# Presentation: 447620

## Reducing Structural / Cultural / Legal Barriers to Adoption and Optimal Use of Certified EHRs

- American Health Information Community
- Electronic Health Records Workgroup
- August 15, 2006                                                                                                                     *Peter Basch, MD*
- Washington, DC*                                                                                                                    Medical Director, eHealth*
*                                                                                                                               **MedStar Health*

## My perspective(s)

- Practicing general internist, Washington, DC
- Early adopter of HIT
- Using EMR for ~ 10 years
- Using ePrescribing / email
- Participating in a P4P demo
- Medical Director eHealth, MedStar Health
- Largest not-for-profit healthcare system in the area
- My primary role – expand the EMR implementation to other physicians within MedStar Health
- Implementations – focused on enhancing quality / safety of practice

- Chair, Maryland Task Force on EHRs
- Co-Chair, Physicians’ EHR Coalition
- Board member, MD-DC Collaborative for HIT
- Board member and Leadership Council member, eHealth Initiative
- Member, Health Information Technology Advisory Panel, JCAHO
- (Views expressed today are mine and not necessarily those of any of the organizations listed above)

## Testimony commentary

- I was asked to discuss legal / cultural barriers
- Not a lawyer
- Not a sociologist
- Viewpoint of the HIT ‘endgame’
- Early adopter of HIT
- Practicing clinician
- Process redesign / change management for a health system
- What will / could / should an interconnected HIT healthcare system look like?
- What are the implications for clinicians / health systems who participate in such a transformed system (using HIT / HIE)?
- Cost / benefit
- Workflow / careflow considerations
- Unintended consequences
- Duty / liability
- Potential for / likelihood of new errors

##  Washington Primary Care Physicians – then, 

- _1995_
- 4-person general internal medicine
- Two offices
- Capitol Hill (Washington, DC)
- PG County (Maryland)
- 12 support staff
- Drowning in paper
- Struggling to survive with declining reimbursements / increasing responsibilities
- Decision made to get an EMR
- Increase physician productivity
- Have same information available at   both locations
- Simplify compliance with emerging E/M documentation requirements

##  Washington Primary Care Physicians – and now

- _1995_
- 4-person general internal medicine
- Two offices
- Capitol Hill (Washington, DC)
- PG County (Maryland)
- 12 support staff
- Drowning in paper
- Struggling to survive with declining reimbursements / increasing responsibilities
- Decision made to get an EMR
- Increase physician productivity
- Have same information available at  both locations
- Simplify compliance with emerging E/M documentation requirements

- _2006_
- 8-person general internal medicine
- One office
- Capitol Hill PG County (Maryland)
- 12 support staff
- Drowning in information
- Surviving
- All enabled by an EMR
- Outcomes?
- No increased productivity, but substantially improved efficiency
- Yes, chart available (securely) anywhere
- Yes, we have entered the world of ‘digital garbage’

## Impact on patients – then, 

- _1995_ (pre-EMR)
- Evaluated in context
- Chart missing 1/3 of time
- Chart sometimes pulled for calls
- Chart never available when on-call at night, weekends
- Safety – limited by
- Up-to-date med list available
- Knowledge of doc
- Alertness / attentiveness of doc
- Use of a text reference (e.g. PDR)
- Quality – limited by
- Up-to-date problems / meds / labs in chart
- Knowledge of doc
- Alertness / attentiveness of doc
- Use of a text reference

- _2006_
- Evaluated in context
- Chart always available for visits
- Chart always available for calls
- Chart always available when on-call
- Safety
- Med list always available
- Medication reconciliation part of each visit
- All new prescriptions and refills trigger interaction software alerts
- Quality
- Problems / meds / labs in chart
- Granular / actionable alerts galore
- Docs
- Staff
- Patients

## Impact on patients – and now 

- _1995_ (pre-EMR)
- Evaluated in context
- Chart missing 1/3 of time
- Chart sometimes pulled for calls
- Chart never available when on-call at night, weekends
- Safety – limited by
- Up-to-date med list available
- Knowledge of doc
- Alertness / attentiveness of doc
- Use of a text reference (e.g. PDR)
- Quality – limited by
- Up-to-date problems / meds / labs in chart
- Knowledge of doc
- Alertness / attentiveness of doc
- Use of a text reference

- _2006_
- Evaluated in context
- Chart always available for visits
- Chart always available for calls
- Chart always available when on-call
- Safety
- Med list always available
- Medication reconciliation part of each visit
- All new prescriptions and refills trigger interaction software alerts
- Quality
- Problems / meds / labs in chart
- Granular / actionable alerts galore
- Docs
- Staff
- Patients

