Technology in the office
 Carl Dirks, MD, CMIO, Saint Luke’s Health System
Vision of technology
Vision of technology
Dr. Homer Warner
 Salt Lake City, Utah 1960’s
State of the Union
        2004

“By computerizing
health records, we
can avoid dangerous
medical mistakes,
reduce costs, ...
Drivers of technology
     acquisitions
•                      •
    Improve quality        Recruit provider staff

•     ...
•   “A repository of electronically maintained
    information about an individual's lifetime health
    status and health...
2005- EHR plans


No Plans
EHR in use
Currently Implementing
within 2 years
Percentage of EMR utilization, by Practice Size
50

         General EMR            EMR System

40



30



20



10



 0...
HIMSS - 2003 - EHR
The Electronic Health Record (EHR) is a secure, real-time, point-
of-care, patient-centric information ...
Institute of Medicine -
           EHR
Core functionalities           Other functions

 •                             •
  ...
health information and data
health information and
          data
• clinical information
• medical problems
• medical history
• lab information
• codi...
http://www.medcomsoft.com/images/products/components/cpoe_system.jpg




Order entry and support
potential unintended
         cons

• division of health information
• alert fatigue
• provider revolt
Saint Luke’s Care
                                                         Saint Luke’s Health System

                   ...
•   Electronic communication and connectivity


        •   HIPAA compliant messaging


        •   interfaces


        •...
Reporting initiatives

• PQRI - Medicare Physicians quality
  reporting intiative Societal Reporting
  initiatives
• Other...
Certification Commission for
            Health care Information
            Technology

• The Certification Commission is a...
CCHIT.ORG

•   Formed 2004
    •   American Health Information Management Association
        (AHIMA)

    •   Healthcare ...
2005 CCHIT funders
•                           •
    AAFP                        Sutter Health

•                         ...
society endorsements
•                       •
    AAFP                    AMIA

•                       •
    AAP        ...
Current Stakeholders
•   Clinicians and provider organizations who purchase health IT products

•   Safety net providers w...
Certification highlights
•                                •
    EHR vendors apply for            Certification for 3 year
  ...
CCHIT.ORG- Certification


• Functionality
• Interoperability
• Security
Final Ambulatory Functionality Criteria                                                                                   ...
Final Security Criteria                                                   2007 Certification of Ambulatory and Inpatient E...
KLAS ambulatory EHR
      rankings
                                      EpicCare Ambulatory
                             ...
State of the Union
        2004

“By computerizing
health records, we
can avoid dangerous
medical mistakes,
reduce costs, ...
Medicare Modernization
                Act-2003
•                                             •
    Called on secretary of...
EHR anti-kickback exception 9/8/2006
•   “software necessary and used predominantly to create,
    maintain, transmit, or ...
Wait….


• Provisions did not affect tax law.
• enurement restrictions still applied to not
  for profits….
Internal Revenue Service
      memorandum
   date:     05/11/07

             Director, Exempt Organizations, Examinations...
incremental steps


• transitional state-
 • benefits/risks
RelayHealth Hosted Service             Clinical
          interface host                        View




                 ...
• Pharmacy information exchange network-
• enables electronic prescribing transactions
• formulary checking
• patient util...
complimentary
  Technology
complimentary
         Technology
• Interface engine
complimentary
         Technology
• Interface engine
• voice recognition
complimentary
         Technology
• Interface engine
• voice recognition
• fax server
complimentary
         Technology
• Interface engine
• voice recognition
• fax server
• data archiving/
  backup
complimentary
         Technology
• Interface engine
• voice recognition
• fax server
• data archiving/
  backup
• office s...
complimentary
         Technology
• Interface engine
• voice recognition
• fax server
• data archiving/
  backup
• office s...
complimentary
         Technology
• Interface engine    • computer
                        platform - laptop,
• voice reco...
complimentary
         Technology
• Interface engine    • computer
                        platform - laptop,
• voice reco...
implementation
           prioritites
•                      •
    Improve quality        Recruit provider staff

•       ...
Success Factors
• practice management commitment
• Provider commitment
• technology access provisions
• Process reevaluati...
Final thought
        Archives of Internal Medicine
           2007;167 (13):1400-1405
Electronic health record use and th...
Questions?
Technology in the office
Technology in the office
Technology in the office
Technology in the office
Technology in the office
Technology in the office
Technology in the office
Technology in the office
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Technology in the office

