EHR Functionality and the Patient- Centered Medical

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Charting a Course When Charting Isn't Enough

Redwood Health Information Collaborative - Webinar Series

January 21, 2009

Jason M. Mitchell, M.D.Assistant Director

AAFP - Center for Health ITLeawood, KS

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AAFP - Center for Health IT

• Established: October 2003

• Mission: To assist family physicians in acquiring and using EHR systems and other HIT that are affordable and standards-based, for the purposes of improving quality, enhancing safety and increasing efficiency in clinical practice

www.centerforhit.org

Steven E. Waldren, MDDirector

Jason M. Mitchell, MDAssistant Director

David C. Kibbe, MDSenior Advisor

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Objectives for this session:

• Understand the origins and key components of the patient-centered medical home (PCMH).

• Understand the central role of information technology as a tool to enable the PCMH.

• Highlight the core functionalities that electronic health record (EHR) systems must bring into the ambulatory practice.

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EHR Adoption Paradigm

*Rand Health. The Diffusion and Value of Healthcare Information

Technology. 2005.

Family Physicians

Family PhysiciansAll PhysiciansAll Physicians

Rand Study*: 2016 Rand Study*: 2016 before 80%+ before 80%+

physician adoptionphysician adoption

Rand Study*: 2016 Rand Study*: 2016 before 80%+ before 80%+

physician adoptionphysician adoption

Innovators

Early adopters

Early majority

Late adopters

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Jumping Ahead...

Value Based Payment

Consumer Directed

Quality Reporting

Connected Patients

Volume Based Payment

Health Plan Directed

Claim Data Reporting

Online Patients

Current Health Care

Sector

Future Health Care

System

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Medical Home Definition• AAFP Board of Directors - 2008

• "A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a personal physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience and optimal health throughout their lifetimes."

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Technology Hype Curve

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Where is EHR?

Where is the PCMH?

Source: Gartner Consulting

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Origins of the Medical Home

• "Wherever the child is cared for, the question should be asked, ‘Where is the child’s medical home?’ and any pertinent information should be transmitted to that place" - AAP, 1967

• Crossing the Quality Chasm: A New Health System for the 21st Century (the Chasm Report). IOM, 2001

• Future of Family Medicine Project, 2002-2004

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“Chasm Report”(2001)• Six Aims • Ten Rules

• Safe

• Effective

• Patient-Centered

• Timely

• Efficient

• Equitable

• Care based on continuous healing relationships

• Care is customized for patient needs and values

• Patient is source of control

• Knowledge is shared and information flows freely

• Decision making is evidence-based

• Safety is a system property

• Transparency is necessary

• Needs are anticipated

• Waste is continuously decreased

• Cooperation among clinicians is a priority

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Characteristics of the New Model of Family Medicine (2004)

• Personal medical home

• Patient-centered care

• Team approach

• Elimination of barriers to access

• Redesigned offices

• Whole-person orientation

• Care provided within a community context

• Emphasis on quality and safety

• Enhanced practice finance

• Commitment to provide family medicine’s basket of services

AND...

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Characteristics of the New Model of Family Medicine (2004)

• Advanced information systems

• "A standardized electronic health record, adapted to the specific needs of family physicians and the patients they serve, will constitute the central nervous system of the New Model practice."

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HIT Expectations of the New Model

• Integration of information from multiple, diverse sources into a single system to support the comprehensive information needs of primary care

• Based on common health information technology standards

• Up-to-date and accurate problem and medication lists and information about each patient encounter

• Export functionality to share standardized data elements for quality parameters and assessment measures

• Evidence-based clinical practice guidelines

• Order entryReferral tracking

• Disease and population based registriesIntegration of clinical and practice management functions

• Web interface for patients to provide clinical data and facilitate self-care processes

(1 of 2)

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HIT Expectations of the New Model

• Support practice based research concerning costs, processes and outcomes of care

• Clinical decision support systems for application of the latest evidence at the point of care

