Transcript Presentation to the 37 o Congreso Argentino de Pediatria Joseph H

Lessons for Argentina
from the Health Information Technology
Experience of the United States
Presentation to the 37o Congreso Argentino de Pediatria
Joseph H Schneider, MD
Chief Health Information Officer
Indiana University Health
AAP Council of Clinical Information Technology and Child Health Informatics Center
October 1,2015
4/6/2016
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Hola y Gracias
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My First Meal in Mendoza
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Our Objectives – To communicate:
• How the United States’ path towards electronic
medical records (EMRs) and health information
technology (HIT) evolved
• Selected benefits and risks of electronic medical
records
• Lessons for Argentina as you look to making pediatric
care electronic
• Opportunities for cross-collaboration in development of
EMRs and HIT “por un futuro mejor: niños y
adolescentes saludables en tiempos de cambio“
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How We Fly/Bank/Buy
How Pediatric Care Is Recorded
What Are the Problems with Paper?
2005 JAMA Study:
• Clinical information missing in 14% of
visits
– 44% had an adverse effect on patient care
– 59% caused delayed care/additional services
– Missing charts three times more prevalent
with complex patients
• Charts were not available when the office
was closed or if urgent care needed
• Studies like this helped support the US to
implement the Meaningful Use program
where $30 billion is being spent
Where is the US in EMR use?
• From 2006–2013, the % of physicians using any
EMR system increased from 29% to 78%.
• Nearly half use a “basic” EMR, i.e., with patient
history, demographics, problem list, physician notes,
medications, allergies, e-prescribing, and laboratory
and imaging results.
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Where is the US with EMR use?
• In a 2012 study, pediatrician EMR usage was at 79%
with 31 % using a “basic” EMR.
• But only 14% used advanced EMR tools such as
weight-based dosing/tracking immunizations
• One-to-two pediatrician practices were less likely to
have an EMR
• Younger physicians were more likely to have an EMR.
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Where is the US in EMR use?
AAP and other Pediatric Activity
• 2002: Council on Clinical Information Technology (COCIT)
• 2003: #1 Board resolution for a pediatric friendly EMR
• 2004: First electronic transfer of pediatric patient
information using AAP-supported Continuity of Care
Record
• 2005 Partnership for Policy Implementation formed to
improve “computability” of AAP guidelines
• 2009: Child Health Informatics Center (CHIC) formed to
help lead AAP’s HIT efforts
• 2013: Model Child Electronic Health Record Format
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Where is the US in EMR use?
2009: Meaningful Use Acceleration
• From 2004-2009 a US Office of the National
Coordinator of HIT existed, but its biggest
accomplishment probably was just a strategic plan.
• But in 2009 over $30 billion was committed to
Meaningful Use and the development of many
supporting structures for HIT such as informatics
education, health information exchanges, and more
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Where is the US in EMR use?
Meaningful Use: goods/bads
• Lots of physicians and hospitals now have EMRs,
yielding some great benefits in legibility and quality
• Unfortunately there are over 1,000 different vendors
• New types of errors and problems have arisen
• Still limited health information exchange despite EMRs
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EMR Benefits and Risks:
Things EMRs Currently Do Well
• Legibility
• In about 80% of cases, improved practice finances
• Quality improvements: quick record access, protocols
allergy, interaction checking, etc.
• Improved staff & physician morale
• Reduced turnover
• Parents love the technology - Known as “The Docs with
the EMR”
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EMR Benefits and Risks:
Opinions Before Implementation (Pre-MU)
Expense of implementation
94%
Inability to find an EMR that meets needs
80%
Physician resistance
77%
System downtime
72%
Lack of clear return on investment
71%
Transience of vendors
70%
Increase in physician workload
64%
Physicians have inadequate computer skills
60%
No improvement in patient care or quality
58%
EMR Benefits and Risks:
Opinions Post Implementation (Pre-MU)
Improved documentation completeness
94%
Improved access to records
94%
Reduced risk of medical errors
86%
Improved quality of care
84%
Improved communication with specialists
83%
Improved office productivity
77%
Long-term savings
75%
Made documentation easier
65%
More confidential and secure
64%
EMR Benefits and Risks:
Typical Physician Acceptance (Pre-MU)
100%
80%
60%
40%
20%
0%
2 months (n=39)
No Answer
4 months (n=37)
Disagree
Neutral
Agree
Are you satisfied with using your EMR?
