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Accenture

Embracing all levels and types of clinical practice, EHRs provide real-time access to key patient data,optimize scarce resources and enhance collaboration along the entire care continuum.

EHRs (electronic health records) drive dramatic, positive change within clinical practice. By improving information and knowledge exchange, they make it possible for clinicians to act more proactively and collaboratively.

A multitude of legacy systems hold a wealth of information about patients and their care. Payers, providers, patients and supporting vendors all “own” a piece of the puzzle. Integrating their systems for bidirectional connectivity creates an interactive umbrella covering vast amounts of information and data.

With bidirectional access, everyone involved in patient care benefits from current and retrospective data. The emergency room physician, for example, can review information already collected by the primary care physician and specialists, and the primary care physician can maintain up-to-date information about the patient’s status in acute, post-acute and home-care venues. Great potential exists for enhancing all levels and types of clinical practice but, in practical terms, what are the obstacles to EHR implementation and meaningful interoperability?

What Are the Roadblocks?

To make EHR work in a highly fragmented market, the various venues must come together at the information and data level, because the patient can be anywhere along the care continuum at any given moment. Aligning data access, input and retrieval creates a seamless virtual system that leads to a consistent standard of care and the best outcomes.

Diverse systems and a lack of standardization challenge implementation of EHRs. Literally hundreds of vendors populate the market. Many focus solely on segments. Most offer desktop, remote and wireless integration, but not all offer a portable device or one with full functionality. Although the marketplace for EHR applications and products has consolidated, only a fraction of the hundreds of vendors offer meaningful solutions and even fewer may address specific clinical needs. In addition, physicians, acute-care facilities, post-acute care venues and homecare providers – as well as their suppliers – remain invested in their legacy approaches and systems, which may or may not accommodate interconnectivity.

Other roadblocks to implementation include the cost and technical challenges related to modifying or creating new systems, complying with evolving standards, navigating antitrust and other legal issues and the generally arduous processes of systems selection and decision making.

In addition, as clinical information systems improve, expectations for those systems increase exponentially. Physicians, in particular, tend to seek out “the next best thing,” looking for ways to improve workflows. Remote information retrieval, for example, makes it possible to access X-rays from home, so why not retrospective data from specialist visits, too? In essence, the expectation and satisfaction cycle shrinks every day as more clinicians adopt – and want more from – new processes. That makes it more and more difficult for any system to satisfy its users.

What’s on the Market?

The hundreds of vendors who offer EHR products include small companies with specific capabilities and large medical information systems providers. Each offers different capabilities for handling key requirements, depending on the size(s) of the businesses it targets. For example, some vendors offer implementation assistance while others do not.

In general, physicians want EHR tools that provide clinical value, are easy to access and do not slow them down. From their perspective, a desirable system:

• Uses the same or less time in clinical care per patient;
• Does not encroach on nonwork time;
• Allows easy entry of orders with little training;
• Provides useful access to current clinical information, such as lab and pathology results, diagnostic studies, vital signs, current orders and history;
• Can be accessed from home, hospital, office or elsewhere;
• Provides one-stop shopping with a single sign-on for all tools;
• Allows access to useful reference information;
• Enhances Part B documentation and coding; and
• Improves patient safety.

At the most basic level, some products offer limited clinical note-taking capability, together with e-prescribing, some document image management, clinical results tracking and messaging, and the ability to view lab results and dictated reports. Further up the scale, other products offer “charting systems” with complete clinical notes and some alerts and decision support. This level of functionality usually incorporates limited coding methodology and a limited summary of clinical results.

Some products provide more complete electronic medical record (EMR) functionality, with a full charting system, including automated coding and drug alerts, as well as access to a limited national knowledge base and clinical decision support. This level includes limited formulary compliance and a summary of clinical results. At about 40 percent of the cost of full EHR capability, this approach tends to be the most popular.

At the full EHR level, in addition to meeting charting system and EMR requirements, the product provides national drug and clinical alerts, access to national clinical protocols and guidelines, a third-party clinical knowledge base, clinical decision support, information about clinical standards and a physician-specific summary page with workflow. This highest level of functionality also includes multi-health plan health-maintenance rules, direct patient interaction and other capabilities.

The costs of various products vary, depending on their ability to meet these requirements, including one-time capital and operating investments and ongoing operating costs. Financing options range from governmental programs and payer subsidies to employer/business coalitions and fee-for-service approaches. Implementation time frames depend on the level of service needed and prioritization of modules.

What Does It Mean?

EHR implementation offers great promise for clinical practice and care management. Fortuitously, as order entry drives direct use of electronic interfaces, more and more physicians engage in such processes and see the benefits. (Most studies indicate that being able to view results and other patient information strongly influences adoption, as does the ability to involve patients in their own care management.) Participation by more physicians — and the accompanying benefits of expanding adoption — will drive EHR implementation exponentially.

EHR breaks down the arbitrary silos between care venues, all operating independently and not fully communicating. By eliminating such barriers, clinicians can collaborate across the entire care continuum. In addition, such care takes place in an environment of automated checks and alerts built on evidence-based algorithms. Outcomes improve dramatically when clinicians, caregivers and patients interact based on objective information.

