Diverse Roles of Physicians in Health IT

April 12, 2015

Michael Zaroukian, MD, PhD, MACP, FHIMSS VP & CMIO – Sparrow Health System

Professor of Medicine, Michigan State UniversityDISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest

Michael Zaroukian, MD, PhD, MACP, FHIMSS

Has no real or apparent conflicts of interest to report.

2© HIMSS 2015

Learning Objectives

• Discuss the critical physician role in ensuring and advancing EHR usability

• Outline how Health IT can be used to detect safety issues

• Describe how to successfully work with vendors

• Discuss how to advance care in a technologically connected world

• Describe informatics learning / training opportunities for physicians to support IT-connected care

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Usability

Safety

Individuals & Caregivers

Clinicians

Vendors

Informatics & IT staff

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The Perspectives I Bring• Clinical

– General internal medicine, PCP, daily EHR user x 14 years– Clinical informatics (ABPM - Practice Pathway)

• Academic - Professor of Medicine, MSU• Executive - VP & CMIO, Sparrow Health• Policy - HITPC Advanced Health Models and MU WG• HIMSS Boards and Committees• Vendor relationships – EHR UG past-president; EHRA • Professional society health IT activities

– ACP Medical Informatics Committee– AMA Advisory Committee on EHR Physician Usability – AMIA EHR 2020 Task Force– AMDIS Board of Advisors

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There’s a LOT Going on in Healthcare Today…

• Access – ACA, Medicaid expansion

• Cost shifting– High deductible plans

• Consumer forces– Consumer expectations– Retail health services– Disruptive technologies– Privacy and security– Precision medicine

• Regulatory– Meaningful use– Interoperability– Telehealth– ICD-10– Data capture requirements

• Public reporting– Quality, outcomes, costs– Hospitals, providers

• Risk:– Accountable care, MSSP– Clinical integration

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but “the Main thing is to…

…Keep the Main Thing, the Main Thing”-Stephen Covey

Health Care Triple Aim

Patient Experience

& Outcomes

Health of the

Population

Reducing Per Capita Costs of

Care

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Berwick DM et al. Health Affairs. 2008;27:759-769.http://www.ihi.org/resources/Pages/Publications/TripleAimCareHealthandCost.aspx

Health IT ‘Main Things’

Health IT Use that Transforms Care

Health IT that is Used

Health IT that Works

(Developers, Implementation/Support Team)

(Physician and Organizational Leadership)

(Clinical and Informatics Leadership)

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Ensuring and Advancing EHR Usability

The Critical Role of Physicians

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Physician Information Management Tasks and Need for EHR Usability

• Gather – exchange• Find – search• Record – data entry, capture• Organize – visual displays• Analyze – reports,

dashboards• Learn – knowledge resources• Distill – filters, summaries• Communicate – FTF, audio,

video, messaging

• Teach – patient instructions• Deliberate – patient

preferences• Decide – decision support• Remember – reminders• Do – CPOE, order sets• Share – routing, messaging• Verify – notifications• Adjust – CPOE,

communication

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Usability: A Technical Definition

• The extent to which a product can be used – by specified users– to achieve specified goals– in a specified context of use– with effectiveness, efficiency, and satisfaction

• ISO 9241-11

International Organization for Standardization (ISO)

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If Broad Health IT Usability Was Easy…

• It would have been solved by now

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People

TechnologyProcess

Things to Keep in Mind About Usability

Usability Affects How You• Think• Feel• Act

Usability Factors: The 3 Fs• Form

– Shape, size, mass, "look"• Fit

– Ability to physically interface, connect, integrate

• Function– Actions the product is

designed to perform

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EHR Usability = Lightening the “Load”

• Navigation– Clicks, scrolls,

keystrokes, moves• Reading

– Legibility, signal-to-noise, layout, emphasis

• Thinking– Icon meaning, recall

• Writing– Typing, clicking

• Emotional– Task stress, getting

lost, dissonance

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Attributes of EHR Usability: HIMSS

1. Simplicity2. Naturalness3. Consistency4. Minimizing cognitive load5. Efficient interactions6. Forgiveness and feedback7. Effective use of language8. Effective information presentation9. Preservation of context

http://www.himss.org/files/HIMSSorg/content/files/himss_definingandtestingemrusability.pdf

