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Health Information Technology: Bridging the GapJake Lancaster, MD, MSHA, MSACICMIO Baptist Memorial Health Care Corporation

No Disclosures

“”

The spread of computers and the internet will put jobs in two categories: people who tell computers what to do, and people who are told by computers what to do.

- MARC ANDREESSAN

Learning Objectives

Describe the definition of HIT and related topics as discussed Recognize the impact of HIT adoption Recognize various Informatics fields Utilize the learning objective to further their informatics knowledge Recognize the benefits of HIT to improve patient care

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HHS Health IT Definition

Health information technology (health IT) involves the exchange of health information in an electronic environment. Widespread use of health IT within the health care industry will improve the quality of health care, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork, and expand access to affordable health care. It is imperative that the privacy and security of electronic health information be ensured as this information is maintained and transmitted electronically.

Health IT at the Organizational Level

CIO

Hardware

PCs

Network

Security

Software

Clinical

Business

Reporting

Training

PMO

EHR Technical Org. Structure

EHR Director

Inpatient

Lab

Orders

Clin. Doc.

Outpatient

Portal

Orders

Clin. Doc.

Pharmacy PACS

Vendor

CEO

Client Relations

Site Managers Site Physician

Sales

Specific Products

Operations

Product Development

Technical Assistance

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External Agencies

ONC – “ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.”

AMIA – “AMIA aims to lead the way in transforming health care through trusted science, education, and the practice of informatics.”

HIMSS “a global, cause-based, not-for-profit organization focused on better health through information and technology.”

External Agencies Cont.

CHIME – “The College of Healthcare Information Management Executives (CHIME) is the professional organization for Chief Information Officers and other senior healthcare IT leaders. CHIME enables its members and business partners to collaborate, exchange ideas, develop professionally and advocate the effective use of information management to improve the health and care throughout the communities they serve.”

AMDIS – “Founded in 1997, the Association of Medical Directors of Information Systems is the premier professional organization for physicians interested in and responsible for healthcare information technology.”

HL7 – “Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.”

Learning Objectives

Describe the definition of HIT and related topics as discussed Recognize the impact of HIT adoption Recognize various Informatics fields Utilize the learning objective to further their informatics knowledge Recognize the benefits of HIT to improve patient care

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Shared Phone Analogy

Told by employer to buy smartphone Promised increased efficiency Multiple phones but all share same background Committee to decide on placement of icons and access to each Cannot rearrange icons Customized content specific for your organization Customization prevents the ability to take regular updates Numerous external agencies define the requirements and specs

about how you can use the phone

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Phone analogy cont.

Required to review multiple apps before you call a client Calls routinely drop After call, required to document entire conversation If wish to share transcript, must print and fax over information Do not get paid for your work unless it is in the transcript

End product does not resemble what smartphone company designed

Why Doctors Hate Their Computers

Two hours of doing computer work for every hour of time spent with a patient

Rising level of burnout and depression More work after hours (pajama time) Interference with doctor and patient relationship High expense due to productivity loss Revenge of the Ancillaries Older generation of physicians trained before computers were a

normal part of everyday life

Atul Gawande – New Yorker, November 2018

Revenge of the Ancillaries

Design sessions prior to implementation include physicians, nursing, radiology, lab, quality etc.

Due to scheduling conflicts, physicians historically less likely to make these meetings

Non-physicians design workflow for the physicians Include hard stops and required fields to improve their own

workflows Difficult to undo and continues to accumulate over time Results in tasks that were previously done by others falling on the

physician

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EHR design features and burnout

Information overload Slow system response times Excessive data entry Inability to navigate the system quickly Note bloat Interference with patient-clinician relationship Fear of missing something Notes geared towards billing

Kroth, JAMA Open, 2019

Outpatient specific issues

Updating and maintaining the problem list (ICD 10) Quality programs and health maintenance putting more and more

on the to-do list EHR message centers creating additional work that was previously

handled elsewhere or by someone else Nurses or MAs that previously could do certain tasks on paper no

longer can due to their privileges in the system

Quiet Dark vs. Loud Bright

Aviation industry Quiet Dark

information is not displayed until something goes wrong or needs attention

Indicator lights are off during normal conditions

Medicine Loud Bright

All info appear in almost same manner regardless of importance

Normal labs and vitals given same priority as abnormal

Abnormal Chloride looks same as abnormal Potassium

Tar PitFred Brooks-The Mythical Man Month

“No scene from prehistory is quite so vivid as that of the mortal struggles of great beasts in the tar pits. In the mind's eye one sees dinosaurs, mammoths, and sabertoothed tigers struggling against the grip of the tar. The fiercer the struggle, the more entangling the tar, and no beast is so strong or so skillful but that he ultimately sinks.

