Pankaj Jandwani, MD MMM

VPMA- Post Acute Care &

Chief Medical Information Officer, MidMichigan Health, Midland MI

Navigating the Socio-technical maze Clinical Informatics

1. Learn about history and key concepts in CI

2. Understand the sociotechnical framework and the role it plays to affect quality and safety of patient care

3. Current state: Use of Clinical Information Systems (EMRs) in Post Acute Care

4. Clinical Decision Support - What is possible in current environment of Post Acute Care.

Objectives

History of Informatics

• The first computer is widely considered to be the Abacus and it was dated to as far back as 100 B.C

• The first electronic-digital computer was built sometime between 1939 and 1942 credited to John Atanasoff and Clifford Berry at Iowa State university.

• The term “informatics” was introduced in the 1960s in France – a French version of the word, of course: Informatique.

• Electronic medical records (also called electronic health records) have been in existence since the 1970s.

• Clinical operations had a programming language known as MUMPS, a name developed from the Massachusetts General Hospital Utility Multi-Programming System,

• The National Library of Medicine began using MEDLINE as a way to retrieve medical information and articles in 1965. However, since then, the database has expanded to include archives going all the way back to 1950. This is one of the finest examples of medical informatics, since it arranges data in a way that is easy to retrieve.

http://mastersinhealthinformatics.com/2011/15-intriguing-facts-about-the-history-of-informatics/

Slide – Courtesy of

Key Concepts

Domains of Clinical Informatics Key

Concepts

Electronic Medical Record Systems

An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

The National Alliance for Health

Information Technology (NAHIT)

Key Concepts

EHR (electronic health record) EMR (electronic medical records)

A digital record of health information

A digital version of a chart

Streamlined sharing of updated, real-time information

Not designed to be shared outside the individual practice

Allows a patient’s medical information to move with them

Patient record does not easily travel outside the practice

Access to tools that providers can use for decision making

Mainly used by providers for diagnosis and treatment

Differences between EHR and EMR Key Concepts

Basic EHR functionality

• patient demographics,

• patient problem lists,

• patient medication histories,

• clinical notes,

• electronic orders for prescriptions,

• laboratory results viewing, and

• imaging results viewing.

Key Concepts

Key Concepts

Clinical Decision Support

Clinical decision support (CDS) is defined as a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery. Achieving these benefits requires CDS interventions that address the CDS Five Rights. Such interventions provide: • the right information (evidence-based guidance, response to clinical

need) • to the right people (entire care team – including the patient) • through the right channels (e.g., EHR, mobile device, patient portal) • in the right formats (e.g., order sets, flow-sheets, dashboards,

patient lists) • at the right times (for key decision or action)

Key Concepts

Key Concepts

Key Concepts

Consolidated Clinical Document Architecture (C-CDA)

• CDA - an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange

• "consolidated" refers to the development of a single implementation guide

Nine different types of commonly used CDA documents, said Brull, including: • Continuity of Care Document • Consultation Notes • Discharge Summary • Imaging Integration, and DICOM Diagnostic Imaging Reports • History and Physical • Operative Note • Progress Note • Procedure Note • Unstructured Documents

Key Concepts

Key Concepts

Key Concepts

Key Concepts

Usability is the effectiveness, efficiency, and satisfaction with which specific users can achieve a specific set of tasks in a particular environment

Key Concepts

Simplicity • a) No information or visual elements are included that are not necessary to the task. • b) Important information stands out, and function options are easy to understand. • c) The application has clear, clean, uncluttered screen design (ergonomic recommendations

for information presentation on computer screens6 limit character density to no more than 40 percent of informational space).

• d) Functionality is limited to that which is essential to core tasks and decision making. Naturalness • a) The screen metaphors are familiar to everyday life, or commonly expected computer

experiences for the clinician. • b) Workflows match the needs of the practice. • The application appears intuitive and easy to learn; training will not be an overwhelming

process. Consistency • a) All the different parts of the application have the same look and feel, consistent

placement of screen elements, etc. Terminology and data entry fields are used consistently. Understanding how one screen works helps you understand how other screens work.

Forgiveness and Feedback • a) It is hard to lose data or destroy time-consuming effort with a wrong click or wrong choice

of buttons. • b) If you make a mistake, the application helps you avoid it or the application provides a

method to recover from errors gracefully (the system is “forgiving”). • c) The system provides informative feedback to the user about actions they are about to

take or have taken. • d) Information is provided to the user when the system is processing, indicating what is

occurring and how long it might take.