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User Interface Design Heuristics7. Flexibility and efficiency

– Accelerators, personalization8. Aesthetic, minimalist design

– Only relevant, commonly needed information

9. Help users recognize, diagnose, recover from errors– Clear error messages with

constructive solutions10. System help and documentation

– Easy to search, concise, context sensitive, step-by-step

Nielsen J, 1995. http://www.nngroup.com/articles/ten-usability-heuristics/

1. System status visibility– What’s going on…

2. System matches real world– Natural, logical, clear

3. User control & freedom– Cancel, undo, redo

4. Consistency & standards– Words, actions, locations

5. Error prevention– Avoid errors, confirm before

committing6. Recognition, not recall

– Objects, actions visible

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Usability Principles for EHR Design: TURFTask - User - Representation - Function

1. Design consistency and standards utilization

2. System state visibility3. System and world match4. Design minimalism5. Minimize memory load6. Informative feedback7. Customizable & flexible

8. Useful error messages9. Use error prevention10. Clear closure11. Actions reversible12. User language utilization13. User control14. Help and documentation

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• Zhang J, Walji MF. TURF: toward a unified framework of EHR usability. J Biomed Inform 2011;44:1056–67.• Middleton B, et al. J Am Med Inform Assoc 2013;20:e2–e8.

Usability Priorities: AMA

1. Enhance ability to provide high-quality patient care2. Support team-based care3. Promote care coordination4. Offer product modularity and configurability5. Reduce cognitive workload6. Promote data liquidity7. Facilitate digital and mobile patient engagement8. Expedite user input into product design, post-

implementation feedback

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http://www.ama-assn.org/resources/doc/ps2/x-pub/ehr-priorities.pdf

User-centered Design (UCD)*

Principles1. Optimize around how users

can, want, or need to use IT

2. Don’t force user behavior change to accommodate IT

3. Designers analyze, see how users will likely use IT

4. Real world tests of validity of designer assumptions about user behavior

Standards & Certification Focus 1. CPOE2. Interaction checks: drug-drug,

drug-allergy3. Medication list4. Medication allergy list5. CDS: Clinical decision support6. e-MAR7. e-Rx8. Clinical information reconciliation

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* ONC Test Procedure §170.314(g)(3) – Specifying User-Centered Design (UCD) Approach

Methods for Assessing Usability

Testing• Thinking out loud

• Use cases with simulations

• Testing labs, real world

• Usability software

• Performance

– Qualitative

– Quantitative

Inspection• Expert evaluations, reviews

• Heuristic checklist

Inquiry• Field studies

• User focus groups

• Surveys

Middleton B, et al. J Am Med Inform Assoc 2013;20:e2–e8.

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Working Together to Advance Usability

Clinical and IT Teams Developers/Vendors• Configure for usability

• Learn to use systems well

• Encourage personalization

• Consider third party tools

• User experience teams– Feedback

– PDCA

• Follow user-centered design (UCD) principles

• Minimize load factors

• ↓ delays, detours, waste

• Usability testing, focus groups, expert reviewers

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Health IT Safety and Safe Use

Health IT Use to

Improve Patient Safety

Health IT and Safety

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Examples of EHR Risks and Errors

• Wrong chart

• Data displays unclear

• Incomplete workflows

• Data integrity problems

• Dosage rounding rule missed

• Dosing mode (mg vs. mg/kg)

• Recall requirement

• Signal-to-noise fatigue

• Nonstandard – Measurements

– Terms

– Abbreviations

• Accepting defaults without review

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Error

Detection

Commission

Omission

Improving Safety and Health IT

• Institute of Medicine (IOM)– Health IT and Patient Safety (2011)

• Department of Health and Human Services (HHS)– Health IT Patient Safety Action and Surveillance Plan (2013)

• Centers for Medicare and Medicaid Services (CMS)• Office of the National Coordinator (ONC)

– ONC Health IT Safety Program (2013)

• Agency for Healthcare Research and Quality (AHRQ) • Food and Drug Administration (FDA)

