Emr webinar


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Emr webinar

  1. 1. UBC International Medical Graduate Program Webinar September 13, 2011
  2. 2. DISCLOSURE I have no known financial interest or affiliation with any commercial organizations reviewed in this presentation Carol Rimmer - Assistant Director, PITO Program
  3. 3.  Created & funded through the 2007 PMA  BCMA physician support program working alongside the Practice Support Program and the Divisions of Family Practice  Objective, Unbiased, Physician Advocates  Menu of Optional Programs / Services:  Funding  Implementation & Transition Support  Post-Implementation Support  Communities of Practice and Peer Mentor Program  Clinical Innovation Support
  4. 4. MISSION: To support physicians in the adoption of EMR and related technology to support quality of care and physician satisfaction GOALS: Build CAPACITY Deliver effective TECHNOLOGY Support ADOPTION Achieve positive IMPACT
  5. 5.  Capacity Create capacity for EMR leadership, knowledge, skills, communication and peer support at the local level  Technology Make available robust, effective and efficient solutions which meet the clinical requirements – including network, EMR, templates/tools, and interoperability (eReferral, results/reports delivery, EHR)  Adoption EMRs implemented and in at least basic use  Impact EMRs in active use to support clinical goals – chronic disease prevention & management, complex care, shared care, etc.
  6. 6. EMR Adoption Rates: International, National, Provincial
  7. 7. Doctors Use Electronic Patient Medical Records* 100 99 97 97 96 95 94 94 72 Percent 75 68 46 50 37 25 0 NET NZ NOR UK AUS ITA SWE GER * Not including billing systems. Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. FR US CAN
  8. 8. Doctors Use Electronic Patient Medical Records in Their Practice, 2006 and 2009* 2006 2009 100 98 99 92 97 96 95 89 79 72 Percent 75 50 46 42 37 28 25 23 0 NET NZ UK AUS GER US * 2006: “Do you currently use electronic patient medical records in your practice?” * 2009: “Do you use electronic patient medical records in your practice (not including billing systems)?” Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. CAN
  9. 9. TARGET GROUP (~5,000): - Full Service Family Practice GPs - Clinics serving unattached patients (continuity of care) ELIGIBLE BUT UNSUITED (1,368): - Retiring in <5 years (mostly urban solo doctors) - Specialists in community-based practice (med, surg, & psych) - Specialists with heavy hospital or HA focus (e.g. many psychiatrists) - Health Authority owned clinics (eligible but often self-supported by HA) NOTE: Established goal was 70% of target group by 2012 (i.e. 3,800 physicians) NOT ELIGIBLE (2,404): - Hospital-based/Diagnostic - Anaesthesia, CCU, ED, I/P Psych. - Pathologists, Radiologists, etc. - Locums, Hospitalists - Under $50k billing threshold ~5,000 (to 5,500 max) Target Physicians * 6,368 Eligible Physicians 8,772 Total Physicians Source: MSP pay stats 2007/2008: http://www.health.gov.bc.ca/msp/paystats/index.html and PITO data * NOTE:: Assumes ~200 retiring solo GPs will close practices over 5 years. New physicians joining group practices is additional to the 5,000 target collected directly from
  10. 10. Three themes defining EMR adoption in BC: 1. Size/Type of Practice 2. Full Service Family Practice vs Walk-in 3. Urban vs Rural
  11. 11. Category Current BC Adoption Rate Full Service Family Practice Groups 6+ 90% Full Service Family Practice Groups 2-5 Approaching 50% Full Service Family Practice Solo Physicians Approaching 10% Walk-in / Treatment Centres Negligible Surgical Specialties 30-40% Medical Consultants 30-40% Psychiatry ~ 3% Ophthalmology ~20% • EMR adoption is highest in large full service family practice (FSFP) clinics where there is sufficient scale, a practice manager, and physician leadership within the practice. Solo/small clinics see value in EMR, but the barriers to adoption are significantly higher. Often 1 or 2 physicians in a small group hold the others back due to retirement or lack of interest. • Walk-in clinics experience significantly lower value from EMR until extensive interoperability is available for accessing lab/medication profiles in the provincial EHR, ePrescribing, eReferral, and the ability to send a visit note to the GP. • Adoption amongst specialists is now accelerating rapidly. NOTE: Figures represent adoption of any EMR, not necessarily through PITO, and includes partial adoption.
