Curtis L. Whitehair, MD, FAAPMR

Electronic Medical Record

March 27, 2009

Board Certified PhysiatristPhysical Medicine & Rehabilitation

Fellow American Academy of Physical Medicine & Rehabilitation• President – Maryland Society of PM&R

National Rehabilitation Hospital, Washington, DC Medical Director – Outpatient Center for

Orthopedic Rehabilitation Medical Director – Oncology Rehabilitation

Program, NRH/NRH Regional Rehab

Shepherd University, Shepherdstown WV◦ Major

Business Administration Information Systems & Computer Programming

◦ Minor Communications

CASE Consultant – Datatel, Inc.◦ 3 Books

ETK: Introduction to Screen Processing ETK: Introduction to Batch and Report Writing Managing Custom Source

Ross University School of Medicine, NY/Dominica

Internship – Family Medicine at Medical College of Virginia (VCU), Richmond VA

Residency – Physical Medicine & Rehabilitation at NRH/GTUH, Washington, DC

According to the IOM, an EHR system has several key capabilities:

◦ It’s a longitudinal collection of electronic health information for and about persons.

◦ It provides immediate electronic access to person- and population-level information by authorized users.

◦ It provides knowledge and decision-support systems that enhance the quality, safety, and efficiency of patient care.

◦ It supports efficient processes for health care delivery.

Physicians spend 38% of their time writing chart notes.

35-39% of total hospital operating cost are spent on patient and provider communication activates.

Medical records could not be located 30% of the time when needed.

Once found the volume of information in them was often so large that it became unmanageable.

It was shown that simply organizing information flow sheets accelerated retrieval of needed data at least 4-fold.

Top 10 Causes of Death in 1998

1 Heart Disease 724,269

2 Cancer 538,947

3 Stroke 158,060

4 Lung Disease 114,381

5 Medical Errors 98,000

6 Pneumonia 94,828

7 Diabetes 64,574

8 Motor Vehicle Accident 41,826

9 Suicide 29,264

10 Kidney Disease 26,295

Stage III, IV pressure ulcers Fall or trauma resulting in serious injury Vascular catheter-associated infection Catheter-associated urinary tract infection Foreign object retained after surgery Certain surgical site infections Air embolism Blood incompatibility Certain manifestations of poor blood sugar

control Certain deep vein thromboses or pulmonary

embolisms

> 50% of all healthcare expenditures in the US is on ambulatory care (rate of increase is greater for outpatient than inpatient services)

~80% of the nearly 1 billion annual outpatient visits take place in practices of 10 or fewer clinicians

~50% in practices with fewer than 5 clinicians

Practices between 1-9 physicians account for Practices between 1-9 physicians account for 88% of physicians88% of physicians

In practices larger than 9 physicians, adoption In practices larger than 9 physicians, adoption rates are significantly higher rates are significantly higher

Source: Burt and Sisk, 2005Source: Burt and Sisk, 2005

Practice Size

(# of Physicians)

% Using EHR % Distribution of Physicians in Sample (n=3,360)

1 13.0 35.3

2-4 16.2 39.9

5-9 19.9 12.8

10-19 28.7 7.1

20-above 38.9 4.9

88%

Reactive episodic visits

“Top-of-mind” decisions

Paper-based ad hoc prescribing

Non-interactive documentation

No news = good news

Reactive episodic visits

“Top-of-mind” decisions

Paper-based ad hoc prescribing

Non-interactive documentation

No news = good news

Reactive and proactive care

Embedded CDSS/guidelines

Knowledge based Medication Management (eRx)

Interactive documentation

Orders loop management

While promoting medical quality and E/M compliance, in 15 minutes a provider must be able to:◦ Perform and complete documentation of a

medically indicated, audit-proof, level 4 or level 5 patient visit with individualized narrative information in all

appropriate areas of the medical record including completion of counseling the patient ordering test ordering treatment charge entry

A value configuration describes how value is created in a company for its customers. It shows how the most important primary and secondary activates function to create value for customers.

It represents the way a particular organization conducts business.

The development of an Electronic Medical Record is not merely the construction of an IT system but a continual organizational improvement process aimed at bringing the healthcare organization to a higher achievement level through people, processes and technology.

The process changes with the users needs and requirements as they learn as well as technology and knowledge evolves.

