2. Overview
• Overview of national health information
technology initiatives
• Forces driving adoption of information
technology in healthcare
• Evidence for computerized recommendations
changing behavior
• Evidence for EHRs in Rehabilitation
3. Objectives
Upon participating in this session, you will be able to:
• Explain the forces in the current healthcare environment
promoting adoption of information technology
• Appreciate the types of problems in clinical practice and
healthcare delivery that may be amenable to improvement with
more judicial use of information technology
• Discuss the key factors for success as well as important barriers
to implementing electronic health record systems in
rehabilitation
Required Readings:
• Vreeman DJ, Taggard SL, Rhine MD, Worrell TW. Evidence for electronic health
records in physical therapy. Phys Ther. 2006;86(3):434‐449.
7. Widespread Recognition
A brief history
• 1960’s – First studies of computers in healthcare
• 1991 – IOM Task Force
• 2003 – HHS begins promoting widespread use of HIT
• 2003 – HHS, DoD, VA form Consolidated Health Informatics
• 2004 – President Bush makes HIT a top national priority
– State of the Union Address: “by computerizing health records, we can
avoid dangerous medical mistakes, reduce costs, and improve care”
– Calls for EHRs for most Americans in 10 years
– Creates the Office of the National Health IT Coordinator
• 2004 – DHHS Responds
– Secretary Thompson launches the “Decade of Health Information
Technology”
– Creates a strategy to develop a national health information network
• Flurry of federal activity…
• 2009 – Stimulus package: $20 billion for adopting HIT
8. The Decade of Health Information Technology
• The vision
– Complete, longitudinal health information follows the consumer
– Health decisions are made with information tools to assist and guide
• The (envisioned) result
– Fewer medical errors
– Less wasteful care
– Fewer variations in care
– Patient‐centered care
– Employers with productivity and competitive edge from reduced spending
9. Big Picture
What is the Role of Electronic Health Records?
• EHRs are the primary building blocks
– Delivering info to clinicians
– Collecting info from clinicians (and instruments)
– Repositories for storing data
• A suite of applications and processes
– Not just one ‘program’
– Far more than electronic documentation systems
• Lots of acronyms
– EHR, EMR, EPR, PHR, CPRS, DMR, etc…
– No consensus definition
– IOM concept is most prevalent
10. The EHR
An EHR Includes:
1. Longitudinal collection of electronic health
information for and about persons
2. Immediate electronic access to person‐ and
population level information by authorized, and
only authorized users
3. Provision of knowledge and decision‐support that
enhance the quality, safety, and efficiency of patient
care
4. Support of efficient processes for health care
delivery
• Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. Board on Health Care Services. Key Capabilities of an Electronic Health Record System.
Washington, DC: National Academy Press; 2003.
11. Big Picture
What Will This Look Like?
• A ‘Network of Networks’
– Not a central database
– Communication via shared set of technical and
policy requirements
– Lots of ways underlying networks can form
• Geography
• Affinity
• Benefits
– Leverage existing data pools
– ‘All healthcare is local’
12. Indiana Network for Patient Care
• A working health information exchange for 13+ years
– 100 source systems
– 1 billion discrete results
– Core participant in NHIN prototype projects
• 5 major Indianapolis healthcare systems
– 24 hospitals (95% of hospital/ER care in Indy)
– Hospital‐associated group practices
• County and State health departments
– Immunization records, lab results, tumor registry
• National and regional laboratories
• Lots more on the way…
– 18 new hospitals within existing systems
– 12 new hospitals have signed agreements
– 10 new hospitals have verbally committed
McDonald CJ, Overhage JM, Barnes M, et al. The Indiana network for patient care: a working local health information infrastructure. Health Affairs. 1005;24(5):1214‐1220.
13. Key Challenges to Creating an NHIN
• Limited adoption of EHRs
– Social/political challenges often hardest
– Unequal adoption rates by practice size
• Financial risk
– Uncertain ROI
– Unequal accumulation of benefits
• Threats to privacy and security
15. The Decade of Health Information Technology
Key Focus Areas
• Regional Health Information Organizations (RHIOs)
• Nationwide Health Information Network (NHIN)
• Driving EHR Adoption
– Reduce the risk of investing in EHRs
– Developing a certification process
– Provide implementation support
18. Consumerism
• Empowered patients with changing expectations
– Technology‐enabled experiences
• Consumers (patients) are demanding
– Speed
– Convenience
– Customized service and tools
– Security, confidentiality
• Patients move faster and further than their
health information
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
19. Consumerism
How can information technology help?
