Using Using EMRs EMRs to Improve to Improve Patient Care Patient Care Lee Ferguson, MD Lee Ferguson, MD Acting Associate Chief of Staff for Ambulatory Care Acting Associate Chief of Staff for Ambulatory Care Department of Veterans Affairs Department of Veterans Affairs Medical Center Medical Center Washington, DC Washington, DC
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Using Using EMRsEMRs to Improve to Improve Patient CarePatient Care
Lee Ferguson, MDLee Ferguson, MDActing Associate Chief of Staff for Ambulatory CareActing Associate Chief of Staff for Ambulatory Care
Department of Veterans Affairs Department of Veterans Affairs Medical CenterMedical Center
Washington, DCWashington, DC
2005: Who is 2005: Who is ““VAVA””??Veterans Health AdministrationVeterans Health AdministrationVHA is an Agency of the Department of Veterans AffairsVHA is an Agency of the Department of Veterans Affairs
LocationsLocations~ 1,300 Sites ~ 1,300 Sites –– of of –– Care Care Including 157 medical centers, ~ 850 clinics, Including 157 medical centers, ~ 850 clinics, longlong--term care, term care, domiciliariesdomiciliaries, home, home--care programscare programs
AffiliationsAffiliationsAffiliations with 107 Academic Health SystemsAffiliations with 107 Academic Health SystemsAdditional 25,000 affiliated MDAdditional 25,000 affiliated MD’’ssAlmost 80,000 trainees each yearAlmost 80,000 trainees each year60% (70% MDs) US health professionals have 60% (70% MDs) US health professionals have some training in the VAsome training in the VA
Washington, DC VAMCWashington, DC VAMC
Electronic record:Electronic record:Available at >1900 sites in hospitalAvailable at >1900 sites in hospital
Easy to shareEasy to shareCannot be misplacedCannot be misplaced
Available at 4 surrounding Available at 4 surrounding Community Based Outpatient Community Based Outpatient ClinicsClinicsDedicated on site IRM staff for 24/7 Dedicated on site IRM staff for 24/7 service of the EMR, training, and service of the EMR, training, and generation of data reportsgeneration of data reports
Washington DC VAMCWashington DC VAMC
Washington, DC VAMCWashington, DC VAMC
Praise for VistAPraise for VistA……
““VHAVHA’’s integrated health information system, s integrated health information system, including its framework for using performance including its framework for using performance measures to improve quality, is considered one of measures to improve quality, is considered one of the best in the nation.the best in the nation.””
Institute of Medicine (IOM) Report, Institute of Medicine (IOM) Report, ““Leadership by Example: Leadership by Example: Coordinating Government Roles in Improving Health Care Quality Coordinating Government Roles in Improving Health Care Quality
(2002)(2002)””
““The Electronic Health Record in the Department The Electronic Health Record in the Department of Veterans Affairs is the best in the United States, of Veterans Affairs is the best in the United States, absolutely the best at large scale, and probably the absolutely the best at large scale, and probably the best in the world.best in the world.””
John Glaser, Ph.D., October 2003John Glaser, Ph.D., October 2003Vice President & CIOVice President & CIO
Partners (Harvard) HealthCare SystemPartners (Harvard) HealthCare System
Highest Quality of Care For Highest Quality of Care For Patients in VA Measured Patients in VA Measured
BroadlyBroadly““Patients from the VHA received higherPatients from the VHA received higher--quality quality care according to a broad measure. Differences care according to a broad measure. Differences were greatest in areas where the VHA has were greatest in areas where the VHA has established performance measures and actively established performance measures and actively monitors performance.monitors performance.””
Annals of Internal Medicine, December 21, 2004Annals of Internal Medicine, December 21, 2004
Clinical IndicatorClinical Indicator VA 2003VA 2003 Medicare 03Medicare 03 Best Not VA or MedicareBest Not VA or MedicareAdvised Tobacco Cessation (VA x3, others x1)Advised Tobacco Cessation (VA x3, others x1) 7575 6262 68 (NCQA 2002)68 (NCQA 2002)
Beta Blocker after MIBeta Blocker after MI 9898 9393 94 (NCQA 2002)94 (NCQA 2002)
Breast Cancer ScreeningBreast Cancer Screening 8484 7575 75 (NCQA 2002)75 (NCQA 2002)
Cervical Cancer ScreeningCervical Cancer Screening 9090 6262 81 (NCQA 2002)81 (NCQA 2002)
Mental Health F/U 30 D post D/CMental Health F/U 30 D post D/C 7777 6161 74 (NCQA 2002)74 (NCQA 2002)
VA Sets the U.S. Benchmark18 Comparable Indicators
Washington, DC VACOWashington, DC VACO
VHAVHA’’ss electronic record electronic record includes:includes:
• Computerized Patient Record System (CPRS)-basic EMR framework
• VistA Imaging-static and real time imaging/document scanning functionality
• My HealtheVet-veteran’s personal health record accessible from home
• Remote Data/VistA Web-access data from outside individual medical center
• Bar Code Medication Administration (BCMA)-inpatient medication administration software
Computerized Patient Record Computerized Patient Record System (CPRS)System (CPRS)
• Windows based GUI software that overlies VistAdatabase
• Clinical enduser is able to: – Review and enter progress notes– Review and enter procedure notes/operative
notes/discharge summaries– Review, order, adjust medications– Review and order labwork/imaging studies– Order consultations with specialists– Access remote views/VISTA web
The The ““gapgap”” between best between best practices and actual practicespractices and actual practices
• It is widely known and accepted that certain interventions after a myocardial infarction (“heart attack”) reduce complications and prolong life.