  1. 1. Technology in the office Carl Dirks, MD, CMIO, Saint Luke’s Health System
  2. 2. Vision of technology
  3. 3. Vision of technology
  4. 4. Dr. Homer Warner Salt Lake City, Utah 1960’s
  5. 5. State of the Union 2004 “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. “
  6. 6. Drivers of technology acquisitions • • Improve quality Recruit provider staff • • Improve safety Increase billing • • Report quality Competitive enhancements • Improve provider • efficiency “it’s the way of the future” • Save Money • “my partner wants it” • Empower patients
  7. 7. • “A repository of electronically maintained information about an individual's lifetime health status and health care, stored such that it can serve the multiple legitimate users of the record.” • “The current term used to refer to computerization of health record content and associated processes.”
  8. 8. 2005- EHR plans No Plans EHR in use Currently Implementing within 2 years
  9. 9. Percentage of EMR utilization, by Practice Size 50 General EMR EMR System 40 30 20 10 0 1 2 3-5 6-10 >11 Adapted from Blumenthal and Glaser, NEJM June 14, 2007 356:2527-2534
  10. 10. HIMSS - 2003 - EHR The Electronic Health Record (EHR) is a secure, real-time, point- of-care, patient-centric information resource for clinicians. The EHR aids clinicians’ decision-making by providing access to patient health record information when they need it and incorporating evidence-based decision support. The EHR automates and streamlines the clinician’s workflow, ensuring all clinical information is communicated and ameliorates delays in response that result in delays or gaps in care. The EHR also supports the collection of data for uses other than clinical care, such as billing, quality management, outcomes reporting, and public health disease surveillance and reporting.
  11. 11. Institute of Medicine - EHR Core functionalities Other functions • • Health Information and Electronic data communication and connectivity • Results management • Patient support • Order entry and support • Administrative support • Decision support • Reporting and population helath management
  12. 12. health information and data
  13. 13. health information and data • clinical information • medical problems • medical history • lab information • codified versus free text • CCR/CDA - document - the future??
  14. 14. http://www.medcomsoft.com/images/products/components/cpoe_system.jpg Order entry and support
  15. 15. potential unintended cons • division of health information • alert fatigue • provider revolt
  16. 16. Saint Luke’s Care Saint Luke’s Health System Physician Orders Write Down and Read Back for all Verbal Orders DATE TIME ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY Acute Coronary Syndromes – STEMI 1. Admit as inpatient status 2. Level of care: PCU/CVRU ICU 3. Diagnosis – Acute MI 4. Admit to Dr. _________________________________ 5. Obtain H & P, discharge summary, consults and ECGs from most recent previous admission 6. SLH only Resident Case Non-resident case 7. Allergies: 8. Telemetry monitoring 9. Labs: (With next lab draw today) Draw HgA1c Finish ACIP (CK-MB and Troponin at 0 hour, 3 hour, and 6 hour) started in ED ABG B-type Natriuretic Peptide – BNP CBC In A.M. Coag Screen Fasting Lipid Profile Magnesium Renal Panel T4/TSH Urinalysis Other________________________________ 10. Fingerstick blood glucose AC & HS 11. Diet: clear liquids and/or snacks until sheath removal followed by Simply Healthy __________ cal ADA Clear liquids NPO No food after midnight for early morning lab 12. Daily weight 13. Vital signs every 4 hours and prn 14. Consult Endocrinology if patient does not have a history of diabetes & HgA1c greater than 7% 15. Psych consult for any patient who expresses thoughts that they would be better off dead or of hurting themselves in someway (positive on item #9 of the Depression Screening Protocol) 16. Bedrest 17. Oxygen: continuously monitor oxygen saturation, apply O2 per nasal cannula for SpO2 less than 92% 18. ECG in morning STAT ECG for angina and notify physician. 19. Echocardiagram – order routine 20. ECG in morning and as needed for angina and notify physician. 21. Offer tobacco cessation education (if patient has used tobacco in the part 12 months) (Continued) ALLERGIES / INTOLERANCES Affix Patient Label To ALL Pages DANGEROUS ABBREVIATIONS – DO NOT USE! MS, MSO4, MgSO4, q.d. or QD, Height ______ q.o.d. or QOD, U or u, IU Weight ______ ! kg ! lbs gms Latex Allergy Yes ! No ! Never use zero after decimal point (1.0 mg) Page 1 of 3 Always use zero before decimal point (0.5 mg) SYS-1001 (Rev. 08/01/07) Decision support
  17. 17. • Electronic communication and connectivity • HIPAA compliant messaging • interfaces • interchange/exchange of data - rhio?? • Patient support • disease managemeent • personal health record • Administrative support
