Top 10 Reasons

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Top 10 reasons we need open-source EHRs

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  • 1. Top 10 Reasons Why We Need EHRs &Why They Should Be Open-Source Bob Hoyt MD FACP Co-Director Medical Informatics Program University of West Florida

2. EHRs: Not a panacea 3. Background

  • EHRs are associated with a significant amount of vendor and academic hype, as well as mixed reviews in the medical literature
  • Many of the earlier studies reported came from the same 4 large academic institutions, not representing the average small office or hospital
  • What, therefore, are the facts about EHRs?

4. Why we need EHRs #1

  • Paper records are grossly inadequate:
    • Dangerous because they may be illegible or missing
    • Difficult to share
    • Expensive to copy
    • Expensive to retrieve ($5-$7/pull) and store
    • Unable to data mine or easily generate quality reports because they contain non-computable data

5. Paper-based template 6. Why we need EHRs #2

  • Vital information is frequently missing:
    • 25% of paper charts are missing at the time of the visit
    • When charts are present, they still have missing information 14% of time
    • Without e-prescribing: no prior medication histories
    • Bottom line: decisions are made with incomplete information and about 20% of tests are repeated unnecessarily

7. Why we need EHRs #3

  • Faster retrieval times:
    • Previous patient notes, lab results, x-rays and medication histories much faster to retrieve using an EHR compare to a paper chart
    • Permits better trend analysis
    • Permits graphs and flow charts of important results, like PSA, weight, blood pressure, etc
    • Computable data and associated with data standards such as HL7, DICOM and LOINC

8. OpenEMR Vital Signs 9. Why we need EHRs #4

  • EHR is available from the office, hospital or home if web based or using VPN
    • How many clinicians take call at home at night with the inability to access records on patients they are not familiar with?
    • How many clinicians make rounds on a patient at the hospital without office records?
    • These are patient safety and quality of care issues

10. Why we need EHRs #5

  • Electronic record can be viewed by medical and non-medical staff simultaneously and 24/7 (Not possible with paper)
    • If on the same system, a consultant can view the record remotely, as can billing personnel, etc
    • Can access records after-hours and on weekends
    • Other team players like pharmacists and social workers could have access

11. Why we need EHRs #6

  • EHRs are a building block of regional health information organizations and the Nationwide Health Information Network (NHIN)
    • It is pointless to spend billions on creating health information organizations and the NHIN if the adoption rate for EHRs stays in the 10% range

12. Why we need EHRs #7

  • EHRs can save money, compared to paper by:
    • Reducing transcription costs by using templates and voice recognition
    • Upcoding encounters because the note is more complete
    • Reducing pharmacy call backs by using e-prescribing
    • Reducing FTEs and record storage space
    • Reducing mailing and faxing costs

13. Why we need EHRs #8

  • EHRs support patient (consumer) informatics. There is a trend to allow patient access via a web portal to the electronic health record for:
    • Lab results
    • Online appointing
    • Med refills and renewals
    • E-visits
    • Secure messaging with office staff or clinicians

14. Why we need EHRs #9

  • Data mining is far easier with electronic records:
    • American medicine is very late in digitizing its records so aggregated patient information can be analyzed
    • We need comparative effectiveness research so we know what the best treatments are, but we cant do that with paper records
    • AI and NLP will help when data is not structured
    • This is why Google, Microsoft and IBM are jumping on board the electronic data ship

15. Why we need EHRs #10

  • Electronic disease registries are far superior to paper registries
    • Compare an auto-populating electronic disease registry with a manual populating disease registry
    • You can build in alerts, reminders, rules engines, auto-e-mails and text messages to patients, etc
    • Also important for pay-for-performance programs

16. EHR DiseaseR egistry Use Lee BJ BMJ 2009;339:b2395

  • Kidney doctors (6) who work for Kaiser-Permanente (largest non-profit system in US) in Hawaii wanted to improve the early care of patients with chronic kidney disease with earlier referrals from the 110 generalists
  • Their population base is 214,000 patients, 10,000 have known decreased kidney function based on accessing lab results
  • K-P has Epic EHR so they could estimate kidney function in all patients and place abnormals in disease registry

17. Electronic disease registry

  • Because all patients are in the same EHR they could also access medications and clinical notes
  • Kidney doctors notified generalists by secure e-mail about any patient with decreased kidney function

18. Electronic disease registry

  • Bottom Line: Kidney docs either made treatment recommendations or referred patients to themselves (unsolicited referrals). The rate of late referrals dropped from 32% to 12%
  • Is this a logical step for population health and disease management?
  • This will work for other diseases

19. Electronic disease registry

  • This is an intelligent human-machine hybrid clinical decision support initiative
  • Why not do this for several years as generalists come on board and slowly work towards computer generated alerts?
  • Simple tool for all EHRs to include open-source

20. Why no mention of improved patient safety and quality?

  • E-prescribing reduces costs because of fewer call backs and increased use of generics
  • E-prescribing reduces a few medication errors but not many adverse drug events and we are seeing new errors due to e-prescribing
  • Clinicians tend to ignore drug alerts
  • Clinicians often ignore guideline recommendations as part of the EHR

21. Why do Open-Source EHRs make sense to me? #1

  • They are usually developed from the bottom up, with the end-user in mind
    • Compare the DODs AHLTA and the VAsVistA to note the extreme differences in usability and clinician satisfaction

22. Why do Open-Source EHRs make sense to me? #2

  • Private EHR vendors are not willing to create and share a training database for students or prospective clients.
    • We need hands-on experience for all healthcare workers, including medical students, who want EHR training
    • OpenEMR is being used by University of West Florida students as we speak for teaching purposes

23. Why do Open-Source EHRs make sense to me? #3

  • Much more cost effective
    • Still require implementation, support, upgrades and backup but cost likely to be about 10% of proprietary cost to purchase and maintain
    • No haggling with the vendor for best deal

24. What does the literature say? 25. Why do Open-Source EHRs make sense to me? 26. Why do Open-Source EHRs make sense to me? #4

  • 60-70% of US primary care medicine is practiced by very small (1-3 clinicians) groups that are often rural
    • They dont have the capital for upfront expenses
    • They have no in-house IT support
    • They may have no physician champion
    • Initial decreased productivity is a hardship

27. Why do Open-Source EHRs make sense to me? #5

  • There are multiple other communities that could benefit from low cost EHRs, besides typical outpatient medical offices:
    • Public health
    • Nursing homes
    • School nurses
    • Home health
    • Community clinics