As care processes become more dependent on IT clinical expectations of availability increasses.

Clinicians are used to high availability technical infrastructures.

Improve Quality Care

Avoid Adverse Drug Events

Improve Quality Measures

Enhance Patient Safety

Improve Operational Efficiencies and Reallocate Staff

Increase Reimbursements Decreased cost

Benefits of Implementing EMRs

DesRoches, et. al., NEJM, July3, 2008

Simultaneous 24/7 health record availability◦ Emergency/On Call physician

Improved chronic disease management◦ Prompts doctors and nurses whenever health

maintenance services are past due.◦ Prompts doctors and nurses to perform chronic

disease management services and identifies when parameters are not met.

Improved continuity of care and preventative care among different providers

Record is legible and timely

Record is more consistent across different providers

CPOE

eRX

eMAR

Standardize and integrate data capture for quality measurement into the normal documentation of care within the ambulatory EMR.

Reporting abilities of flow and process allow better understanding of process and procedures.◦ Data can flow into PI modules/software with import and

export

Implementation of an automated system for data extraction including valid, reliable reports that provide actionable insight for the measurement, analysis and improvement of care.

Increased safety in prescribing due to drug interactions and allergy alerts.

Ease of accessing patient prescription information in case of drug recall.

More efficient phone triage due to immediate access to patient records.

Consultant Reports and legible and timely.

Increased staff job satisfaction◦ Reduced staff stress related to failed searches for

paper records◦ Improved communication among staff

Staff to physician ratio decreased below national ratio average◦ FTE decrease 1 – 2.5 per physician.

Physical Plan reduction◦ Convert filing area to 3 exam rooms.

Better E/M documentation enhances provider confidence to code and bill appropriately for services rendered◦ It is common to down-code for fear of the audit or denials.◦ Service Notes are more defensible from a billing perspective

Transcription cost saved

Discounts from malpractice insurer◦ The malpractice insurer believes EMR greatly reduces

potential of drug errors / misunderstood notes

Improve charge capture◦ Reduction in delays in billing activities◦ Reduction in payer denials

Basic EHR Intermediate EHR Advanced EHR

On line chart with: - Clinical note

documentation - Results viewing

Basic plus:- Electronic

prescribing with: - Adverse drug

prevention capability - Alternative drug

suggestion

Intermediate plus:- Lab order entry with testing

guidance- Radiology order entry with

test guidance- Electronic Charge Capture

($18,200) Net Cost

$44,600 Net Benefit

$86,400 Net Benefit

Goshen, NY

520 Beds

4 Buildings

15 Units

– Sub-Acute Rehabilitation

– Long Term

– Dementia/Alzheimer's

– Palliative Care

Over 600 Employees

Valley View Case Study

Less time on resident care due to inefficiencies

Clinician and staff frustration high

In danger of losing reference lab

Inefficiencies resulted in an underlying concern for resident safety

Lost RevenueMedicare billing inefficiencies

Inaccurate data captureIncreasing CostsFormulary non-compliance was resulting in

escalating drug costs

Inefficient Work FlowRenewal process lengthy and error prone

Difficult to manage off-hour admissions

Cumbersome communication within facility

Nursing staff mired in paperwork

Resident Safety ConcernsDifficult to manage quality with paper and

retrospective MDS data

Incomplete or ambiguous orders

DUR alerts missed or late

Valley View’s Business Issues

Business Issues

Medication order renewal process

Formulary updates, communication and control

Facility communication and order data entry (telephone, ADT, etc.)

Pharmacy communication and order data entry

Resident identification, alert and room/bed assignment

* Through attrition

92% reduction in adverse drug events (from avg. of 2.81 per month to .23 per month)

9% additional time for over 200 employees (700 hours per week) to focus on direct resident care

Reporting (resident safety, quality indicators, DUR, shift productivity, census)

Compliance with State, Federal and accreditation audits, surveys and ad hoc requests

5 FTE Staff Reduction*Medication savings Renewal efficienciesEfficiencies in formulary trainingConsultation formsMedicare billing improvementLab billing improvement

$ 250,000$ 262,000$ 120,000$ 8,000

$ 20,000$ 15,000

$ 10,000

Valley View’s Return on Investment

Business ProcessAutomated

Direct Financial Benefit

AdditionalEfficiencies

Questions ?