  12. 12. Almost 100% EMR adoption in many small/rural communities Very low adoption in the large urban areas The Two Extremes Primary gaps: • Greater Vancouver • Greater Victoria • Surrey/Delta/Langley • Abbotsford/Chilliwack • Kelowna/Vernon
  13. 13. Understanding EMR Adoption (FSFP) – By Division Primary gaps: • Greater Vancouver • Greater Victoria • Surrey/Delta/Langley • Abbotsford/Chilliwack • Kelowna/Vernon Full Service Family Practice GP EMR Adoption by Community Updated May 27, 2011
  14. 14. EMR adoption by Specialist Physicians Total Candidates On EMR % on EMR
  15. 15. Ontario is in exactly the same situation (as are Alberta, Saskatchewan, and Nova Scotia)
  16. 16. Based on feedback from Peer Mentors
  17. 17. EASE OF USE The chart is never lost Record is legible Record is quickly accessible ( document phone calls, compare images etc.) System can be accessed from anywhere Rx and referral letters can be generated very easily Commonly used sentences and paragraphs can be entered with a few keystrokes No need to archive increasing amounts of paper Easy to transfer files when patients move
  18. 18. IMPROVE PATIENT CARE Easy to graph lab results – allows trends to be identified Easy to search the patient database – many uses: Identify all patients with certain conditions (i.e. diabetes) By condition, determine if appropriate care is being provided Create recall lists based on care needs (CDM and preventive care) Search for all patients on certain medications (i.e. Meridia or patients with dementia on statins)
  19. 19. IMPROVE PATIENT CARE Easy to have computer run constant background searches and display alerts at patient visit Examples:  Patient on Amiodarone – no LFT in last 6 mo.  Patient with diabetes - no HgA1c in last 6 mo.  Patient with history of heart disease – not on a statin Easy to generate high quality referral letters with all selected attachments included
  20. 20. IMPROVE PATIENT CARE Can generate Cardiac Risk scores automatically Check for drug interactions automatically Templates allow a standard approach to problems Patient information can be easily printed From the web From pre-scanned material From medical websites (i.e. www.cma.ca)
  21. 21. • • Controversial EMR can be used just like a paper chart • “The use of EMR in primary care practices is insufficient for ensuring high-quality diabetes care. Efforts to expand EMR use should focus not only on integrating technology but also on developing methods for implementing and integrating this technology into practice reality.” Crosson, J C et al Am Fam Med 2007; 5:209-214 • To optimize use of the EMR for patient care requires selfaudits and intervention reminders – this requires work on the part of the user.
  22. 22. Funding Implementation & Transition Support Technical Support Program  Communities of Practice, Peer Mentor Program and User Groups Interoperability/Provincial EHR
  23. 23. 70% Reimbursement for HW & SW  One-time EMR Costs  Recurring EMR Costs Up to $7,000 Up to $4,494 /year  Hardware & Other Costs  EMR Conversion Support Up to $4,900* Up to $3,000 Field Resources MOH Private Physician Network (PPN)
  24. 24.  Outcomes-based instead of reimbursement for costs  Complete a declaration of meaningful use  Validation of meaningful use  Payments tied to achievement of specified levels of meaningful use  Useful process in building positive relationships and initiating post-implementation support.