• Consumers view technology as ‘state‐of‐the‐art’
– Can promote a perception of high quality
• Integrate information from multiple sources across
the life‐span, but with challenges
• Repositories can be substrate for
– Customizing healthcare delivery and resource
distribution
– Enabling process/system integration to improve
consumer experience
Kaplan B, Brennan PF. Consumer informatics supporting patients as co-producers of quality. JAMIA. 2001;8(4):309-316.
21. Expanded Uses of Health Information
• JCAHO
– Requires data to support management ops,
performance improvement, patient care
• HIPAA
– Admin procedures, physical safeguards, security
– Standards for electronic claims attachments
• Public Health
• Clinical Research
– Clinical data repositories have well documented
research uses
22. Expanded Uses of Health Information
• Practice Management
– Exponential increases in demand for
various types of administrative reports
• Referral patterns
• Productivity
• Lots more…
– Outcomes tracking
• Practice‐based Evidence
• Pay for performance initiatives
23. Expanded Uses of Health Information
How can information technology help?
• Large potential efficiencies via improved data
– Storage
– Processing and analysis
– Transmission
– Monitoring and tracking (quality assurance)
• Key enabler: structure of underlying data
– Build flexible analytics on top
25. Cost of Care
How can information technology help?
• Estimates of saving $140 billion annually
– Central Indiana estimates $120 million
• How?
– Improved information sharing and care coordination
– Reduced redundancy and medical errors
• Challenge: mere adoption won’t produce savings
– Real process change (transformation) must occur
• Misaligned financial incentives
Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings and costs. Health Affairs. 2005;24(5):1103-1117.
26. Clinical Decision Making
• Making sound clinical decisions requires:
– Right information, right time, right format
• EBP (Patients + evidence + clinical expertise)
– Lots of hype
– Clinicians want it, but don’t have time
• Clinicians face a surplus of information
– ambiguous, incomplete, or poorly organized
• Rising tide of information
– Expanding knowledge sources
– Improved communication methods
Tierney WM. Improving clinical decisions and outcomes with information: a review. Int J Med Inf. 2001;62:1-9.
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
27. Clinical Decision Making
What’s the Problem?
• Man is an imperfect data processor
– Sensitive to quantity and organization of information
• Decisions hurt by too many, too few, or poorly organized data
– Clinicians are susceptible to errors of omission
• Humans are “non‐perfectable” data processors
– Better performance requires more time to process
– Irony
• Clinicians increasingly face productivity expectations
• Clinicians face increasing administrative tasks
• McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N Engl J Med 1976;295(24):1351-5.
• Lopopolo RB. Hospital restructuring and the changing nature of the physical therapist’s role. Phys Ther. 1999;79(2) 171-185.
• American Physical Therapy Association. Reported Productivity Expectations of PTs 1999-2002. Available from http://apta.org
28. EBP and Quality of Care
How can information technology help?
• Eliminate the logistic problems
• Efficient access to primary literature
• Efficient access to needed clinical
information
• Tools to support implementing the best
evidence at the point of care
– Computers are tireless data processors
Vreeman DJ. Clinical prediction rules. Phys Ther 2006;86(5):761-762.
Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312(13):71-72
Jette DU, Bacon K, et al. Evidence-based practice: beliefs, attitudes, kowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805.
29. What is a Computerized Reminder?
• A computer‐generated suggestion about clinical care
for an individual patient
– Informed by data stored in an EHR
– Suggestions based on programs that operationalize EBP as
computable rules
• Often integrated into a clinical application
– E.g. Provider order entry or documentation
• Most common form of computerized decision support
• Can be presented on paper or a workstation
37. Why Information Technology?
• All of these forces
– Clinical decision making (EBP)
– Quality of care
– Consumerism
– Expanded uses of health information
are converging on the need to effectively
manage health information
• Inadequacy of our current paper‐based
health information system
39. Reminders for Rehab Providers
How Can Computers Help?
• Activity: Examples from clinical practice
– Content of the reminder
– What data would the computer need?
47. Additional Recommendations
My Opinion
• Adopt EHRs, but be mindful of the complexity
involved
– Clinician workflow (not hardware) is paramount
• Make EHR purchase decisions with the NHIN
vision in mind
– Demand features of interoperability
• HL7 Messaging (import/export) essential
– What features will help me make better clinical
decisions?
– What vocabulary standards are supported?
