How Electronic Health Records Influence Behavior

How electronic health records may influence behavior

George Hripcsak, MD, MSDepartment of Biomedical Informatics/

Medical Informatics ServicesColumbia University & NewYork-Presbyterian

Promise of clinical decision support

• Long history of reminders• McDonald, NEJM 1976• Barnett, Med Care 1978

• Computerized orders• Tierney, JAMA 1993

• Increase compliance with corollary orders• Overhage, JAMIA 1997

• Reduce maximum dosing errors• Teich, Archives Int Med 2000

• Improve prophylaxis• Kucher, N Engl J Med 2005

Institute of Medicine

• To Err is Human: Building a Safer Health System (1999)

• Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

Caveats

• Many positive studies from 4 institutions• Chaudhry, Ann Int Med, 2006;144:E12-E22

• Unintended consequences of CPOE• Koppel, JAMA 2005

• Increased mortality after CPOE• Han, Pediatrics 2005

• CDSS improve process most of the time, but outcomes are understudied

• Garg, JAMA, 2005

Documentation and Workflow

Will we repeat the hype cycle?

10/2/08 PGY1 Progress Note

S: No events o/n. CXR yesterday showed lung still reexpanded while on water seal. Pt participated in physical therapy yesterday, felt weak afterwards. Still has transient cough.

O: VS Tm 98.6 Tc 98.5 68-77 110-116/62-66 20-22 95%General NAD, sitting on edge of bed, with NC, appears improved HEENT PERLA, EOMI, no JVD CV RRR nml S1, S2 Pulm chest tube on R, dry crackles predominantly at the bases Abd soft, nt, nd, + BS, no HSM Ext trace ankle edema, no cords/calf tenderness

Labs: see webcis ANA negative RF negative ESR 22 Hep B cAB/sAB positive, sAG negative, Hep C Ab negative stool O and P- negative

Other Studies:

9/24 abd u/s Hepatomegaly. Increase in echogenicity and echotexture may be due to hepatic steatosis or a fibrotic process.

TTE: Moderately limited study due to poor acoustic penetration. The left ventricle is mildly hypertrophied with normal systolic function. The left atrium is mildly dilated. The right ventricle is not optimally visuallized but overall right ventricular size and function are normal. No significant valvular abnormalities are seen on limited views. The measured peak right ventricular systolic pressure is approximately 40mmHg.

A/P: 61 yo man with UIP vs. malignancy s/p VATS biopsy 2 wks ago at OSH, p/w worsening SOB found to have pneumothorax. Chest tube placed in ER, PTX now resolved on CXR.

Pulm - likely HP, PTX s/p VATS biopsy and subsequent chest tube, now with reexpansion of lung. Hypersensitivity panel negative, though this does not r/o hypersensitivity pneumonitis. -f/u pulm recs -decrease O2 to maintain O2 sat of 95% -continue steroids -appreciate thoracic surgery consult - chest tube now on waterseal -PFTs when chest tube is out -daily CXR

GI - LFT elevation, hepatomegaly of unclear source, hepatitis panels negative, TTE normal, LFTs have stabilized, relatively acute onset, possibly reactivation of Hep B vs. parasitic infection -appreciate GI consult - will repeat stool O and P/stool culture, f/u stronglyloidis and schistomiasis Ag, continue ivermectin, ANA, anti-sm Ab, quantitative immunoglobulins, alfa 1-antitrypsin, Ceruloplasmin, and GGT -MRCP if pt can have it with chest tube

Heme - eosinophila, likely 2/2 parasitic infection -trend WBC count and eosinophila -Ivermectin

FENGI -Cardiac diet

PPX -sub q heparin

FULL CODE

10/2/08 PGY1 Progress Note

S: No events o/n. CXR yesterday showed lung still reexpanded while on water seal. Pt participated in physical therapy yesterday, felt weak afterwards. Still has transient cough.

