Transcript EHR Functionality and the Patient

EHR Functionality and the PatientCentered Medical Home:
Charting a Course When Charting Isn't
Enough
Redwood Health Information
Collaborative - Webinar Series
January 21, 2009
Jason M. Mitchell, M.D.
Assistant Director
AAFP - Center for Health IT
Leawood, KS
AAFP - Center for Health
IT
•
Established: October 2003
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Mission: To assist family
physicians in acquiring and
using EHR systems and
other HIT that are affordable
and standards-based, for
the purposes of improving
quality, enhancing safety
and increasing efficiency in
clinical practice
Steven E. Waldren, MD
Director
Jason M. Mitchell, MD
Assistant Director
David C. Kibbe, MD
Senior Advisor
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www.centerforhit.org
Objectives for this session:
• Understand the origins and key components of the
patient-centered medical home (PCMH).
• Understand the central role of information technology
as a tool to enable the PCMH.
• Highlight the core functionalities that electronic health
record (EHR) systems must bring into the ambulatory
practice.
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EHR Adoption
Paradigm
All Physicians
Family
Physicians
Early majority
Rand Study*: 2016
Early adopters
before 80%+ physician
adoption
Innovators
Late adopters
*Rand Health. The Diffusion and Value of
Healthcare Information Technology. 2005.
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Jumping
Ahead...
Volume Based
Payment
Health Plan
Directed
Claim Data
Reporting
Online
Patients
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Value Based
Payment
Current
Health
Care
Sector
Future
Health
Care
System
Consumer
Directed
Quality
Reporting
Connected
Patients
Medical Home
Definition
• AAFP Board of Directors - 2008
• "A patient-centered medical home integrates
patients as active participants in their own health
and well-being. Patients are cared for by a personal
physician who leads the medical team that
coordinates all aspects of preventive, acute and
chronic needs of patients using the best available
evidence and appropriate technology. These
relationships offer patients comfort, convenience
and optimal health throughout their lifetimes."
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Technology Hype Curve
?
Where is EHR?
Where is the PCMH?
?
?
?
Source: Gartner Consulting
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Origins of the Medical Home
• "Wherever the child is cared for, the
question should be asked, ‘Where is
the child’s medical home?’ and any
pertinent information should be
transmitted to that place" - AAP, 1967
• Crossing the Quality Chasm: A New
Health System for the 21st Century (the
Chasm Report). IOM, 2001
• Future of Family Medicine Project,
2002-2004
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“Chasm Report”(2001)
• Six Aims
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• Ten Rules
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Safe
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Care based on continuous healing relationships
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Effective
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Care is customized for patient needs and values
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Patient-Centered
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Patient is source of control
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Timely
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Knowledge is shared and information flows freely
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Efficient
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Decision making is evidence-based
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Equitable
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Safety is a system property
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Transparency is necessary
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Needs are anticipated
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Waste is continuously decreased
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Cooperation among clinicians is a priority
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Characteristics of the New Model
of Family Medicine (2004)
• Personal medical home
• Patient-centered care
• Team approach
• Elimination of barriers to access
• Redesigned offices
• Whole-person orientation
• Care provided within a community context
• Emphasis on quality and safety
• Enhanced practice finance
• Commitment to provide family medicine’s basket
of services
AND...
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Characteristics of the New Model
of Family Medicine (2004)
• Advanced information systems
• "A standardized electronic health record,
adapted to the specific needs of family
physicians and the patients they serve, will
constitute the central nervous system of the
New Model practice."