• Actual implementation of these “standard” therapies fall far below expected levels of use
• For example, aggressive monitoring of cholesterol after a myocardial infarction is a “no brainer”, with accepted target goals for lowering levels of LDL “bad” cholesterol
• Best practice outside VHA as recently as 2003 reveal only 79% had cholesterol levels checked (VHA was 94%)!
Why does this happen?Why does this happen?
• The reality of modern medical practice is that an older, more complicated patient population is living during a time of an ever increasing number of beneficial therapies, which is superimposed on a reimbursement system which puts pressure to minimize the time allotted between patient and care provider.
• The bottom line: leaving it to even the best trained, well intentioned physicians to remember and review everything is a losing position.
EMRsEMRs help close the help close the ““gapgap””between best practices and between best practices and
actual practicesactual practices
EMR: Improving Patient CareEMR: Improving Patient Care
• Two perspectives– Individual patient interactions-how can an EMR
improve the care of a patient sitting right in front of me?
– Aggregate care of a community-how can an EMR improve the care of a large population of patients?
“Micro and macro” views are mutually reinforcing
EMR role in improving EMR role in improving individual patient careindividual patient care
• Formatted note templates that display patient specific problem lists, allergies, and recent lab data
• Time savings/elimination of redundant care through – order entry of labs/images/medications– review of past appointments/consultants reports– test results/imaging availability
• MyHealtheVet• Vista Web remote access data retrieval• Clinical reminders
Order XOrder X--rayray
Washington, DC VAMCWashington, DC VAMC
Images Images –– Chest XChest X--rayray
Washington, DC VAMCWashington, DC VAMC
GREEN, DEAN (100-10-1000)
Remote View – VistA Web
GREEN, DEAN (100-10-1000)
Remote View Remote View –– VistA WebVistA Web
GREEN, DEAN (100-10-1000)
Remote View – VistA Web
My HealtheVetMy HealtheVet
Vista extracts sent toMy HealtheVet account• Demographics,
admissions, and appointments
• Vitals and allergies• Prescriptions• Progress notes• Discharge summaries• Problem list • Lab reports: chemistry,
•• Acquire health Acquire health data beyond data beyond care delivered care delivered in VAin VA
Clinical remindersClinical reminders
Clinical remindersClinical reminders
Power of clinical remindersPower of clinical reminders• Do the right thing in the right patient at the right time
– Avoid missed treatment– Avoid wasted time confirming issues that are
already dealt with• Gain clinician confidence that the reminders will let
them know when something is due• Produce “reminder reports” for feedback to
individuals, groups, institutions
EMR role in improving the care EMR role in improving the care of a populationof a population
• Different tools are available to identify problem areas, monitor progress over time, and compare to performance between individuals/groups– VistA data extracts– Clinical reminder reports
Analysis at 4 month IntervalAnalysis at 4 month IntervalBalt
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Baltim
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Martinsb
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Washington
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Baltim
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Washington
00
2020
4040
6060
8080
100100
Perc
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ient
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atie
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September 20, 2001September 20, 2001 January 3, 2002January 3, 2002
00
2020
4040
6060
8080
100100
High(> 160 / 100 )