O: VS Tm 98.6 Tc 98.5 68-77 110-116/62-66 20-22 95%General NAD, sitting on edge of bed, with NC, appears improved HEENT PERLA, EOMI, no JVD CV RRR nml S1, S2 Pulm chest tube on R, dry crackles predominantly at the bases Abd soft, nt, nd, + BS, no HSM Ext trace ankle edema, no cords/calf tenderness

Labs: see webcis ANA negative RF negative ESR 22 Hep B cAB/sAB positive, sAG negative, Hep C Ab negative stool O and P- negative

Other Studies:

9/24 abd u/s Hepatomegaly. Increase in echogenicity and echotexture may be due to hepatic steatosis or a fibrotic process.

TTE: Moderately limited study due to poor acoustic penetration. The left ventricle is mildly hypertrophied with normal systolic function. The left atrium is mildly dilated. The right ventricle is not optimally visuallized but overall right ventricular size and function are normal. No significant valvular abnormalities are seen on limited views. The measured peak right ventricular systolic pressure is approximately 40mmHg.

A/P: 61 yo man with UIP vs. malignancy s/p VATS biopsy 2 wks ago at OSH, p/w worsening SOB found to have pneumothorax. Chest tube placed in ER, PTX now resolved on CXR.

Pulm - likely HP, PTX s/p VATS biopsy and subsequent chest tube, now with reexpansion of lung. Hypersensitivity panel negative, though this does not r/o hypersensitivity pneumonitis. -f/u pulm recs -decrease O2 to maintain O2 sat of 95% -continue steroids -appreciate thoracic surgery consult - chest tube now on waterseal -PFTs when chest tube is out -daily CXR

GI - LFT elevation, hepatomegaly of unclear source, hepatitis panels negative, TTE normal, LFTs have stabilized, relatively acute onset, possibly reactivation of Hep B vs. parasitic infection -appreciate GI consult - will repeat stool O and P/stool culture, f/u stronglyloidis and schistomiasis Ag, continue ivermectin, ANA, anti-sm Ab, quantitative immunoglobulins, alfa 1-antitrypsin, Ceruloplasmin, and GGT -MRCP if pt can have it with chest tube

Heme - eosinophila, likely 2/2 parasitic infection -trend WBC count and eosinophila -Ivermectin

FENGI -Cardiac diet

PPX -sub q heparin

FULL CODE

Cut and paste

• Once entered, a mistake lasts forever

… 36 year old man … 27 year old woman …

• Doctors are telling us not everything needs to be restated every time

Sublanguage

• Misspellings and interesting abbreviations– text messaging

s/p LURT 1998 c/b 1A rejection 7/07 back on HD

pHtn 2/2 ASD w L->R shunt p/w abd pain x 3

• Doctors are telling us data entry and review must be made more efficient

Medicine resident daily progress note:

Events overnight


Subjective


Vital sign flowsheet


Vital signs by physician


Medications


Physical exam


Laboratory


Radiology


EKG and telemetry


Assessment


Problem list


Plan

Proposed addition for compliance

Pain

Smoke

Pt edu

Inform

PERRLA

Structured data entrygeneral o fatigue fever or chills o lumps or masses eyes wear glasses/contacts visual changes o eye pain o itchy/watery eyes nose and throat o bloody nose congestion/runny nose o sore throat hoarsenessgastrointestinal o dysphagia (trouble swallowing) heartburn o nausea and vomiting o abdominal pain o jaundice o diarrhea constipation

cardiovascular chest pain/tightness o palpitations o fainting spells edema or fluid retentionears o hearing aids o earache o tinnitus (ringing in ears) ear drainage recurrent infections respiratory o shortness of breath cough/congestion o wheezing productive of sputum/phlegm o hemoptysis (coughing up blood) dermatologyo skin lesions/skin cancer rash

…

Cost per click

• $16M nationally per checkbox– # doctors, # notes per year, time on checkbox

• Should do cost benefit

Weekly Notes Written in Eclipsys XA:Inpatient Providers

17,991

8,227

October 2007 October 2008

“I don’t read notes anymore; I just write them.

