Transcript www.solutionssummit.org

Jonathan E. Siff, MD, MBA, FACEP
Director of Clinical Informatics
The MetroHealth System
Cleveland, Ohio
“You don’t know
the power of the
dark side”
Darth Vader speaking
to tech support after the
death star implemented
a new Electronic Health
Record
Disclosures
• I really do love electronic
medical records and
computers.
• However I’m realistic
about the fact that they
are not perfect and can
introduce new risks along
with their benefits.
• This talk will be vendor
neutral
Put picture of
me kissing
computer here
Objectives
• Discuss some basic definitions related to
Electronic Health Records (EHRs)
• List some of the reported benefits of electronic
records systems
• Learn about some of the risks associated with
electronic records in the ED
• Understand ways to mitigate the risk of EHRs to
the ED
The promise of a better
future through EHRs
• Publicity around medical errors created
pressure to adopt EHRs as a solution
• American Recovery and Reinvestment Act
provided $20 Billion for providers and
hospitals to “meaningfully use” EHRs
– Extra money now, penalties later
• End goal of increased safety and health at
lower costs
The advertised
benefits of EHRs
• Patient care benefits
– Safety – error reduction,
interaction checking,
allergy checks
– Computerized Physician
Order Entry (CPOE)
– Decision support
– Legible and immediately
available notes
– No lost charts
– Multiple users can
access chart at once
– Immediate access to
past charts and data
– Connection to Health
Information Exchanges
(HIE) or Regional Health
Information
Organizations (RHIOs)
The advertised
benefits of EHRs
• Operational benefits
– Streamlined workflows
– Structured data for reporting
– Increased productivity and throughput
• Revenue advantages
– Cost savings
– Better documentation leading to higher billings
– Better reporting
The Reality
• Some benefits are undeniable
– Legible charts, remote access
• But the biggest promises have yet to
consistently materialize
– Cost containment, improved efficiency, safety
• New risks due to complicated, difficult to use
systems
– Health IT and Patient Safety: Building Safer
Systems for Better Care. IOM 2012
EHR Risks
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Operational
Staff
Liability
Regulatory
Patient Care
OPERATIONAL RISKS
Operational Risk: Decreased
Productivity and Turnaround Times
• Revised workflows and new responsibilities
– Providers doing more than before
– Initial unfamiliarity with system
– Tasks in the EHR may take longer than before
– Decreased provider productivity
– Often never returns to baseline
• Biggest benefit where baseline operations poor
• Lower productivity leads to
– Increased wait times and LWBS
Operational Risk: Lower
Revenue
• Revenue is always at risk
– Lack of good checks and balances in new
system
– Fewer billed visits, lost encounters
– Lower levels of service, missed procedures
– Documentation may take longer
– Charge capture can improve but it requires
effort
Operational Risk: Downtime
and Upgrades / Enhancements
• Computer systems go down - Always.
– Scheduled vs. Unscheduled
– Leads to operational inefficiencies and patient
risk
– The further from EHR implementation you are
the greater these risks are likely to be
• Upgrades and system enhancements may
lead to unintended consequences
Operational Risk: Increased
cost of care
• Use of EHR’s has been shown to
increase the cost of care in some studies
– More imaging
– Testing ordered to react to findings in chart
• Quality measures easier to report but do
they really improve cost and care
• Other studies show no cost reduction
eliminating promised ROI benefits
Operational Risk: Costs
• Electronic Health Records are not cheap
– $700M reported for one major academic center
• “Going it alone” very difficult and expensive
• Departments part of an enterprise rollout will
see increased costs too
– Upstaffing, champions, paper
• Promised staff reductions often never
materialize
Operational Suggestions:
Champions
• Champions
– One from each role
– Not from traditional leadership positions
– Get them involved on implementation
committees and teams
– Champions can engage staff and improve
systems acceptance and use
– This is a long term commitment as the need
never ends
Operational Suggestions:
Workflow analysis and review
• Review all workflows prior to EHR
implementation
• Don’t try to reproduce the current state in
the EHR
• Get your operations in order before go live
– You can fix it later but its harder and more
expensive
Operational Suggestions:
Training and Build
• Training, Training, Training
– Safety and efficiency issue
– Don’t skimp – consider vendor recommendations
– Role specific
• Content build should be done BEFORE golive
– Preference lists, order sets, D/C instructions
– Optimization never ends
Operational Suggestions:
IT issues
• Have adequate infrastructure
– Enough devices of varying types
– Fast enough network connections and servers
• Test interfaces between clinical systems
• Have downtime processes in place
– Train these processes
– Educate IT on the impact of ED downtime
• Participate in upgrade testing
Operational Suggestions:
Staffing and Financial
• Up staff around go live if possible
• Adjust provider incentive plans
• Put billing and audit procedures in place to
proactively catch issues
– Involve your billing company or staff
• Have the right metrics
• Look at potential new or changed costs
and get them in the EHR project budget
STAFF RISKS
Staffing Risks
• “Implementation of an EHR is a complex
social project that involves computers”
• Changing roles create uncertainty and
pushback
• Decreased employee satisfaction