Moderate(140 - 159 / 90 - 99 )
Normal(< 140 / 90 )
Washington, DC VAMCWashington, DC VAMC
VAMC PATIENTS WITH HYPERTENSION ON ACTIVE PROBLEM LIST VAMC PATIENTS WITH HYPERTENSION ON ACTIVE PROBLEM LIST -- AND AT LEAST 1 SCHEDULED P C CLINIC APPOINTMENT, JUN 15,2002 TOAND AT LEAST 1 SCHEDULED P C CLINIC APPOINTMENT, JUN 15,2002 TO SEP SEP 12,2002 12,2002
FOR RED FOR RED -- PROVIDER: MUBSAO,FAAE PROVIDER: MUBSAO,FAAE
36 PATIENT(S) HAVE ELEVATED OR NO BP READING. 36 PATIENT(S) HAVE ELEVATED OR NO BP READING. AMONG THESE PATIENTS: AMONG THESE PATIENTS: ACTIVE BETA BLOCKER RX: 12 ( 33.3%) ACTIVE BETA BLOCKER RX: 12 ( 33.3%) ACTIVE CALCIUM CHAN RX: 18 ( 50.0%) ACTIVE CALCIUM CHAN RX: 18 ( 50.0%)
ACTIVE DIURETIC RX: 17 ( 47.2%) ACTIVE DIURETIC RX: 17 ( 47.2%) ACTIVE ACE INHIBITOR RX: 18 ( 50.0%) ACTIVE ACE INHIBITOR RX: 18 ( 50.0%)
ACTIVE CENTRAL ACTING RX: 9 ( 25.0%) ACTIVE CENTRAL ACTING RX: 9 ( 25.0%) AT LEAST 1 OF ABOVE RXES: 34 ( 94.3%) AT LEAST 1 OF ABOVE RXES: 34 ( 94.3%)
A. (*No Recent Test*:) OLD MI(S) WITH NO LDL TEST SINCE JUL 8A. (*No Recent Test*:) OLD MI(S) WITH NO LDL TEST SINCE JUL 8,2001: (6),2001: (6)
44--DIG NAME DIG NAME PHONE #PHONE #---------- -------------------------------------- ------------------------P3332 FAT,ALBERT OTTOP3332 FAT,ALBERT OTTO 555555--555555--55555555R5554 ROSE,SAMR5554 ROSE,SAM 555555--555555--55555555
B. (*Highest*:) OLD MI(S) WITH AT LEAST 1 LDL TEST SINCE JUL B. (*Highest*:) OLD MI(S) WITH AT LEAST 1 LDL TEST SINCE JUL 8,2001,8,2001,LATEST VALUE 119+: (3)LATEST VALUE 119+: (3)
# LDL LATEST# LDL LATEST--RESULT LOWESTRESULT LOWEST--RESULT HIGHESTRESULT HIGHEST--RESULT PHONE #RESULT PHONE #44--DIG NAME TESTS DIG NAME TESTS -------------------------------- ---------------------------- ---------------------------- ------------------------F0350 FLTSTNE,FRED 6 JUL 01,03 178.0 NOV 14,02 124.0 F0350 FLTSTNE,FRED 6 JUL 01,03 178.0 NOV 14,02 124.0 JUL 01,03 178.0 555JUL 01,03 178.0 555--555555--55555555R7777 WARD,RUSSR7777 WARD,RUSS 1 JUL 08,02 165.0 551 JUL 08,02 165.0 5555--555555--55555555J2222 JEFFREY,GEORGE 4 JUN 11,02 140.0 JUN 11,02 114.0 J2222 JEFFREY,GEORGE 4 JUN 11,02 140.0 JUN 11,02 114.0 JUN 04,03 140.0 555JUN 04,03 140.0 555--555555--55555555N3258 NORMAL,ABBEY 1 JUN 26,02 163.0 N3258 NORMAL,ABBEY 1 JUN 26,02 163.0 555555--555555--55555555S1451 SMITH, S1451 SMITH, ANONYMOUSANONYMOUS 2 AUG 30,02 187.0 FEB 08,02 90.0 AUG 30,02 187.0 5552 AUG 30,02 187.0 FEB 08,02 90.0 AUG 30,02 187.0 555--555555--55555555W1234 WELCH,JOHN 2 MAR 25,03 156.0 MAR 11,02 95.0 W1234 WELCH,JOHN 2 MAR 25,03 156.0 MAR 11,02 95.0 MAR 25,03 156.0 555MAR 25,03 156.0 555--555555--55555555
Washington, DC VAMCWashington, DC VAMC
Diabetes Foot Exam, Red Team Diabetes Foot Exam, Red Team Exceptional Exceptional ≥≥ 87%, FS 82 87%, FS 82 -- 86%86%
Electronic Health Records are Fully Electronic Health Records are Fully Deployed Throughout VA Deployed Throughout VA
Washington, DC VAMCWashington, DC VAMC
EHR (VistA) Strategies EHR (VistA) Strategies ––Summary Summary •• Use expert and nonUse expert and non--expert advisors.expert advisors.•• Local ownership Local ownership ---- Customize templates, Customize templates,
reminders and overall organization.reminders and overall organization.•• Package popular(discharge summaries,Package popular(discharge summaries,
labs, images) with unpopular (order labs, images) with unpopular (order entry, notes) componentsentry, notes) components
•• Maintain hybrid status until 60Maintain hybrid status until 60-- 70%70%use is achieved. ( use is achieved. ( ““Tipping pointTipping point””) )
•• Keep software intuitive and user friendlyKeep software intuitive and user friendlyfor rapid adoption by new providersfor rapid adoption by new providers
•• Provide real improvement in patient care.Provide real improvement in patient care.
