Top 10 Reasons

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Top 10 reasons we need open-source EHRs

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Top 10 Reasons

  1. 1. Top 10 Reasons Why We Need EHRs & Why They Should Be Open-Source Bob Hoyt MD FACP Co-Director Medical Informatics Program University of West Florida
  2. 2. EHRs: Not a panacea
  3. 3. Background <ul><li>EHRs are associated with a significant amount of vendor and academic hype, as well as mixed reviews in the medical literature </li></ul><ul><li>Many of the earlier studies reported came from the same 4 large academic institutions, not representing the average small office or hospital </li></ul><ul><li>What, therefore, are the facts about EHRs? </li></ul>
  4. 4. Why we need EHRs #1 <ul><li>Paper records are grossly inadequate: </li></ul><ul><ul><li>Dangerous because they may be illegible or missing </li></ul></ul><ul><ul><li>Difficult to share </li></ul></ul><ul><ul><li>Expensive to copy </li></ul></ul><ul><ul><li>Expensive to retrieve ($5-$7/pull) and store </li></ul></ul><ul><ul><li>Unable to data mine or easily generate quality reports because they contain non-computable data </li></ul></ul>
  5. 5. Paper-based template
  6. 6. Why we need EHRs #2 <ul><li>Vital information is frequently missing: </li></ul><ul><ul><li>25% of paper charts are missing at the time of the visit </li></ul></ul><ul><ul><li>When charts are present, they still have missing information 14% of time </li></ul></ul><ul><ul><li>Without e-prescribing: no prior medication histories </li></ul></ul><ul><ul><li>Bottom line: decisions are made with incomplete information and about 20% of tests are repeated unnecessarily </li></ul></ul>
  7. 7. Why we need EHRs #3 <ul><li>Faster retrieval times: </li></ul><ul><ul><li>Previous patient notes, lab results, x-rays and medication histories much faster to retrieve using an EHR compare to a paper chart </li></ul></ul><ul><ul><li>Permits better trend analysis </li></ul></ul><ul><ul><li>Permits graphs and flow charts of important results, like PSA, weight, blood pressure, etc </li></ul></ul><ul><ul><li>Computable data and associated with data standards such as HL7, DICOM and LOINC </li></ul></ul>
  8. 8. OpenEMR Vital Signs
  9. 9. Why we need EHRs #4 <ul><li>EHR is available from the office, hospital or home if web based or using VPN </li></ul><ul><ul><li>How many clinicians take call at home at night with the inability to access records on patients they are not familiar with? </li></ul></ul><ul><ul><li>How many clinicians make rounds on a patient at the hospital without office records? </li></ul></ul><ul><ul><li>These are patient safety and quality of care issues </li></ul></ul>
  10. 10. Why we need EHRs #5 <ul><li>Electronic record can be viewed by medical and non-medical staff simultaneously and 24/7 (Not possible with paper) </li></ul><ul><ul><li>If on the same system, a consultant can view the record remotely, as can billing personnel, etc </li></ul></ul><ul><ul><li>Can access records after-hours and on weekends </li></ul></ul><ul><ul><li>Other team players like pharmacists and social workers could have access </li></ul></ul>
  11. 11. Why we need EHRs #6 <ul><li>EHRs are a building block of regional health information organizations and the Nationwide Health Information Network (NHIN) </li></ul><ul><ul><li>It is pointless to spend billions on creating health information organizations and the NHIN if the adoption rate for EHRs stays in the 10% range </li></ul></ul>
  12. 12. Why we need EHRs #7 <ul><li>EHRs can save money, compared to paper by: </li></ul><ul><ul><li>Reducing transcription costs by using templates and voice recognition </li></ul></ul><ul><ul><li>Upcoding encounters because the note is more complete </li></ul></ul><ul><ul><li>Reducing pharmacy call backs by using e-prescribing </li></ul></ul><ul><ul><li>Reducing FTEs and record storage space </li></ul></ul><ul><ul><li>Reducing mailing and faxing costs </li></ul></ul>
  13. 13. Why we need EHRs #8 <ul><li>EHRs support patient (consumer) informatics. There is a trend to allow patient access via a web portal to the electronic health record for: </li></ul><ul><ul><li>Lab results </li></ul></ul><ul><ul><li>Online appointing </li></ul></ul><ul><ul><li>Med refills and renewals </li></ul></ul><ul><ul><li>E-visits </li></ul></ul><ul><ul><li>Secure messaging with office staff or clinicians </li></ul></ul>
  14. 14. Why we need EHRs #9 <ul><li>Data mining is far easier with electronic records: </li></ul><ul><ul><li>American medicine is very late in digitizing its records so aggregated patient information can be analyzed </li></ul></ul><ul><ul><li>We need comparative effectiveness research so we know what the best treatments are, but we can’t do that with paper records </li></ul></ul><ul><ul><li>AI and NLP will help when data is not structured </li></ul></ul><ul><ul><li>This is why Google, Microsoft and IBM are jumping on board the electronic data ship </li></ul></ul>
  15. 15. Why we need EHRs #10 <ul><li>Electronic disease registries are far superior to paper registries </li></ul><ul><ul><li>Compare an auto-populating electronic disease registry with a manual populating disease registry </li></ul></ul><ul><ul><li>You can build in alerts, reminders, rules engines, auto-e-mails and text messages to patients, etc </li></ul></ul><ul><ul><li>Also important for pay-for-performance programs </li></ul></ul>
