Impact of EHR design and operational procedures on health ......EHR Data more complete than claims • Analysis of diabetics using claims data vs data extracted from the EHR • Claims
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Impact of EHR design and operational procedures on
health care data for research EdgarChou,MD
ChiefValueOfficer/ChiefMedicalInformaticsOfficerDrexelUniversityCollegeofMedicine
September29,2016
Objectives
• UnderstandtheunderlyingdriversforElectronicHealthRecordDesign
• UnderstandthedriversthatimpactdataintegrityintheElectronicHealthRecord
• Understandthelimitationsofdatasets
DISCLOSURE STATEMENT
• Nonetoreport
Drexel University College of Medicine: Drexel Medicine • Multispecialtyambulatorypractice• 250Physicians• 17subspecialties• 500Residents/Fellows• 1000medicalstudents• 1000staff• 300,000outpatientvisitsperyear• ImplementationofEHRin2007
How did we get to this point?
http://www.hermes-press.com/SP17.jpg,AccessedOctober31,2014
Crossing the Quality Chasm - 2001
• 6AimsofHealthcare:• Shouldbe:
• Safe• Effective• PatientCentered• Timely• Efficient• Equitable
Crossing the Quality Chasm
• Tobepursuedby:• HealthCareorganizations• ProfessionalGroups• PrivatePurchasers• PublicPurchasers
• Goals:• Reducetheburdenofillness,injuryanddisabilitytoimprovethehealthandfunctioningof[ourpopulation]
Crossing the Quality Chasm
• Patientassourceofcontrol• Sharedknowledgeandfreeflowofinformation• Evidencebaseddecisionmaking• Safetyasasystemproperty• Needfortransparency• Anticipationofneeds• Decreaseinwaste• Cooperationamongstclinicians
Slides on US healthcare spending
OECD=OrganizationforEconomicCo-operationandDevelopment(internationalorganizationof34countriesfoundedin1961tostimulateeconomicprogressandworldtrade)
“Once again, U.S. has most expensive, least effective health care system in survey” – The Washington Post, June 16, 2014
http://www.washingtonpost.com/news/to-your-health/wp/2014/06/16/once-again-u-s-has-most-expensive-least-effective-health-care-system-in-survey/,AccessedOctober31,2014
Meaningful Use
CentersforMedicare&Medicaid.2011.Accessedfrom:https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM_Webinar_10-25-2011.pdf
Meaningful Use Summary
http://www.advisory.com/~/media/Advisory-com/Research/ITSC/Resources/Posters/2012/2014-Edition-MU-Whiteboard_2%2010%2014.pdf
Adoption of Electronic Health Reords
https://www.healthit.gov/sites/default/files/data-brief/2014HospitalAdoptionDataBrief.pdf,lastaccessedSeptember13,2016
Triple Aimà Quadruple Aim • “improvingtheexperienceofcare,improvingthehealthofpopulations,andreducingpercapitacostsofhealthcare”–TheInstituteforHealthCareImprovement,2012
HealthoftheProvider
Quality Payment Program: Merit Incentive Payment System (MIPS)
Element Was… Weight FutureWeight
ReportingMethod
Quality PatientQualityReportingSystem(PQRS)
50% 30% Registry/QCDR/WebInterface(248patients)
Resource PhysicianValue-PQRS(PV-PQRS)/ValueModifier(VM)
10% 30% Claims
ClinicalPracticeImprovementActivity(CPIA)
Didn’texistbefore 15% 15% Registry/QCDR
AdvancingCareInformation(ACI)
MeaningfulUse(MU) 25% 25% Registry/QCDR
https://www.gpo.gov/fdsys/pkg/FR-2016-05-09/pdf/2016-10032.pdf,lastaccessedJuly12,2016
Time in the EHR measured
• Forevery1hourofclinicalcaredelivered,2additionalhoursofclerical/documentationworkintheoffice
• Anadditional1-2hoursofworkoccurathome• Increasedriskforphysicianburnout• Increasedriskforlowerqualitycare(anddocumentation…)
http://annals.org/article.aspx?articleid=2546704,lastaccessedSeptember14,2016
Medical Education • OnejustneedstolookathowphysiciansaretrainedinfurtherunderstandingthedatacollectedinEHRs
• “90%ofdiagnosescomefromadetailedhistory”• Identifythereasonforvisit(ChiefComplaint)• Discussthedetailsregardingthecomplaint(e.g.timing,severity,associatedsignsandsymptoms)
• ContributoryFamily,Medical,SocialHistory,SurgicalHistory• ReviewofOrganSystemstoidentifyotherrelatedissues• PhysicalExam• Assessment(synthesisoftheinformationgathered)• Plan
Documentation and Billing
• Completedocumentationreflectstheperformanceofthephysicianwiththepatientandfollowsaregimentedsetofguidelines
• 1995EvaluationandManagementguidelines• ChiefComplaint(CC)• HistoryofPresentIllness(HPI)• PastFamily,Medical,SocialHistory• ReviewofSystems(ROS)• PhysicalExam• Assessment• Plan
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764TextOnly.pdf,Lastaccessed8/13/16
Evaluation and Management Guidelines • DocumentationmayeitherbeinHPIorspecificsections:Duplication!
http://www.aafp.org/fpm/2010/0300/p22.html,lastaccessed9/6/16
Electronic Progress Notes
• Benefits:• Legible• Betterqualitynotes
• Shortfalls• NoteBloat
• Improperuseof“CutandPaste”withduplicationwithoutupdating• SingleClicktemplates“Allnormal”
Documentation approaches vary…
FREETEXTGOESHERE
SINGLECLICKOPTIONS
Data Integrity
• Dataintegrityreferstotheoverallcompleteness,accuracyandconsistencyofdata.