Effective Use of Language • a) The application uses the same words that your clinicians use (while providing mapping to

standardized codes and terms used for data retrieval). • b) List or entry-form choices are clear and unambiguous. • c) Sentences read like plain English or the selected language (see www.plainlanguage.gov ). Efficient Interactions • a) The application minimizes the number of steps it takes to complete tasks; appropriate

defaults are always provided. • b) The application provides navigation options such as shortcuts for use by frequent and/or

experienced users. • c) Navigation methods minimize user movements such as scrolling and switching between

typing and mouse clicking.

Effective Information Presentation • a) Information on screens includes sufficient white-space and large enough fonts to be read

easily with high comprehension. No information should be in all upper case. b) Colors are used to convey meaning (e.g. red to indicate medical urgency), not just for visual appeal. Preservation of Context • a) The application keeps screen changes and visual interruptions to a minimum during

completion of a particular task. • 9. Minimize Cognitive Load (in other words, “help me think about the patient, not about the

system”)

Key Concepts

Key Concepts

Key Concepts

Key Concepts

“We need portability of information about the patient. Back in the day as a family doc, I used to provide that portability, in my office, hospital and in the facility. Now, none of us can afford to do that anymore”

Dennis Perry, MD, during his talk on “Respecting Choices” at MiMDA annual symposium,

Sept 17th, 2017.

Current State

HIMSS EMR Adoption Model

11

10

9

8

7

6

5

4

3

2

1

Personalized medicine

Clinical process optimization

Outcomes-based condition management (all venues)

Complete device integration

Medical record fully electronic; care delivery organization able to contribute to electronic health record as byproduct of electronic medical record

Physician documentation, full clinical decision support system

(variance and compliance), full PACS

Closed-loop medication administration

CPOE, clinical decision support system (clinical protocols)

Nursing documentation, eMAR, clinical decision support system (error checking), PACS

Clinical data repository, controlled medical vocabulary, clinical decision support interface engine, document imaging

Ancillaries: laboratory, radiology, pharmacy

0 All three ancillaries not installed

15.6%

0.0%

0.3%

1.5%

2.1%

22.6%

39.7%

18.3%

Stage Cumulative Capabilities APR 2007 JAN 2006

0.0%

0.1%

0.5%

1.9%

8.1%

49.7%

20.5%

19.3%

N=3917 N=4343

12.6%

0.0%

0.9%

1.0%

1.8%

32.0%

33.9%

17.7%

Q2 2008

N=5073

©2008 HIMSS Analytics HIMSS Analytics™ Database

Current State

2012

Current State

Current State

What’s the Issue?

• In 2008, almost 40 percent (38.7%) of all Medicare beneficiaries discharged from acute- care hospitals received post-acute care.

• Further, of these beneficiaries, 15.5 percent were readmitted to the acute care hospital within 30 days.

• Acute care hospital re-admission rates vary among Medicare beneficiaries receiving post-acute care services, ranging from 11% for beneficiaries discharged to in-patient rehabilitation facilities to 28% for beneficiaries discharged to home health agencies.

• In addition, among those Medicare beneficiaries using post-acute care services, use of multiple post-acute care sites is common within 60 days following an acute care hospital discharge.

• “an estimated 60% of medication errors occur during times of transition.” • A study estimated that 45% of Medicare beneficiaries receiving Medicare-covered skilled

nursing facility services or Medicaid-covered nursing facility services experienced potentially avoidable hospital readmissions

Current State

Current State

Not-for-profit and chain-affiliated nursing homes were more likely to have computers in clinical areas, positioning them for easier participation in a health information exchange.

Current State

Current State

As of the first quarter of 2013, nine LTPAC vendors have obtained the ONC-Authorized Testing and Certification Body (ATCB) modular certification and four have obtained the Certification Commission for Healthcare Information Technology (CCHIT) 2011 Long Term and Post-Acute Care Certification.

To receive CCHIT Certification for LTPAC “an EHR must demonstrate that it meets comprehensive functional, interoperability, and security criteria developed by a workgroup of industry representatives and designed to support primary clinical needs for LTPAC providers.”

A study in the March 2012 Health Affairs found that only 6% of long-term, acute care hospitals and 4% of rehabilitation hospitals had at least a basic electronic health record system. Short-term, acute care hospitals, by comparison, had an EHR adoption rate of 12% in 2012.

