Example: Improving Care by Design of an EHR

Lecture by Farrokh Alemi, Ph.D.

Narrated by Jonathan Duxbury

An Example

Design an EHR that will reduce unnecessary visits while improving quality

Assumptions A staff model HMO Both patients and providers have access to

email and Internet Informed consumers willing to take care of their

own health (not for everyone but for a minority of patients)

An Example

Design an EHR that will reduce unnecessary visits while improving quality

Assumptions A staff model HMO Both patients and providers have access to

email and Internet Informed consumers willing to take care of their

own health (not for everyone but for a minority of patients)

An Example

Design an EHR that will reduce unnecessary visits while improving quality

Assumptions A staff model HMO Both patients and providers have access to

email and Internet Informed consumers willing to take care of their

own health (not for everyone but for a minority of patients)

An Example

Design an EHR that will reduce unnecessary visits while improving quality

Assumptions A staff model HMO Both patients and providers have access to

email and Internet Informed consumers willing to take care of their

own health

An Example

Design an EHR that will reduce unnecessary visits while improving quality

Assumptions A staff model HMO Both patients and providers have access to

email and Internet Informed consumers willing to take care of their

own health (not for everyone but for a minority of patients)

Design an EHRto meet these assumptions

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant Neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant Neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant Neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant Neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant Neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

63 clusters of diagnoses explain 80% of primary care

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

Each cluster is ause case, a scenario,under which we can

examine impact of EHR

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

In each cluster, ask internal & external expertshow EHR will reduce visits

Describe the Content of Primary Care Visits

1. General medical examination

2. Acute upper respiratory infection

3. Pre- and postnatal care including complicated pregnancy and abortion

4. Hypertension

5. …

6. …

63. Malignant neoplasms of skin

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care Ronald Schneeweiss; Roger A. Rosenblatt; Daniel C. Cherkin; C. Richard Kirkwood; Gary Hart Medical Care, Vol. 21, No. 1. (Jan., 1983), pp. 105-122.

In each cluster, trace decisionsand see what information

is useful

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

What impact will EHRhave on our business

objective in this use case?

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

Experts: Reduces time for a well visit from 1 hour to ½

hour in 70% of the cases

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

Given this use casewhat information

is needed to carryout the necessary decisions?

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

Information needed:

exercise, weight,

smoking, etc.

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

Information needed:

key findings and

thoroughness of self

exam

For General Medical Examination Cluster

Patients will visit lab before scheduled appointment

Patients will complete a health risk assessment online. Computer will provide feedback.

Computer will guide patient in doing self examination.

Computer will help patient plan questions they want to ask during the visit.

Information needed:

clients’ questions

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

Lets’ look at Information needed in

other use cases

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

What impact will EHRhave on our business

objective in this use case?

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

Experts: Reduces visits in 60% of cases, where

patient gets better after resting

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

Given this use casewhat information

is needed to carryout the necessary decisions?

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

Information needed:

patients signs and

symptoms

For Acute Upper Respiratory Infection Cluster

Patients contact clinicians by phone or email

Clinicians reviews the symptoms and asks the patients to come in next day if symptoms get worst

System follows up with the patient to see if symptoms have gotten worse

Information needed:

Pt verification,

permission to

contact, preferred

contact time,

change in symptom

s

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

New information

items added in

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

Lets’ look at Information needed in

other use cases

For Pre and Postnatal Care Cluster

Some prenatal visits avoided for patients with positive laboratory tests

Some post-partum visits avoided by the system triaging depressed patients to specialists

For Pre and Postnatal Care Cluster

Some prenatal visits avoided for patients with positive laboratory tests

Some post-partum visits avoided by the system triaging depressed patients to specialists

For Pre and Postnatal Care Cluster

Some prenatal visits avoided for patients with positive laboratory tests

Some post-partum visits avoided by the system triaging depressed patients to specialists What impact will EHR

have on our businessobjective in this use case?

For Pre and Postnatal Care Cluster

Some prenatal visits avoided for patients with positive laboratory tests

Some post-partum visits avoided by the system triaging depressed patients to specialist

Experts: Reduces visits in 10% of

cases

For Pre and Postnatal Care Cluster

Some prenatal visits avoided for patients with positive laboratory tests

Some post-partum visits avoided by the system triaging depressed patients to specialist

Given this use casewhat information

is needed to carryout the necessary decisions?

For Pre and Postnatal Care Cluster

Some prenatal visits avoided for patients with positive laboratory tests

Some post-partum visits avoided by the system triaging depressed patients to specialist

Informatio

n needed:

items u

sed in

triage

protocol

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

New information added in

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

Note that r

isk ass

essment

was also

needed

in a previo

us use

case

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

Lets’ look at Information needed in

other use cases

For Hypertension Cluster

Patients measure blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

For Hypertension Cluster

Patients measure blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

For Hypertension Cluster

Patient measure blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

For Hypertension Cluster

Patient measures blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

What impact will EHRhave on our business

objective in this use case?

For Hypertension Cluster

Patient measures blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

Experts: Reduces visits in 70% of cases, adds in cost of home equipment

For Hypertension Cluster

Patient measures blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

Given this use casewhat information

is needed to carryout the necessary decisions?

For Hypertension Cluster

Patients measures blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

Informatio

n needed:

patient re

ported B

P

For Hypertension Cluster

Patients measures blood pressure at home

Patient calls in or is called by the system regarding control of their hypertension

Clinician available by email to change prescription, explain progress and evaluate patient condition

Information needed:

patient verification,

side effects, change

in blood pressure

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

As more use

case

s are

examined m

ore inform

ation

items a

re added to th

e list.

List of Decisions & Information Items

General medical

examRespiratory

infectionPre and post

natal careHypertensio

n

Health risks

Self exam results

Self exam thoroughness

Questions for the visit

Signs and symptoms

Patient verification

Permission to contact

Preferred contact time

Change in symptoms

Protocol for triage to specialist

Patient reported blood pressure

Side effects of medication

Why Do This?

Succeed by design Design the improvements within the EHR

system Specify functional information needs

that correspond to real upcoming decisions

Why Do This?

Succeed by design Design the improvements within the EHR

system Specify functional information needs

that correspond to real upcoming decisions

Take Home Lesson

Improve through design because what is not imagined is not done.