Kevin S. Hughes, MD, FACSCo-Director, Avon Comprehensive Breast Evaluation Center

Massachusetts General Hospital

Bruce LinProject Director, Family History for Prenatal Providers

Manager, Public Health InitiativesMarch of Dimes

Electronic Health Records vs. Niche Software that is actually useful for Family History

The EHR has tremendous promise as a means of decreasing workload, decreasing

cost and improving quality of care

Reality• EHRs decrease productivity or are neutral• EHRs have not been shown to increase quality• EHRs have not been shown to decrease cost

Consider what Jonathon Bush (AthenaHealth) calls the ‘Cash for Clunkers’ program. Doctors have to

be paid to install these EHRs

The EHR has tremendous promise as a means of decreasing workload, decreasing

cost and improving quality of care

EHR HIT has tremendous promise as a means of decreasing workload, decreasing

cost and improving quality of care

•Apply Algorithms/Guidelines to patient data

•Identify best course of action

•Results displayed as intuitive Visualizations

BRCAPRO Mutation Risk 25%

Suggest Genetic Testing

Facilitates best action as part of workflow

Clinical Decision Support

EHR Issues

“Computerization hasn't saved a dime, nor has it improved administrative

efficiency”• 4,000 hospitals 2003 to 2007 • Computerization

– Weak correlation • Quality for MI

– No correlation• Cost savings• Improvements in administrative efficiency• Quality for pneumonia• Quality for heart failure• Overall quality (MI, heart failure, pneumonia)

Himmelstein, The American Journal of Medicine (2010) 123, 40-46

EHR and productivity varies by specialty100 internists, pediatricians and family practitioners

• 25 to 33 percent drop in MD productivity

• Over time

– Internists slightly above original productivity

– Pediatricians /family practitioners never recovered

Hemant Bhargava, UC Davis Graduate School of Management

Quote from a breast surgeon beginning EHR use

• …our productivity is down 28%

• I am the highest paid transcriptionist in the state

• Each cancer patient chart takes me apprx 1 hour

• For the first time in my career, I turned down an add-on patient

Currently: Paper + memory

Patient completes paper form

Reviews data using memory of guidelines

Orders Genetic Testing

Documents and Orders

EHR: Paper + extra work + memory

Patient completes paper form

Reviews data using memory of guidelines

Staff enters data into the EHR

Documents and Orders

EHR

Generic InterfaceMostly

Filing CabinetOr

Document Management System

SmallDatabase

MedsAllergies

Same interface for every Specialty

EHRMammography

Pathology

Generic

Anesthesia

Cardiovascular

IT ≠ EHR

Role of the EHR in Family History…close to non-existent

While EHRs do poorly for most aspects of medical care, they are worse relative to family history and

genetics

Health IT

• EHR– Designed to manage the entire

spectrum of medical care• Created by large corporations

– E.g., NextGen, Allscripts, eClinicalWorks, Misys, Centricity, Eclipse, LMR

• ‘Niche’ Software– Designed for specialty areas

• Homegrown or developed by small vendors

– E.g., My Family Health Portrait, Jameslink, GREAT, Progeny, HughesRiskApps

Health IT• EHR

– Designed to manage the entire spectrum of medical care

• Created by large corporations

• ‘Niche’ Software– Designed for specialty areas

• Homegrown or developed by small vendors

Health IT and Clinical Care

• EHR

• ‘Niche’ Software

Notes

Lab

ProblemList

Path Reports

Meds

Allergies

EHRs are limited to major areas

Notes

Lab

ProblemList

Path Reports

Meds

Allergies

■

Risk

Ө Pedigree

Θ Family History

■

Genetics

Adding new features for small markets is expensive

Every EHR must rebuild the same basic route

EHRs have difficulty improving • AHIC Core Data Set

– Published 2008– No EHR Vendor has adopted it

• HL7 Pedigree model for interoperability– Approved 2006– No EHR Vendor has adopted it

• Family history upgrade to EHR at my institution– submitted 2006– slated for analysis 2009– Implementation 2013 or later

The American Health Information Community (AHIC) Personalized Health Care Workgroup

Recommendations to Secretary 2007

… Modular family history tool… collection of family health history within the EHR…messaging of … information to a variety of richer … tools that perform risk analyses… results of … calculations … returned to the EHR … for curation

EHR 2

NicheSoftware

Niche/Modular Software Innovative approaches to data entry

Patient data entryClinician data interface

Innovative approaches to CDSRisk Algorithms/GuidelinesVisualization appropriate to userPedigree drawing

EHR as a repositoryCore data setInteroperable

Testing and iteration possible

EHRs and Niche Software

EHR vendors say:• Wait for the EHR to do this

• Niche software is not needed

• EHR should not exchange data with Niche Software

Current EHR Future EHR

Monolithic Interoperable with multiple ‘Specialty Specific’ systems

Family History CDS

AlgorithmsKnowledge

Base

Vendor 1Vendor 2

Vendor 3

Family History CDS

AlgorithmsKnowledge

Base

Family History CDS

AlgorithmsKnowledge

Base

Monolithic Approach150 Vendors create 150 different CDS approaches to the same problemCurrent EHR Future EHR

Monolithic Interoperable with multiple ‘Specialty Specific’ systems

CDS

Hereditary Risk Identification

Click open 4 screens

BRCA1+

Hereditary Risk Identification

Hereditary Risk Identification

Typical EHR

HughesRiskApps

Better workflow

Reviews Report & Pedigree

Reviews suggestedmanagement Documents and

Orders

Patient educatio

nal material

sClinical

Decision Support

Patient enters data Tablet PC

iPadWebsite

Clinical Decision Support

EHR

Current EHR Future EHRDecrease productivity or neutral

Increase productivity

Mostly document repository Database

Mostly free text Structured data

Data entered by staff or provider

Data entered by patient, staff or provider

Generic interface Specialty specific interfaces

Rudimentary CDS/Drug-Drug interactions

Effective CDS for multiple specialties

View isolated transactions View consolidated information about a given problem

Proprietary hidden information

Open access to patient data

Monolithic, barely intraoperable

Interoperable with multiple ‘best of breed’ systems

Clinical Decision Support

AlgorithmsKnowledge

Base

HL7

Vendor 1

Vendor 2

Vendor 3

Current EHR Future EHRMonolithic Interoperable with multiple

‘Specialty Specific’ systems

HughesRiskAppsBreast Surgery Module

Kshughes@Partners.org

www.HughesRiskApps.net