Lab .. Worksheet Graph of HgbLab .. Worksheet Graph of Hgb
Washington, DC VAMCWashington, DC VAMCAbrupt fall in Hgb with acute bleedingAbrupt fall in Hgb with acute bleeding
VISN 5 Performance Measures
Target patients not in complianceTarget patients not in compliance..
Create a master list from reminder reports orCreate a master list from reminder reports orhospital databasehospital database
assign to a coordinator assign to a coordinator report to providerreport to provider
Create a central clinic to correct deficiencies Create a central clinic to correct deficiencies e.g.e.g.
LDL >100 or not doneLDL >100 or not doneHbA1c >9 or not doneHbA1c >9 or not doneBP >140/90 BP >140/90 Mammography overdueMammography overdue
Washington, DC VAMCWashington, DC VAMC
Strategies
VistA outside VA VistA outside VA –– Hurricane KatrinaHurricane Katrina560 patients from Gulfport AFRH560 patients from Gulfport AFRH
evacuated to Washington DC AFRHevacuated to Washington DC AFRH16 laptop works16 laptop workstationstations in three in three buildings buildings –– internet with VPN access.internet with VPN access.Patients immediately registeredPatients immediately registeredRemote views available Remote views available –– Katrina webKatrina webMedications ordered and delivered Medications ordered and delivered thru our pharmacy thru our pharmacy -- 1000 Rx in 3 days1000 Rx in 3 daysNotes added with AFRH template Notes added with AFRH template listing meds for AFRH Walk In Cliniclisting meds for AFRH Walk In ClinicConsults, appointments requested.Consults, appointments requested.
Washington, DC VAMCWashington, DC VAMCWeight controlled with thorocentisis x2 and FurosemideWeight controlled with thorocentisis x2 and Furosemide
Images Images –– Chest XChest X--rays rays –– Right and Left Pleural EffusionsRight and Left Pleural Effusions
Washington, DC VAMCWashington, DC VAMCPleural effusions resolved with thorocentisis and diureticsPleural effusions resolved with thorocentisis and diuretics
Images Images ––Widening LBBB on sequential ECGsWidening LBBB on sequential ECGs
Washington, DC VAMCWashington, DC VAMCQRS increased from 0.154 TO 0.178QRS increased from 0.154 TO 0.178
Images Images –– MRI Video loop with LBBB on ECGMRI Video loop with LBBB on ECG
Washington, DC VAMCWashington, DC VAMCSeptum moves paradoxically away from left ventricleSeptum moves paradoxically away from left ventricle
EHR (VistAEHR (VistA))
Remote Views• Remote data button and remote
health summaries.• VistaWeb – patient specific data• Remote ECG view – map MUSE• Remote image view
X-ray, scanned images, and PDF files.
• Direct sign on to remote site withseparate access and verify code
Pacemaker/Device Data to EHR (VistAPacemaker/Device Data to EHR (VistA))
Future remote views• Health Data Repositry –
Data and notes from all VA visitsare integrated chronologically.
Fall 2005
• Current functionality will be preserved on Java platform
Reminders MHVReminders MHV
Reminders MHV Reminders MHV ---- WeightWeight
Self Entered InformationSelf Entered Information
My Health My Health eeLog Log (Self(Self--enteredentered ))
Medication Administration: UDMedication Administration: UD
Washington, DC VAMCWashington, DC VAMC
IRM Steering CommitteeIRM Steering CommitteeDirector and StaffDirector and Staff
IRM chiefIRM chief
Clinicians with computer expertiseClinicians with computer expertiseNational CommitteesNational CommitteesLocal applicationsLocal applications
Clinicians with high use but little computer Clinicians with high use but little computer expertiseexpertise
OrganizationOrganization
Washington, DC VAMCWashington, DC VAMC
When to declare victory?When to declare victory?
Question Question –– ““When can we set a date to stop When can we set a date to stop pulling paper records for Clinics?pulling paper records for Clinics?””
Response Response –– ““Stop now Stop now –– the paper record is no the paper record is no longer used.longer used.””
Begin to dismantle medical record and xBegin to dismantle medical record and x--ray file ray file rooms.rooms.
Road to the Paperless HospitalRoad to the Paperless Hospital
Washington, DC VAMCWashington, DC VAMC
SolutionsSolutionsData RetrievalData Retrieval
Know database structure for logical retrieval.Know database structure for logical retrieval.
Create automatic reportsCreate automatic reports
Use reports to improve computer entry.Use reports to improve computer entry.
Use reports to improve patient careUse reports to improve patient care..Assess compliance with current guidelines.Assess compliance with current guidelines.Determine outcome to define efficacious treatmentDetermine outcome to define efficacious treatment