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Top 10 Reasons

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Top 10 reasons we need open-source EHRs

Top 10 reasons we need open-source EHRs

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    Top 10 Reasons Top 10 Reasons Presentation Transcript

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