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HIT Expectations of the New
Model
Integration of information from multiple, diverse sources into a single system to
support the comprehensive information needs of primary care
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Based on common health information technology standards
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Up-to-date and accurate problem and medication lists and information about
each patient encounter
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Export functionality to share standardized data elements for quality parameters
and assessment measures
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Evidence-based clinical practice guidelines
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Order entryReferral tracking
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Disease and population based registriesIntegration of clinical and practice
management functions
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Web interface for patients to provide clinical data and facilitate self-care
processes
(1 of 2)
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HIT Expectations of the New
Model
Support practice based research concerning costs, processes and outcomes of
care
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Clinical decision support systems for application of the latest evidence at the
point of care
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Collection, analysis and reporting of clinical decisions and their outcomes
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Informatics infrastructure to support practice-based research, quality
improvement and generation of new knowledge
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Easy integration in the daily practice of family physicians
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Reasonable cost
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Major enhancement to the efficiency and quality of care that is delivered
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User friendly
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Flexible
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Stable and reliable
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Delivered with appropriate training for physicians with varying levels of technical
expertise
(2 of 2)
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"Required" features of an
ambulatory care EHR system
• Harvard “Expert Panel” (NEJM article - 7/3/2008)
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“Basic EHR” - 15%
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Patient demographics, problem list, medication list and clinical notes
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Prescription ordering
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View lab and radiology results
“Fully functional EHR” - 6%
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Notes include medical history and follow-up
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Lab and radiology orders are created and sent electronically
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Prescriptions are created and sent electronically
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Digital images of ordered radiology tests can be viewed
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Drug interactions or contraindications
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Abnormal test results are flagged
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Reminders for guideline based interventions or screenings
(No mention of registry or data analysis functions)
"Required" features of an
ambulatory care EHR system
• Patient-Centered Medical Home
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An "EHR system" isn't just a "system" but a "system of systems”
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Identity management system - (EMPI)
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Communication/messaging system - (eVisits)
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Schedule/resource management system - (Workflow optimization)
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Medication management system - (eRx)
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Care coordination/integration system - (Referrals/Consultations/Results)
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Advanced data analysis and visualization system - (Registries)
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Diagnostic ordering and results management system - (Lab/Xray)
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Advanced data capture and documentation system - (Notes)
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Patient education system - (not crumpled, dated handouts)
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Practice web portal - (patient self-service)
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Point of care clinical decision support system - (Evidence-based)
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Point of care financial decision support system - (Efficiency/Value)
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Practice administration/management system - (Integrated)
"Required" features of an
ambulatory care EHR system
Patient-Centered Medical Home
"Infrastructure" Tools
• Semantic Interoperability
Not just the ability to view others "documents", but to incorporate and
understand clinical data from other sources into your own system
• Primary Care Data Model (Ontology)
Defining and organizing the "nouns" and "verbs" of family medicine and their
relationships
• System design and dependencies
• Workflow analysis and management tools
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NCQA PPC-PCMH Recognition
• Nine Standards
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PPC 1: Access and Communication
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PPC 2: Patient Tracking and Registry Functions
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PPC 3: Care Management
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PPC 4: Patient Self-Management Support
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PPC 5: Electronic Prescribing
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PPC 6: Test Tracking
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PPC 7: Referral Tracking
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PPC 8: Performance Reporting and Improvement
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PPC 9: Advanced Electronic Communications
http://www.ncqa.org/tabid/629/Default.aspx#pcmh
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NCQA PPC-PCMH Recognition
• Without an EHR / Electronic registry / e-Prescribing
• “Level 1” PPC-PCMH may be possible
• “Level 2” and “Level 3” will not be achievable without fullfeatured, well-implemented, and optimally-utilized HIT
systems
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Conclusions
• Semantic Interoperability remains the IT (clinical?) priority
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It’s just so darn hard
• Quality and Safety are the "hallmarks" of the Medical Home
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It's not the paper that kills, it's the process
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An "electronic" version of the "paper chart" won't cut it
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It’s about “data” not “documents”
• EHR = “central nervous system of the New Model practice”
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Won’t get above NCQA “Level 1” without it
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Do current “EHR”s represent the needed “system of systems”?
(1 of 2)
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Conclusions
• EHR for Family Physicians
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No longer a matter of "IF" but "When" and "What"
• Most implementation failures are not due to the technology
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"Sociotechnical" factors
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Plan for organizational and user process issues
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No reports of problems due to "over" training
• This is not a “one time”, “big bang” process
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Ongoing adaptation and updates
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Annual updates are not an "option" but a "necessity"
• Choose carefully, Implement wisely, Use optimally
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(2 of 2)
Questions? Comments!
www.centerforhit.org
Jason M. Mitchell, M.D.
[email protected]
(800) 274-2237 x 4102