– FDA Safety and Innovation Act (FDASIA) Report on health IT safety

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IOM Report: Health IT, Patient Safety and Usability

• Health IT has an ever-larger role in patient care

• Some components have improved quality and reduced errors

• Harm from use of health IT is a concern

• Must be designed and used in ways that maximize patient safety while minimizing harm

• Can better help patients if it becomes more usable, interoperable, easier to implement and maintain

IOM. 2011. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC

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http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx

IOM Report: Health IT and Patient Safety

• Health IT is part of a “sociotechnical system”

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Social• People & leadership

• Workflow and communication

• Policies, procedures, environment & culture

• External rules, regulations & pressures

Technical• Hardware and software

– Configurations, upgrades, maintenance

• Clinical content

• Interfaces

– Computer-computer

– Computer-human

• System measurement, monitoring

Examples of Sociotechnical Risks• Hardware and software

– Faulty interface• Clinical content

– Test results unstructured• Human-computer interface

– No critical results prompt• People

– Order set workarounds• Workflow & communication

– No push of critical results

• Policies, procedures, environment, culture

– Password policy not enforced

• External rules, regulations,pressures

– ED throughput pressures

• System measurement, monitoring

– No monitoring of critical results receipt

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ONC Health IT Safety Strategy:Learn – Improve - LeadLearn• Facilitate reporting to Patient Safety Organizations

(PSOs)

• Incorporate health IT safety in post-market surveillance of CEHRT (ONC-ACBs)

• Align CMS patient safety initiatives with health IT safety

• Identify opportunities to make care safer through the use of health IT - CDS, eCQMs

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ONC Health IT Safety Strategy (2)

Improve• Use MU and National Quality Strategy to establish,

advance health IT patient safety priorities

• Incorporate safety into health IT product certification criteria (UCD, quality management systems)

• Support R&D of testing, user tools, and best practices related to health IT safety

– SAFER Guides, TURF EHR Usability Toolkit

• Investigate, address serious adverse events or hazards involving health IT (Joint Commission, PSOs)

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ONC Health IT Safety Strategy (3)

Lead• Encourage private sector leadership and shared responsibility for

health IT patient safety

– Health IT Safety Center

• Develop a strategy and framework for an appropriate risk-based regulatory framework for health IT

– FDASIA Health IT Report Proposed Strategy and Recommendations for a Risk-Based Framework

– HITPC Health IT Implementation, Usability, and Safety Workgroup (David Bates, MD, Chair)

• ONC Health IT Safety Program

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EHR Safety Self-Assessment:SAFER Guides

• Safety Assurance Factors for EHR Resilience• 158 evidence-based recommended practices

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Foundational GuidesHigh Priority Practices

Organizational ResponsibilitiesInfrastructure Guides Clinical Process GuidesContingency Planning Patient IdentificationSystem Configuration CPOE with CDS

System Interfaces Result Reporting & Follow-upClinician Communication

SAFER Guide Example: CPOE

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AHRQ Common Formats for Reporting Health IT Event Data

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EHR Developer/Vendor Role

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• Support patient safety in product design, development, deployment

• Share safe deployment, implementation, maintenance and use best practices with customers

• Participate with PSO(s) for reporting, reviewing, analyzing health IT-related patient safety events

• Notify customers when patient safety-related issues are discovered, with suggested solutions

• Encourage, value customer participation in discussions about patient safety

Working with IT Vendors

Strategies to Promote Success

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Foundations for Success

• Start with yourself: trustworthiness– Character, competence, readiness

• Build trust– Emotional bank account deposits

• Establish mutual purpose– Quality, value, reputation, financial– Win-Win or No Deal

• Clarify, document roles, goals, expectations, accountability

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Foundations for Success

• Establish metrics, give feedback, set deliverables

– WWWF: Who, does What, by When, Feedback

• Follow best practices, avoid failure paths

• Communicate effectively

• Know what you don’t know, then address it

• Recognize and handle ‘Crucial Conversations’ well

• Use ‘Crucial Accountability’ skills as needed

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https://www.vitalsmarts.com/products-solutions/crucial-conversations/

EHR Developer Code of Conduct

• Reflects commitment to collaborate as trusted partners

• Focuses on:– General business practices– Patient safety– Interoperability and data portability– Clinical and billing documentation– Privacy and security– Patient engagement

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http://www.himssehra.org/ASP/codeofconduct.asp

What is Your EHR CustomerCode of Conduct?

