21
Summary and Prospects
James M. Walker
173 Implementing an EHR is one of the largest and most complex projects a CDO can undertake. More than that, it presents your organization (large or small) with an oppor- tunity to re-think and re-design the ways you do business. It necessitates identifying all your customers, internal and external. It requires an intensified focus on cooperation among work groups (e.g., pediatric and adult subspecialties, physicians and nurses, prac- tices and hospitals, clinicians and administrators). It requires that the lab, pharmacy, and other services analyze their internal customers’ carefully. Table 21.1 lists some of the primary process improvements the EHR has made feasible for us.
Benefits Realized
The primary benefits of the EHR are not easily quantifiable. The most telling is the fact that our physicians simply refuse to practice in new outreach clinics until the EHR is available. The convenience of accessing and adding to the patient’s complete health record, combined with the confidence that comes with automated clinical decision support—such as automatic allergy and drug-interaction checking—make the EHR indispensable for clinicians who have used it longer than six months.
Similarly, our EHR has transformed clinical communication. In our practices, tele- phone tag—and the enormous inefficiencies it creates—is a thing of the past. It has been replaced almost entirely by electronic messaging, sent at the sender’s convenience and answered at the recipient’s convenience—with the patient’s record automatically attached. Even hallway tag, in which physicians and nurses chase each other down to coordinate more time-sensitive patient care, has largely been replaced by e-messaging.
Other benefits of the EHR can be at least partially quantified. Examples from our experience include:
• 372,000 fewer laboratory and radiology reports printed and filed annually
• 36% reduction in outpatient lines of transcription
• 60% reduction in paper medical record chart pulls
• 33% reduction in Medicare disallowance of bills due to medical necessity edits of tests ordered
• 94% of patients find having the EHR in the exam room helpful or very helpful.
• $1,000 per physician saved annually through increased use of generic drugs
• 97% of office visits include allergy checking and documentation.
• 100% of outpatient orders include an ICD-9 code assigned by the provider.
• 90% reduction in unauthorized visits to specialists
Next Steps
Although our outpatient implementation is complete and our inpatient implementa- tion is well underway, we are only at the beginning of using the EHR to transform the ways we provide healthcare. These are some of the next steps we have identified:
• Explicit Goals and Measures: We are becoming more thorough about assessing needs and defining goals—to assure congruence between EHR projects and organizational strategies—and particularly about pre-defining the measures by which we check our progress toward those goals. As goals are reached, we will need to define new ones for the next phase of improvement. When goals are missed, we analyze both the failure and the goal and make the changes needed to accomplish the goal (or a revised goal). Even a change as apparently simple as decreasing chart pulls requires active management.
• Operational Leadership: Clinical and administrative leaders are increasingly leading EHR projects, both through their roles on oversight and feedback committees and by taking responsibility for identifying new business initiatives that the EHR can support. A particularly effective example is the streamlined document distribution discussed in Chapter 20, which was conceived by a task force working on improving our relationships with referring physicians. The task force identified a need for more rapid communication with referring physicians and the EHR team was able to customize the EHR to help meet the need.
• Integrated Workflows: One of the chief virtues of an EHR based on a single data- base is its potential to support seamless care across the spectrum of care, from home to outpatient, inpatient, and long-term care. To achieve this potential will require painstaking analysis and process re-design by all CDOs and equally painstaking efforts on the part of EHR vendors. The solutions to even basic needs—such as com- plete accounting for the changes made in a patient’s medicines in the transition from outpatient to inpatient care and back—are in the early developmental stages.
• Standardized Implementations: If the EHR is to be implemented effectively by thou- sands of American CDOs over the next decade, we will need to develop standard- ized implementation methodologies that are efficient enough that community hospitals, physician practices, and their patients can benefit from using a high- performance EHR (i.e., one that is capable of provider order entry and real-time 174 Part 4. Summary and Prospects
TABLE21.1. Processes Improved with the EHR.
Process Type Benefits
Patient safety Automatic, real-time drug-drug and drug-allergy checking Care quality Automatic, patient-specific reminders in real time Documentation
standardized, searchable, readable.
Patient access Standardized scheduling system integrated with the EMR.
Patient information access Anytime secure access to the EHR and to practices
Clinic workflows Simplified, standardized workflows
Information reporting Automated reports on aggregated clinical data Remote access To clinical and administrative information Digital radiology Remote, real-time access to most images
Outpatient quality Measurement Automated tracking of pharmacy and ER use and patient access
Billing Clinician linkage of orders with diagnoses
Automatic medical necessity checking
decision support, that is accompanied by appropriate workflows and that is sup- ported by the communications capabilities discussed in Chapters 20 and 21). We and other organizations are developing these methodologies, but careful research is needed to identify the critical challenges to widespread implementation and demonstrate how to overcome them.
• EHR Tool Development: One enabler of widespread EHR implementation will be the development of high-efficiency, validated, shareable EHR tools (e.g., note tem- plates and order sets). While many tools have been built, we need to standardize their construction, assessment, and maintenance. We need to set them in the context of proven change methodologies (1, 2). We need to know more about the factors that lead to and discourage their use (3).
• Use of the Patient EHR for Patient Interview and Education: Patients’ access to secure e-messaging has the potential to help us address critical gaps in healthcare provi- sion. For example, a substantial research literature shows that computerized patient interview is effective, especially in patients with low literacy. (4) One way patient interview could be used is suggested by Gandhi, et.al’s. study which found that 8%
of outpatients had an ameliorable adverse event attributable to a newly prescribed medicine, which was not addressed due to the patient not reporting the symptoms to the physician or the physician’s failure to respond to the symptoms. (5) Using cur- rently available technology, a software utility could scan the EHR for new prescrip- tions and send patients an electronic (or telephoned or mailed) questionnaire one week after the prescription inquiring about adverse effects and relaying any positive results to the prescribing provider (along with management suggestions).
• Careful Studies of the Effectiveness of the EHR on Efficiency and Quality: Finally, we need to perform real-world effectiveness studies of production EHRs in routine clinical use. While we have clear evidence that many elements of EHRs—and the systems of care they support—work in research settings, we have little knowledge of the incremental contribution each may make in other settings (e.g., healthcare systems, community hospitals, large and small independent provider groups). We need this information to choose among multiple potentially useful implementation options.
References
1. Davis DA. Translating guidelines into practice: A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Can Med Assoc J 1997;157:408–416.
2. Brook RH, Williams K. Quality assurance today and tomorrow: forecast for the future. Ann Intern Med 1976;85:809.
3. Flottorp S, Oxman AD, Håvelsrud K. Cluster randomised controlled trial of tailored interven- tions to improve the management of urinary tract infections in women and sore throat. Br Med J 2002;325:367.
4. Campbell MK. What patients need beyond more accessible information. AMIA Spring Con- gress: Bridging the Digital Divide–Informatics and Vulnerable Populations. Philadelphia; 2003.
5. Gandhi T, Weingart S, Borus J, Leape LL, Bates DW. Adverse Drug Events in Ambulatory Care. New Engl J Med 2003:348;1556.
21. Summary and Prospects 175