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EMR Benefits and Risks:
New types of errors
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EMR Benefits and Risks:
Our Goals Have Changed
• Pre 2009, legibility, reduced errors and better
information access were seen as important
• Meaningful Use had very robust goals that have only
partly been met
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So - What Have We Learned?
• EMRs and other technology have strengths/weaknesses;
like everything else, we need to address these
• Reducing costs and impact to small practices & hospitals
through cloud computing can help with satisfaction/safety
• Processes must be redesigned. Standardizing our work
nationally and internationally is key for STEEEP care,
efficient research and proper new physician training
• Physician involvement in system development and
implementation is absolutely vital
• Relying on political programs for a strategy is dangerous
• Patient involvement and data access is a key to success; in
fact, a single record for each patient is the ideal
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Recommendations - Can Argentina
Avoid the US Mistakes?
• Each child should have their own unique standardsbased secure record for their data
– EMRs would contribute to the patient’s record after each visit
and draw from it for each visit (EMRs can compete on data
presentation and the algorithms they provide)
– Consider starting a patient registry for birth information
(linked with Plan Nacer?) and add allergies, medications,
immunizations and problems. Then add more with time to
generate a longitudinal views of patients from data
– Patients should have access to the record and be able to
comment on it by using cell phones or computers
• With support, could SAP develop this (inter)/national
registry/patient record system to make it trusted?
• This avoids the data exchange problem that the US has
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Recommendations - Can Argentina
Avoid the US Mistakes?
• Consider a “SAP approved” stamp for vendors that
meet key requirements (such as contributing to a
common patient record)
– This avoids the government setting requirements, which
is a big problem in the US
• Consider that SAP (with the AAP?) could develop cloud
Clinical Decision Support that EMRs could access (e.g.,
growth charts that would be populated automatically)
• Consider having SAP require that vendors use a single
secure communication method to replace regular email, that is tied to all EMRs so that patient
interactions can be better tracked
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Recommendations - Can Argentina
Avoid the US Mistakes?
• Consider asking each patient to be a research subject
so that the database can be use to develop predictive
information for patients/populations
• Consider supporting cloud EMRs as they are likely to
be the least costly, but there are dangers with limited
internet access
– Less risk for downtime?
– Updates processed immediately rather than waiting for
an IT person to do them
• Consider modifying learner education so that this
system is supported by new physicians
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Recommendations - Can Argentina Avoid the US Mistakes?
Redesigning Processes is Critial
Extensive physician
involvement is critical
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Standards: Can we work together
towards “un futuro mejor…?
• Can we work together on international pediatric
standards for:
– A single repository for children, separated by
language
– Patient input to EMRs and HIT
– Protocols/order sets
– Research (should we think of every patient as a
research subject?)
– Quality processes and outcomes measures (e.g.,
newborn screening and follow-up)
– EMR presentation of new data types, e.g., genetics
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Argentine Pediatricans:
Is it Time To Take the EMR Plunge?
Yes, especially if
• you are under 55
• you care about
REALLY improving
quality of care in
Argentina
• you want to help
develop
SAP/Argentina as
a leader in
technology
Adios, Gracias y Preguntas
Joseph H Schneider, MD
[email protected]
Indiana University Health
Indianapolis, Indiana
American Academy of Pediatrics
Council on Clinical Information
Technology (COCIT)
Child Health Informatics Center (CHIC)
Elk Grove Village, Illinois