system being used in that way? (need evidence)
• Align evidence with priority (e.g., rough vs. detailed evidence)
• This message is equally relevant for clients and vendors
34
35
Three main priorities based on our findings:
- From View 1: Ensure that staff can distinguish between the quality of a system and the quality of its use. If unclear, staff may blame the system for problems caused by their use of it.
- From View 2: Focus on reflective practice (in training and leadership) because it underpins the other dimensions of meaningful use.
- From View 3: Focus on front-line inputs because they are the foundation of all other uses of the EHR
Prioritisation
Conclusion
• The meaningful use regulations and similar incentive
schemes are well-placed to increase adoption and use
• But they will not necessarily increase truly meaningful use
• Getting meaningful use requires attention to how a
systems need to be used, and how it is used, to obtain
desired outcomes
– Some lessons: Need to distinguish the system from its use,
encourage reflective practice, and focus on front-line value 36