  18. 18. Reporting initiatives • PQRI - Medicare Physicians quality reporting intiative Societal Reporting initiatives • Other Payors?
  19. 19. Certification Commission for Health care Information Technology • The Certification Commission is a recognized certification body for electronic health records and their networks, and a private, nonprofit initiative. • Our mission is to accelerate the adoption of health information technology by creating an efficient, credible and sustainable certification program.
  20. 20. CCHIT.ORG • Formed 2004 • American Health Information Management Association (AHIMA) • Healthcare Information and Management Systems Society (HIMSS) • The National Alliance for Health Information Technology (Alliance)
  21. 21. 2005 CCHIT funders • • AAFP Sutter Health • • AAP United Health Foundation • ACP • WellPoint, Inc. • California HealthCare Foundation (CHCF) • Hospital Corporation of America • McKesson
  22. 22. society endorsements • • AAFP AMIA • • AAP Physicians Foundation for health systems • excell. ACP • • Physicians’ Foundation ACEP and AEP (ER) for health systems • innovations MGMA • AMA
  23. 23. Current Stakeholders • Clinicians and provider organizations who purchase health IT products • Safety net providers who purchase or receive health IT products • Vendors who develop, market, install and support health IT products; • Payers or purchasers who are prepared to offer incentives for health IT adoption • Health care consumers • Quality organizations • Public health agencies • Clinical and health-services researchers • Standards development organizations • Federal agencies and coordinating bodies representing various Federal agencies as identified by the National Coordinator.
  24. 24. Certification highlights • • EHR vendors apply for Certification for 3 year certification - application periods fee ($30,000) • Annual updates of • Jury observed scripts of criteria functionality - includes MD • attestation of features submitted
  25. 25. CCHIT.ORG- Certification • Functionality • Interoperability • Security
  26. 26. Final Ambulatory Functionality Criteria March 16, 2007 2007 Certification of Ambulatory EHRs AMBULATORY FUNCTIONALITY Provisional Criteria (2007) are highlighted in yellow 2007 Final Criteria - March 16, 2007 Compliance Key: For 2007 Certification of Ambulatory EHRs P = Previous Criteria N = New for Year © 2007 The Certification Commission for Healthcare Information Technology M = Modified for Year Original Source or WG Category and Description Specific Criteria Compliance line # References* Certify in May 2007 Roadmap for May Roadmap for May Phase I 2009 and beyond Discussion / Comments * See reference list 2008 at end of document 1. The system shall provide the ability to display all DC.1.4.3 We assume current and active to mean the F Manage problem list: Create and 13 P current problems associated with a patient. same thing. maintain patient specific problem lists. 2. The system shall provide the ability to maintain a DC.1.4.3 This means both current 14 history of all problems associated with a patient. and inactive and/or resolved problems.These may be viewed on separate screens or the P same screen. Ideally each discrete problem would be listed once. 3. The system shall provide the ability to maintain the DC.1.4.3 It is a vendor design decision whether to 15 onset date of the problem. require complete date or free text of P approximate date. 4. The system shall provide the ability to record the DC.1.4.3 16 chronicity (chronic, acute/self-limiting, etc.) of a P problem. 5. The system shall provide the ability to record the DC.1.4.3 17 user ID and date of all updates to the problem list. P 6. The system shall provide the ability to associate DC.1.4.3 One should be able to identify all visits for a 18 orders, medications, and notes with one or more particular diagnosis/problem. . N problems. Association can be made in structured data or in non-structured data. 7. The system shall provide the ability to associate 18a orders, medications and notes with one or more 2009 problems; association to be structured, codified data. 8. The system shall provide the ability to maintain a DC.1.4.3 For example: ICD-9 CM, ICD-10 CM, 19 coded list of problems. SNOMED-CT, DSM-IV. The Functionality P WG will not specify which code set(s) are to be employed. 9. The system shall provide the ability to display 20 P inactive and/or resolved problems. 10. The system shall provide the ability to separately 21a display active problems from inactive/resolved N problems. CCHIT Ambulatory FUNCTIONALITY Criteria 2007 Final 16Mar07 Page 3 of 46