Large-system programming has over the past decades been such a tar pit, and many great and powerful beasts have thrashed violently in it. Most have emerged with running systems--few have met goals, schedules, and budgets. Large and small, massive or wiry, team after team has become entangled in the tar. No one thing seems to cause the difficulty--any particular paw can be pulled away. But the accumulation of simultaneous and interacting factors brings slower and slower motion. Everyone seems to have been surprised by the stickiness of the problem, and it is hard to discern the nature of it. But we must try to understand it if we are to solve it.”

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Any Upside? Upside of Health IT

Availability of the chart Multiple users, access at home, mobile, iPad

Legibility of notes and orders Chart Search Data Collection Improved Care Coordination CPOE reduced med errors ~ 55% Improved legal and regulatory compliance

Upside continued

Ability to make changes at scale Health Information Exchange Increased Revenue Improved ability to conduct research Increased adherence to evidenced based practice guidelines

Improved rates of immunizations

Improved VTE prophylaxis in hospitalized patients

Improvement in HTN treatment

Reduction in redundant testing

Where do we go from here?

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Learning Objectives

Describe the definition of HIT and related topics as discussed Recognize the impact of HIT adoption Recognize various Informatics fields Utilize the learning objective to further their informatics knowledge Recognize the benefits of HIT to improve patient care

Informatics

Applied form of information science Interaction between humans and information Focuses on the people, processes, and technology Subgroups

Translational Biomedical Informatics

Clinical Research Informatics

Clinical Informatics

Consumer Health Informatics

Public Health Informatics

What is Clinical Informatics?

Clinical informatics is the application of informatics and information technology to deliver healthcare services.

Clinical informatics is the subspecialty of all medical specialties that transforms health care by analyzing, designing, implementing, and evaluating information and communication system to improve patient care, enhance access to care, advance individual and population health outcomes, and strengthen the clinician-patient relationship.

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Clinical Informatics Subgroups

Physician Informatics Nursing Informatics Pharmacy Informatics Laboratory Informatics Radiology Informatics

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Clinical Informatics as a Clinical Specialty?

ACGME accredited with fellowship structure similar to other fellowships

Board Certification requirement and MOC requirements No directed interaction with patients within CI itself No services rendered to patients (unlike path, radiology) No billing codes or procedures codes In CI, ”patients” are anyone that interacts with the IS system Includes, doctors, nurses, lab, registration, pharmacy, and actual

patients

List of ACGME accredited Clinical Informatics Fellowships

University of Arizona

Beth Israel Deaconess Medical Center

Boston Children’s Hospital Clinical Informatics Fellowship

Case Western

The Children’s Hospital of Philadelphia

Columbia University

David Geffen School of Medicine at UCLA and UCLA Health

Duke University School of Medicine

Geisinger Health System

Icahn School of Medicine at Mount Sinai

Madigan Healthcare System

Mass General 34 ACGME Accredited programs Oct 2019

Ohio State Oregon Health & Science University School of

Medicine Regenstrief Institute, Inc. Stanford School of Medicine University at Buffalo University of California (multiple) University of Illinois at Chicago College of Medicine University of New Mexico University of Washington School of Medicine Vanderbilt Washington University School of Medicine Yale/VA Clinical Informatics Fellowship Program

Fellowship Pathway and Practice Pathway

Beginning in 2023Only candidates of programs that are

accredited by the Accreditation Council for Graduate Medical Education (ACGME) will be eligible for certification (board certification) in clinical informatics.

