Health Information Technology · 2019-10-31 · transforms health care by analyzing, designing,...
Transcript of Health Information Technology · 2019-10-31 · transforms health care by analyzing, designing,...
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Health Information Technology: Bridging the GapJake Lancaster, MD, MSHA, MSACICMIO Baptist Memorial Health Care Corporation
No Disclosures
“”
The spread of computers and the internet will put jobs in two categories: people who tell computers what to do, and people who are told by computers what to do.
- MARC ANDREESSAN
Learning Objectives
Describe the definition of HIT and related topics as discussed Recognize the impact of HIT adoption Recognize various Informatics fields Utilize the learning objective to further their informatics knowledge Recognize the benefits of HIT to improve patient care
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HHS Health IT Definition
Health information technology (health IT) involves the exchange of health information in an electronic environment. Widespread use of health IT within the health care industry will improve the quality of health care, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork, and expand access to affordable health care. It is imperative that the privacy and security of electronic health information be ensured as this information is maintained and transmitted electronically.
Health IT at the Organizational Level
CIO
Hardware
PCs
Network
Security
Software
Clinical
Business
Reporting
Training
PMO
EHR Technical Org. Structure
EHR Director
Inpatient
Lab
Orders
Clin. Doc.
Outpatient
Portal
Orders
Clin. Doc.
Pharmacy PACS
Vendor
CEO
Client Relations
Site Managers Site Physician
Sales
Specific Products
Operations
Product Development
Technical Assistance
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External Agencies
ONC – “ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.”
AMIA – “AMIA aims to lead the way in transforming health care through trusted science, education, and the practice of informatics.”
HIMSS “a global, cause-based, not-for-profit organization focused on better health through information and technology.”
External Agencies Cont.
CHIME – “The College of Healthcare Information Management Executives (CHIME) is the professional organization for Chief Information Officers and other senior healthcare IT leaders. CHIME enables its members and business partners to collaborate, exchange ideas, develop professionally and advocate the effective use of information management to improve the health and care throughout the communities they serve.”
AMDIS – “Founded in 1997, the Association of Medical Directors of Information Systems is the premier professional organization for physicians interested in and responsible for healthcare information technology.”
HL7 – “Founded in 1987, Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services.”
Learning Objectives
Describe the definition of HIT and related topics as discussed Recognize the impact of HIT adoption Recognize various Informatics fields Utilize the learning objective to further their informatics knowledge Recognize the benefits of HIT to improve patient care
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Shared Phone Analogy
Told by employer to buy smartphone Promised increased efficiency Multiple phones but all share same background Committee to decide on placement of icons and access to each Cannot rearrange icons Customized content specific for your organization Customization prevents the ability to take regular updates Numerous external agencies define the requirements and specs
about how you can use the phone
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Phone analogy cont.
Required to review multiple apps before you call a client Calls routinely drop After call, required to document entire conversation If wish to share transcript, must print and fax over information Do not get paid for your work unless it is in the transcript
End product does not resemble what smartphone company designed
Why Doctors Hate Their Computers
Two hours of doing computer work for every hour of time spent with a patient
Rising level of burnout and depression More work after hours (pajama time) Interference with doctor and patient relationship High expense due to productivity loss Revenge of the Ancillaries Older generation of physicians trained before computers were a
normal part of everyday life
Atul Gawande – New Yorker, November 2018
Revenge of the Ancillaries
Design sessions prior to implementation include physicians, nursing, radiology, lab, quality etc.