## Impact on patients – and now (except) 

- _1995_ (pre-EMR)
- Evaluated in context
- Chart missing 1/3 of time
- Chart sometimes pulled for calls
- Chart never available when on-call at night, weekends
- Safety – limited by
- Up-to-date med list available
- Knowledge of doc
- Alertness / attentiveness of doc
- Use of a text reference (e.g. PDR)
- Quality – limited by
- Up-to-date problems / meds / labs in chart
- Knowledge of doc
- Alertness / attentiveness of doc
- Use of a text reference

- _2006_
- Evaluated in context
- Chart always available for visits
- Chart always available for calls
- Chart always available when on-call
- Safety
- Med list always available
- Medication reconciliation part of each visit
- All new prescriptions and refills trigger interaction software alerts
- Quality
- Problems / meds / labs in chart
- Granular / actionable alerts galore
- Docs
- Staff
- Patients

## If the EMR provides such clear potential for benefit for doctors and patients...

- ...why is it not (regularly) used to provide that benefit?
- ...why is EMR adoption so low (and so slow)?

## The chasm...

- Informational medicine is suffering
- Preventative services done ~ 50% of the time
- Chronic care management done well < 50% of the time
- “44,000 – 98,000” deaths/yr from medical errors

- “What do you expect from a 7-10 min office visit.”
- “Nobody pays for preventative care, I’m surprised that much is done.”
- “If they really cared about quality of chronic care, maybe they should pay for it; and we shouldn’t have to spend so much of our time trying to meet irrelevant documentation rules and pointless prior authorization forms.”
- “Not in my practice.  That must be from inpatient errors.”
- Broken / fragmented system
- Undervaluing of information / management

## If crossing the chasm →

- Cost of IT solutions
- Incentives for adoption
- Workflow / training
- Usability
- HIT / HIE enablers
- Standards organizations
- RHIOs / NHIN
- ONC
- AHIC

- Reducing barriers to

## If crossing the chasm → resolving

- Healthcare fragmentation
- Waste, redundancy, inefficiency → profit to another stakeholder
- Outdated / out-of-sync reimbursement policies
- Procedural medicine is relatively generously reimbursed
- Visit-based medicine is relatively poorly reimbursed
- Information management is not reimbursed
- And we understand that the maximal value of HIT / HIE
- Improving the value of visits
- Improvement in information management
- Two disturbing conclusions
- The more HIT is optimally used, the worse the financial ROI for physicians and hospitals (HIT purchasers)
- Without concomitant resolution of healthcare fragmentation / outdated reimbursement policies, HIT use will be suboptimal / dysfunctional

## Slide 13

## Slide 14

## Slide 15

## Slide 16

## If crossing the chasm → resolving

- Healthcare fragmentation
- Waste, redundancy, inefficiency → profit to another stakeholder
- Outdated / out-of-sync reimbursement policies
- Procedural medicine is relatively generously reimbursed
- Visit-based medicine is relatively poorly reimbursed
- Information management is not reimbursed
- And we appreciate that the maximal value of HIT / HIE
- Improving the value of visits
- Improvement in information management
- Two disturbing conclusions
- The more HIT is optimally used, the worse the financial ROI for physicians and hospitals (HIT purchasers)
- Without concomitant resolution of healthcare fragmentation / outdated reimbursement policies, HIT use will be suboptimal / dysfunctional

##   May suggest the need to reframe the broad and specific  charge to this workgroup

- Healthcare fragmentation
- Waste, redundancy, inefficiency → profit to another stakeholder
- Outdated / out-of-sync reimbursement policies
- Procedural medicine is relatively generously reimbursed
- Visit-based medicine is relatively poorly reimbursed
- Information management is not reimbursed
- The value achieved by optimization of HIT / HIE
- Improvement in information management
- Improving the value of visits
- Two disturbing conclusions
- The more HIT is optimally used, the worse the financial ROI for physicians and hospitals (HIT purchasers)
- Without concomitant resolution of healthcare fragmentation / outdated reimbursement policies, HIT use will be suboptimal / dysfunctional

-     Strategies to reduce cost, risk, and improve interoperability may be largely irrelevant

-    Success in HIT / HIE adoption may also be irrelevant

-     “The question should not be why is the rate of EMR adoption so low, but rather, why are physicians adopting them at all?”