  27. 27. Final Security Criteria 2007 Certification of Ambulatory and Inpatient EHRs March 16, 2007 Legend: Security - 2007 Final Criteria - Mar 16 2007 Provisional Criteria (2007) are highlighted in yellow Final Secuirty Criteria For 2007 Certification of EHRs P= Previous © 2007 The Certification Commission for Healthcare Information Technology N= New M= Modified Line # Compliance Roadmap for May 2008 Roadmap for May 2009 Source or References Certify in May 2007 WG Category and Description Specific Criteria Discussion/Comments and beyond * See end of document for references. When passwords are used, the system shall not transport Canadian: Ontario 5.3.12.a (System Access Management); S25 P passwords in plain text. CC SFR: FCS_CKM; SP800-53: SC-12 CRYPTOGRAPHIC KEY ESTABLISHMENT AND MANAGEMENT; HIPAA: 164.312(e)(1) When passwords are used, the system shall not display CC SFR: FPT_ITC; S26 P passwords while being entered. ISO 17799 9.2.3; HIPAA 164.312(a)(1) For systems that provide access to PHI through a web CC SFR: AGD_ADM S27 P browser interface (i.e. HTML over HTTP) shall include the capability to encrypt the data communicated over the network via SSL (HTML over HTTPS). Note: Web browser interfaces are often used beyond the perimeter of the protected enterprise network The system shall support protection of integrity of all CC SFR: FPT_RCV S28 P Protected Health Information (PHI) delivered over the Internet or other known open networks via SHA1 hashing and an open protocol such as TLS, SSL, IPSec, XML digital signature, or S/MIME or their successors. The system shall support ensuring the authenticity of remote CC SFR: FPT_RCV S29 P nodes (mutual node authentication) when communicating Protected Health Information (PHI) over the Internet or other known open networks using an open protocol (e.g. TLS, SSL, IPSec, XML sig, S/MIME). Sec The system, when storing PHI on any physical media FIPS 140-2, CC SFR: FCS_COP, OMB M-06-16 N S30 intended to be portable/removable (e.g. thumb-drives, CD- ROM, PDA), shall support use of a standards based encrypted format using triple-DES (3DES), and the Advanced Encryption Standard (AES). Sec Security: Authentication The system shall support two-factor authentication in CC SFR: FIA_UAU; N S31 alignment with NIST 800-63 Level 3 Authentication. Note: SP800-53: IA-2/AC-19, OMB M-06-16 The standards in this area are still evolving. Sec Security: Technical Services The system shall support the storage of any Protected FIPS 140-2, CC SFR: FCS_COP, OMB M-06-16, SP800-53: AC- N S32 Health Information (PHI) data on any associated mobile 19 device(s) such as PDAs, smartphones, etc. in an encrypted format, using triple-DES (3DES), the Advanced Encryption Standard (AES), or their successors. CCHIT Security Criteria 2007 Final 16Mar07 Page 5 of 9
  28. 28. KLAS ambulatory EHR rankings EpicCare Ambulatory 1 • Industry review EMR 2 TouchWorks EHR system • 3 Misys EMR quality, features • marketshare 4 GE Centricity EMR 5 NextGen EMR http://www.healthcareitnews.com/story.cms?id=7697
  29. 29. State of the Union 2004 “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. “
  30. 30. Medicare Modernization Act-2003 • • Called on secretary of underwriting could HHS to promote not be determined development of based on volume standards for • interoperability for electronic prescribing electronic prescribing tool must utilize developed standards • Allows 3rd parties to • underwrite cost of also created medicare electronic prescribing part D drug program for clinicians Federal Register/Vol. 71, No. 152/Tuesday, August 8, 2006/Rules and Regulations http://www.cms.hhs.gov/PhysicianSelfReferral/Downloads/CMS-1303-F.pdf
  31. 31. EHR anti-kickback exception 9/8/2006 • “software necessary and used predominantly to create, maintain, transmit, or receive elecronic health records. Software packages may include functions related to patient administration, for example, scheduling functions, billing, and clinical support” • Must include electronic prescribing capability • Information technology and training services, which would include, for example, internet connectivity and help desk support services. • Electronic health records must be interoperable • providers must pay at least 15% of cost of solution • No hardware included, no underwriter financing Federal Register/Vol. 71, No. 152/Tuesday, August 8, 2006/Rules and Regulations http://www.cms.hhs.gov/PhysicianSelfReferral/Downloads/CMS-1303-F.pdf
  32. 32. Wait…. • Provisions did not affect tax law. • enurement restrictions still applied to not for profits….