Due to scheduling conflicts, physicians historically less likely to make these meetings
Non-physicians design workflow for the physicians Include hard stops and required fields to improve their own
workflows Difficult to undo and continues to accumulate over time Results in tasks that were previously done by others falling on the
physician
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EHR design features and burnout
Information overload Slow system response times Excessive data entry Inability to navigate the system quickly Note bloat Interference with patient-clinician relationship Fear of missing something Notes geared towards billing
Kroth, JAMA Open, 2019
Outpatient specific issues
Updating and maintaining the problem list (ICD 10) Quality programs and health maintenance putting more and more
on the to-do list EHR message centers creating additional work that was previously
handled elsewhere or by someone else Nurses or MAs that previously could do certain tasks on paper no
longer can due to their privileges in the system
Quiet Dark vs. Loud Bright
Aviation industry Quiet Dark
information is not displayed until something goes wrong or needs attention
Indicator lights are off during normal conditions
Medicine Loud Bright
All info appear in almost same manner regardless of importance
Normal labs and vitals given same priority as abnormal
Abnormal Chloride looks same as abnormal Potassium
Tar PitFred Brooks-The Mythical Man Month
“No scene from prehistory is quite so vivid as that of the mortal struggles of great beasts in the tar pits. In the mind's eye one sees dinosaurs, mammoths, and sabertoothed tigers struggling against the grip of the tar. The fiercer the struggle, the more entangling the tar, and no beast is so strong or so skillful but that he ultimately sinks.
Large-system programming has over the past decades been such a tar pit, and many great and powerful beasts have thrashed violently in it. Most have emerged with running systems--few have met goals, schedules, and budgets. Large and small, massive or wiry, team after team has become entangled in the tar. No one thing seems to cause the difficulty--any particular paw can be pulled away. But the accumulation of simultaneous and interacting factors brings slower and slower motion. Everyone seems to have been surprised by the stickiness of the problem, and it is hard to discern the nature of it. But we must try to understand it if we are to solve it.”
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Any Upside? Upside of Health IT
Availability of the chart Multiple users, access at home, mobile, iPad
Legibility of notes and orders Chart Search Data Collection Improved Care Coordination CPOE reduced med errors ~ 55% Improved legal and regulatory compliance
Upside continued
Ability to make changes at scale Health Information Exchange Increased Revenue Improved ability to conduct research Increased adherence to evidenced based practice guidelines
Improved rates of immunizations
Improved VTE prophylaxis in hospitalized patients
Improvement in HTN treatment
Reduction in redundant testing
Where do we go from here?
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Learning Objectives
Describe the definition of HIT and related topics as discussed Recognize the impact of HIT adoption Recognize various Informatics fields Utilize the learning objective to further their informatics knowledge Recognize the benefits of HIT to improve patient care
Informatics
Applied form of information science Interaction between humans and information Focuses on the people, processes, and technology Subgroups
Translational Biomedical Informatics
Clinical Research Informatics
Clinical Informatics
Consumer Health Informatics
Public Health Informatics
What is Clinical Informatics?
Clinical informatics is the application of informatics and information technology to deliver healthcare services.
Clinical informatics is the subspecialty of all medical specialties that transforms health care by analyzing, designing, implementing, and evaluating information and communication system to improve patient care, enhance access to care, advance individual and population health outcomes, and strengthen the clinician-patient relationship.
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Clinical Informatics Subgroups
Physician Informatics Nursing Informatics Pharmacy Informatics Laboratory Informatics Radiology Informatics
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Clinical Informatics as a Clinical Specialty?
ACGME accredited with fellowship structure similar to other fellowships
Board Certification requirement and MOC requirements No directed interaction with patients within CI itself No services rendered to patients (unlike path, radiology) No billing codes or procedures codes In CI, ”patients” are anyone that interacts with the IS system Includes, doctors, nurses, lab, registration, pharmacy, and actual
patients
List of ACGME accredited Clinical Informatics Fellowships
University of Arizona
Beth Israel Deaconess Medical Center
Boston Children’s Hospital Clinical Informatics Fellowship
Case Western
The Children’s Hospital of Philadelphia
Columbia University
David Geffen School of Medicine at UCLA and UCLA Health
Duke University School of Medicine
Geisinger Health System
Icahn School of Medicine at Mount Sinai
Madigan Healthcare System
Mass General 34 ACGME Accredited programs Oct 2019
Ohio State Oregon Health & Science University School of
Medicine Regenstrief Institute, Inc. Stanford School of Medicine University at Buffalo University of California (multiple) University of Illinois at Chicago College of Medicine University of New Mexico University of Washington School of Medicine Vanderbilt Washington University School of Medicine Yale/VA Clinical Informatics Fellowship Program
Fellowship Pathway and Practice Pathway
Beginning in 2023Only candidates of programs that are
accredited by the Accreditation Council for Graduate Medical Education (ACGME) will be eligible for certification (board certification) in clinical informatics.