Data input: If you’ve seen one physician… • you’veseenonephysician… Coronary Artery Disease
CAD Heart Failure Heart Disease HF CHF Congestive Heart Failure Low Ejection Fraction ASCVD Myocardial infarction MI MI s/p stent MI s/p PTCA MI s/p balloon angioplasty CABG Coronary Artery Bypass Graft CHF with EF<55% CHFpEF Ischemic Cardiomyopathy
ALLSCRIPTS ENTERPRISE V11.2.3
LABCORPINDEPENDENT LAB VENDOR
HUH: CERNPATHPATHOLOGYInpatient and
Outpatient results
QUESTINDEPENDENT LAB VENDOR
HUH: HPF: OPERATIVE REPORTS
HUH: PACSWEB LINK: URL
HUH: IDXRADRADIOLOGY
Outpatient radiology results only
HUH: SUNQUEST LABS
Oupatient lab results only
Bidirectional
Bidirectional
UnidirectionalConnect R
Unidirectional Ensemble
UnidirectionalConnectR
HUH: HPF: DISCHARGE SUMMARIES
(Future goal: Task PCP)
Unidirectional (Future Goal: Bidirectional)Open Link
IDX (Centricity)Practice Management System
V5.0Unidirectional to Allscripts: Demographics, Visit Type,
Appointment Status, Preferred method of communication
Charges from Allscripts
HUH: PBARREGISTRATION
SYSTEM
PBAR Thru Connectr
AnyEHR
Most organizations are not like Kaiser Permanente… • Datasourcescomefromdisparatesources
• Payers• Hospitals• Otherhealthcaresystems• AncillaryServices
• HomeHealth• NursingHomes• SkilledNursingFacilities• LabVendors
Data Integrity • InaccurateReporting
• Sensitivityofreportingrangingfrom46-98%permeasure
1AnnInternalMed.2013,158:77-83.
EHR Data more complete than claims
• AnalysisofdiabeticsusingclaimsdatavsdataextractedfromtheEHR• Claimsdataonlyidentified75%ofexistingdiabetics• EHRdataidentified97%ofexistingdiabetics
JAmMedInformAssoc.2007Jan-Feb;14(1):10-5.Epub2006Oct26
83yo with PMHx CAD, atrial fibrillation, MR s/p MVR, DM, HTN, CHF with EF=45%, urinary incontinence presents for followup.
83yo with PMHx CAD, atrial fibrillation, MR s/p MVR, DM, HTN, CHF with EF=45%, urinary incontinence presents for followup.
SUMMARY:34problemsLimitof10submissionsforMedicareClaims(usedtobe4)Diagnosesneedtobesubmittedannuallyforpatients(impactsriskscores)
Documented Plan
Charge Capture
Additional means of data capture
Improving the Health of a Population: Data and Patient Quality Reporting System (PQRS)
• CaseStudy:• PQRSMeasure#7:BetablockertherapyforPriorMyocardialInfarctionorLeftVentricularSystolicDysfunction(LVEF<40%)
• Howwouldyoufindthisinformation?• PQRSreliesonbillingcodes(ICD-10-formerlyICD-9)
• Additionalbackground:• LeftVentricularSystolicDysfunctiondoesnothaveabillingcode
• Requiresadditionalbillingcode:G8694• PatientQualityReportingSystemresultsreportednationallyin2014forconsumerstoallowcomparisonwithotherorganizations
• ValueBasedModifierprogram–Paymenttotheorganizationwillbebasedonperformanceonqualitymeasures
• Whatconcernswouldyouhaveforyourorganization?• Potentialriskfor1)pooroutcomesfalselyattributedsolelybasedonextractiontechnique;2)lowerreimbursements
Data and Predictive Analytics
https://upload.wikimedia.org/wikipedia/commons/f/f9/Poland._Trash_002.JPG;lastaccessed9/14/16
http://www.ghymcablog.org/blog1-wp/wp-content/uploads/2013/05/lemonade.jpg;lastaccessed9/18/16
What’s happening?
http://www.cleveland.com/healthfit/index.ssf/2014/10/cleveland_clinic_ibm_to_begin.html,AccessedNovember1,2014
How to improve?
• Understandthedatasourcesandmethodsofdataentrytounderstandthelimitationsofthedatarequested
• Lessfocusonprogramsthatdonotnecessarilyimprovequality
Additional Sources of Data and Future Applications • HealthShareExchanges• PrecisionMedicine• AdvancementsinArtificialIntelligence
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