A 2012 survey of chief financial officers of senior living organizations that LeadingAge conducted with investment bank Ziegler found that 90% had invested in wireless technology in general, and 36% had Internet access and social networking for residents and clients specifically.

Current State

• software tool extracts clinical information from the federally required patient assessments, Minimum Data Set (MDS) for nursing homes, and OASIS for home health

• Share this information

with other care providers within/across their HIE

Keystone Beacon Community

http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/index.html

What’s Possible

Improving Medicare Post-Acute Care Transformation Act of 2014

IMPACT Act

• Requires the submission of standardized data by Long-Term Care Hospitals (LTCHs), Skilled Nursing Facilities (SNFs), Home Health Agencies (HHAs) and Inpatient Rehabilitation Facilities (IRFs)

• Reporting of standardized patient assessment data with regard to quality measures, resource use, and other measures. It further specifies that the data [elements] “… be standardized and interoperable so as to allow for the exchange of such data among such post-acute care providers and other providers and the use by such providers of such data that has been so exchanged, including by using common standards and definitions in order to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes…”.

Physicians in Nursing Homes

EHR (HITECH Act) standards and regulations – demonstrate meaningful use before October 1,

2014, or face a 1% reduction in Medicare reimbursement in 2015.

– major hurdle is ePrescribing—40% of all prescribed medications must be transmitted using a certified ePrescribing application.

Statutory requirements to report on a series of PQRS measures:

– possible using paper records, but the entire process is designed around using an EHR. The rules for PQRS reporting are highly specific, and it is doubtful a general purpose facility record would include the required measures.

– Failure to report successfully results in a 1.5% payment adjustment in 2014 and 2% in subsequent years.

ePrescribing (stand-alone quality program separate from the EHR requirement to ePrescribe): A second CMS/Medicare program exists.

– This could be satisfied if providers are successful EHR meaningful users, but those who aren’t incur penalties (as of 2012) unless the provider ePrescribes 10 times prior to July 1 of each year. The penalty for nonperformance is 1.5%.

– A small incentive (0.5%) is available for those who perform 25 instances of ePrescribing by December 31 of each year.

Ownership of medical records: Under state medical board regulations, CMS reimbursement rules, and tort law, physicians are required to maintain a clinical record for each patient for whom they provide care. This record must be produced on demand. If the physician’s only record is maintained at the facility, subject to facility control, the physician may be unable to produce legally required documents on demand.

Physician billing and reporting ePrescribing and PQRS data:

• Physician EHRs generate the complex data files necessary to support claims submission that satisfactorily reports CPT II codes for ePrescribing and PQRS measures. (This is much like reporting Minimum Data Set (MDS) 3.0 data—nearly impossible if data are gathered manually). Without a physician-centric EHR that generates claims data, this becomes a significant difficulty for attending physicians

Current State

Value-Based Payment Modifier

Two composite measures of hospital admissions for ambulatory care-sensitive conditions • acute conditions • chronic conditions One measure of 30-day all-cause hospital readmissions. For the cost measure component of the Value Modifier, CMS includes the performance of 6 cost measures: • Total Per Capita Costs for All Attributed Beneficiaries measure, • Total Per Capita Costs for Beneficiaries with Specific Conditions:

– diabetes – coronary artery disease – chronic obstructive pulmonary disease – heart failure

• Medicare Spending per Beneficiary (MSPB) measure (beginning with the 2016 Value Modifier).

Physicians will choose from or land in one of the two paths

• 2019 - PQRS, VBM & MU no longer exist. • 2016 is final reporting period • Same infrastructure used to report for MIPS

beginning 2017 • Except – first yr. Medicare enrollment, eligible &

qualify for bonus w/APM, or below vol. threshold

Source: www.lansummit.org/wp-content/uploads/2015/09/4G-00Total.pdf

• Innovation Center Model, MSSP, Demonstration Program

• Use Certified EHR, base payment on quality (like MIPS &

• QPs (Qualifying participants) participate in most advanced APMs

• Avoid MIPS • 5% bonus lump sum – 2019-2024 • Higher fee schedule update 2026 onward.

Summary of CY 2018 Payment Adjustments

Based on reporting in performance year 2016

– PQRS: -2% for failing to satisfactorily report

– MU: -3% for failure to attest

– Value based Payment Modifier

• -4% for = or > 10 EPs

• -2% for solo or group of <10 EPs