Rotations
Clinically focused Spend time with varying specialties (IM, Peds, Anes, Surg, Path, Rad)
and understand their issues with EHR or other systems and help find solutions to these problems
Technically focused Work with analysts in multiple departments within IT including security,
product development, data warehouse, EHR development Purpose is to learn how to be the bridge between clinical and IT Help translate requests from clinical side and refine new products from IT
side
Electives Startups, other vendors, private hospitals, public health, etc.
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Skills Development
Change Management and Governance SQL Data Science Programming languages (Python, R, Swift, etc.) EHR specific skills
Cerner (Physician Architect Program)Epic (Physician Builder Program)
Post Fellowship Career
Chief Medical Information Officer Physician informaticist Research informatics EHR Vendor Physician Consulting Start up company
Role of Physician Informaticist
Facilitator between colleagues, IT, and administration Represents the interests of other physicians Help customize or refine solutions to best support clinical care Communicates with medical staff about changes Works with analysts to make sure the end product is what was
requested
NOT the HIM police NOT someone who makes all decisions about EHR in a vacuum
CMIO
Responsibilities Help bring issues with the EMR or other technology to the
forefront of administration Help physicians understand the changes that are coming to the
systems Mitigate unexpected and unwarranted changes that adversely
affect clinicians Looks at data on provider efficiency, alerts, quality Sets up governance structure for decision making Help set strategy for the organization for the clinical IT landscape
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How to Handle Issues
Importance of understanding the problem No quick fixes Prioritization Downstream consequences Is it the right thing to do for patient care? Does it meet regulatory requirements?
Levels of Intervention
Personal Filters, macros, custom notes, preference lists, orders
Specialty Notes, navigators, order panels, dashboards, other
Facility
System Bulk of requests,
Vendor Intervention
Decision making and Governance
Decisions should not be made in a vacuum Need multidisciplinary group of well respected clinicians to
collaborate and make decisions Compensate members for their time to ensure participation Regular meeting cadence at convenient time for the group Should mesh with other governances structures (MEC, P&T, etc)
Example
CMO
CMIO
Physician Informaticists
CIO
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ExampleCSC
CCC
Individuals Workgroup Service Lines
Cardiology GI Oncology
Physician Advisory Council
IM
Surgery
OBGYN
PEDS
Radiology
GI
NeuroNursing
IT
Lab
Security
Admin
CC: I can’t get through an admission without 4-5 pop-up alerts
History: Every time time admit orders are placed, multiple alerts display for lab duplicates, imaging duplicates, drug-drug interactions, and drug allergies
Physical: Able to reproduce some of the alerts on a test patient including one for duplicate CBCs though ordered a day apart
Workup: Report is run on alerts that are fired the most and have very high override rates.
Status Informaticus
Plan: Form best practices alerts group to review
and streamline existing and incoming alertsExplore new features for suppressing
redundant alerts in an encounter Offload some alerts to passive alerts Change culture of solving every problem with
an alert
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Informatics in Your Practice
Identify physician liaison in your practice if one does not already exist
Ensure they have dedicated time to spend on practice improvements
Work with them to ensure that change requests get funneled to the right people
Understand that change will not happen overnight Learn from them how to personalize your workflow Stay informed about updates and retrain periodically for continuous
improvement
Future Directions
EHR Voice Assistance Integration Virtual Scribes Artificial Intelligence Cloud based applications FHIR Applications and other 3rd party apps Increased access of data for patients Reduction in regulatory burden
EHR Virtual Assistant and Virtual Scribes
Artificial Intelligence
Epic Sepsis AI
Readmissions predictor
No show predictor
Cerner Chart Assist
Charge Assist
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Movement to Cloud Third Party Applications
Access to data Reduction in Regulatory Burden
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Key Takeaways
Health IT is a large entity within most organizations that works to customize and maintain various clinical IT systems
The issues with EHRs are created from a wide variety of entities and not necessarily with the technology itself
Despite the pitfalls there are many upsides to EHRs Clinical informatics is the bridge to help drive improvement in HIT The landscape of HIT is rapidly evolving and the practicing clinician
needs to keep up in order to compete
Questions?
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