Posts Tagged ‘EHR’

New Publication: Chronic Kidney Disease in an Electronic Health Record Problem List

April 2, 2014

Full title is, “Chronic Kidney Disease in an Electronic Health Record Problem List: Quality of Care, ESRD, and Mortality” published in the American Journal of Nephrology. It has implications for CKD but other chronic conditions as well regarding the appropriate use of problem lists in the EMR. With CKD, diabetes and other chronic conditions which can be initially diagnosed with a lab test (eGFR for CKD), early identification is possible. But if the patient is not formally given the diagnosis in the problem list,  it may lead the lack of early preventive care which can slow the progression of a chronic illness.

On another note, I am also actively blogging for HIMSS and posting blogs from HIMSS volunteers. Check out the HIMSS blog.

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Book Reviews: EHRs

February 6, 2012

I recently read two books on EHR/EMRs: one was published in 2007 but still has relevance, the other published in 2010 and focused on implementation.

EHRsElectronic Health Records: A Guide for Clinicians and Administrators by Jerome Carter is published by the American College of Physicians is a 500+ page volume written primarily for physicians.  The first part of the book is a comprehensive review of EHRs including infrastructure, perspectives on the the use of EHRs for things like outcomes, clinical decision support and quality improvement and legal and privacy issues. The second half of the book is devoted selection and implementation of EHRs with a comprehensive workbook on product features and vendor selection. The majority of the book is still highly relevant with the only exception being some of the information on infrastructure which seems outdated and the lack of discussion of mobile uses of EHRs which is definitely a future goal.

The second book, Keys to EMR/EHR Success: Selecting and Implementing an Electronic Medical Record is also in its second edition. This work by Ronald Sterling begins by walking the reader through the initial questions of why invest in an EMR and how to transition from a practice management system to a full-functioning EMR and how to evaluated the potential legal risks, all common issues for medical practices considering this transition. The author then moves on to product selection and making a decision and negotiating a contract. These implementation details can easily be lost in the selection process and this kind of systematic approach is essential. Finally, the book addresses implementation, activation and support. Again, ongoing support is a common issue for those from the health IT world but not always considered by physicians or practice managers.

Both books provide helpful advice and background for EMR implementation. For those considering an EMR or who want to become familiar with one, these are helpful resources. The book from ACP could also be considered as a textbook in a health informatics curriculum.EMR Success

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Quality and EHRs – What Works

September 6, 2011

A groundbreaking article in the New England Journal of Medicine, Electronic Health Records and Quality of Diabetes Care, by my colleagues in Cleveland, demonstrates several points:

  • Healthcare quality can be effectively measured using EHR data
  • Quality of diabetes care can be improved through the use of EHRs
  • This can be done on a regional basis, beyond the scope of one hospital or health system
  • EHRs are superior to paper records in improving quality care, demonstrating the Meaningful Use Concept
  • This is true over different insurance types.

More background on the initiative, Better Health Greater Cleveland is available Brian Ahier’s blog and on the BHGC website. It is supported by a grant from the Robert Wood Johnson Foundation.

Conclusion: Why shouldn’t this be done more broadly, even nationally. Perhaps through Meaningful Use it will permeate more broadly.

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Secondary Use of EMR Data

December 1, 2010

Part of the value of EMRs is the secondary use of the rich clinical data. Quality studies are an obvious win. This week, a new article by Kaiser Permanente Medical Group used this data in one of several registries to analyze 80,000 Total Joint and 5000 ACL Reconstruction Procedures in the Journal of Bone and Joint Surgery. The data was collected “through standardized documentation at the point of care” and “supplemented with existing administrative data from our electronic health records and other independent databases.” See the registry database structure here.

Also published this week is a second article from the Cleveland Clinic Chronic Kidney Disease Registry regarding the eGFR definition. This is another example utilizing these registries with secondary data for addressing significant issues in medicine.

The HIMSS  2011 conference will feature a symposium on secondary use of data as well.

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Connected for Health: The KP HealthConnect Story

September 16, 2010

Connected For HealthIn a new book edited by Louise Liang, the story of the comprehensive implementation of the EHR at Kaiser Permanent. The story begins in 2002 when George Halvorson, the new CEO, saw the need to implement the EHR  not as a cost savings initiative but as a market differentiator.  He laid down the challenge to accomplish this national implementation in 3 years.  What this represented was not just a software implementation but an organizational change from 9 relatively independent regions to a single practice model centered around this technology. They developed the Blue Sky Vision with consumer centric focus including these themes: home as the hub, integration and leveraging, secure and seamless transition, and customization (perhaps better stated as patient-provider partnership).

The book not only provides a history of this organizational and technology change but also lays out a project management roadmap that can be emulated for smaller hospital systems and hospitals. Regardless of size, EHR implementations must take into consideration timeline, stakeholders and technical challenges. For Kaiser, the timeline affected the implementation in several ways, most notably in delaying customization of provider templates and smart forms until after the go live. Involving stakeholders, two chapters address the building of clinical content by physicians and nurses. They state, “clinicians won’t necessarily be faster, but they should be better” referring to improvements in patient safety and other clinical decision support aspects of the EHR. The role of the patient as a significant stakeholder is addressed in a chapter about My Health Manager, the MyChart product from Epic Systems which was implemented to included eVisits and patient-provider messaging.