Other factors further enhance patient safety and outcomes. Critical information handovers are better managed, such as those involving admissions, discharges and transfers from one hospital, physician or caregiver to another. Key data doesn’t get lost in the shuffle and can be accessed by everyone. Typical failure points are minimized, such as information loss between shifts, units, venues and clinicians.

In addition, e-prescribing made possible by EHR reduces error rates in the ordering process and the reading of orders by physicians, pharmacists and nurses. Dosage verification ties objective algorithms to current medications, disease states and laboratory values, and flags abnormalities or contraindications.

EHR also integrates tracking of patient compliance with directives. This drives optimal use of (and reduces physician liability for) medications, interval lab testing and discharge instructions for follow-up visits.

EHR augments workforce planning by reducing redundancies and optimizing the performance of physicians, physician extenders, nurses, technologists and administrative personnel. Access to diagnostic and therapeutic information, as well as a central repository for patient and care information, dramatically enhances productivity across the spectrum. Typical business processes become more standardized for greater efficiency. Key improvements can be realized in scheduling, for example, by allowing up-to-the-minute access to patient information and enabling immediate documentation, prescribing and billing.

With peer-reviewed online decision support, and disease-appropriate prompting for medications and testing, EHR can integrate formerly fragmented disease management models. This results in improved coordination of services, without an added burden to the primary care physician, and enhances patient understanding of the long-term benefits of disease management.With better documentation and decision support at the time of service, physicians and other providers see dramatic improvements in risk management, particularly in rapidly growing “failure-to-diagnose” malpractice claims.

Finally, many studies have shown that email communication between patient and physician and improved patient access to information via the Web increase satisfaction both for patients and providers. EHR implementation, with its inherent capabilities for enhanced communication and access to information, will surely lead to even greater increases in patient satisfaction.

What’s Next?

Prioritizing needs, starting small and achieving early and continuous success help realize the potential clinical benefits of EHR implementation, but true success depends on physician adoption. Engaging physicians early in design and implementation phases, focusing on practical workflow and operational needs, and using physician champions as leaders and communicators will ensure that the result centers on real patient care.

A Case Study: Mr. Davis and His Diabetes

With EHR-Optimized Care

Mr. Davis visited his primary care physician for a routine yearly physical, prompted by a letter from Dr. Jones’ office‘s EMR system, which tracked health maintenance intervals based on the fact that Mr. Davis is diabetic.

Prior to his visit, labs were ordered through the integrated ordering system, prompting HgbA1c, LDL orders by Dr. Jones. The system also reminded him that Mr. Davis had not had an eye exam in the past year. Mr. Davis went to the lab a week ahead of his appointment and had his blood drawn, based on a telephone reminder from Dr. Jones’ office on the previous day.

On the day of his appointment, the EMR system prompted the medical assistant at the office to collect a urine sample for microalbumin. The screening showed a significant positive result, which was entered into the system by the testing device prior to Dr. Jones entering the exam room.

Dr. Jones explained some of the findings of his lab tests to Mr. Davis. “Tom, I’m seeing some warning signs of early kidney problems, and your cholesterol could be better,” he said. “Your blood pressure was also a little above normal, and for a diabetic, that’s a real problem. I’m going to put you on something called an ACE inhibitor, which will help protect your kidneys as it lowers your pressure. In addition, we’ll need to get on top of that cholesterol with some Zocor. Both medicines are once a day, so you shouldn’t have any problem taking them.We’ll follow up in a month or so and make sure that you’re not having any problems.”

Dr. Jones handed Mr. Davis several brief educational printouts from the EMR that described diabetic complications and potential side effects of the meds he had prescribed electronically. Mr. Davis also received a lab slip for blood work to be done the following week for serum potassium and LFTs, as prompted by the EMR when Dr. Jones prescribed Zocor and Zestril.

One week later, Dr. Jones received notification from the EMR of a high potassium level from Mr. Davis’ follow-up lab draw. He called his patient and discussed Mr. Davis’ diet, discovering that he had been eating three bananas daily on the advice of his neighbor. Dr. Jones told him to cease the Zestril and bananas for three days and have another blood test, ordered directly through the EMR. Follow-up testing showed a normal potassium level, and Mr. Davis resumed his Zestril (though not his bananas) without incident.

Six months later, Mr. Davis emailed Dr. Jones to report that his first toe was becoming mottled and the nail bed reddened at the corner. Dr. Jones immediately called him, making an appointment for him that day through the office EMR scheduling model. Mr. Davis arrived that day and was admitted to the hospital for IV antibiotics for 24 hours, and then set up for home IV therapy for the next 10 days through VNA, all ordered online through the EMR. As Mr. Davis had an allergy to penicillin, the EMR warned Dr. Jones that Mr. Davis’ original Unasyn prescription needed to be changed, and offered Clindamycin and Ciprofloxin as alternatives. Mr. Davis went home the following day and visited the office twice during the course of treatment. He did well and was back to playing golf in three weeks.

