“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
The Electronic Health and
Medical Record
Dyanne P. Westerberg, DO, FAAFP
Associate Professor and Chair
Family and Community Medicine
Cooper Medical School of Rowan University
Goals
• Discuss the use of the electronic medical
record in today’s practice setting
• Review what physicians like about the EMR
• Review what the physicians do not like about
the EMR
• An opportunity to discuss
Why, oh Why, do we need this???
• On February 17, 2009 the $787 Billion, the
American Recovery and Reinvestment Act of
2009 was signed into law by the federal
government.
• $19.2 Billion is intended to be used to increase
the use of Electronic Health Records (EHR) by
physicians and hospitals;
• This portion is called -the Health Information
Technology for Economic and Clinical Health
Act, or the HITECH Act.
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
1
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Purpose
"To improve the quality of our health care while
lowering its costs, we will make the immediate
investments necessary to ensure that, within five
years, all of America's medical records are
computerized. This will cut waste, eliminate red
tape and reduce the need to repeat expensive
medical tests…But it just won't save billions of
dollars and thousands of jobs; it will save lives by
reducing the deadly but preventable medical errors
that pervade our health-care system."
Purpose
"To improve the quality of our health care while
lowering its costs, we will make the immediate
investments necessary to ensure that, within five
years, all of America's medical records are
computerized. This will cut waste, eliminate red
tape and reduce the need to repeat expensive
medical tests…But it just won't save billions of
dollars and thousands of jobs; it will save lives by
reducing the deadly but preventable medical errors
that pervade our health-care system."
It is almost 6 years!
The HITECH (Health Information
Technology for Economic and Clinical
Health) Act of 2009
Mandates that physicians and hospitals adopt
electronic records by 2014, or face penalties in
the form of reduced Medicare/Medicaid
payments.
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Meaningful Use
• The use of a certified EHR in a meaningful
manner, such as e-prescribing.
• The use of certified EHR technology for
electronic exchange of health information to
improve quality of health care.
• The use of certified EHR technology to submit
clinical quality and other measures.
Stages
1. 2011 Basic Function of the Electronic Health
Record
2. Health Information Exchange
3. Still undetermined
Core Measures
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•
•
•
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•
•
•
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•
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Use computerized order entry for medication orders.
Implement drug-drug, drug-allergy checks.
Generate and transmit permissible prescriptions electronically.
Record demographics.
Maintain an up-to-date problem list of current and active diagnoses.
Maintain active medication list.
Maintain active medication allergy list.
Record and chart changes in vital signs.
Record smoking status for patients 13 years old or older.
Implement one clinical decision support rule.
Report ambulatory quality measures to CMS or the States.
Provide patients with an electronic copy of their health information upon
request.
• Provide clinical summaries to patients for each office visit.
• Capability to exchange key clinical information electronically among
providers and patient authorized entities.
• Protect electronic health information (privacy & security)
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Additional menu items
• Implement drug-formulary checks.
• Incorporate clinical lab-test results into certified EHR as structured data.
• Generate lists of patients by specific conditions to use for quality
improvement, reduction of disparities, research, and outreach.
• Send reminders to patients per patient preference for preventive/ followup care
• Provide patients with timely electronic access to their health information
(including lab results, problem list, medication lists, allergies)
• Use certified EHR to identify patient-specific education resources and
provide to patient if appropriate.
• Perform medication reconciliation as relevant
• Provide summary care record for transitions in care or referrals.
• Capability to submit electronic data to immunization registries and actual
submission.
• Capability to provide electronic syndromic surveillance data to public
health agencies and actual transmission.
Incentives and Penalties
Benefits
• Green
• Chart Storage Space can be used for
something else
• View at multiple offices
• View at home
• Legibility
• Care coordination
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Implementation and upkeep
Cost
• A recent survey published in Health Affairs by
Julia Adler-Milstein, Carol Green and David W.
• An initial loss of around $44,000 on their
investment.
• Almost two-thirds of the practices using
electronic records would lose money even
with government subsidies, the researchers
said.
Why??
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Software as a Service
•
•
•
•
SaaS
“On-demand software”
“Cloud computing”
One of the biggest selling points for these
companies is the potential to reduce IT
support costs by outsourcing hardware and
software maintenance and support to the
SaaS provider.
Quality Measures
Tracking patient parameters
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Flow sheets
• Interface with the labs allows information to
settle into the flow sheet.
• Scanning:
• Robust system can allow information to enter
the flow sheet also
• Poor scanning office flow - information is all
over the place.
Quality Reports
• Neither low-cost nor easy
• Can help a physician know how their patients
are doing with a particular disease process.
• Examples:
– Number of Diabetics with A1C < 8
– Number of patients > 65 with pneumococcal
vaccine
Dash board
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Physician Quality Reporting System
(PQRS)
• From the Tax Relief and Health Care Act of
2006 (TRHCA)
• Physicians may earn an incentive
• You must start reporting in 2013 to avoid a
penalty in 2015.