## Conclusions supported by the literature 

- Miller (Health Affairs September-October 2005)
- MDs in small practices can create a rapid ROI from HIT
- Elimination of transcription
- “Right-coding”
- No evidence of improved quality / safety / efficacy
- Sidorov (Health Affairs July-August 2006)
- Benefits of HIT are highly overstated, rarely achieved in actual implementations

## Better solution sequence...

- Along with work on standards / usability, etc.
- De-fragmentation of healthcare
- New reimbursement schema aligned with the IOM goals of STEEEP care
- _HIT / HIE serve as the enabling infrastructure_
- _Adopting advanced (even expensive) HIT is seen as a smart option (and good business decision)_
- _Most of today’s barriers to IT adoption / use vanish_

## Assume success in healthcare de-fragmentation and reimbursement reform...

- _Reimbursement schema is aligned with using every available opportunity to optimize care _
- Enhancing reactive care
- Adding proactive / population-based care
- Adding self-care and eCare
- Adding team-based care (utilizing virtual group practices)
- Including a care model based on interconnectedness

## Where are the new barriers to optimal use of HIT / HIE?

- Workforce
- Software immaturity
- Lack of clinical protocols for interconnectedness
- Unresolved (unasked) medico-legal questions concerning the use of HIT / HIE
- Application of an out-of-date documentation schema to 21st century medicine
- Anticipating new errors caused by HIT / HIE –enabled medical care

## Workforce barriers

- Reactive medical model
- Current physicians
- Current residents
- Current medical students
- How do we train for a new model of care?
- Insertion of new curricula re
- Proactive / population-based care
- Use of HIT / HIE to optimize STEEEP care
- How do we retrain those currently in practice?
- ACP’s Center for Practice Innovation
- AAFP’s Center Health Information Technology
- AMIA
- eHealth Initiative (Workgroup on Practice Transformation)

## Software immaturity

- Most current EMRs are fair-to-excellent
- Documentation support for E/M coding
- Representing episodes of care
- Few (no) EMRs currently have
- Embedded granular / actionable clinical decision support
- Robust tools for determining, aggregating, reporting PMs
- Forms / structure for following episodes of care over time
- Forms for care coordination
- Interoperability sufficient to meaningfully share information with colleagues, patients, payers, QIOs
- Dashboards for monitoring preventative / chronic care adherence

## Clinical protocols for interconnectedness

- Technical interoperability does not result in interconnectedness – it just makes it easier / probably less expensive
- There is a well understood model in place for point-to-point data transmission
- Context
- Responsibility
- Hand-offs
- Without defined protocols for interconnectedness, broad availability of information can easily result in
- Information overload
- Wrong decisions based on information out-of-context
- Care confusion
- Even in our most advanced sites of HIE – this issue is being largely ignored, or left to physician preference

## Medico-legal challenges

- Use of an EHR
- Does access to an EHR elevate the standard of care?
- Does access to an EHR that contains the potential for advanced CDS place the physician who is newly learning the EHR at risk, if the CDS is not activated from day #1?
- Do health systems that participate in EHR networks (to accelerate the adoption of EHRs by their affiliated medical staffs) now assume a quality of care duty for physicians whom they do not employ?
- Use of a HIE
- Will availability of a HIE add a new duty to use it?
- If so, will that duty be shared by all physicians?
- If so, will that duty be episodic or continuous?
- Will information in (or accessible via) a HIE be considered part of a medico-legal record, or just a source of information?
- If considered part of the record; will it be the record of record, or a second or ‘shadow’ record?
- If a medico-legal record, will all components be date-time stamped, permanent, and unalterable?

## Outdated documentation schema

- Much concern is expressed about the difficulty in sharing clinical progress notes
- There is often little value in progress notes
- Made worse by EHRs
- Made much worse by E/M documentation rules
- Before we spend too much time attempting to share these bloated monstrosities
- Work on a new documentation schema
- Based on enhancing quality, longitudinal care
- Called for by Sec 941 of the MMA of 2003

## Potential for unintended consequences

- New errors from EHRs
- Never misspelled – but sometimes wrong / useless
- Faithful propagation of errors
- Multi-tasking
- Pick-list / drop-down list errors
- Attention to CDS prompts
- A narrow focus on outcomes
- Measure-centric and not patient-centric care
- Cherry-picking / patient-dumping
- A return of medical paternalism
- Further de-professionalization of medicine

## Conclusions

- Major problems with healthcare delivery in the US are not caused by a lack of HIT or interoperability – but rather by system fragmentation and an outdated reimbursement schema
- Resolving these problems will require an infrastructure of interoperable HIT
- What are now thought of as barriers to HIT adoption would greatly diminish or even disappear, if a sustainable business case was developed for information management and quality
- Even if such a sustainable business case were developed, there would still be barriers to optimal use – but all are resolvable