  16. 16. EHR Disease R egistry Use Lee BJ BMJ 2009;339:b2395 <ul><li>Kidney doctors (6) who work for Kaiser-Permanente (largest non-profit system in US) in Hawaii wanted to improve the early care of patients with chronic kidney disease with earlier referrals from the 110 generalists </li></ul><ul><li>Their population base is 214,000 patients, 10,000 have known decreased kidney function based on accessing lab results </li></ul><ul><li>K-P has Epic ® EHR so they could estimate kidney function in all patients and place abnormals in disease registry </li></ul>
  17. 17. Electronic disease registry <ul><li>Because all patients are in the same EHR they could also access medications and clinical notes </li></ul><ul><li>Kidney doctors notified generalists by secure e-mail about any patient with decreased kidney function </li></ul>
  18. 18. Electronic disease registry <ul><li>Bottom Line: Kidney docs either made treatment recommendations or referred patients to themselves (unsolicited referrals). The rate of late referrals dropped from 32% to 12% </li></ul><ul><li>Is this a logical step for population health and disease management? </li></ul><ul><li>This will work for other diseases </li></ul>
  19. 19. Electronic disease registry <ul><li>This is an intelligent human-machine hybrid clinical decision support initiative </li></ul><ul><li>Why not do this for several years as generalists come on board and slowly work towards computer generated alerts? </li></ul><ul><li>Simple tool for all EHRs to include open-source </li></ul>
  20. 20. Why no mention of improved patient safety and quality? <ul><li>E-prescribing reduces costs because of fewer call backs and increased use of generics </li></ul><ul><li>E-prescribing reduces a few medication errors but not many adverse drug events and we are seeing new errors due to e-prescribing </li></ul><ul><li>Clinicians tend to ignore drug alerts </li></ul><ul><li>Clinicians often ignore guideline recommendations as part of the EHR </li></ul>
  21. 21. Why do Open-Source EHRs make sense to me? #1 <ul><li>They are usually developed from the bottom up, with the end-user in mind </li></ul><ul><ul><li>Compare the DOD’s AHLTA and the VA’s VistA to note the extreme differences in usability and clinician satisfaction </li></ul></ul>
  22. 22. Why do Open-Source EHRs make sense to me? #2 <ul><li>Private EHR vendors are not willing to create and share a training database for students or prospective clients. </li></ul><ul><ul><li>We need hands-on experience for all healthcare workers, including medical students, who want EHR training </li></ul></ul><ul><ul><li>OpenEMR is being used by University of West Florida students as we speak for teaching purposes </li></ul></ul>
  23. 23. Why do Open-Source EHRs make sense to me? #3 <ul><li>Much more cost effective </li></ul><ul><ul><li>Still require implementation, support, upgrades and backup but cost likely to be about 10% of proprietary cost to purchase and maintain </li></ul></ul><ul><ul><li>No haggling with the vendor for best deal </li></ul></ul>
  24. 24. What does the literature say?
  25. 25. Why do Open-Source EHRs make sense to me?
  26. 26. Why do Open-Source EHRs make sense to me? #4 <ul><li>60-70% of US primary care medicine is practiced by very small (1-3 clinicians) groups that are often rural </li></ul><ul><ul><li>They don’t have the capital for upfront expenses </li></ul></ul><ul><ul><li>They have no in-house IT support </li></ul></ul><ul><ul><li>They may have no physician champion </li></ul></ul><ul><ul><li>Initial decreased productivity is a hardship </li></ul></ul>
  27. 27. Why do Open-Source EHRs make sense to me? #5 <ul><li>There are multiple other communities that could benefit from low cost EHRs, besides typical outpatient medical offices: </li></ul><ul><ul><li>Public health </li></ul></ul><ul><ul><li>Nursing homes </li></ul></ul><ul><ul><li>School nurses </li></ul></ul><ul><ul><li>Home health </li></ul></ul><ul><ul><li>Community clinics </li></ul></ul>
  28. 28. Why do Open-Source EHRs make sense to me? #6 <ul><li>They are customizable, unlike proprietary EHRs </li></ul><ul><ul><li>Modifications can be made to match workflow or other requirements </li></ul></ul><ul><ul><li>Modifications can be shared with others </li></ul></ul>
  29. 29. Why do Open-Source EHRs make sense to me? #7 <ul><li>Open-source EHRs have a long track record in the business </li></ul><ul><ul><li>More than 10 FOSS EHRs available </li></ul></ul><ul><ul><li>Example is VistA which has been around for about 15 years </li></ul></ul><ul><ul><li>Has been improved multiple times from input from VA physicians and is not available in many flavors </li></ul></ul>
  30. 30. Why do Open-Source EHRs make sense to me? #9 <ul><li>Open-source in healthcare is on the rise </li></ul>
  31. 31. Why do Open-Source EHRs make sense to me? #9 <ul><li>Open-source in healthcare is on the rise </li></ul>
  32. 32. Why do Open-Source EHRs make sense to me? #10 <ul><li>FOSSs are reliable and secure </li></ul><ul><ul><li>“ FOSS systems can meet, or even exceed, the quality of their proprietary counterparts” and “FOSS-developed systems have a distinct advantage in their ability to respond to security threats (Boulanger, A 2005) </li></ul></ul>
  33. 33. Conclusions <ul><li>Electronic Health Records do have unequivocal benefits over paper records </li></ul><ul><li>FOSS is here to stay in the healthcare field </li></ul><ul><li>Open-source EHRs are unique and a very good fit for many medical communities </li></ul>

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