• Provide information on the quality of care
across different settings
Legibility
Voice Recognition Software
• Medical professionals can
easily adjust to their new
EHR system
• Increase reimbursements
• Save time because they
are not typing.
• Focus on patients.
• Remember to proof read.
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Watch for errors
• Should be…
• Normal male genitalia, he is circumcised
• What the voice recognition heard
• Normal male genitalia, he is “circus size”
Watch for errors
• Should be…
Normal male genitalia, he is circumcised
• What the voice recognition heard
Normal male genitalia, he is “circus size”
Make sure you fix this before you close
the chart.
Chart errors
An intern recently presented a
newly admitted patient on
morning rounds, reporting
that the patient was “status
post BKA (below the knee
amputation).” “How do you
know?” the attending
physician inquired. “It has
been noted on each of the
patient’s prior three discharge
notes,” replied the intern,
looking up from his computer
screen. “Okay,” responded the
attending physician. “Let’s go
see the patient.”
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
9
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
When the team arrived in the
patient’s room, they made a
surprising discovery. The patient
had two feet and ten toes. Where
did the history of BKA come
from? It turned out that four
hospitalizations ago, the voice
recognition dictation system had
misunderstood DKA (diabetic
ketoacidosis) as BKA, and none of
the physicians who reviewed the
chart had detected the error. It
had now become a permanent
part of the electronic medical
record — as if written in stone.
Too legible?
This 14 yo male patient presents to the office with a complaint of wheeze and increasing
SOB that has been going on for a week. He is using his albuterol inhaler about 4 times per
day and now he cannot sleep at night because the wheeze is worse. With the warmer
weather he is playing outside and so his allergy symptoms such as the runny nose and itchy
eyes are present.
ROS: no chest pain, no fever, no chills
PMH: Reactive Airway Disease
Meds: albuterol inhaler PRN
Social: non one in the home smokes
Vital signs: BP 110/70, HR 94, RR 24, temperature 98.6 PO
Physical Exam:
Disposition: Patient is alert and oriented x 3 and in no distress
HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge
Heart: Regular Rate and normal Rhythm
Lungs CTAB
EXT no edema
Skin warm and dry
Assessment:
Reactive Airway Disease with exacerbation: add steroid inhaler and loratadine
Too legible?
This 14 yo male patient presents to the office with a complaint of wheeze and increasing
SOB that has been going on for a week. He is using his albuterol inhaler about 4 times per
day and now he cannot sleep at night because the wheeze is worse. With the warmer
weather he is playing outside and so his allergy symptoms such as the runny nose and itchy
eyes are present.
ROS: no chest pain, no fever, no chills
PMH: Reactive Airway Disease
Meds: albuterol inhaler PRN
Social: non one in the home smokes
Vital signs: BP 110/70, HR 94, RR 24, temperature 98.6 PO
Physical Exam:
Disposition: Patient is alert and oriented x 3 and in no distress
HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge
Heart: Regular Rate and normal Rhythm
Lungs CTAB
EXT no edema
Skin warm and dry
Assessment:
Reactive Airway Disease with exacerbation: add steroid inhaler and loratadine
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Cloning notes
This patient is a 15 yo female who presents with a sore throat x 3 days.
She has cough and rhinorrhea. She tried no medications for this
problem
ROS: no chest pain, no fever, no chills
PMH: migraine headaches
Meds: Tylenol PRN
Social: No one in the house smokes
Physical Exam:
Disposition: Patient is alert and oriented x 3 and in no distress
HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge
Heart: Regular Rate and normal Rhythm
Lungs CTAB
EXT no edema
Skin warm and dry
Next Patient
This patient is a 35 yo female who presents with a sore throat x 3 days.
She has cough and rhinorrhea. She tried no medications for this
problem
ROS: no chest pain, no fever, no chills
PMH: migraine headaches
Meds: Tylenol PRN
Social: No one in the house smokes
Physical Exam:
Disposition: Patient is alert and oriented x 3 and in no distress
HEENT: PERRLA, EOMI, normal throat, normal ears, no nasal discharge
Heart: Regular Rate and normal Rhythm
Lungs CTAB
EXT no edema
Skin warm and dry
What happens in a malpractice case?
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
11
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Improper documentation can
undermine the entire record!!!
• What is real and what is not real?
• The lawyer can cast doubt on all
documentation.
• Watch for “cut and paste” abilities
• Watch for “cloning.”
Example
…Patient has a right BKA from a non-healing
fracture. ..