  33. 33. Internal Revenue Service memorandum date: 05/11/07 Director, Exempt Organizations, Examinations SE:T:EO:E to: Director, Exempt Organizations, Rulings & Agreements SE:T:EO:RA Director, Exempt Organizations SE:T:EO From: !quot;#$%&'%!()*()% /s/ Hospitals Providing Financial Assistance to Staff Physicians Involving Electronic subject: Health Records The purpose of this memorandum is to provide a directive for handling examination and exemption application cases involving hospitals that provide physicians who have staff privileges at those hospitals (“medical staff physicians”) with financial assistance to acquire and implement software that is used predominantly for creating, maintaining, transmitting, or receiving electronic health records (“EHRs”) for their patients. Many hospitals described in section 501(c)(3) of the Internal Revenue Code (“Code”) plan to establish interoperable EHR systems to improve the effectiveness and efficiency of their medical care and to reduce medical errors. Some hospitals believe that their medical staff physicians need a financial incentive to acquire and implement EHR software that would allow the physicians to connect to the hospitals’ EHR systems. On August 8, 2006, the U.S. Department of Health and Human Services (“HHS”) issued final regulations (see 42 C.F.R. Section 411.357 and 42 C.F.R. Section 1001.952) (“HHS EHR Regulations”) that allow hospitals to provide, within specific parameters, EHR software and technical support services (“Health IT Items and Services”) to their medical staff physicians without violating the federal anti-kickback law, 42 USC §1320a-7b and physician self-referral law, 42 USC §1395nn. We will not treat the benefits a hospital provides to its medical staff physicians as impermissible private benefit or inurement in violation of section 501(c)(3) of the Code if the benefits fall within the range of Health IT Items and Services that are permissible under the HHS EHR Regulations and the hospital operates in the manner described below. A hospital that is otherwise described in section 501(c)(3) of the Code enters into Health IT Subsidy agreements with its medical staff physicians for the provision of Health IT Items and Services at a discount (“Health IT Subsidy Arrangements”). These Health IT Subsidy Arrangements require both the hospital and the participating physicians to comply with the HHS EHR Regulations on a continuing basis. The Health IT Subsidy Arrangements provide that, to the extent permitted by law, the hospital may access all of
  34. 34. incremental steps • transitional state- • benefits/risks
  35. 35. RelayHealth Hosted Service Clinical interface host View Payor Partner RelayHealth View View Patient View HL7 Primary Care HL7 SoC HL7 •Lab Results •Radiology Studies Physicians with SoC •Transcription subscribing EMR •Pathology •Discharge Summary •H&P •Others? SoC
  36. 36. • Pharmacy information exchange network- • enables electronic prescribing transactions • formulary checking • patient utilization histories
  37. 37. complimentary Technology
  38. 38. complimentary Technology • Interface engine
  39. 39. complimentary Technology • Interface engine • voice recognition
  40. 40. complimentary Technology • Interface engine • voice recognition • fax server
  41. 41. complimentary Technology • Interface engine • voice recognition • fax server • data archiving/ backup
  42. 42. complimentary Technology • Interface engine • voice recognition • fax server • data archiving/ backup • office software
  43. 43. complimentary Technology • Interface engine • voice recognition • fax server • data archiving/ backup • office software • marketing website
  44. 44. complimentary Technology • Interface engine • computer platform - laptop, • voice recognition tablet, handheld • fax server • data archiving/ backup • office software • marketing website
  45. 45. complimentary Technology • Interface engine • computer platform - laptop, • voice recognition tablet, handheld • fax server • PACS • data archiving/ backup • office software • marketing website
  46. 46. implementation prioritites • • Improve quality Recruit provider staff • • Improve safety Increase billing • • Report quality Competitive enhancements • Improve provider • efficiency assist in research protocols • Save Money • “it’s the way of the • future” Empower patients • “my partner wants it”
  47. 47. Success Factors • practice management commitment • Provider commitment • technology access provisions • Process reevaluation, rather than reimplementation • Project selection - right tool, right time
  48. 48. Final thought Archives of Internal Medicine 2007;167 (13):1400-1405 Electronic health record use and the quality of ambulatory care in the U.S. • retrospective, cross sectional analysis of visits in 2003 and 2004 national ambulatory medical care survey • compared 17 ambulatory outpatient quality indicators to visits from “paper” practices • 14/17 indicators - no difference • 2 better- BZD/depression, routine UA • 1 worse- statins for hypercholesterolemia
  49. 49. Questions?

×