Attending the “Informatics Year-in-Review” presentation at the AMIA [American Medical Informatics Association] 2015 Annual Symposium in San Francisco was a little like watching one of those history-of-the-world-in-five-minutes shows. Beneath the breathtaking volume of research highlighted, however, was the clear implication that medical informaticists are bent on staying relevant in an industry quickly moving to value-based care. In her presentation, “Clinical & Consumer Informatics,” Patti Brennan, R.N., Ph.D, of the University of Wisconsin-Madison, shared many nuggets on how the medical informatics community is embracing the issue of EHR [electronic health record] optimization for accountable care. Here are a few :
EHRs do more for process than for outcomes.
“EHRs result in better care management but do not improve patient outcomes,” said Brennan, “so we have to think about integrating the technology into the process.” She cited research that showed use of EHRs resulted in
- improved case management;
- reduced in-hospital mortality (but not much else);
- better interception of wrong patient orders;
- reduced inappropriate haloperidol orders by 80% (those not consistent with an alert);
- more appropriate ED admit/discharge decisions;
- and improvement on 11 of 12 quality measures.
Meaningful use is really useful, but not helpful (yet).
The MU incentive program has resulted in better and more accessible electronic health records and the next step is to ensure they demonstrate an impact on outcomes. “The tools work as they promise,” said Brennan. MU has improved provider performance in the sense that use of specific EHR functions was associated with higher performance on healthcare process metrics such as condition-specific, best-practice alerts and order sets), but not outcomes. Interestingly, pediatric hospitals lag in adoption of key MU features.
Extracting meaningful info from EHRs
“When you use the right models—new tools like natural language processing, information extraction and online learning—we can extract the right information out of an EHR. However, EHRs will require additional technology work in order to ensure we’re not just pulling data out but are able to draw conclusions about patients and their health status,” said Brennan.
It’s not your mother’s EHR.
FHIR is a data-exchange standard that enables a piece of information from one EHR to integrate itself into another EHR completely, going beyond the limitations of data messaging.
“EHRs can now become platforms for population health, identifying risk and facilitating predictive analytics. They can be engines to help the business side, become more proactive. This is really exciting,” said Brennan, adding that evidence shows EHRs can help identify clinical-trials participants via relevance-based method reasoning, promote open communication with patients, improve medication adherence and predict future health.
Novel EHR structures
Three points here, noted Brennan, about EHR customizability: One, EHRs are not simply shrink-wrapped products, but can offer innovative access to data such as large image files in the cloud. Two, EHRs can provide the platform for specialty electronic records. Three, using innovative data architecture, grids can be overlaid on EHRs that allow visualization and image management.
HIEs promote care coordination, seem to save money, & reduce test ordering.
“HIEs are proving to be as good as they promised,” said Brennan, noting that they have cut costs 11 percent in Korea and have led to improved care coordination and reduced imaging in EDs in the United States. However, the Veterans Administration has found, not surprisingly, that HIEs are only good as the data they exchange.
Clinical Decision Support systems WORK…if they are used and built to standards.
“This theme comes through over and over in all the research: the tools are having an effect but not showing effectiveness,” said Brennan. “If clinicians are not using them, they are worthless.”
- Clinicians who used CDS gave twice as much care, but patients did not lose weight, for example.
- Value is in the computational support, not knowledge access.
- CDS does not improve outcomes.
- Case studies reveal limits of CDS and the lack of standards to guide vendors or purchasers.
Assisted cognition, cognitive informatics and situation awareness
“All EHRs have individual users who think in unique ways. It’s possible to augment someone’s thinking rather than merely present data to them. If you build your CDS alerting system for a drug/drug interaction, for example, you can save a clinician or pharmacist time and make them more efficient. However, health systems can individually target CDS to help a clinician in the ER in the things they don’t do well and leave alone the things they do well. Don’t try to replace human judgment,” said Brennan.
“We know poor implementation of EHRs can lead to serious errors, especially when inappropriately integrated into care,” Brennan said. “It’s even worse if you force people to use a bad tool.”
Research among nurses shows that attitude—not skill or EHR features—is the most predictive factor of future “cognitive burden” of EHR implementation.
Providers using the same EHR developed personalized patterns of use and that’s ok. Health systems need to accommodate these differences to best optimize EHR adoption.
“Our HIT infrastructure is not as ready as we would like,” said Brennan, “and is becoming more burdened as we add more devices. We’ve been building EHRs for institutions and have developed HIEs in order to share among institutions. However, those HIEs are built on a hub-and-spoke model that lacks integration. We need to have more of a network focus.”
As we move into value-based care, telemedicine is fulfilling its promise as never before. However, healthcare organizations generally lag in telemedicine implementations and face challenges in how to integrate data from remote devices like robots. Some key points about telemedicine today:
- It reduces ICU mortality, liability and gaps in care;
- Is cost-effective in ophthalmology and supports collaboration;
- But it may result in longer wait times for treatment re-initiation when monitoring for neo-vascular AMD;
- Specialty hospitals & their EDs lag in use of telemedicine;
- Except for that telemedical robot during patient rounds;
- Montana rural-dwellers don’t want to substitute tele-visits for in-person visits, but Minnesota urological patients will, if they are tech-savvy and time-crunched;
- But for that they need to be standardized and properly licensed.
mHealth moves clinical care into everyday living.
“mHealth,” said Brennan, “provides a window into patient lives and gives tools to patients to engage in their own health.”
EHR 2020—near-term strategies
In keeping with the staying-relevant-with-value-based-care theme, earlier this year JAMIA—the Journal of the American Medical Informatics Association—published the EHR 2020 vision of a highly standardized system that still has the capacity for innovation. The vision incorporates 10 principles:
- Simplify & speed documentation.
- Separate data entry from data reporting.
- EHRs should enable systematic learning and research.
- Refocus Regulation.
- Reimbursement regulations should support novel changes and innovation in EHR systems.
- Demonstrating certification criterion should be flexible and transparent.
- Full transparency about unintended consequences and new safety risk.
- Use public-standards-based application programming interfaces (APIs) exchange standards (FHIR) and data standards.
- Promote the integration of EHRs into the full social context of care.
- Improve the designs of interfaces so that they support and build upon how people think (i.e., cognitive-support design).