There is no information in them. I do look at vital signs, labs, and resident signout notes.”

Medication reconciliationReview of eight medical centers:• ED enters meds on paper, review and edit on floor, no other med list

allowed in chart; await better software

• Nurse enters meds on paper, doctor reviews; await better software

• Nurse enters meds on paper, doctor reviews, doctor attests electronically c hard stop on meds at 6 hours; await better software

• Nurse enters meds electronically (some from insurer), prints for doctor; await better software

• Pharm tech enters meds electronically, prints for doctor; await better software

• Pharm tech enters meds electronically• All paper; await better software

• Failed attempts at nurse and doctor entry; await better software

NYPH:• Doctor (or nurse) enters meds electronically, doctor attests c hard stop at 18

hours; look forward to better software

Reconciliation and attestation

Unit Patients

Med Rec Orders Home Med List Both Med and Orders

# # % # % # %

Special 9 6 67% 6 67% 6 67%

ICU 10 10 100% 10 100% 10 100%

ICU 10 10 100% 10 100% 10 100%

ICU 9 9 100% 9 100% 9 100%

ICU 15 15 100% 14 93% 14 93%

Medsurg 32 31 97% 32 100% 31 97%

Medsurg 33 33 100% 32 97% 32 97%

Medsurg 20 19 95% 19 95% 19 95%

Medsurg 24 24 100% 24 100% 24 100%

. . .

Medsurg 18 18 100% 18 100% 18 100%

Medsurg 38 37 97% 35 92% 35 92%

Medsurg 23 20 87% 20 87% 20 87%

Medsurg 15 12 80% 12 80% 12 80%

TOTAL 591 570 96% 565 96% 564 95%

Lessons

• Quality initiatives improve quality, not EHRs– Why home-grown systems succeed– EHR is an infrastructure, not an intervention

Lessons

• Focus with clear goals– If the goal is only Leapfrog, that is all that will

be achieved

Lessons

• Slow, iterative process– What does not kill the patient makes the

system stronger

Lessons

• Culture and buy in– May get away with strong arm

Lessons

• Research– Basic research: we don’t yet know how to do

this right– HSR: evidence-based EHRs or at least better

art

Focused initiatives

• Focused initiatives with clear goals

• Measure process and outcomes

• Discharge summary writer

DSUM Writer vs. Dictation(focused intervention)

DSUM Writer vs. Dictation

Next generation documentation

• What would really support both individual and team care

• Past medical history as a central resource• vs. cut and paste

• Document only current thoughts & actions• review everything else

• Merge intern progress and signout notes• Improved user interface technology

• natural language processing, speech

Data entry technology

• Natural language processing– Convert narrative text to encoded form

– Natural interface for MD– Computable for use in databases

Clinical data warehouse

2,500,000 patient records

62,000,000 laboratory test batteries

6,000,000 clinical notes: discharge summary, admission, progress, signout, and visit notes

34,000,000 narrative reports from 40 ancillary departments, including radiology, pathology, cardiology, pulmonary

20,000,000 inpatient orders, outpatient orders

Flowsheeted nursing documentation c VS

Micro-consults

• Anticoagulation– evidence for dosing, genetics, contraindications– variable practice

• Reminders are insufficient• Order a micro-consult

– Advise on dosing based on EHR (automated to human review)– Primary MD gets order set– Consult tracks in a registry (with automated surveillance)– Escalate to consult as needed– Bill for micro-consult?

• “Mega-reminders”

Primary Care Information Project (PCIP)

Public Health’s Role in Health Information Technology: The New York City Model

Farzad MostashariMat Kendall

New York City Department of Health and Mental Hygiene [email protected]

PCIP

• 3000 Medicaid providers in NYC

• The following storyline illustrates the TCNY Clinical Decision Support System in action

Jane Doe, a 48 year-old woman is cared for by her family practitioner, Dr. James Bear.

