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Electronic Health Record Presentation
Transcript of Electronic Health Record Presentation
Created cabinet level position: National Health Information Coordinator Obama Era Health Information Technology for Economic and Clinical Health (HITECH) Act - part of ARRA (2009)
Why are the use and functionality
so low? Widespread adoption and development requires a Critical Mass of users. Clinicians in the US have been historically resistant to change
US has relied on market-driven individual care systems or individual Physician investment to build IT capacity, rather than public spending
Australian and the Netherlands have been publicly funding IT development since the mid 1990s Historical US Perspectives on Medicine: pre 1970: Science! 1970s: Fee for Services 1980s: Cost Savings 1990s: Patient as Consumer Rozenblum et al (2011) Cost Savings
More accurate billing
Fewer unnecessary or repeated tests/procedures Convenience for Patients
No more remembering lists of medications
Ideally portable - records move with you
More control over health information makes them better consumers of health care Better Health Care leading to Improved Population Health Outcomes Maybe... Studies by Herrin et al. and O'Connor et al. Suggest some positive outcomes among Diabetic Patients Maybe not... Studies by Crosson et al. Suggest much more modest effects of EHR on health outcomes among Diabetic patients Herrin et al. 2012:
Studied Phased Roll-out of EHR between 2005 and 2010 in 34 Primary Care Practices in one network. Tracked 14,051 patients. The Good Patients with an EHR had lower:
and higher rates of smoking cessation. The Not So Good No effect on Glycolated Hemoglobin (HbAlc) Crosson et al. 2007 and 2012: 42 clinics in Northeastern states
16 using EHR, 26 using traditional paper records first over one, then three years
relationship between EHR use and adherence to care guidelines. Looked at Three Areas:
Process of Care (is patient getting tests every 6 mos?)
Treatment (are patient's measurements within an acceptable range?)
Outcomes (have patient's measurements below the range?) Patients in clinics with EHR were less likely to achieve any of the objectives over any of the years.
All clinics showed improvement, but EHR clinics showed less improvement. Conclusion: Systems were not being used effectively for patient care, work flows had not been adjusted to accommodate new systems. EHR Makes it easier to "copy and paste" diagnoses (called cloning), procedures etc and then bill insurance to have them reimbursed OIG Admits that "coding of evaluation
services is vulnerable to fraud" Abelson et al. (2012) Robert Burleigh: Health Care consultant went to ER for kidney stone. Noticed a physical exam that never took place on his bill: “No one would admit it,” Mr. Burleigh said, “but the most logical explanation was he went to a menu and clicked standard exam,” and the software filled in an examination of all of his systems. After he complained, the doctor’s group reduced his bill. As software vendors race to sell their systems to physician groups and hospitals, many are straightforward in extolling the benefits of those systems in helping doctors increase their revenue. In an online demonstration, one vendor, Praxis EMR, promises that it “plays the level-of-service game on your behalf and beats them at their own game using their own rules.” Coordination and Jurisdiction
Problems Systems Philosophy Patient Populations Meaningful Use - Clinicians both utilizing the system and actively engaging with its development by providing feedback and taking part in testing and pilot programs.
Difficult to achieve because many doctors like to maintain autonomy over their practice and see EHR/CDS as an invasion Ways to support meaningful engagement:
Consult all staff in system choice and development from the beginning.
Develop highly flexible and customizable systems.
Have a change agent or "Clinical Champion" Coordination and Jurisdiction EHR implementations rely on coordination between developers/implementers, clinicians, other caregivers, hospital staff, and managers. There is also often conflicting jurisdictions, national level incentives superceding local needs.
Is it more important to first have nationally interoperable records, or records that are interoperable between regional networks? System Philosophy or Architecture Style There's often a desire for "top down" approach with national standards and specifications
This model should allow for more insights and innovation from localized and regional cases, since the needs of each practice will be slightly different DeVoe et al. (2011) Studied Services Provided that showed up in a patient's EHR, but not in the corresponding Medicaid Billing Record (and vice-versa) "fewer than one-half the patients who received services had documentation in both EHR and Medicaid claims data" If a service is rendered at a clinic outside an EHR network, it won't make it onto the patient's EHR.
Patients have coverage gaps, so services might be billed to different insurers or not billed to any insurer. Especially if they have dual coverage (Medicaid and Medicare) Strong Leadership Overarching Vision Incentives for Clinician Buy-in and Use Adaptability Further Study Annual Percentage increase in claims coded at the highest levels Hospitals receiving incentives for electronic recordkeeping 2006 2008 2010 Other Hospitals +32% +47% Source: New York Times analysis of Medicare data provided by American Hospital Directory
http://www.nytimes.com/interactive/2012/09/22/business/a-sharp-rise-in-medicare-payments.html Questions? Writing