• Collection, analysis and reporting of clinical decisions and their outcomes

• Informatics infrastructure to support practice-based research, quality improvement and generation of new knowledge

• Easy integration in the daily practice of family physicians

• Reasonable cost

• Major enhancement to the efficiency and quality of care that is delivered

• User friendly

• Flexible

• Stable and reliable

• Delivered with appropriate training for physicians with varying levels of technical expertise

(2 of 2)

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"Required" features of an ambulatory care EHR system

• Harvard “Expert Panel” (NEJM article - 7/3/2008)• “Basic EHR” - 15%

• Patient demographics, problem list, medication list and clinical notes

• Prescription ordering

• View lab and radiology results

• “Fully functional EHR” - 6%• Notes include medical history and follow-up

• Lab and radiology orders are created and sent electronically

• Prescriptions are created and sent electronically

• Digital images of ordered radiology tests can be viewed

• Drug interactions or contraindications

• Abnormal test results are flagged

• Reminders for guideline based interventions or screenings

• (No mention of registry or data analysis functions)

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"Required" features of an ambulatory care EHR system

• Patient-Centered Medical Home• An "EHR system" isn't just a "system" but a "system of systems”

• Identity management system - (EMPI)

• Communication/messaging system - (eVisits)

• Schedule/resource management system - (Workflow optimization)

• Medication management system - (eRx)

• Care coordination/integration system - (Referrals/Consultations/Results)

• Advanced data analysis and visualization system - (Registries)

• Diagnostic ordering and results management system - (Lab/Xray)

• Advanced data capture and documentation system - (Notes)

• Patient education system - (not crumpled, dated handouts)

• Practice web portal - (patient self-service)

• Point of care clinical decision support system - (Evidence-based)

• Point of care financial decision support system - (Efficiency/Value)

• Practice administration/management system - (Integrated)

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"Required" features of an ambulatory care EHR system

Patient-Centered Medical Home"Infrastructure" Tools

• Semantic Interoperability

Not just the ability to view others "documents", but to incorporate and understand clinical data from other sources into your own system

• Primary Care Data Model (Ontology)

Defining and organizing the "nouns" and "verbs" of family medicine and their relationships

• System design and dependencies

• Workflow analysis and management tools

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NCQA PPC-PCMH Recognition

• Nine Standards• PPC 1: Access and Communication

• PPC 2: Patient Tracking and Registry Functions

• PPC 3: Care Management

• PPC 4: Patient Self-Management Support

• PPC 5: Electronic Prescribing

• PPC 6: Test Tracking

• PPC 7: Referral Tracking

• PPC 8: Performance Reporting and Improvement

• PPC 9: Advanced Electronic Communications

http://www.ncqa.org/tabid/629/Default.aspx#pcmh

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NCQA PPC-PCMH Recognition

• Without an EHR / Electronic registry / e-Prescribing

• “Level 1” PPC-PCMH may be possible

• “Level 2” and “Level 3” will not be achievable without full-featured, well-implemented, and optimally-utilized HIT systems

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Conclusions• Semantic Interoperability remains the IT (clinical?) priority

• It’s just so darn hard

• Quality and Safety are the "hallmarks" of the Medical Home

• It's not the paper that kills, it's the process

• An "electronic" version of the "paper chart" won't cut it

• It’s about “data” not “documents”

• EHR = “central nervous system of the New Model practice” • Won’t get above NCQA “Level 1” without it

• Do current “EHR”s represent the needed “system of systems”?

(1 of 2)

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Conclusions• EHR for Family Physicians

• No longer a matter of "IF" but "When" and "What"

• Most implementation failures are not due to the technology• "Sociotechnical" factors

• Plan for organizational and user process issues

• No reports of problems due to "over" training

• This is not a “one time”, “big bang” process

• Ongoing adaptation and updates

• Annual updates are not an "option" but a "necessity"

• Choose carefully, Implement wisely, Use optimally (2 of 2)

Questions? - Comments!

www.centerforhit.org

Jason M. Mitchell, M.D.jmitchell@aafp.org

(800) 274-2237 x 4102