  25. 25. • Tools • Relationship Managers • Physician & MOA Peer Mentors
  26. 26.  Physician-initiated  Physician-led  Voluntary  Driven by Shared Care
  27. 27.  Health authority results / reports distribution  eReferral  Provincial eHealth – Initial Priorities  Client Registry (PHNs)  CHARD – Referral Directory  Pharmanet Medical List Review & ePrescribing  PLIS – Lab History Review  Future: Immunizations, requisitions, etc.
  28. 28. STARTING A NEW PRACTICE Best time to implement an EMR! No existing paper charts to convert No ingrained office workflow practices to change Can design office space to accommodate computers, printers etc.
  29. 29. JOINING AN EXISTING PRACTICE EMR in place: Don’t get to choose system All you have to do is learn it. No EMR in place: Need strategy to convert paper charts to electronic Need change management to address office workflow issues Need to retrofit office space to accommodate computers, printers etc.
  30. 30. Post Implementation Support Impact
  31. 31.  Measurement by just “uptake” figures has little meaning  No clear clinical impact  No measure of whether clinic has enhanced clinical usage with an upgrade  Funding not linked to performance/outcome  MUC Approach  Shift evaluation approach and overall program strategy to performancebased, health system/clinical impact model  Developed preliminary 5-Stage Meaningful Use Criteria model based on the US approach*  Different criteria for FSFP and Specialists  Can be further refined if desired to specific specialties and different types of GP clinics
  32. 32. The Theory of Technology Adoption Credit: Adapted from Gartner “Hype Cycle”
  33. 33. The reality of EMR adoption in most practices “Now we will use the EMR for CDM!!!!!” “I’ll just stick with the basics for now…” “It takes too long to enter the data in all the fields… It’s slowing me down…” Credit: Adapted from Gartner “Hype Cycle”
  34. 34. The goal…. New Opportunities • • • • Credit: Adapted from Gartner “Hype Cycle” CDM Complex Care eReferral etc.
  35. 35. Ongoing PSP Support/Modules can then be based on the availability of EMRs and a community of physicians proficient in using EMR for Quality Improvement The how…. Targeted Improvement Support New joint PITO/PSP support to establish knowledge and skills for using EMR for proactive quality improvement General Adoption Support Credit: Adapted from Gartner “Hype Cycle”
  36. 36.  “Physicians using EMR as principle method of record keeping” (PMA) – Prescribing, templates, etc  Physicians have the skills and knowledge of how to use the EMR tools to support Practice Analysis and Quality Improvement  PSP can expect a “Level 4” physician to know how to use the EMR for QI before beginning a PSP module
  37. 37. Summary: Problem Statement A substantial portion of physicians on EMR are still not making full use of the EMR to support CDM (in particular) and those not on EMR have not seen the value. 1. Many physicians who have adopted EMR have not received sufficient training and support, or been able to take the time, to fully adopt the functionality to effectively support CDM 2. Many physicians who have adopted EMR have not participated or completed the PSP CDM Modules, resulting in some not being fully familiar with CDM approach 3. It takes up-front work and change to properly code data, but the benefits (clinical, financial, time) don’t occur until much later and some physicians still don’t foresee/value those benefits – a change management nightmare 4. Physicians frequently report that the way the CDM Toolkit flowsheets, templates and reports were incorporated into the EMR are difficult to use and they often don’t like those developed by other colleagues
  38. 38. EMR “Meaningful Use” / “Clinical Value” Level 5 “Community Shared Care” • Data transfer enables effective shared care between GP and specialists and other care providers Escalating Clinical Value Level 4 “Proactive Care / Data-Driven Practice” • Use of registries, recalls, reminders, templates/flowsheets to measure and follow guideline-informed care Level 3 “Full EMR” • • EMR is the “principle method of record keeping” (PMA) Consistently entering fully structured data (problem list, allergies, prescriptions, etc.) using generally accepted coding standards Level 2 – “EMR Basics” • • Receiving electronic lab and other reports from health authorities and private labs May enter a few notes and/or scan documents, but at best an “electronic paper chart” Level 1 – “Front Office Administration” • Basic Billing & Scheduling system in use – little or no clinical data or point-of-care use