Six-monthly visit reminders were sent to Mr. Davis by the office EMR system via email and he was generally compliant with visits, having periodic HgbA1c, LDL, microalbumin and retinal exams. With aggressive weight and nutritional counseling, as well as the addition of Glucophage to his medication regimen, he reduced his BMI (body mass index) from 31 to 25 over a two-year period, and was able to increase his physical activity appreciably.

Four years later, interval retinal exams showed some small hemorrhages, which were treated with YAG laser. Mr. Davis continued to have more frequent ophthalmic visits but experienced no significant loss of visual acuity over the subsequent decade.

Without EHR-Optimized Care

Mr. Davis has been taking Glipizide for the past six years and has seen his primary care physician Dr. Jones only twice in that time, even though he has been reminded at each visit to come in every six months. Because of its paper-ledger system, however, Dr. Jones’ office can only schedule three months in advance and Mr. Davis forgets to set up his appointments. Mr. Davis’ medications have been refilled as a matter of course because Dr. Jones would rather he be taking them than refuse to fill them because he hadn’t been seen in the office.

It has been two-and-a-half years since Mr. Davis had an HgbA1c test and at that time, the result was high. Dr. Jones advised him to increase his medication to the maximum 20 mg daily and exercise more, since he was gaining weight. He received a lab slip for follow- up in three months and was told to call the lab for an appointment, but was too busy to call and forgot after one week.

A year later he noticed that his big toe was becoming darker and showing some discharge on the sock. After a week, when it began to smell foul, he became alarmed and called Dr. Jones. Since the schedule was full, he could not be seen that day and was told to go to the emergency room. There he neglected to mention his diabetic status to the ER physician, who debrided the nail bed and started him on oral Keflex.

Two days later, his toe had turned black and his entire foot was red and swollen. He returned to the emergency room and was admitted, after calling Dr. Jones again. A surgeon saw him and started him on Unasyn, obtained an X-ray which showed bone involvement and scheduled him for surgery. He had not been admitted before and had no allergies on file in the hospital since the surgeon was unfamiliar with him.Within two hours, Mr. Davis was short of breath and flushed. The surgeon diagnosed an allergic reaction and administered treatment, changed the antibiotic and transferred Mr. Davis to the ICU for stabilization.

Surgery was delayed for three more days while Mr. Davis recovered, but finally resulted in a fore-foot amputation, due to metatarsal osteomyelitis. Mr. Davis was transferred to SNF for a week of wound care, and then home. He had a special orthotic fitting and was mobile with crutches after one week.

While he had been hospitalized, his labs showed decreased creatinine clearance and increased cholesterol levels. He was started on Zestril and Zocor in the hospital before discharge. Due to his new mobility issues, however, he was unable to get to the lab for follow-up blood testing.

At two weeks following his operation, he complained to his wife of palpitations, and she called Dr. Jones. Dr. Jones suggested ambulance transport to the emergency room. On arrival, Mr. Davis discovered he had forgotten to bring his medications and could not recall the names, telling the staff, “One is for my heart, and I don’t know what the other one is for.” His EKG immediately demonstrated sharp T-waves suggestive of hyperkalemia. His serum potassium was 6.2.

Mr. Davis was admitted to the ICU again and started on Kayexalate, but had an episode of chest discomfort within two hours. His treating physician decided on emergency hemodialysis. A Tenkoff cath was started and dialysis successfully lowered his potassium level to 3.4. He had a complete cardiac workup, including stress testing, which was equivocal, and was sent for catheterization due to his multiple risk factors and diabetic status. This showed one area of 50 percent stenosis of the LDA (left anterior descending) coronary artery of his heart and 75 percent ratty stenosis of the circumflex artery of his heart, neither lesion amenable to PCTA (percutaneous coronary transluminal angioplasty). He had no enzyme elevations, however, so it was decided that he would be managed medically and closely followed.

After three days, Mr. Davis returned home on daily aspirin, Zocor, Zestril and Glucophage, and was instructed to follow up with his primary care physician. He became dramatically less active at home, due to anxiety over his “heart trouble,” and continued to gain weight. He had one post-discharge visit with Dr. Jones, who explained that he needed to return every three months to have his blood tested. Dr. Jones further instructed him to schedule a visit with an ophthalmologist, which he did for two years. He only saw Dr. Jones twice in that time, and often did not get his lab results after testing because he was given orders at each visit, rather than beforehand, and did not receive reminders for visits and regular testing.

Four years later, Mr. Davis’ BMI had reached 33, and he was less active due to his weight and diminishing eyesight.When he was unable to read the newspaper clearly, even with his glasses, he again saw the ophthalmologist, who noted severe retinopathy, functionally unimproved by laser treatment. He was certified legally blind and lost his driver’s license, much to his wife’s initial relief, but with less opportunity to attend follow-up appointments, visit with friends and build on his already diminished activities, Mr. Davis became depressed. At 67, he became essentially homebound, and even less compliant with treatment and follow-up visits than before.