Rotations

Clinically focused Spend time with varying specialties (IM, Peds, Anes, Surg, Path, Rad)

and understand their issues with EHR or other systems and help find solutions to these problems

Technically focused Work with analysts in multiple departments within IT including security,

product development, data warehouse, EHR development Purpose is to learn how to be the bridge between clinical and IT Help translate requests from clinical side and refine new products from IT

side

Electives Startups, other vendors, private hospitals, public health, etc.

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Skills Development

Change Management and Governance SQL Data Science Programming languages (Python, R, Swift, etc.) EHR specific skills

Cerner (Physician Architect Program)Epic (Physician Builder Program)

Post Fellowship Career

Chief Medical Information Officer Physician informaticist Research informatics EHR Vendor Physician Consulting Start up company

Role of Physician Informaticist

Facilitator between colleagues, IT, and administration Represents the interests of other physicians Help customize or refine solutions to best support clinical care Communicates with medical staff about changes Works with analysts to make sure the end product is what was

requested

NOT the HIM police NOT someone who makes all decisions about EHR in a vacuum

CMIO

Responsibilities Help bring issues with the EMR or other technology to the

forefront of administration Help physicians understand the changes that are coming to the

systems Mitigate unexpected and unwarranted changes that adversely

affect clinicians Looks at data on provider efficiency, alerts, quality Sets up governance structure for decision making Help set strategy for the organization for the clinical IT landscape

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How to Handle Issues

Importance of understanding the problem No quick fixes Prioritization Downstream consequences Is it the right thing to do for patient care? Does it meet regulatory requirements?

Levels of Intervention

Personal Filters, macros, custom notes, preference lists, orders

Specialty Notes, navigators, order panels, dashboards, other

Facility

System Bulk of requests,

Vendor Intervention

Decision making and Governance

Decisions should not be made in a vacuum Need multidisciplinary group of well respected clinicians to

collaborate and make decisions Compensate members for their time to ensure participation Regular meeting cadence at convenient time for the group Should mesh with other governances structures (MEC, P&T, etc)

Example

CMO

CMIO

Physician Informaticists

CIO

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ExampleCSC

CCC

Individuals Workgroup Service Lines

Cardiology GI Oncology

Physician Advisory Council

IM

Surgery

OBGYN

PEDS

Radiology

GI

NeuroNursing

IT

Lab

Security

Admin

CC: I can’t get through an admission without 4-5 pop-up alerts

History: Every time time admit orders are placed, multiple alerts display for lab duplicates, imaging duplicates, drug-drug interactions, and drug allergies

Physical: Able to reproduce some of the alerts on a test patient including one for duplicate CBCs though ordered a day apart

Workup: Report is run on alerts that are fired the most and have very high override rates.

Status Informaticus

Plan: Form best practices alerts group to review

and streamline existing and incoming alertsExplore new features for suppressing

redundant alerts in an encounter Offload some alerts to passive alerts Change culture of solving every problem with

an alert

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Informatics in Your Practice

Identify physician liaison in your practice if one does not already exist

Ensure they have dedicated time to spend on practice improvements

Work with them to ensure that change requests get funneled to the right people

Understand that change will not happen overnight Learn from them how to personalize your workflow Stay informed about updates and retrain periodically for continuous

improvement

Future Directions

EHR Voice Assistance Integration Virtual Scribes Artificial Intelligence Cloud based applications FHIR Applications and other 3rd party apps Increased access of data for patients Reduction in regulatory burden

EHR Virtual Assistant and Virtual Scribes

Artificial Intelligence

Epic Sepsis AI

Readmissions predictor

No show predictor

Cerner Chart Assist

Charge Assist

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Movement to Cloud Third Party Applications

Access to data Reduction in Regulatory Burden

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Key Takeaways

Health IT is a large entity within most organizations that works to customize and maintain various clinical IT systems

The issues with EHRs are created from a wide variety of entities and not necessarily with the technology itself

Despite the pitfalls there are many upsides to EHRs Clinical informatics is the bridge to help drive improvement in HIT The landscape of HIT is rapidly evolving and the practicing clinician

needs to keep up in order to compete

Questions?

Jake.Lancaster@bmhcc.org

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