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Advancing Care in a Connected World

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How Consumers, Health and Careare Changing

Consumers / Patients• ↑ Deductibles ↑ shopping

• ↑ Self-care options

• ↑ Devices, knowledge sources

• ↓ Loyalty for commodity services

• ↑ Priority on convenience

• ↑ Interest in e-connection

• Sharing economy

• Seeking data on quality, value

Providers / Caregivers• Changing payment system• Volume Value, Triple Aim focus• Incentives Adjustments• PCMH, care teams, coordination• Need data to prove/improve value• Need to use EHR to show value• Need IT tools to

– Capture data, report results– Facilitate safety, value– Make it easier…

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Connected Health

Smart Technology

Consumers & Patients

Caregivers

Communities

Providers

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How Patients Want to Connect

• Mobile and communications technologies– Smartphones, sensors and tablets – Health trackers– Health apps

• Easy, secure ways to access, collect, display, relay personal health data

• Receive targeted health and wellness education

• Consult with healthcare providers• Get health-related support from friends and

family

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Connected Health: Critical Physician Role

• Put the patient first• Make them partners in health• Support their preferences • Lead by example

– Get connected– Use with your patients, encourage others

• Champion in your practice/organization– Patient portals (web, mobile)– Secure messaging– Expand access to data, services

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Supporting IT-Connected Care

Informatics Learning/Training Opportunities for Physicians

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Clinical Informatics Defined

• The interdisciplinary study of the design, development, adoption and application of IT-based innovations in healthcare services delivery, management and planning - HIMSS

• The application of informatics and information technology to deliver healthcare services - AMIA

• Relentless pursuit of assisting people, as they work to improve health through appropriate use of IT, and conducting studies to determine whether the assistance has been successful - C. Friedman

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Friedman C: What informatics is and isn't. JAMIA 2013, 20:224-226

How Physicians Learn Informatics and Demonstrate Expertise

• Education and training – formal or informal– Undergraduate and graduate degree programs– Clinical or research fellowship programs– Courses with certification– On the job training, mentorship, experience– Independent learning – conferences, readings,

professional organizations• Knowledge• Experience• Recognized contributions, accomplishments

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Is Clinical Informatics Board Certification Required to Work in CI?

• Not yet but may be coming (e.g., EM; Critical Care)• CI board certification likely to be relevant or required

– MD, DO (US, Canada), others with Board approval– Medical license – current, active, unrestricted – Current certification by an ABMS Board– Practice pathway available 2013-2017– 24-month clinical fellowship required in 2018

• Graduate program not accredited by ACGME is not sufficient for board eligibility

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Accredited CI Fellowship Programs1. Children’s Hospital of Philadelphia

Email: diltz@email.chop.edu

2. David Geffen School of Medicine at UCLA and UCLA HealthEmail: CIFellowship@mednet.ucla.edu

3. Oregon Health & Science University School of MedicineEmail: ilgan@ohsu.edu

4. Regenstrief Institute, Inc.Email: riifello@regenstrief.org

5. Stanford School of MedicineEmail: gkhedr@lpch.org

6. University of Arizona College of Medicine – PhoenixEmail: COMPHX-DBMI@email.arizona.edu

7. University of Illinois at Chicago College of MedicineEmail: sisiem@uic.edu

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https://www.amia.org/programs/academic-forum/clinical-informatics-fellowships

Some Other Ways the Busy Physicians Can Gain CI Credentials, Training

• Medical professional societies

– AMIA 10 x 10 program

– Specialty society conferences, programs

• Healthcare IT organizations

– CPHIMS Certification Program

– HIMSS Conference and Exhibition, Symposia

– HIMSS Physician Community resources

– HIMSS eLearning Academy

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Remembering Why We Are Doing This…

Quality51

Questions?

• Email: michael.zaroukian@sparrow.org• Twitter: @mzaroukian • LinkedIn: https://www.linkedin.com/pub/michael-

zaroukian-md-phd-macp-fhimss/1/39/471

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