Part of the vision from the initiation of project is value realization beyond utilizing the EHR in routine clinical practice.This involves aligning KP HealthConnect with KP values: high quality care, personal care, convenient and affordable. The three phases of value realization are: value creation, value requiring harvesting and transformation of care. This steps included everything from reducing duplication of services, to re-engineered workflows to developing metrics around best practices and clinical guidelines. Population care has become a reality including practice innovation. While most of the care management emphasizes primary care (including a chapter on Redesigning Primary Care), there is some material on specialty practices, such as, oncology.

Adding value for KP HealthConnect also means improving patient safety and enhancing research. In the safety realm, one of the most important concepts behind the EHR which should be true of every EHR is “Making the Right Thing Easy to Do.”  This is where may EHR implementations fail, actually accomplishing quite the opposite and leading to open rebellion by clinicians. If the right thing is easy to do and especially easier than paper, then this single fact makes the cost worth the investment.  In research, the efforts are still at early stages but include retrospective and prospective research, comparative effectiveness research and personalize medicine/genomics. As an adjunct to research, a chapter is devoted to the Archimedes Model as a future direction for KP. Utilizing EHR data, the model takes population studies to a new level by simulating clinical trials and developing mathematical predictive models.

Has Kaiser realized its Blue Sky Vision? The implementation was certainly accomplished on time but admittedly over budget (3.2 billion vs. 4 billion).  At one point, the authors admit to the technical challenges which resulted in stopping the accelerated weekly implementations. Stress on the IT core systems forced a six month hold. Overall the book presents an optimistic view of EHR implementation, successful because of  systematic, team approach including all regions and all professions.  Many of the themes in the book are reminiscent of the optimism of Health Care Reform and EHRs which some times seem a distant dream with very gradual adoption.

Who should read this book? First, any hospital or healthcare system planning or in the midst of an EHR implementation.  Second, hospital CIOs but perhaps more importantly, project managers. Project management professionals are the boots on the ground of EHR implementation and need to learn how to involve stakeholders and move past obstacles toward successful, on schedule implementation. Also, those interested in exploiting or harvesting the value of the value of the EHR in quality improvement, patient safety and research. Finally, clinicians who are involved in EHR implementations or governance will better appreciate the need for vision and the comprehensive impact of EHR on practice and potential practice innovation.

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PHRs, EHRs and Social Media – Where are We Headed?

February 2, 2010

Two coincidental articles were published today. First, in iHealthBeat, John Moore and Matthew Holt talk about why ”Consumers Not Ready for Do-It-Yourself PHRs.” In response to the decision by Revolution Health to discontinue their PHR, the experts comment that “the direct-to-consumer market for PHRs just doesn’t work.” But they say that populated records are the future, those tethered to EHRs, like Kaiser’s and how Google Health and Microsoft HealthVault enable this kind of population of data from other sources. In the future, as it is now for some, the PHR will not be separate from the EHR, just the interface on the front of patient data. But this will mean patient entered data, like diaries of their conditions, and from home monitoring devices.

The second article appeared in JAMA, from the Centre for eHealth Innovation in Toronto, titled, “Electronic Health Records in the Age of Social Networks and Global Telecommunications.” Here the authors talk about the intersection of social media and EHRs. Specifically, the authors envision the future with open standards which can enhance interoperability and “natural language enrich by audio or video…Rich media has the potential to reduce ambiguity and enhance performance in complex tasks.”

So while the concept of PHRs may be on the decline, the future of patient empowerment through information has only begun. The convergence of personal health information, provider-based information and social and rich media will provide a basis for future health decisions on a very individual, personal level.

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Intelligent EHRs – What are they?

September 12, 2007

In an article on Government Health IT, the Intelligent EHR is discussed by a Mayo Clinic physician. Is is something more that an EHR with decision support tools? One quote says, “information becomes [directly] available and usable to a computer so one can repurpose that information for secondary uses such as quality monitoring and research and education.” The article also cites this as “minimally invasive informatics” which avoids disruptive changes in medical practice. But what does it really look like?

Is it simply decision support like alerts? This can result in alert fatigue. It may include quality monitoring, research, pay for performance, biosurveillance – all items which add value to the EMR. Yet there are “some barriers, particularly the increasingly complex ethical, political, technical and social issues surrounding secondary uses of personal information.”
Maybe the real future of an intelligent EHR with be something similar to the sematic web – intelligent agents bringing just the right amount of information to the point of care.

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EHRs Fix Everything?

May 12, 2007

The Healthcare IT Guy pointed to this very interesting article from Family Practice Management, EHRs Fix Everything and Nine Other Myths. Points like, software needs to work the way we work and software will eliminate errors question typical selling points for EHRs.  It is well known that making absolute statements or even inflated statements about software is par for the course but rarely proven out. For instance, software can cause other unintended consequences and reduce efficiency.  However, planning, training and implementation can make significant strides toward reducing these problems and more closely approach the hoped for outcomes of EHRs. Everyone in healthcare IT should read this article just to keep us humble about what we can accomplish.

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Americans Positive about EHRs/PHRs – Markle Survey

December 7, 2006

In a new survey released today by the Markle Foundation, reports that the  “Survey shows that consumers view personal health records as an important element in reducing medical errors and increasing quality of care.” Yet 80% were concerned about privacy and the possible use of information by marketers. 75% see a role for government in protecting their privacy. The report on the survey will be presented at the Connecting Americans to Their Health Care conference in  Washington, D.C. The conference includes a keynote address by Adam Bosworth of Google.

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