Neuro Exam:
CN 2-12 intact
Strength = R and L (upper and lower extremities)
DTR: Achilles and Patellar: +2/+4 = R and L
Documentation Tips
• Concise and accurate
• Avoid extraneous information
• You are responsible for the entire content of
the note
• Reference original source if taking from
another note
• Avoid default to the negative templates
• Avoid Physical Exam templates
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
12
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Pop up Reminders
Patient is due for
Pneumococcal vaccine!
Last Hemoglobin A1C was
3 months ago.
Do you want to order this?
Drug Interaction
• Drug Interactions
• Allergies
• Incorrect dosing
E- Prescribing
• Do not have to write
each one out.
• Accurate date of
script.
• Goes directly to the
pharmacy.
• Except scheduled
drugs.
• If they change their
mind- call the
pharmacy.
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
13
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
E- Prescribing
• Do not have to write
each one out.
• Accurate date of
script.
• Goes directly to the
pharmacy.
• Except scheduled
drugs.
• If they change their
mind -call the
pharmacy.
You could cause a
medication error!!
Record Retrieval
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•
•
•
At home
At another office
By the specialist
By the billing
department
Patient interaction
• Forbes Magazine - February 2014 suggests
that the Electronic Medical Record may be
contributing to medical errors because
doctors and nurses are spending so much time
documenting that they spend less time with
the patient and make medical errors.
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
14
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
EHRs distracting physicians from patient
encounters
• The study by Northwestern University and
published by the International Journal of
Medical Informatics in January –
– Paper charts: 9% of visit looking at the paper chart
– EMR: 33% of the visit looking at the computer
screen.
JAMA 2012
Enid Montague, PhD
• “When doctors spend that much time looking
at the computer, it can be difficult for patients
to get their attention… It’s likely that the
ability to listen, problem-solve and think
creatively is not optimal when physicians’ eyes
are glued to the screen.”
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
15
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
After Visit Summary
• Reflective of the visit
• Helps the patient
understand changes
made during the visit
Cooper Family Medicine
After Visit Summary
It was great to see you in the office today.
Today you were treated for the following problems:
Essential Hypertension
Hyperlipidemia
These are the medications you should stop:
Hydrochlorthiazide 25 mg
These are the medications you should start:
Linsinopril 10 mg
Atorvastatin 20 mg
This is when you should return to the office:
2 months or sooner if you experience problems
Goal Setting
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•
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•
Specific
Measurable
Mutually defined
Patient centered
Cooper Family Medicine
After Visit Summary
It was great to see you in the office today. To
improve your health we discussed these goals
today:
Goals:
I will exercise for 15 minutes 4 days a week.
I will eat less rice at dinnertime
I will not skip any medication doses
Patient Portal
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Potentials
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View labs
View immunizations
View medication list
Make appointments
Enter billing information
Take questionnaires.
Potentials
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View labs
• Patients can “email”
you all of their
View immunizations
questions – some do!
View medication list
Make appointments
Enter billing information
Take questionnaires.
Anywhere information
• Allows another treating physician to view the
medical record and learn about the patient.
• Prevent duplication of expensive tests
• Provides better care???
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Transmission Between Systems
Not yet!
New York Times, 9/21/12
56
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
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“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
Office of the Inspector General
expects physicians and hospital to
insure that proper safe guards are
in place to prevent fraud.
• Annual cost of health care fraud is between
$75 billion and $250 billion
• Concerns: cloning and over documentation
Fraud Prevention
• Audit logs
• Monitor of user ID’s to see who is actually
entering the note.
• Possibly allow patients to view their record
and identify fraud
What physicians do not like about the
EMR?
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Time-Consuming Data Entry
User Interfaces That Do Not Match Clinical Workflow
Interference with Face-to-Face Care
Insufficient Health Information Exchange
Information Overload
Mismatch Between Meaningful-Use Criteria and
Clinical Practice
• EHRs Threaten Practice Finances
• EHRs Require Physicians to Perform Lower-Skilled Work
• Template-Based Notes Degrade the Quality of Clinical
Documentation
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
19
“The Electronic Health and Medical Record”
Dyanne P. Westerberg, D.O.
What physicians like?
• 1) Better Access to Patient Data
"Physicians in multiple specialties and practice models noted that their EHRs improved
their abilities to access patient data, both in health care settings and at home."
• 2) Improved Tracking of Guideline Compliance and Disease Markers
"Physicians and administrators in some practices described how EHRs improved their
ability to provide guideline-based care and track patients' markers of disease control
over time. These advantages were predominantly noted in primary care practices."
• 3) Better Communication with Patients and Between Providers.
"Interviewees described enhanced communication through the medical record itself
(e.g., by facilitating access to other providers' notes and eliminating illegible
handwriting) and through EHR-based messaging applications (e.g., patient portals).
Improvements in between-provider communication were most commonly noted in
larger practices, where all providers were on the same EHR."
Comments?
POMA 107th Annual Clinical Assembly
April 29 – May 2, 2015
20