  39. 39. Communities of Practice User Groups Peer Mentor Program Post Implementation Support Program Development Maximizing Clinical Value Pilots with PSP
  40. 40. We already have some pieces that we know work well Peer Mentors – Expert Users Community Engagement User Groups
  41. 41. Team-based approach  MD/MOA Peer Mentors  Clinical context  Coaching on approach, adaptation, workflow, tips  EMR Practice Automation Coach (PAC)  Hands-on assistance in:  Adopting templates  Consistent coding  Configuring reports/queries  Worfklow adjustments  Applying recalls, setting up CDS  Typically a past practice manager, senior MOA
  42. 42. Key characteristics: Coordinated effort Delivered in the context of the priorities and other realities of the local Division of FP Expanded in-practice support (both PSP and PITO) Incentives based on clear measurable results (“meaningful use”) to offset cost and time Improved EMR tools/templates/reports to support PSP Modules Two independent but complementary jointly delivered efforts Initial prototypes to test the model
  43. 43. PITO Division of FP Board EMR CoP may report to Division governance or liaise with Division EMR Committee (CoP) Strategic Support to CoP RM PITO Relationship Manager EMR X User Group EMR Y User Group PAC may be employed directly by Division (e.g. Prince George Pilot) Practice Automation PAC Coach (PAC) MD In-practice EMR Support - Coding - Templates - Reports / Registries Supports PSP Coordinator with EMR-specific knowledge Clinic Clinic MD/MOA Peer Mentors Clinic MOA Clinic - Clinical Context Approach Tips / Tricks PITO funded, may be reimbursed through the Division (e.g. Chilliwack & White Rock Pilots) May be combined PITO/PSP role (e.g. Prince George pilot) Currently CoPs and support roles are being funded and coordinated directly through PITO. PITO is currently undertaking pilots with Prince George, White Rock, and Chilliwack Divisions of FP to deliver/coordinate these services through the Division governance. This model could be expanded in the future as a truly local delivery model. It is envisions that by ~2016, PITO’s role in this support model would diminish and any local support required would be through Divisions.
  44. 44. 2012 – 2015
  45. 45. Environmental Factors – Drivers & Considerations It is important to recognize that the environment has changed since 2006:  Divisions – Require EMR leadership, peer support, special projects  PSP – Require EMR readiness, EMR tools, clinic-based EMR support  Demographics – Significant portion of physicians retiring, causing delay in EMR adoption rate  Adoption curve – We are into the late adopters now who are more conservative and less technology savvy, and typically in smaller practices  Vendor market – The EMR market has consolidated significantly, but with an expanded maturity and popularity of specialist-oriented and open source solutions
  46. 46. 2006-2010 2012-2015 2016+ “Enhancing EMR Use” FOCUS 2011 “Shifting to Impact” “Late Adopters and Optimization” “SelfSufficiency” •Adoption •Adoption and Impact •Adoption and Impact •Interoperability •Ongoing Enhancement
  47. 47.  By 2015  All physicians know how to use the EMR for QI, and can fully benefit from GPSC/SSC incentives  EHR/eHealth interoperability makes practice operation efficient – dependent on:  HA results/reports delivery  Access to EHR (medication/lab/allergy profile and DI reports)  ePrescribing  eReferral  eRequisitions
  48. 48. SUPPORT: Clinic-based support model aligned with Divisions  PITO Relationship Manager supports the EMR CoP (Division “EMR Committee”)  Local Practice Automation Coaches (PACs) with EMR product-specific knowledge support clinics in adopting & using advanced functionality  Local Physician and MOA peer mentors provide clinical/workflow support  Local EMR user groups exist for all locally popular EMRs VALUE: Clear value proposition  EMR in active use for quality improvement and allows full benefit of related GPSC/SSC incentives  EHR/eHealth Interoperability makes practice operation efficient