Dr. Bear wants to find out how he is performing compared to other physicians in his practice in controlling high blood pressure for his patients.

Using the QUALITY MEASURE REPORTS FUNCTION, Dr. Bear is inspired by the performance of his peers in managing the blood pressure (BP) of their hypertensive patients; only one-third of his hypertensive patients have achieved good BP control.

• Dr. Bear queries the EHR to identify which of his patients have diabetes and an HbA1C > 7.

1. Measure Reports 2. Enhanced Registry 3. Automatic Visual Alerts 4. CDSS

5. Quick Orders 6. Comprehensive Order Sets 7. eMedNY 8. CIR and School Health

Dr. Bear wants to improve his score on BP control and queries the EHR to identify patients with poorly controlled hypertension

Using the ENHANCED REGISTRY FUNCTION, Dr. Bear identifies five patients with high blood pressure who do not have an appointment scheduled, and reaches out to each patient; he generates a letter scheduling a follow-up visit with patient Jane Doe.



• Jane Doe receives the letter and makes a f/u appointment

• During the visit, Dr. Bear’s assistant takes her history and vitals

• Jane mentions that she has had a few weeks of excessive thirst and fatigue

Jane’s blood pressure is elevated (150/90) and highlighted in red by the AUTOMATIC VISUAL ALERT FUNCTION. Dr. Bear can trend her BP over time.



• Based on Jane’s chief complaint of excessive thirst, Dr. Bear performs a fingerstick test and confirms his suspicion that Jane has diabetes

• Dr. Bear enters a diagnosis of diabetes into the EHR

Based on Jane’s new diagnosis of diabetes, the CLINICAL DECISION SUPPORT FUNCTION identifies four preventive care services that should be performed. This list of services is automatically populated in the CDSS panel.



Dr. Bear agrees that these tests are appropriate and should be performed

Dr. Bear uses the QUICK ORDER FUNCTION to order an HbA1C test for Jane, as well as a flu vaccine; the alerts disappear from the panel once they are ordered. Dr. Bear may also choose to suppress alerts, if he deems them unnecessary.



Dr. Bear also selects the “LDL control (high risk)” alert, which displays the order set for high LDL levels

The 1st part of the COMPREHENSIVE ORDER SET displays a selected list of recommended medications (brand & generic) for lipid control.



Dr. Bear views other order sets for high LDL levels

The 2nd part of the COMPREHENSIVE ORDER SET displays a selection of recommended labs, immunizations, follow-up appointments, referrals as well as printable physician and patient education materials.



• Dr. Bear wonders if he should change Jane’s medication regimen to better control her lipids and wants know what medications have been filled by her in the past 90 days

• Jane has signed a consent form to give the provider access to her medication history

Since Jane is a Medicaid patient, Dr. Bear can use the eMedNY FUNCTION to view her 90-day medication history. He notices that Jane has not filled her lipid medication (simvastatin) for the past three months; she admits that she has stopped taking them because she wondered if her tiredness might have been due to these pills.



• While she’s there, Jane asks Dr. Bear for a school health form for her 5 year-old (Tim) who is entering day care.

• Dr. Bear generates a preloaded NYC School Health form populated with Tim’s information for Jane to take with her.

Tim’s information has already been automatically uploaded to the CITYWIDE IMMUNIZATION REGISTRY. The CIR will maintain a complete record of Tim’s immunizations which can be accessed by other providers as needed.



Tim male 01/01/03

Mother

Quality initiatives improve quality, not EHRs

• Partnership among clinical leadership, quality, IS

Focus with clear goals

Slow, iterative process

Culture and buy in

• Need to pair bottom-up initiative with top-down, evidence-based approach

Research

• There is something there

• We need to find it

How Electronic Health Records Influence Behavior

Documents

subsequent chest tube

p negative

s2 pulm chest tube

chest tube heme eosinophila

hepatitis panels negative

hep c ab negative stool

med care

tte normal