– Increased stress, higher call off rates, turnover
• Increased post shift work
• Physical challenges
Staff suggestions
• Engage them in the process
• Place workstations with patient contact
and staff safety in mind
• Ensure comfortable workstations with
good mice and keyboards
• Show them you understand their pain
• Consider scribes
Liability Risks
Liability Risk
• Some systems make risk management a
priority (ED specific, homegrown)
• Enterprise systems generally do not
• Liability Risks
– Privacy and Security
– Charting Liability
– Alert fatigue / Ignored alerts
– Failure to access available data
– Metadata and audit trails
Privacy and Security Risks
• EHR information may be restricted from ED
Providers leading to patient care risk
• Data loss is easier with EHRs than paper
– Easy downloads, remote access
• Electronic greaseboards may create a risk
• HIPAA minimum necessary standard not met
• Inappropriate access easier
Charting Liability
• Documentation automation risks
– Macros
– Pre-populated exams
– ”All normal” buttons
– Auto-population of data
• Cut and paste
• All charting shortcuts create some risk
Charting Liability
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System design risks
Loss of calculated values
Failure to use structured data fields
Template risk
Provider comments ending up in the chart
Data validation risks
Wrong patient entries
Alerts & Alert Fatigue
• Warnings presented to users based on
conditions in the system
• If alerts are too frequent or not a high
enough priority they create alert fatigue
• Ignored alerts increase risk
• Out of date or inaccurate alert databases
• Vital sign alerts can be very helpful but
potentially deadly if ignored
Failure to access available
data
• Electronic records make it much easier,
but no less time consuming, for providers
to review prior visits
• The extent to which ED providers will be
expected to review internal records and to
access external records is unclear at this
point
Metadata and Audit Trails
• Information attached to each action taken
(transaction) in the EHR
– User, date / time stamps, edits, order origin
• Bypassed alerts and pathways evident
• Easy to see if providers altered history
• Timing of actions is evident
– Time of attending note vs time of actual
procedure
Liability and Risk Suggestions
• Train and re-train staff on correct workflows
• Encourage providers to ensure that times are of
events are accurately entered in the system
• Educate staff on permitted access to charts
• Minimum necessary
• Limit use of cut and paste and optimize macros
to reduce risk
Liability and Risk Suggestions
• Limit data on displays in public areas
• Lock down and secure computers
– Physical security, limit ability to download data
• Optimize alerts
– Work to limit alerts to only critical information
– Keep underlying databases up to date
– Make alerts easy to address for providers
Regulatory Risks
Regulatory Risks
• Template Risk
– Medicare transmittal 438 > 453 > 455
– Some templates provide limited options and/or space for the
collection of information such as by using “check boxes,”
predefined answers, limited space to enter information, etc. CMS
discourages the use of such templates. Claim review experience
shows that that limited space templates often fail to capture
sufficient detailed clinical information to demonstrate that all
coverage and coding requirements are met.
• Meaningful Use scrutiny
Regulatory Risks
• EHR built in coding tools / rules
– “EHR vendors are deploying tools for clinicians to
ensure their clinical documentation is complete.
These tools may embed rules engines and other logic
that is not transparent to the end user” (AHA to HHS)
• EHR Coaching to providers for E/M Level
• Teaching physician workflows
– Consistently problematic
• Scope of practice
Regulatory Risk
Suggestions
• Educate providers on billing rules
• Limit the use of cut and paste and copy forward
• Avoid macros or templates with infrequently
used options pre-selected
• Make general charting tools available
• Avoid auto-coding and coaching tools in EHR
• Enforce scope of practice
• Teaching physician workflows
Patient Risks
Patient Risks
• Workflow changes
– May delay patient care
– Ordering issues
• Decreased communication with patients
– Computers intrude on provider patient dynamic
• Increased distractions
– Clinical alerts, other patient data
Don’t change it if it really
works (and it’s important)
• If something is really important and the
current system works you may not want to
change it
– X-ray reading changes
– Critical lab results
Final thoughts
• You can never do enough training and you
need to keep training because the system
keeps changing
• Monitor your processes and “inspect what
you expect” your users to do
• Never be afraid to admit something does not
work and make it better
• Don’t assume your IT department knows or
understands the risks discussed here today
The Final Truth
• There is no one solution
• Each organization will make choices that
are right for it
– May increase risk but deemed “worth it”
• Few problems have definitive solutions
– Be sure the cure is not worse than the
disease
• Everyone has to work together to address
EHR risk
Suggested Reading
• The problem with EHR’s and coding.
http://medicaleconomics.modernmedicine.com/news/problem-ehrsand-coding
• Institute of Medicine report: IT and Patient Safety: Building Safer
Systems for Better Care, 2012.
• ED information systems primer – ACEP white paper.
http://www.acep.org/_Informatics-Section-Microsite/ED-InformationSystems-Primer---ACEP-White-Paper---April-2009/
• In development – ACEP Informatics section paper on EHR safety
Jonathan Siff, MD, MBA
[email protected]